Blood sampling is obtained upon a healthcare prescriber’s order using aseptic technique and standard precautions.
Venipuncture is completed by a registered nurse (RN), licensed practical nurse (LPN), healthcare prescriber, or appropriately certified technician.
Unlicensed assistive personnel (UAPs) may perform blood drawing as delegated by the RN, upon completion of a competency program and consistent with their job description.
EQUIPMENT
Local anesthetic topical agents (as indicated)
Chlorhexidine 2% solution or swabs or other facility approved cleansing agent
Dry sterile gauze pads
Tourniquet
Small adhesive bandage
Appropriate specimen tubes for tests ordered
Phlebotomy needle attached to a vacuum container or venous access device of choice and several sterile syringes
LED-powered or near-infrared transillumination device (as needed for infants, small children, or patient’s who have a history of difficulty with obtaining specimens)
Patient labels for specimen tubes
Appropriate laboratory requisitions
Nonsterile gloves
Cold pack for specimens that need to be transported cold (i.e., coagulation studies)
Biohazard bag
CHILD AND FAMILY ASSESSMENT AND PREPARATION
Assess severity of child’s illness and determine whether there is time for use of topical pain relief and amount of time that can be devoted to explanation of procedure.
Determine whether fasting or timing of medication administration is a consideration for the test being performed.
Assess child for previous puncture experiences and reactions to latex. Use this information in preparing the child.
Assess child’s total blood volume and associated pathology that affects oxygen-carrying capacity of blood (e.g., anemia, ongoing blood loss, shock) to determine necessity of limiting amount of blood taken. Consider amount of blood previously taken for specimen analysis and degree of total blood deficit in child. If indicated, calculate minimal amount of blood necessary to perform microanalysis of specimens; compare necessity of test versus amount of blood needed. Check with laboratory to determine the minimum amount of blood needed, particularly for a preterm infant; many tests can be run on 0.5 mL or less of blood.
Prepare child and family for procedure as developmentally appropriate. In emergent situations, explain actions as they are implemented. Use simple clear explanations. Explain that the child needs to stay still but can yell or cry if so desired. Teach the child simple distraction techniques to assist in pain management. Tell the child, “I need to check your blood.” Be careful of statements such as, “I need to take some blood.” Children may interpret this as literally all of their blood will be taken and they won’t have any left.
Encourage a family member to remain with the child during the procedure. Discuss with the family member comfort measures (e.g., swaddling, skin-to-skin contact, breastfeeding, use of sucrose pacifiers, sweet tasting solutions) and distraction techniques (e.g., audio-visual, music) that they can use with their child. Select measures to employ and initiate use of these measures prior to beginning the procedure (see Chapter 7).
When not emergent, apply a topical anesthetic to two sites (see Chapter 7); if the initial puncture is unsuccessful, a second site is already prepared. When using a eutectic mixture (e.g., EMLA), it should remain on the skin for at least 60 minutes before puncture. When using a stimulated iontophoresis method, it should remain on the skin for 5 to 15 minutes before puncture.
PROCEDURE Performing Venipuncture
Steps
Rationale/Points of Emphasis
1 Verify orders, laboratory requisitions, and patient labels.
Prevents unneeded punctures. Allows the gathering of correct materials for tests ordered.
2 Identify the child using two different patient identifiers (see Chapter 82 ).
Ensures correct patient for specimen collection.
3 Perform hand hygiene.
Reduces transmission of microorganisms. Antibiotic-resistant gram-negative organisms frequently contaminate the hands of healthcare personnel, in addition to the usual skin flora.
4 Gather the necessary supplies based on size of child, method of collection, and tests required.
Promotes efficient time management and provides an organized approach to the procedure.
Too large a needle may damage valves in the vein. Butterfly wings provide more control and thus less trauma to vessels.
Use of a syringe and straight needle to draw blood is not recommended because the amount of pressure exerted cannot be controlled, the vein collapses, and damage may occur.
caREminder
Do not puncture the stopper on the specimen tubes. If the stopper is punctured, the tube will lose its vacuum, and blood will not enter the tube.
5 Select puncture site, using the distal veins first. Veins most commonly used are the antecubital fossa (Figure 18-1).
The median antecubital vein may not always be visible, but it is usually large and palpable. It is well supported by subcutaneous tissue and less likely to roll.
Figure 18-1. Veins in the upper extremities most commonly used for venipuncture sites.
6 Place the site in dependent position.
Facilitates blood flow to the area.
KidKare Older children may cooperate better if they can sit up with the arm well supported on a pillow, if they are given detailed explanations, and if they are involved in decisions as appropriate (e.g., site selection). If child is younger than school age, have child lie down. A second person to assist in stabilizing the site may be helpful.
7 Don gloves.
Standard precaution to reduce transmission of microorganisms.
8 If child is able to follow commands, ask the child to make a fist.
Assists in vein distention for older children.
9 Apply tourniquet around child’s extremity above the site.
Obstructs venous blood flow and causes vein distention so that the vein is easier to see and palpate.
10 Cleanse the skin over the chosen insertion site with antiseptic swab. For povidone-iodine and alcohol, work from the center outward in a circular motion and allow area to dry for 30 seconds. For 2% chlorhexidine use a back and forth friction scrub for at least 30 seconds and allow area to dry. Do not touch the cleansed area again with your finger or any other unsterile object.
In infants younger than 2 months of age, remove cleansing solution after it dries, with sterile water. Use of chlorhexidine may be associated with contact dermatitis in low-birth-weight infants.
Moves microorganisms away from the proposed puncture site, thus decreasing the transfer of microorganisms. Alcohol is known to be less effective than chlorhexidine in decreasing bacterial colonization and causes the greatest amount of permanent tissue damage in animal studies.
11 Remove needle shield. Anchor the child’s vein with thumb of your nondominant hand.
Prevents rolling of vein.
12 Hold the needle bevel up, positioned at a 45-degree angle over the vein. Puncture the site. If unsuccessful after two attempts, have another practitioner perform procedure.
Allows placement of needle parallel to the vein.
13a Obtain blood using a phlebotomy needle attached to a vacuum container. Stabilize the vacuum holder and push in on the specimen tube to puncture the stopper; when first specimen tube is full, remove it from the vacuum holder while stabilizing the holder, being careful not to jar the needle; stabilizing the holder, insert succeeding tubes in holder, making sure that the stoppers are punctured on each tube to initiate blood flow. Gently invert tubes containing additives 8 to 10 times.
If the needle is in the vein, the tube will begin to fill with blood.
Ensures mixture of additives.
Do not shake tubes. Rough specimen handling, such as forceful injection or shaking, may damage erythrocytes and alter laboratory results.
13b Obtain blood using venous access device of choice and sterile syringes. When a blood backflow is seen, gently withdraw blood with a 1- or 3-mL syringe if blood for several tests is needed.
Once the specimen tube is full, vacuum stops the flow of blood. Inserting succeeding tubes quickly and evenly allows obtaining several specimens from one puncture site. The order of tube selection may vary depending upon the type of additive in the tube.
caREminder
If no blood flows into specimen tube or ceases to flow before an adequate sample is collected, the following steps should be taken:
• Confirm correct needle position, change the angle of needle insertion by a few degrees.
• Remove specimen tube and replace with a new specimen tube.
• If the new tube does not fill with blood, remove needle as described below.
• Evaluate need for repeat puncture.
14 Release the tourniquet.
Prevents blood from entering surrounding tissue.
15 Remove tourniquet.
Allows venous blood flow to resume.
16 Apply dry sterile gauze and withdraw needle. Apply pressure to puncture site until bleeding stops. Keeping the arm straight, elevate the extremity above the level of the heart.
Stops the bleeding. Elevation promotes negative pressure in vein and promotes clotting.
Do not bend the arm after drawing blood because it promotes hematoma formation. Children with cardiac disease should not raise their extremities because this action creates negative pressure in veins.
17 Place specimen in appropriate tube.
Ensures adequate preparation and stabilization of specimen for accurate analysis.
18 Note the total amount of blood withdrawn.
Provides a gauge of how much blood has been taken and when replacement may be needed.
19 Dispose of sharps immediately:
If using a needle-protection device, withdraw the needle back into the container until a click is heard.
When not using a needle-protection device, place the needle in the needle-protection box immediately without reshielding it.
Prevents accidental needle-stick injuries with contaminated sharps.
20 Apply small bandage, as appropriate.
Prevents further bleeding. Reassures children, particularly preschool-aged children, that all their blood will not leak out.
Bandages may present a choking hazard in infants and toddlers.
21 Label all specimen tubes with the following:
Child’s name
Time and date of collection
Initials of person collecting
Medical record number
Ensures that correct specimens are tested for correct child.
22 Place in biohazard bag and transport to the laboratory.
Protects against blood contact.
23 Dispose of equipment and waste in appropriate receptacle. Remove gloves and perform hand hygiene.
Standard precautions. Reduces transmission of microorganisms.
24 Recheck puncture site.
Detects further bleeding.
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PROCEDURE
KidKare Older children may cooperate better if they can sit up with the arm well supported on a pillow, if they are given detailed explanations, and if they are involved in decisions as appropriate (e.g., site selection). If child is younger than school age, have child lie down. A second person to assist in stabilizing the site may be helpful.
In infants younger than 2 months of age, remove cleansing solution after it dries, with sterile water. Use of chlorhexidine may be associated with contact dermatitis in low-birth-weight infants.
Do not shake tubes. Rough specimen handling, such as forceful injection or shaking, may damage erythrocytes and alter laboratory results.
Do not bend the arm after drawing blood because it promotes hematoma formation. Children with cardiac disease should not raise their extremities because this action creates negative pressure in veins.
Bandages may present a choking hazard in infants and toddlers.
