9. Pediatric and Geriatric Procedures

Transcription

1 9. Pediatric and Geriatric Procedures A. Age Specific Care 1. Every person is unique, but each will go through various stages of development. a. Special consideration needs to be given to certain age groups, based on their age, physical, mental, emotional and developmental stage. b. Children and older adults have different needs than young adults. c. By learning about how people in different stages of development respond to others and their surrounding environment, the healthcare worker can better formulate and implement appropriate care. 2. The following are general guidelines to assist healthcare workers in dealing with patients based on age: a. Infancy - the period between birth and 1 year. Totally dependent on adults for care. They need to be provided with a protective environment; ensure warmth, cuddles and hugs, and protect them from skin abrasions. Infants develop fear of strangers at about 6 months of age. Skin puncture (Heel) is the most common blood collection, but venipuncture may be performed in the antecubital area when necessary. b. Toddlers the period from 1 3 years. Speak to both the parent and child. Toddlers may still fear strangers and have a fear of pain. Assess past blood collection experience to formulate a plan. Will usually require additional assistance to help hold child still. Distraction works well during collection. Toddlers may be very curious - keep materials and supplies out of reach of child. Skin puncture (finger) can be used for many lab tests, but venipuncture may be used in the antecubital area when necessary. c. Pre-School the period from 4-5 years. Child may know their name and birthday date, but always verify with parent or caregiver. Child may want to help. Keep collection area child-proof. Use distraction techniques during collection. Additional assistance during the collection is still important. Can usually be collected from finger stick, but venipuncture may be used. d. School Age - the period between 6 and 12 years. Speak to them and the parent or caregiver. They need to have unfamiliar objects explained, should not be left unattended, and may need to be immobilized if necessary. Distraction techniques may still be used. May try to be brave during collection. Finger sticks are still the most common method of blood collection. e. Adolescent - the period between 13 and 18 years. May be embarrassed to show fear. Blood collection is usually by venipuncture, will need to explain the procedure if it is their first venipuncture. They need to be included in explanations of procedures, provided privacy, and may need pregnancy addressed. Watch for syncope (fainting), especially in adolescent males. Unit 9: Pediatric and Geriatric Procedures [Nov. 2018] Page 1

2 d. Adult - period between 18 and 65 years. They require explanations of procedures, want to ask questions, and be addressed with respect. e. Older Adult - 65 years and over. Things to consider include mobility, visual acuity, skin protection, and fragile veins. 3. Healthcare workers can use this information to help them provide the best care for each individual patient. 4. Study the chart in your textbook which illustrates age-specific care considerations which incorporate knowledge of child development, their fears and concerns, and possible parental involvement and tips for the phlebotomist. 5. Patients of any age can have special physical, emotional or mental challenges. a. Temporary challenges may affect mobility due to broken bones, injury or recent surgery. b. Chronic challenges may be due to a variety of factors 1) Disease state (Examples: Arthritis, Multiple Sclerosis, Parkinson disease) 2) Metal or Emotional state (Examples: Head injury, Autism, Depression, Stroke) c. Any patient with a special challenge must be carefully assessed to develop an appropriate plan for performing blood collection; assistance may be needed by family members, caregivers, co-workers or other medical staff members. II. Pediatric Patients A. Pediatric Challenges 1. Pediatric patients are very challenging due to size and emotional response to blood collection. 2. Skill in pediatric phlebotomy is gained by knowledge of special collection equipment, observation of skilled phlebotomists and practice. 3. New phlebotomists should learn skills by performing procedures on older children. 4. Pediatric blood collection may be by skin puncture or venipuncture. 5. Essential to recognize limitations, always request help when necessary. B. Preparing Child and Parent 1. Important to develop good interpersonal skills and routine during pediatric blood collection. a. During the introduction be warm, friendly, calm and confident. You should gain the trust of the parent or caregiver before attempting blood collection. Unit 9: Pediatric and Geriatric Procedures [Nov. 2018] Page 2

3 b. Correctly identify the patient, using at least two patient identifiers. c. Ask about previous blood drawing experiences the child has had. d. Develop a plan based on your impression of the child's and parent's cooperation (or lack of cooperation); involve the child if possible. e. Explain and demonstrate the procedure using age appropriate words. f. Establish guidelines. g. Be honest when asked about the amount of discomfort. Never say it won't hurt. h. Encourage parental involvement. i. Some parents may be so upset about their child s illness or have their own fears about blood collection that it may be best for the parent if they wait outside the room. j. Never attempt to collect blood from a small child by yourself. Always have a parent or another staff member there to assist. 2. Children may have an extremely negative psychological response to the needle. 3. Prepare equipment out of site of the child to reduce anxiety. 4. Distraction techniques are useful for helping young children cope and can lessen their distress. a. For patients age 3 or older, have parent or other health care worker refocuse the child's attention towards another activity. b. Possible activities include blowing bubbles, reading a book, watching a video or listening to music. Parents may suggest the child play a game on parent's electronic device. c. School age children may want to help with procedure. 5. It is best for the hospitalized child psychologically if the procedure can be performed in a treatment room away from the child's bed or play area, especially if the room is shared by another child. C. Restraining the Child 1. Restraints may be necessary to help assure a successful procedure with no injury to the child. 2. Important to restrain the arm during venipuncture to prevent injury to the child. a) Have the parent hold the child on their lap with one arm around the child's waist the other hand under the clasping the child's elbow. Unit 9: Pediatric and Geriatric Procedures [Nov. 2018] Page 3

4 b) Have the child lay down, the parent leans over the child restraining the near arm with their body while holding the extended arm securely. c) For small children do not allow full weight of adult to be put on child. 3. Infants younger than 3 months usually do not need to be restrained. D. Combative children 1. At times the child may kick and thrash about even while restrained. 2. Do not use excessive force to restrain the child; this may result in injury. 3. Try to anticipate problems, make sure other health care workers are available to provide additional assistance if needed. E. Pain alleviation 1. If many venipunctures are anticipated during a hospital stay, a topical anesthetic EMLA (eutectic mixture of local anesthetics) may be applied to intact skin. 2. Combination of lidocaine and prilocaine which has minimal side effects. 3. The anesthetic affect occurs after 60 minutes and lasts 2 to 3 hours. 4. Disadvantages are cost, waiting 60 minutes, and advanced knowledge of vein to use. 5. Do not use EMLA if child has allergies to local anesthetics. 6. Visit the EMLA web site for additional information: 7. Sucrose nipples or pacifiers given to infants during phlebotomy do not alleviate pain but may comfort the infant. F. Prevention of Disease Transmission for Pediatrics 1. If isolation notice is posted, wear the appropriate PPE. 2. Always follow Standard Precautions. 3. Be aware of the need to protect the child from infection. a. PPE may be required to protect extremely ill children. b. Always wash hands and change gown before going to the next infant or child. 4. Latex allergies are becoming more common; be aware and use non-latex supplies. G. Pediatric Capillary Collection Procedures 1. For pediatric and neonatal patients' documentation of amounts drawn are critical. Unit 9: Pediatric and Geriatric Procedures [Nov. 2018] Page 4

5 a. Every blood collection of a hospitalized neonatal or pediatric patient should be documented with the date, time, and amount of blood collected. b. Removal of too much blood in a short period of time can cause anemia. Removal of 10% of an infant s blood volume at one time can lead to shock and cardiac arrest. c. The amount of blood that can be collected is based on the weight of the child and the total amount collected in both short time periods (24 hours) and longer time periods (up to 1 month). 2. Capillary skin puncture is the procedure of choice when only a small amount of blood is needed. a. Follow the Micro Collection Order of Draw: 1) Lavender (Or any other samples for hematology studies) 2) Other anticoagulant additives (green, gray) 3) Tubes without anticoagulant additives (red or gold) b. Sites include the heel (infants) or finger (older than 1 year of age) 3. Warming the site is critical to increase blood flow to the area -- commercial heel warmers or warm wash cloth may be used. 4. The heel stick is the collection procedure of choice for infants. a. Avoid bruised areas and sites of previous punctures. b. The size of the lancet must not exceed 2.0 mm to avoid puncturing bones, nerves or tendons. c. Automatic puncture devices are available for preemies (0.85mm puncture depth) and infants (1.25mm). d. Hold the heel gently as infants bruise easily. e. Avoid excessive milking or squeezing. f. Do not use adhesive bandages. g. Check site before leaving. 5. Complications of heel stick a. Cellulitis b. Osteomyelitis of the calcaneus bone c. Abscess formation d. Tissue loss Unit 9: Pediatric and Geriatric Procedures [Nov. 2018] Page 5

6 e. Scarring of the heel 6. Capillary puncture on children using finger H. Newborn Screening a. Use a pediatric safety skin-puncture device appropriate for the age and size of the child. b. Distance from skin surface to bone or cartilage in the middle (3rd) finger is between 1.5 and 2.4 mm. c. For infants use an automatic puncture device with a puncture depth of 1.25mm, or for older children, one for toddlers with a puncture depth of 1.75mm 1. Newborn screening is performed to detect inheritable (genetic) and metabolic disorders such as phenylketonuria (PKU) and hypothyroidism and is mandated by law. a. The State of Texas screens for 29 disorders. b. If these diseases are not caught early, they can result in mental retardation or other lifelong health problems. c. Collected between 24 and 48 hours after birth. d. Screening is repeated when the infant is between 7-14 days of age. 2. The heel is the collection site of choice. Proper procedure is followed, the blood is collected onto circles on special filter paper. a. Each circle must be filled completely. b. The blood should be filled from one large drop, not layered on. c. To ensure proper blood collection, apply blood to one side while viewing from the other. d. Excessive squeezing may cause hemolysis. e. Visit the Texas Department of Health Web Site for excellent illustrations of the procedure, a Specimen Collection Training Video, as well as pictures of improperly filled cards: 3. Interferences in Newborn Screening Collections a. Specimen not properly dried before mailing. b. Circles on filter paper not completely filled, not saturated, or not all circles filled. c. Contamination of filter paper before or after collection with substances such as hand lotion, powder, alcohol, or antiseptic hand solution. Do NOT touch paper. d. Blood applied to both sides of the filter paper. Unit 9: Pediatric and Geriatric Procedures [Nov. 2018] Page 6

7 e. Excess blood applied. f. Heel squeezed or milked, resulting in tissue fluid diluted specimens. g. Alcohol not wiped off or allowed to dry completely before puncture is made. I. Pediatric Venipuncture Blood Collection Techniques 1. Venipuncture a. Performed on infants and children when larger quantities of blood are needed. b. Veins of the antecubital fossa or forearm are most accessible for toddlers and children. c. Toddlers and children have same vein anatomy as adults. d. Equipment of choice is the butterfly used with a syringe or pediatric tubes. e. Always collect the smallest amount of blood necessary and document blood volume collected. J. Other Pediatric Blood Collection Techniques 2. Dorsal Hand Vein Procedure a. May be used for infants, children and adults with small difficult veins to collect venous blood into a micro-collection container. b. Uses a 22 to 23-gauge needle, butterfly or syringe needle. c. No tourniquet is necessary. e. A vein on the back side of the hand is located, site is cleansed. f. Needle is inserted, when blood appears in the hub allow blood to drip into appropriate microtainers. h. After collection, remove needle and apply pressure until bleeding stops. i. The technique reportedly results in decreased hemolysis, decrease sample dilution with tissue fluid, fewer multiple punctures and decrease phlebotomist stress. It also appears to be less painful. j. Only one site in Austin that performs routinely -- even there, not all nurses and phlebotomist feel comfortable with it. 3. Scalp vein procedure a. This is performed by individuals who have acquired additional specialized training. b. The infants scalp is shaved if necessary. Unit 9: Pediatric and Geriatric Procedures [Nov. 2018] Page 7

8 c. Palpate, make sure pulse is not present. If vein cannot be palpated a rubber band can be placed around the upper head. d. The site is disinfected with povidone iodine or alcohol. 4. Blood may be withdrawn from IV lines. This procedure must be performed by nurses. 5.. Heparin locks are special needles that are inserted and left in veins for several hours. a. The line must be flushed with saline prior to drawing the sample by a nurse. b. The first blood is withdrawn is discarded, and the specimen collected. c. The line is then flushed with a heparinized solution. d. In Texas, the flushing can only be performed by nurses or specially trained personnel. 6. Central venous catheters can be used for blood collection but require special training. III. Geriatric Patients 1. The elderly account for almost 15% of the total population but uses over 30% of the healthcare services in the nation. It is estimated that in the next 25 years, 20% of the U.S. population will be elderly. 2. Some of the special interpersonal skills needed when dealing with this age group include: a. Treat patients with the upmost respect and dignity b. Establish eye contact c. Be sensitive to their needs and have patience d. Smile 3. The normal aging process causes a variety of physical and emotional issues that can be difficult for both the geriatric patient and healthcare worker. Some common conditions experienced by this group: a. Hearing loss speak slowly and clearly; patient may turn so they can hear you in their good ear. Avoid shouting at the patient. b. Failing eyesight may need assistance with being guided to a chair, may have difficulty seeing who is in the room. c. Communication Issues Stroke, Parkinson Disease and Dementia can affect speech; allow the patient time to speak and do not try to finish their sentences for them. d. Memory loss they may not remember when they last ate, so you may not be sure if a specimen is truly fasting. Unit 9: Pediatric and Geriatric Procedures [Nov. 2018] Page 8

9 e. Loss of taste, smell and feeling loss of appetite may lead to malnourishment and dehydration. f. Tremors Parkinson Disease can affect a patient s ability to hold still for phlebotomy; you may need assistance from someone to help hold the arm still. g. Tissues become thinner veins become more fragile and are not as well anchored; more likely to roll; avoid tight tourniquet applications that can cause bruising, adhesive bandages which may remove skin, use butterfly needles for fragile veins. h. Muscles become smaller angle of needle may need to be shallower; they may not be able to make a fist due to muscle weakness i. Increased susceptibility to hypothermia may make them feel cold, so warming of site prior to venipuncture or finger stick may be necessary. j. Increased sensitivities and allergies -ask about allergies. k. Emotional problems may be depressed or angry at life in general due to loss of family, friends, career, abilities, independence. l. Infection Control the decline of the immune system in elderly patients increases their chances of infection. Pay special attention to Standard Precautions. Avoid drawing elderly patients if you have a cold or wear a mask. m. Coagulation Issues may be due to blood thinning medications or aspirin for stroke or heart problems or other coagulation disorders. Make sure bleeding has stopped after you have completed the blood collection. 5. Special considerations for collections at the patient s home, assisted living facility, rehabilitation facility or nursing home a. Have extra supplies and equipment, including sharps and biohazard containers b. Take special care in identifying the patient c. Place patient in a comfortable, reclining position d. Locate the nearest sink and towels e. Use hand disinfectant prior to putting on gloves and starting procedure f. Make sure puncture site has stopped bleeding before you leave g. Carefully inspect area after procedure; remove all trash and supplies h. Carefully label samples and place in leak proof container or bag for transport i. Carefully document delays in delivery of specimens to laboratory Unit 9: Pediatric and Geriatric Procedures [Nov. 2018] Page 9