IVs/blood draws

KelRN215, BSN, RN · Apr 23, 2013

A ten year old is too old to "hold down".

It depends on the child. If you tell a two year old with cancer who's used to getting his/her port accessed "I'm going to put your tubie in", they may just say "Ok." I have a two year old who sits calmly and even says "I'm not going to cry because I'm brave." The younger the child, the less advance notice you should give them that you are going to draw blood. Use the parents- they know their children best.

uRNmyway, ASN, RN · Apr 23, 2013

Don't lie to them. Don't tell them it won't hurt. As far as using parents, I have always been told to try to avoid that. The reasoning was that you don't want the kids to think their parent was responsible for their pain in any way.

And stickers. Stickers are amazing for keeping kids calm during unpleasant procedures.

ChristineN, BSN, RN · Apr 23, 2013

I also work in a primarily adult ER that gets peds pts. I did peds for years before making the switch and am disappointed at how non-peds aware my facility is. Having child life available to us in the ER would be a big help, but we don't, they only cover our inpt units.

Distract them with toys/stickers. We have some I-Spy type books that the kids can get focused on.

If the IV/lab stick is not a true emergency see if you can numb the area first, either with a spray or with LMX (topical lidocaine). You will need to wait about 20 min after applying the topical before you can stick them.

If you do have a infant or toddler that doesn't understand what is going on and does need stuck, you can wrap them up in a blanket burrito style and leave the extremity you will be poking sticking out.

Always give the parents the option to stay at the bedside. I have found most prefer to be there with their child.

turnforthenurse, MSN, NP · Apr 23, 2013

A ten year old is too old to "hold down".
It depends on the child. If you tell a two year old with cancer who's used to getting his/her port accessed "I'm going to put your tubie in", they may just say "Ok." I have a two year old who sits calmly and even says "I'm not going to cry because I'm brave." The younger the child, the less advance notice you should give them that you are going to draw blood. Use the parents- they know their children best.

The other nurse was more so just holding her arm in place. She kept moving and without her arm being held, I definitely would have missed. Mom couldn't really help because she was across the room in a wheelchair. Our ER rooms are very small so there really wasn't room for her to be at the other side of the bed, she just spoke to her daughter during the process.

Thanks for your tips!

iluvivt, BSN, RN · Apr 24, 2013

First,I always discuss the plan of treatment with the parent(s) or legal guardians. I try to do this out of the earshot of the child (if they can understand) because often when they hear the word needle or stick they freak out and I want to approach them separately.

Then I make it age specific.it would help if you review developmental stages so you can understand how to approach them. You need to know the age of reason for example, so you do not waste your time trying to reason with a child that has not achieved that ability yet. I get all my supplies ready before I approach the child. I explain to them what I need to do and why I need to do it and what I need them to do. This is all age specific of course. If a parent wants to stay I do not have any issue with it but I give them the option...many do not want to stay and if they do not I reassure them I will take very good care of their child. That little statement really helps to reassure them and I truly mean it and treat that child as if they were my own.

There are many things you can do to aid you and the patient and ease the pain and I use them if clincally time permits.

hella_RN · Apr 24, 2013

You're not alone! The youngest pedi pt I had that I put an IV in was probably 10 months old. I try to avoid sticking them because I really don't look forward to the crying and the anxious parents who always say "we want someone who can do it the first try." It makes the pressure even worse! I guess I'm just glad that I'm not the only one who dread sticking kids! :)

hiddencatRN, BSN, RN · Apr 24, 2013

I always make a point of telling then that the IV is actually a little straw and that I'm not leaving a needle in their arm. Parents are welcome to stay or go depending on comfort but I never let them hold because frankly, they almost never do it well and a good hold is essential to success. Tell the patient their job is to hold still, and praise them afterwards even if they were demon spawn during the stick. Definitely don't lie about pain: it will hurt but that stops as soon as the IV is in place.

flyingchange · Apr 24, 2013

Unrelated, but kind of related. We often get orders to rehydrate kids via IV saline. Well, poking a dehydrated kid is pretty terrible. Recently I've heard that some studies suggest hypodermaclysis (subcutaneous) infusions would work equally as well to rehydrate kids, and with a lot less trauma! I suggested it to a doc a few months ago, but he didn't want to try it.

Do any of your centers use this?

hiddencatRN, BSN, RN · Apr 24, 2013

I've read about subq fluid but have never seen it used. For dehydration cases the docs almost always want electrolytes drawn and we potentially will be giving other medications too, so perhaps the concern is that is doesn't save them sticks in the end?

EaglesWings21, ASN, RN · Apr 25, 2013

To whoever said 10 is too old to hold down, some children have had traumatic events happen where needles absolutely terrify them. A couple of children very close to me were traumatized by a dentist who claimed they had cavities and needed to remove them right then and there. The dentist injected anesthesias into their gums and the screamed and cried for the dentist to stop, but the dentist told them it didn't hurt and they needed to stop. Now one of these children has to be held down when getting immunizations at check ups...

BTW another dentist they were referred to said they did not have any cavities, so watch out for those dentists!!

Double-Helix, BSN, RN · Apr 25, 2013

To whoever said 10 is too old to hold down, some children have had traumatic events happen where needles absolutely terrify them. A couple of children very close to me were traumatized by a dentist who claimed they had cavities and needed to remove them right then and there. The dentist injected anesthesias into their gums and the screamed and cried for the dentist to stop, but the dentist told them it didn't hurt and they needed to stop. Now one of these children has to be held down when getting immunizations at check ups...
BTW another dentist they were referred to said they did not have any cavities, so watch out for those dentists!!

Where the hell were the parents? Consent forms?

I also don't agree that the best way to handle a child who has been traumatized by medical procedures is to hold them down and force them to endure more medical procedures against there will. That child needs counseling, not to be restrained and further traumatized.

To answer the OP- every kid is different. Some are great with needles and some are terrible. I once had to help start an IV on a 6 year old and needed 4 nurses and Child Life Specialists to keep her still. Just the other day I stuck a 4 year old who barely moved and played a video game through the whole thing.

For babies and toddlers, please please please take your time choosing a vein. Use a tourniquet to assess the ACs, hands, and feet. The saphenous vein can be a wonderful place to get labs (or even an IV) in children who appear to have poor access. Unless you really think you can get it, don't try. EMLA cream or lidocaine is a good option, if you have the time. And remember that if a kid has been sitting in the ER waiting room for an hour, you've probably got time to wait for EMLA.

Explain to the parents what is going to happen. Let them know that there's a chance that you might have to stick more than once. Most labs can be run with far less blood than what they require for adults. We rarely send more than 0.5mL per lab test. CBC, BMP- you shouldn't need more than 1mL of blood.

Heelsticks can often be done to obtain blood specimens in young children. This is how all of the labs are collected on healthy newborns in the nursery. Again, 0.5mL per test is usually what's needed. It can save your from trying to stick a tiny vein, and save the child some trauma.

For older toddlers and young children utilize distraction. Explain what you're going to do in simple terms. Use TV, cell phone games, toys, etc. to keep their attention during the procedure.

Once you've got an IV in these kids, please secure it as best as possible so it doesn't fall out or can't be easily pulled out. But PLEASE don't wrap it so well that it's impossible to assess the site. I can't tell you how many kids have been transferred to our facility with infiltrated IVs that wasn't noticed before arrival because whoever started the IV wrapped it with gauze like they were trying to mummify the kid. Transparent dressings over the insertion site. An arm board if the IV is in the AC or hand. A sock over the hand works great to conceal IVs from babies and young children but allows for easy removal and assessment of the site.

For school age and older kids, tell them what's going to happen and why. Don't ask questions like "Can I draw your blood" because they don't have a choice. If they do have a choice about something (maybe they have great veins and can choose which hand they want the IV) then give them the choice. Show them the equipment beforehand if they want to see it. Use distraction (age appropriate) for these kids as well. Sometimes having a conversation about school or a TV show helps keep their attention off their anxiety. Do have someone there to help stabilize the extremity. Even the most cooperative kid might flinch when stuck.