ALTERNATIVE LEARNING MODULE FOR MLS 123 AND MLS 123L

PRINCIPLES OF
MEDICAL LABORATORY SCIENCE PRACTICE 2

Department of Medical Laboratory Science

SCHOOL OF NATURAL SCIENCES
 MLS 123
Second Semester 2020-2021

COURSE LEARNING OUTCOMES

At the end of the course, you should be able to:
1. Trace the evolution of phlebotomy and how it
became a practice
2. Describe who is a phlebotomist and what are the
roles of a phlebotomist
3. Know the proper disinfection and
decontamination procedures, the safety
guidelines and the other pertinent safety
protocols in the laboratory
4. Identify the parts and functions of the body’s
cardiovascular system, particularly the anatomic
locations which can be utilized to collect blood
samples
5. Recall the materials and equipment used in the
performance of a phlebotomy procedure
6. Enumerate the preanalytical variables that could
affect the patient’s test results
7. Discuss and perform the different blood collection
techniques, as well as point of care testing
8. Identify when and how to troubleshoot when
problems are encountered during a phlebotomy
procedure
9. Know the proper etiquette when dealing with a
patient and provide the proper patient care
10. Characterize the specimen handling and
processing techniques
11. Discuss the importance and proper technique of
an arterial puncture
12. Describe the concept of quality assurance in the
context of the practice of phlebotomy

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited. 1
 COURSE INTRODUCTION

Dear future Medical Laboratory Scientists,

This course will enable you to understand the basic concepts and techniques in blood extraction that
will always be part of you as a Medical Laboratory Scientist.

The topics and concepts that you will learn this second semester is interrelated to the concepts
learned from the previous semester in the course MLS 112, Principles of Medical Laboratory Science
Practice 1. In this regard, you will be learning the art of extracting blood sample from patients.

Specimen collection, handling, and processing remains one of the primary areas of preanalytical
error. Therefore, careful attention to each phase is necessary to ensure proper subsequent testing
and reporting of meaningful results.

The primary role of a medical laboratory scientist is to aid the physician in the diagnosis and treatment
of diseases. Hence, this course will provide an avenue for you to know the importance of phlebotomy,
and other special techniques to obtain blood sample which is one of the most important steps to
provide accurate results.

With everything said, we pray that you will enjoy what you will learn this semester and will take into
heart the concepts and principles not only until you finish this course but until you become
professionals in the future. A blessed semester to each and every one of you!

Best regards,

MLS 123 and 123L Facilitators

AY 2020-2021

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited. 2
 MODULE 6: UNIT 3
VENIPUNCTURE PROCEDURE: WINGED COLLECTION SYSTEM

MODULE CONTENTS

COURSE LEARNING OUTCOMES ..................................................................................................... 1

COURSE INTRODUCTION ................................................................................................................... 2
MODULE CONTENTS............................................................................................................................ 3
MODULE INTRODUCTION .................................................................................................................. 4
MODULE OBJECTIVES ........................................................................................................................ 4
MODULE SELF MONITORING FORM .............................................................................................. 4
MODULE 6: VENIPUNCTURE PROCEDURE ................................................................................... 5
UNIT 3: WINGED COLLECTION SYSTEM ........................................................................................ 5
Engage ................................................................................................................................................ 5
Explore................................................................................................................................................ 6
Explain ................................................................................................................................................ 7
Elaborate ........................................................................................................................................... 10
Evaluate ............................................................................................................................................ 11
REFERENCES ....................................................................................................................................... 12

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited. 3
 MODULE INTRODUCTION
This module will introduce you to the different methods of collecting blood specimens, including
venipuncture procedures via the syringe system and evacuated tube system, use of the winged
collection set, and capillary blood puncture. Additionally, point-of-care testing will also be tackled in
this module.

MODULE OBJECTIVES
After you are done reading and doing the tasks in this module, you are expected to be able to:
1. Describe and perform the venipuncture procedure utilizing the syringe system
2. Describe and perform the venipuncture procedure utilizing the evacuated tube system
3. Describe and perform the venipuncture procedure using the winged collection set
4. Describe and perform the capillary blood puncture
5. Describe and perform point-of-care testing

MODULE SELF MONITORING FORM

To help you keep track of your tasks for this module, you are provided with a self- monitoring form
below. Take the time to tick on the “YES” box for each activity that you finish. Be reminded about
pending events that you are yet to do. Remember that your success in achieving the module
objectives depends entirely on how conscientious you are of your progress.

Schedule Activities Completed

Yes No
Engage  
Week 9 Explore  
Explain  
Elaborate  
Evaluate  

Do Read Quiz Submit

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited. 4
 MODULE 6
VENIPUNCTURE PROCEDURE

UNIT 3: WINGED COLLECTION SYSTEM

UNIT LEARNING OBJECTIVES
At the end of this unit, you should be able to:
1. Identify the different parts of a the winged-infusion set.
2. Explain how the Winged-Infusion set for venipuncture work, and when it is used.
3. Identify the different types of butterfly-winged infusion set.

Have You Ever?

The winged system (or butterfly method) is not a

commonly used way of collecting blood samples. The syringe
system and/or the evacuated tube system are usually the
methods preferred by healthcare workers to extract blood
from their patients.

In your lifetime, have you ever been hospitalized?

During your stay in the hospital, have you ever noticed the
medical technologists, or probably the nurses or the doctors,
using the butterfly technique in obtaining blood sample from
you? Or maybe…from another patient beside you? What are
your thoughts about seeing a medical professional using this
method? Write your answers below.

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited. 5
 As you have seen in the photo previously shown, the winged-infusion
set or also known as “butterfly-infusion set” or “scalp vein set” has 2 flaps or wings
that help support in locating the vein of the patient and a long tubing to which
blood is allowed to flow and collected. This device is used to access a vein for
drawing blood or giving intravenous medications. Similar to a straight needle, the
tip of a butterfly needle has a beveled edge.

As mentioned earlier, the use of the syringe system or evacuated

BEVEL
tube system is more common than this method. Because the winged-
infusion set method is often used on people who might be difficult to
perform venipuncture on. And these include the elderly, infants, children,
cancer patients, and even burn victims who tend to have veins that are
fragile, small, or that roll (spastic veins). Winged infusion needles are
preferable to standard venipuncture needles when drawing from tiny veins
because they are commercially available in very small gauges.

Needle gauge:
Gauge 21-23 - most commonly used for phlebotomy
Gauge 25-27 - rarely used, since this gauge is used by specially trained
personnel to collect blood from scalp or tiny veins of premature infants and
other neonates
Gauge 27 - usually used for insulin injections

“The higher the needle gauge number, the smaller the bore of the needle”
CAUTION:
* Using a needle smaller than 23 gauge increases the chance of hemolyzing and clotting the specimen.
* The wrong needle size can result in blockage and the need for a second draw if a large quantity of blood is
needed.

Butterfly winged infusion needles can adapt to either a

syringe or a pediatric or adult vacuum collection tube. Some
phlebotomists may also use a butterfly needle when numerous
tubes are collected, as it is easier to change tubes using this
method.

Butterfly needles offer certain advantages over straight

needles. For instance, they allow more precise placement,
particularly in hard-to-access veins, because the butterfly needle
is short and the grasp is close to the needle. Straight needles
can often roll or wiggle in the fingers.

Because of the small size of the butterfly set, butterfly

needles can access superficial veins near the surface of the skin.
This not only makes them less painful to use, but allows them to
access veins that are small or narrow.

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited. 6
 This type of method used for venipuncture are less likely to cause profuse bleeding, nerve
injury, or vein collapse once the needle is removed from the puncture site.

Parts of the
Butterfly Infusion Set
1. Needle
 The length of the needle is usually ½ to ¾ inch, which limits its use to surface
veins.

2. Plastic Wings
 For gripping

3. Plastic Tubing
 The tubing is approximately 5 to 12 inches long (standard length: 12 inches) and
is permanently attached to the needle; The tubing is flexible that makes it easy to
collect blood sample.

❖ Shorter tubes: used for blood draws

❖ Longer tubes: intended for IV applications and may have roller valves to regulate
the flow.

4. Syringe and Evacuated Tubes

A. Syringe
 No adapter is necessary for using the butterfly-winged infusion set with the syringe
method. The syringe is directly attached to the screw-type end of the tubing. (see
photo on types of butterfly-winged infusion set: syringe method)

B. Adapter of evacuation tube system

 A special adapter is necessary to attach the tubing to the holder of the vacuum
collection system. The use of pediatric sized tubes is less likely to cause small
veins to collapse because the exertion of vacuum pressure is significantly lessened
as compared to the vacuum in a standard-size evacuated tube.

Proper use of the equipment involves bending the wings together over the needle with the
bevel up. The needle is inserted into the vein using a very low angle.

Because of the small size of the needle, blood collection tends to be slower. This can be
problematic at a blood bank if a person is squeamish or in urgent situations where blood is needed
fast. In situations like these, the selection of the needle size is key.

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited. 7
 TYPES OF BUTTERFLY / WINGED INFUSION SET

1. BUTTERFLY / WINGED INFUSION SET: syringe system method

This method makes use of a screw-type end on

the tubing to allow attachment of the syringe. The
syringe plunger is then used to control pressure from
the vein coming into the syringe barrel. This is further
elaborated in the succeeding statements.

Butterfly needles are best used with syringes.

Syringe insertion You need to first remove air from the syringe by moving
(“Female” port) the plunger back and forth in the barrel before using,
breaking the seal on the syringe. Once the needle is
inserted into the vein, the plunger should be pulled back
gently, yet firmly.

After collecting blood using this method with a syringe, great care must be taken when
transferring blood from the syringe into the appropriate tubes. The blood sample collected in the
syringe without its needle is then dispensed slowly on the side of the appropriate tube(s) for
testing. The old method of directly piercing the stopper of the evacuated tube with the needle to
transfer blood is no longer recommended to prevent needle stick exposure.

NOTE: Pulling back on the plunger with excessive force to speed blood coming into the
syringe may cause the vein to collapse or, if extreme pressure is applied, may
cause hemolysis of the blood sample.

2. BUTTERFLY-WINGED INFUSION SET: evacuated tube system method

The method makes use of a Luer adapter to ETS adapter insertion

allow multiple blood draws. Order of draw for the ETS ( “male” port )
method is slightly different from the syringe method,
whereby a discard tube is used if an anticoagulated
test is required when using the ETS method.

The butterfly comes with an adapter to be

used for vacuum tube collection. This technique
should rarely be used. If the vein is large enough to
be used for a butterfly/vacuum collection then a
regular vacuum collection holder/needle assembly
should be used. An exception for this would be a large
hand vein. Drawing blood from a hand vein using a holder/needle assembly is very awkward.
Also, smaller needles are less painful in the hand veins. Be aware that if the butterfly is used
with vacuum tubes the vacuum in the tubes will cause small veins to collapse. The butterfly
method, the primary use is for a syringe draw where the amount of vacuum can be controlled
by gentle pulling on the plunger of the syringe.

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited. 8
 ALTERNATIVE VENIPUNCTURE SITE

You may be wondering. What if it is difficult to locate a vein suitable for

venipuncture in the antecubital fossa of a patient’s arm? Are there any possible sites for
venipuncture using the butterfly-winged method?

The appropriate course of action is to inspect the

patient’s other arm for a suitable vein. In the event that ALTERNATIVE SITES
neither arms provide a vein suitable for venipuncture, the
phlebotomist may then consider using a vein in the • TOP OF THE HAND
patient’s top of the hand, top of the wrist, ankle or top of • TOP OF THE WRIST
the foot.
• ANKLE
As mentioned earlier, the butterfly-winged • TOP OF THE FOOT
infusion set using the vacuum collection set may be
preferred with patients with large hand vein. Same is true
for the butterfly-winged infusion set with syringe.

Hand veins may also be difficult to access than

in veins in the antecubital fossa because they are
generally smaller. In addition, hand veins are not as
well anchored by surrounding tissues as those in the
antecubital fossa area. Consequently, these areas
have a tendency to move or roll when the needle is
inserted, making it difficult to puncture the vein. And as
the phlebotomist, you should exercise extra care when
anchoring a vein located in the hand or wrist to prevent
it from moving during insertion.

OTHER USES OF BUTTERFLY / WINGED INFUSION SET

1. IV Hydration

If you need IV fluids, a nurse or doctor may use butterfly needle to access a vein like treating
dehydration or if you are unable to eat or drink due to illness.

2. Medication

A butterfly needle also allows a doctor to give IV medications. These medications can be
pushed through a syringe. Getting them through a vein is helpful when you can’t take
medications by mouth or you need the medications to work quickly. Though butterfly needles
can be left in a vein for 5-7 days if properly secured, take note that butterfly needles usually
aren’t a long-term solution to IV-therapy since the needle can easily become displaced from
the vein.

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited. 9
 Method Considerations

1) Identifying the best site for blood extraction is key to obtain the right amount of specimen
sample needed and quality specimen.

2) Choose the correct type of butterfly infusion set, whether it be the syringe or ETS method,
based on the number of draws needed for the patient’s test. If the patient is required to have
multiple tests using multiple tubes, the ETS method is best. But if the test/s only require/s a
small amount of blood (maybe a single test or multiple tests but using the same tube), the
syringe method is best.

3) The butterfly-infusion set syringe method is advantageous over the ETS method because
during blood extraction, the pressure is controlled by the phlebotomist preventing possible cell
hemolysis.

4) One of the major disadvantages of the Butterfly-infusion set is that the needle is short (½ to
¾ inch) that retraction from the vein is possible.

5) Note that cell hemolysis may result when using a higher needle gauge number (higher than
gauge 23: 25-27 needle gauge). The higher the needle gauge number, the smaller the bore
of the needle.

6) Do not push the laboratory tube onto the needle inside the barrel until the winged needle is
inside the blood vessel or the vacuum will be lost.

7) When collecting blood from pediatric patients, a winged steel needle with a gauge of 23 or 25
is used. Keep the tube and needle separate until the needle is in the vein.

To help you further understand the methods, here are some concepts that you should know…

What is the purpose of using the winged/ butterfly-infusion set?

The butterfly-infusion set is purposely used to extract blood samples from patients with
veins that are small, fragile or that rolls that make it difficult to collect from (infants,
children, cancer patients, elderly). Since the set has a wide range of needle gauge
number with a flexible tubing the method makes it easy to collect blood from patients.

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited. 10
 Why will the first tube collected underfill using the butterfly-infusion set ETS
method?

This scenario is likely to initially happen due to the air in the tubing.

KEY POINT
If the tube contains an additive, the blood-to-additive ratio will be affected. If an additive
tube is the first tube to be collected, it is important to draw a few milliliters of blood into a
nonadditive tube or another additive tube of the same type and to discard it prior to
collecting the first tube. This is referred to as collecting a “clear” or discard tube and is
especially critical when one is collecting coagulation tubes using a butterfly.

This can be prevented when the butterfly-infusion set syringe method is used since the
syringe upon attaching to the tubing, the plunger is used to gently expel the air from the
syringe and tubing pushing it back and forth before blood extraction.

Where should you dispose the butterfly infusion

set?

Same is true with the needles from syringes and

needles used in evacuated tube system. The needle
that is permanently attached to the tubing is disposed
in a sharp’s container with a biohazard label.

Some manufacturers also have invented a protective

shield for the butterfly needle that can be flipped down
after usage to prevent needle sticks.

Task. Considering all that you have read and

learned, what are the advantages and
disadvantages of using a butterfly needle?

Kindly wait for the instructions of your MLS 123 course facilitator.

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited. 11
 REFERENCES

› Strasinger, S. and Schaub, M. 2011. The Phlebotomy Textbook. 3rd Edition.

› Ernst, D. 2005. Applied Phlebotomy.

› McCall, R. 2012. Phlebotomy Essentials. 5th Edition.

› Bishop, M. 2013. Clinical Chemistry. 7th Edition.

› Turgeon, M. 2012. Clinical Hematology. 5th Edition.

› WHO guidelines on drawing blood: Best practices in phlebotomy. 2010.

› Clinical and Laboratory Standards Institute: Collection of Diagnostic Venous Blood

Specimens. 2017. 7th Edition.

› Kaplan, A. 1988. Clinical Chemistry: Interpretation and Techniques.

› Burtis, C. and Bruns, D. 2014. Tietz Fundamentals of Clinical Chemistry and Molecular
Diagnostics. 7th Edition.

› McPherson, R. and Pincus, M. 2011. Henry’s Clinical Diagnosis and Management by

Laboratory Methods. 22nd Edition.

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited. 12