Interventional procedures for neonates

To administer intravenous medications and fluids and remove the cannula when it is no longer needed or if swelling occurs.

Procedure:

First: Insertion of Intravenous Cannula

Equipment:

• Sterile gloves
• Two cannulas (sizes 24, 22)
• Three syringes (1 ml)
• Saline solution or sterile water for injection
• Sterile gauze and cotton
• 70% ethyl alcohol
• Sterile towel
• Sterile scalpel
• Adhesive tape
• Tourniquet
• Sharps disposal container

Steps:

• Wash hands using routine handwashing and prepare the required equipment.
• Examine the veins to determine the best site for cannula insertion based on priority.
• Prepare pieces of adhesive tape for securing the cannula.
• Disinfect the area with alcohol using a unidirectional motion from top to bottom or a circular motion from the center outward.
• Fill the syringe with saline or sterile water.
• Open the cannula package.
• Inject saline into the cannula to confirm its patency.
• Keep the cannula in its plastic cover.
• Lightly tie the arm or leg above the vein with a tourniquet to make the vein visible or instruct the assisting nurse to apply pressure using their index finger.
• Insert the needle gently without pushing it too far into the vein until blood appears.
• Release the tourniquet.
• Withdraw the stylet (needle) while applying pressure on the skin above the vein to prevent blood flow.
• Place the stylet in its plastic cover in case it is needed again if blood does not flow properly.
• Inject 1 ml of saline to ensure the blood flow is unobstructed.
• Cover the cannula entry point with the white cap.
• Place a piece of sterile gauze under the cannula hub (especially if it has no wings) and another over the insertion site.
• Remove gloves to secure the cannula with adhesive tape.
• Record the date and time of insertion, as well as the name of the person performing the procedure, on the tape and in the documentation.
• Dispose of the used equipment properly and place the stylet in the sharps container.
• Remove gloves and wash hands using routine handwashing.

Precautions When Inserting a Cannula:

• Use a new sterile cannula for each new attempt.
• Perform routine handwashing and wear gloves before handling the cannula.
• Whenever possible, use upper limbs for cannula insertion.
• If inserting the cannula in the scalp, carefully remove excess hair using a scalpel and wash hands again.
• Attempt insertion in the lower part of the arm first, moving upward if necessary.
• Avoid inserting the cannula in areas with wounds, infections, or near joints.
• Avoid touching critical areas of the cannula, including:
• Cannula opening
• Inner surface of the cap
• Upper port opening and its inner surface
• Area in front of the wings

Second: Removal of Intravenous Cannula

Indications for Removal:

• If the area around the needle swells or shows signs of infection.
• Immediately after administering blood, blood products, or lipids.
• After 72 hours of insertion (ensuring a new cannula is placed in another site before removal and verifying fluid flow in the new vein).

Equipment:

• Sterile gloves
• Sterile gauze
• 70% ethyl alcohol
• Surgical betadine
• Adhesive tape
• Sterile towel
• Medical waste bin with a red bag
• Sharps disposal container

Steps:

• Perform routine handwashing and prepare the equipment.
• Moisten the adhesive tape with alcohol to ease removal and reduce pain.
• Disinfect the cannula site with betadine and apply sterile gauze over the site to prevent bleeding.
• Dispose of the removed cannula in the sharps container.
• Remove gloves and wash hands using routine handwashing.

Responsible Personnel:

• Nursing staff.

Blood tests are performed on newborns to aid in diagnosis and treatment planning. Blood samples are collected from veins, capillaries, or arteries. This process requires high precision, skill, and clinical experience from the nurse.

Methods of Blood Sample Collection

First: Venous Blood Sampling

Used to collect large blood volumes for tests such as complete blood count (CBC), blood compatibility testing, bilirubin levels, or blood culture.

Equipment:

• Butterfly needle (sizes 23, 25)
• 70% ethyl alcohol
• Sterile cotton and gauze
• Sterile gloves
• 5 ml syringe
• Test tubes
• Tourniquet
• Adhesive tape

Note: Blood culture collection requires additional preparation with betadine and a culture bottle.

Order of Priority for Venous Access Sites:

1. Dorsal hand and foot veins
2. Wrist veins
3. Inner elbow veins
4. Scalp veins
5. Ankle veins

Steps:

• Perform routine handwashing and prepare equipment.
• Apply a pain-reducing method as blood collection is an invasive procedure.
• Perform surgical handwashing.
• Disinfect the skin at the chosen site with alcohol and allow it to dry.
• Open the butterfly needle package.
• Wear sterile gloves.
• Apply a tourniquet above the sampling site or instruct an assistant nurse to use their fingers to apply pressure.
• Hold the area around the puncture site firmly.
• Insert the butterfly needle into the vein with the bevel facing up until blood appears in the tubing.
• Release the tourniquet immediately after blood appears.
• Attach the syringe to the tubing and withdraw the required blood volume.
• Avoid intermittent squeezing as it may cause hemolysis and affect test accuracy.
• Transfer the sample gently into the test tube by running it along the tube wall.
• Remove the needle and apply pressure with sterile gauze to stop bleeding.
• Label the tube with the newborn's name, test type, and date.
• Send the sample to the laboratory immediately.
• Dispose of used equipment safely.
• Remove gloves and perform routine handwashing.
• Document the blood collection in the newborn's records.

Precautions:

• Use disposable equipment for every sample collection.
• Avoid using the femoral or jugular veins unless necessary.
• Do not use large veins in cases of blood clotting disorders or local infections.
• Avoid leaving adhesive tape over the puncture site for more than 15 minutes.

Second: Capillary Blood Sampling

Used to collect small blood volumes from capillary-rich areas such as the heel or fingers. In infants, the heel or the big toe is commonly used. This method is widely practiced in neonatal care units for tests like blood glucose and blood gas analysis.

Contraindications for Capillary Sampling:

• Severe circulatory shock
• Leg swelling (edema)
• Foot or heel infection
• Increased blood viscosity (polycythemia)

Equipment:

• 70% ethyl alcohol
• Sterile cotton
• Sterile lancet
• Capillary tubes
• Sterile gloves
• Adhesive tape
• Sterile gauze (2×2 cm)

Steps:

• Perform routine handwashing and prepare equipment.
• Warm the heel by wrapping it in a gauze pad soaked in warm water (40°C) for 5 minutes.
• Apply a pain-reducing method.
• Perform surgical handwashing.
• Select the puncture site.
• Disinfect the site with 70% alcohol using a single motion and allow it to dry.
• Wear sterile gloves.
• Hold the heel firmly.
• Quickly puncture the heel with a lancet.
• Wipe away the first drop of blood with sterile cotton.
• Gently squeeze to collect blood in the capillary tube, avoiding air bubbles.
• Apply sterile gauze to stop bleeding.
• Dispose of the lancet in a sharps container and other waste in a red bag.
• Perform routine handwashing.

Precautions:

• Do not use water above 40°C.
• Avoid lancets longer than 2.5 mm.
• Ensure alcohol dries completely before collecting blood.
• Avoid mid-heel punctures to prevent pain and infection.
• Do not excessively squeeze the heel.

• The date of catheter insertion must be recorded in the follow-up records.
• No topical antibiotics (ointments or creams) should be applied to the umbilical catheter site to prevent fungal infections or antibiotic resistance.
• A daily examination must be conducted to check for signs of infection, inflammation, bleeding, or circulatory insufficiency, such as skin discoloration in the lower limbs.
• The catheter must be removed immediately in the following cases:
• If it is no longer needed.
• Arterial catheters should be removed before the fifth day.
• Venous catheters should be removed by the fourteenth day, as the risk increases with prolonged use.
• The catheter must not be replaced immediately after removal due to signs of catheter-related bloodstream infection, circulatory insufficiency in the lower limbs, or blood clotting. However, an umbilical venous catheter may be replaced only if it is not functioning efficiently and no infection is present.
• The catheter must never be left open to prevent air embolism risks.
• A continuous infusion of a heparin-containing solution (0.25 units/mL) must be maintained when using an umbilical arterial catheter. This infusion should never be stopped during its use.
• If inflammation appears at the catheter insertion site, a sample should be taken for culture.
• A blood culture should be performed both from the catheter and a peripheral vein if catheter-related infection is suspected. If the catheter is removed, a culture should be taken from the catheter tip.

Responsible Personnel:

• Nursing staff.

Required Equipment:

• A urine collection bag for newborns
• Antimicrobial soap
• Small pieces of sterile cotton
• Sterile water
• Test tubes for urine collection
• Sterile gloves

Steps for Collecting a Urine Sample:

·  Perform surgical handwashing.

·  Prepare the necessary equipment.

·  Confirm the newborn’s identity before proceeding.

·  Wear sterile gloves.

·  Clean the newborn’s genital area as follows:

For Female Newborns:

• Separate the labia and clean the area using a cotton ball soaked in antiseptic soap, wiping in one direction from the clitoris to the anus along one side of the urethral opening. Then, wipe with another cotton ball soaked in sterile water and dry the area.
• Use a second cotton ball to clean the other side of the urethral opening, then wipe with another sterile water-soaked cotton ball and dry.
• Clean the pubic area with a third cotton ball, followed by a sterile water-soaked cotton ball, and dry.

For Male Newborns:

• Clean the penis using a circular motion toward the scrotum. If the newborn is uncircumcised, gently retract the foreskin before cleaning, then dry the area.
• Clean the pubic area with a cotton ball, followed by a sterile water-soaked cotton ball, and dry.

·  Peel off the protective film from the lower half of the adhesive strip on the urine collection bag.

·  Place the urine collection bag over the vagina or penis and scrotum.

·  Press the adhesive strip onto the skin, starting from the narrow skin bridge between the anus and the genitalia, and move outward, ensuring firm adhesion.

·  Once the lower part of the adhesive strip is secured, remove the upper protective film and press the strip firmly onto the skin (avoiding wrinkles). The bag should now be correctly positioned.

·  Leave the bag in place until the newborn urinates.

·  The newborn is diapered.

·  Once urination occurs, carefully remove the bag.

·  Transfer the required urine amount from the collection bag to a sterile sample bottle.

·  Label the bottle with the newborn’s name, the unit from which the sample is taken, and the requested analysis type.

·  Send the sample to the laboratory immediately.

Urine Sample Collection via Bladder Aspiration:

Indications:

• Used for urine culture.

Contraindications:

• If the newborn has urinated within the last hour.
• Presence of skin infections above the bladder.
• Congenital abnormalities of the urinary or genital system.
• Blood clotting disorders.

Required Equipment:

• Sterile gloves
• Sterile gauze
• Forceps
• 5 mL syringe (three syringes)
• 21 and 25 gauge needles
• Antiseptic solution
• Sterile tubes with lids for sample collection

Procedure Steps:

• Confirm the newborn’s identity.
• Perform surgical handwashing and wear sterile gloves.
• Ensure there is urine in the bladder.
• Position the newborn on their back with the legs in a frog-leg position.
• Clean the sample collection site thoroughly.
• Prepare the urine collection container and transfer the urine into the sample bottle, sealing it tightly.
• Label the sample bottle with an appropriate adhesive strip, recording the urine volume.
• Send the sample to the laboratory.
• Safely dispose of used equipment in designated areas.
• Perform routine handwashing.
• Ensure the sample reaches the laboratory within 1–2 hours of collection.

2. Stool Sample Collection:

Required Equipment:

• Clean diaper
• Plastic or cellophane sheet
• Wooden tongue depressor
• Antimicrobial soap
• Large pieces of dry and moistened cotton
• Sample collection container
• Gloves

Procedure Steps:

• Perform routine handwashing.
• Prepare the necessary equipment.
• Confirm the newborn’s identity.
• Wear gloves.
• Remove the newborn’s diaper.
• Clean the anal and perineal area using a cotton ball soaked in antiseptic soap, wiping in one direction. Then, wipe with a cotton ball soaked in sterile water and dry.
• Place a clean diaper on the newborn.
• If the stool is solid, use a wooden tongue depressor to scrape a small amount from the diaper and place it into the sample collection container.
• If the stool is loose (diarrhea), place a piece of cellophane or plastic between the newborn’s body and the diaper to collect the stool before it is absorbed. Transfer the stool directly from the plastic sheet to the collection container.
• Label the container with the newborn’s name, the time of collection, the unit from which the sample is taken, and the requested analysis type.
• Send the sample to the laboratory immediately.
• Dispose of used equipment safely in designated areas.
• Perform routine handwashing.

Responsible Personnel:

• Nursing staff.