Blood Specimen Collection: Venipuncture (Pediatric) - CE/NCPD

The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.

ALERT

Do not use a vein that is proximal to IV fluid delivery.

Do not leave a tourniquet in place longer than necessary to prevent hemoconcentration, stasis, localized acidemia, and hemolysis.

Take precautions with a patient who takes medications that increase the risk for bleeding.^{undefined#ref5">5}

OVERVIEW

Venipuncture is used for venous blood specimen collection. Venipuncture is primarily used for larger quantities of blood than is feasible with a heel stick or for blood culture. The most common method is using a winged infusion set (butterfly needle) attached to a small-volume syringe or a vacuum tube holder to collect the blood specimen (Figure 1).

Common sites for venipuncture in pediatric patients include the antecubital fossa and the saphenous vein (Figure 2) (Figure 3). The scalp veins can be used in infants. Veins of the foot can be used in infants who are not yet walking.

For skin prep, there is not enough evidence to recommend a single product for all neonates. Be aware that:

• Chlorhexidine should be used cautiously because it may cause skin irritation and chemical burns in infants less than 2 months old or premature infants.¹
• Isopropyl alcohol is drying to the skin, does not work as well as chlorhexidine gluconate and povidone-iodine, and has been linked with chemical burns in premature infants.¹
• Povidone-iodine can cause alterations in thyroid function if absorbed through the skin.¹

Venipuncture can be a painful and stressful experience for a child. In most cases, venipuncture is viewed as a routine procedure, but just the appearance of a needle can be frightening to a child. A calm approach and skilled technique can limit a child’s anxiety, pain, and stress during venipuncture. A combination of nonpharmacologic and pharmacologic strategies can be used to treat pain associated with venipuncture. Distraction, offering a pacifier, and swaddling are nonpharmacologic strategies. Sucrose administration and topical anesthetics may be used with distraction to minimize pain with venipuncture in infants. In infants younger than 6 months old, oral sucrose has been shown to work well to manage needle-related pain.²

A child may fear that the loss of blood is a threat to life; therefore, developmentally appropriate language should be used to explain that blood is continually being made. An adhesive bandage may give the child assurance that the blood will not leak out through the puncture site. Make sure the bandage is removed if the child may chew or suck on the extremity as this may result in a choking hazard. Several topical agents may be used to provide analgesia for venipuncture (Table 1).

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Give developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state.
• Explain the procedure, including the purpose, the steps, and the benefits.
• Explain how the family can assist and support the patient.
• Explain the risks related to the procedure, including pain, multiple venipuncture attempts, bruising, and hematoma.
• Explain that the patient may experience pain or anxiety during the procedure.
• Tell the patient and family that pressure will be applied to the venipuncture site briefly. For a patient with a bleeding disorder or who is receiving anticoagulant therapy, explain that pressure will be applied until hemostasis is achieved.
• Instruct the patient or the family to notify the nurse or practitioner if persistent or recurrent bleeding or an expanding hematoma develops at the venipuncture site.
• Explain how the patient can assist with the procedure.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Clean hands and don appropriate personal protective equipment (PPE) based on risk of exposure to bodily fluids or infection precautions.
2. Introduce yourself to the patient and family.
3. Verify the correct patient using two identifiers.
4. Assess the patient’s developmental level and ability to interact.
5. Determine if the patient’s family has health literacy needs or requires tools or assistance to effectively communicate. Be sure these needs can be met without compromising safety.
6. Review the family’s previous experience and knowledge of a venipuncture for labs and understanding of the care provided.
7. Ask if the patient has benefited from the use of topical analgesia in the past.
8. Assess the patient for conditions that can be aggravated or disrupted by venipuncture, such as anticoagulant therapy, low platelet count, and bleeding disorders.
9. Review the patient’s history of injury and infection; assess the patient for contraindicated venipuncture sites because of a hematoma, IV line, a Blalock-Taussig or hemodialysis shunt, or renal grafts and fistulas in the extremities.
10. Identify fasting restrictions for the ordered laboratory tests.
11. Review the patient’s medication history.
12. Assess the patient’s hydration and perfusion status.
13. Find out the patient’s and the family’s desires for the family to be present.

Preparation

1. Request the participation of a child life specialist, if available.
2. Verify the practitioner’s orders.
3. Collect and assemble the equipment and supplies for the procedure. Use small-volume syringes to avoid vein collapse from the negative pressure created by a larger syringe.
4. Identify any special requirements (e.g., being placed on ice) regarding specimens.
5. Confirm the minimum blood volumes required for specimen collection.

   Rationale: Drawing minimum volumes decreases the incidence of needless blood loss.

6. If using a topical anesthetic cream, don gloves and apply it per the manufacturer’s recommendation (Table 1).

   Rationale: Topical anesthetics have varied times to peak effect. Follow the manufacturer’s recommendation for time from application to procedure.

7. Take the patient to a procedure or treatment room, if possible.
8. Enlist the help of an assistant, as needed, to position the patient and limit movement during the procedure

PROCEDURE

1. Explain the procedure to the patient and family and be sure that they agree to treatment.
2. Provide privacy for the patient.
3. Ensure adequate lighting.
4. Consider using vein-finding ultrasound.
5. If a topical anesthetic is used, remove the topical anesthetic from the skin completely after the allotted time.
6. Consider using oral sucrose in infants.
7. Find a venipuncture site (Figure 2) (Figure 3).
   1. Use ultrasound vein finder if indicated.
   2. Use veins in the hand, forearm, or the antecubital fossa.
   3. Consider using the veins of the scalp for an infant or the veins of the foot, if not walking, for infants and toddlers. Use these sites only if other sites are not available.
   4. Avoid using veins in the right arm after procedures treating congenital cardiac defects that may have decreased blood flow to the subclavian artery.
   5. If the patient can participate in activities of daily living or sucks a thumb, avoid the dominant or preferred hand.

      Do not use veins that are painful to palpation, have open wounds, or are compromised (e.g., previously cannulated, bruised, or reddened, or that have phlebitis or anomalies).³

8. Be sure that the site is warm and well perfused. Consider applying a warm pack to help dilate the blood vessels.

   Rationale: Getting a sample from a cool extremity may be difficult because of vasoconstriction.

   Do not apply the warm pack directly to the skin.

9. Use distraction techniques for pain management.
10. Position the patient based on age and developmental level (Figure 4).
11. Have the assistant or family member hold the patient and position the extremity (Figure 4).
12. If unable to see or palpate a vein, apply a tourniquet a few inches above one of the selected venipuncture sites.

    If possible, avoid using a tourniquet to reduce the risk of injury to the vein. If a tourniquet is required, limit the time of use to reduce the risk of hemolysis and inaccurate laboratory test results.

    1. Encircle the extremity and pull one end of the tourniquet over the other, looping one end under the other (Figure 5).
    2. Apply the tourniquet so that it can be removed by pulling the end with a single motion (Figure 6).

       Do not keep the tourniquet on the patient longer than needed.

13. Palpate the venipuncture site (Figure 7).
    1. If the vein cannot be palpated and the tourniquet is in place longer than 1 minute, remove it and either assess another vein site or wait 1 minute before reapplying it.⁶
    2. If the alternate vein cannot be palpated or viewed easily, remove the tourniquet and apply a warm compress over the extremity.
14. Clean the site with a single-use applicator and antiseptic solution per the manufacturer’s instructions.⁴
15. Allow the area to air dry.

    Do not touch the site after preparation unless sterile gloves are worn.

16. Hold the butterfly needle by the wings (Figure 8). Enter the vein at a slight angle from the arm with the bevel facing upward just distal to the exact site selected for vein penetration and look for blood return (Figure 9).

    Rationale: This technique allows controlled entry into the vein after the skin has been pierced. Entering the skin distal to the vein prevents unanticipated vein puncture, which may result in inadequate blood specimen retrieval and development of a hematoma.

17. While applying slight traction to the skin and vein, insert the tip of the needle distal to the site selected for vein penetration, holding the needle at a slight angle with the bevel facing up.

    Rationale: Applying traction serves to stabilize and straighten the vein.

18. Enter the vein using a quick, short thrust to penetrate the skin. A slight popping sensation may be felt as the needle enters the vein.

    Rationale: This technique allows a controlled entry into the vein to avoid through-and-through penetration of the vein and development of a hematoma.

19. Watch for a flashback of blood into the tubing of the butterfly system.
20. Draw the blood volume needed for the ordered laboratory tests by pulling gently on the syringe plunger to fill the syringe with blood.
21. Release the tourniquet, if applied, before removing the needle.

    Rationale: Removing the tourniquet decreases hematoma formation.

22. Apply a clean gauze pad over the puncture site without applying pressure and quickly but carefully withdraw the needle from the vein, activating the safety lock system.

    Rationale: Pressure over the needle can cause discomfort. Carefully removing the needle minimizes discomfort and vein trauma.

23. Immediately apply pressure over the venipuncture site with gauze until the bleeding stops.
24. If blood was collected in syringes, transfer the blood to the appropriate laboratory specimen tubes using a blood transfer device.

    Follow the order of the draw specified by the laboratory to be sure that the specimens are processed correctly and yield accurate results (Figure 10).

25. Label the specimen(s) in the presence of the patient.⁵
26. Apply an adhesive bandage to the site when hemostasis is achieved. If there is a risk of aspiration, remove the bandage.

    Do not use adhesive bandages on neonates.

    Praise the patient for cooperating and holding still. Encourage the family to comfort the patient.

27. Comfort the patient. Give stickers or other rewards for good behavior as developmentally appropriate
28. Discard supplies, remove PPE, and clean hands.

    At the end of the procedure, be sure that all choking hazards are removed from the patient’s bedding.

29. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Monitor the venipuncture site for active bleeding.

   Reportable condition: Persistent active bleeding

2. Monitor perfusion distal to the puncture site.

   Rationale: Inadvertent arterial puncture may affect perfusion distal to the puncture site.

   Reportable condition: Decreased or absent perfusion distal to the puncture site

EXPECTED OUTCOMES

• Venipuncture is performed successfully with one attempt.
• Laboratory specimens show accurate results.
• Pain and anxiety are managed adequately during the procedure.
• Patient remains free from complications of venipuncture.
• Patient and family tolerate the procedure with minimal distress.

UNEXPECTED OUTCOMES

• More than one attempt is needed to get specimens.
• Specimens cannot be processed because of inadequate blood volume.
• Pain and anxiety are inadequately managed.
• Specimen is hemolyzed.
• Significant hematoma or infection develops at the puncture site.
• Hemostasis is not achieved.
• Patient or family member does not tolerate the procedure and becomes dizzy or faints during venipuncture.

DOCUMENTATION

• Date and time of venipuncture, specimens drawn, disposition of the specimen
• Gauge and type of needle used to perform venipuncture
• Number of attempts
• Site of venipuncture
• Techniques used to facilitate procedure (e.g., distraction or positioning techniques)
• Patient’s tolerance of procedure
• Unexpected outcomes and related interventions
• Education

REFERENCES

1. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), National Association of Neonatal Nurses (NANN). (2018). Skin disinfectants. In Neonatal skin care: Evidence-based clinical practice guidelines (4th ed., pp. 88-94). Washington, DC: AWHONN.
2. Hellsten, M.B. (2024). Chapter 5: Pain assessment in children. In M.J. Hockenberry, E.A. Duffy, K.D. Gibbs (Eds.), Wong’s nursing care of infants and children (12th ed., pp. 131-166). St. Louis: Elsevier.
3. Infusion Nurses Society (INS). (2024). Infusion therapy standards of practice. Standard 25: Vascular access device planning and site insertion. Journal of Infusion Nursing, 47(Suppl. 1), S85-S92.
4. Infusion Nurses Society (INS). (2024). Infusion therapy standards of practice. Standard 31: Vascular access site preparation and skin antisepsis. Journal of Infusion Nursing, 47(Suppl. 1), S106-S107.
5. Joint Commission, The. (2024). National Patient Safety Goals for the hospital program. Retrieved August 1, 2024, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2024/npsg_chapter_hap_jan2024.pdf
6. Perry, A.G. (2025). Chapter 7: Specimen collection. In A.G. Perry and others (Eds.), Clinical nursing skills & techniques (11th ed., pp. 178-226). St. Louis: Elsevier.

Clinical Review: Sarah A. Martin, DNP, MS, RN, CPNP-AC/PC, CCRN

Published: September 2024