BUTUAN DOCTORS’ COLLEGE/HOSPITAL

J.C. AQUINO AVENUE, BUTUAN CITY

DEPARTMENT OF MEDICAL TECHNOLOGY
BS MED. TECH. LEVEL IV – BDH MT INTERNSHIP ASSESSMENT PROGRAM
by SIR ONZYBOI!, RMT
Tel. No. (085) 342-8572; Fax No. (085) 225-3616 E-mail: butuandoc@yahoo.com

!REMINDERS!
! INTERNS MUST READ ME IF THE DUTY IS NOT BUSY! NO CELLPHONES! TO
INCREASE THE CHANCES OF PASSING THE BOARD EXAM! #BDC100%MEDTECH
#DileMagTinapolan
! DO NOT TAKE ME HOME! THIS IS A LABORATORY COPY! THIS SHOULD REMAIN
INSIDE THE LABORATORY AT ALL TIMES! ASK FOR A SOFTCOPY!
! BDH MEDTECH INTERNS MUST ALSO BE KNOWLEGABLE THEORETICALLY (NOT
JUST IN PRACTICE!)
! BDH MTIs MUST BE ABLE TO ANSWER WHEN ASKED FOR THE
SIGNIFICANCE/PURPOSE OF THE TESTS/PROCEDURES! STUDY WHEN THE SHIFT IS
NOT BUSY! NO CELLPHONES!

Prepared by:
SIR ONZYBOI! (AITHER BENEDICT OCLARIT, RMT)
Junior BDH RMT, Microbiology Staff
 HEMATOLOGY 1 PROFESSIONALISM SAMPLES
TOPIC 02: BASIC METHODS AND SPECIMEN COLLECTION IN
HEMATOLOGY the skill, the good judgment, and polite behavior usually used for CBC, WBC, or RBC counts
professionalism that is expected of a person who is trained to do the whole blood
still has all the components of blood
INTRODUCTION job well the liquid portion of the blood which has
the study of blood PROFESSIONALISM AND INTERPERSONAL SKILLS anticoagulants
hematology comes from the Greek word “Hema” which during centrifugation, blood forms three layers:
good interpersonal skills plasma
means blood and “logy” which means study ▪ how you handle/talk with the people around you; always be ▪ plasma
is a suspension of red cells, white cells, and polite and humble ▪ buffy coat: WBC and platelets
▪ packed RBCs
platelets in plasma ▪ are necessary for the phlebotomist
1 liquid that is expressed out of the clot
physiologically: o person trained to collected blood
blood blood, without any anticoagulant, will clot normally
▪ in vivo: remains liquid o the frontliner, hence, how he handles his patients is vital in serum
▪ outside the body: clots w/in 5-8 minutes the lab within 5-8 minutes and the liquid produced by it is
the specimen used in our hematology lab ▪ good communication skills called the serum
have a professional attitude (the skill, good judgment, and polite
2 behavior that is expected from a person who is trained to do a job
well)
3 neat appearance
consideration and care for patient by insuring the patient of safety
4 and confidentiality of results
▪ have empathy: put yourself in others’ shoes
confidentiality: laboratory results and personal information about a
5 patient should not be discussed unless it is relevant to the patient’s
care (should not be discussed in public)
lymphocyte blue cytoplasm and the rounded nucleus 6 Characteristics Asosciated With Professionalism
the smallest fragment of megakaryocyte (other books ▪ dependable ▪ competence
platelets
call it cells) ▪ cooperative ▪ organized DIFFERENTIATION OF SERUM AND PLASMA
typical reddish orange cytoplasmic granules ▪ compassionate ▪ responsible Many of the tests in CC and BB departments are performed in serum. You
eosinophil
typical bilobed nucleus ▪ courteous ▪ flexible should remember always that the main coagulation difference between
neutro meaning “neutral” it has?? affinity for both ▪ respectful ▪ good communication
neutrophils the serum and the plasma is the presence of fibrinogen.
basic and acid dyes ▪ integrity ▪ clean appearance
Majority of biochemical & BB test are performed on serum. Fresh
have the typical biconcave disks ▪ honesty ▪ committed
blood, allowed to stand for 1 hr., separates into a red cell-fibrin
RBC inside the disks is the central area of pallor, 6-8 um
BIOHAZARD PRECAUTIONS 1 mass that collects at the bottom of the tube and into the overlying
in diameter
All body fluids are treated as biohazards. Since blood is a body fluid, it is liquid, the serum. Once clotting has taken place, the process of
GENERAL CONSIDERATIONS considered a biohazard. When collecting blood sample, the operator should separation can be speeded up by centrifuging the blood.
Proper patient specimen blood collection is vital in the laboratory’s first step whenever possible, wear disposable masks, plastic, or thin rubber gloves, If anticoagulated blood is centrifuged, it separates into the three
especially if he/she has any cuts, abrasions, or skin breaks on the hands. main layers: the red mass, buffy coat, and plasma. The main
toward reporting accurate and reliable results. Knowledge and skill of the
2 coagulation factor difference between plasma and serum is that
person performing the procedure is very important.
Care must be taken to prevent injuries when handling syringes, needles, and plasma contains fibrinogen. The buffy coat consists mainly of
Important things necessary to achieve accurate and reliable result in the lancets. Disposable syringes, needles, and lancets should be used once, and platelets and leukocytes.
hematology laboratory. should not be reused. SERUM
knowledge of necessary equipment and supplies wearing of protective devices (PPEs) Whole blood collected in order to obtain serum should be delivered
1 ▪ disposable gloves into sterile tubes or screw capped bottles and allowed to clot
▪ the things you are going to bring to the ward for CBC test
technical skills 1 ▪ disposable mask undisturbed for about 1 hour at room temperature. Then you rim
▪ lab gowns 1
2 ▪ for CBC: pipetting of the blood (loosen the clot gently) the clot from the container wall by means of
▪ for RBC or WBC count ▪ face shields a wooden stick, or thin plastic or glass rod. If it is roughly treated,
strict attention to patient and specimen identification prevent injuries from needles/sharps lysis is certain to follow.
2
3 ▪ the most important part of spx collection ▪ should be used only once Close the tube with a stopper and centrifuge for 10 minutes at about
▪ the mortal sin of the lab if you miss the ID of px proper disposal 2 3000 rpm. Pipette the supernatant serum into another tube and
3
awareness of and adherence to institutional safety requirements ▪ color-coded bins for centrifuge for 10 minutes about 3000 rpm.
4 ▪ very important, especially nowadays, during COVID (proper proper delivery (ASAP) containers: 3 Transfer the serum to tubes for tests or for storage.
4
PPEs) when attending patients with the symptoms ▪ closed plastic containers – prevent leaks serum should be kept at a temperature of:
5 proper specimen transport techniques 5 proper specimen transport techniques ▪ at room temp: if used immediately
4
▪ 4°C: for more than 30mins to 1hr before use
▪ -20°C: if delayed, stored for up to 3 months

AIRAH M.
 ▪ -40°C or lower: if delayed; for long term storage 3.0 DURING HANDLING OF SPECIMEN (AFTER COLLECTION) Therefore, these tests should be performed within 2
frozen specimens: should be thawed (before using it) on the bench insufficient or excess anticoagulant hours after the blood has been obtained.
5 or in water bath at room temperature, then inverted several times 1 ▪ insufficient: causes agglutination indications: usually used only in infants less than 1 year
to ensure homogeneity before use for a test ▪ excess: dilution of blood sample old or when it is not possible to obtain venous blood
do not freeze thawed specimens, discard after, since thawing inadequate mixing of blood with anticoagulant disadvantage: capillary blood Is liable to give erroneous
6 capillary
destroys cells and analytes for chemical test 2 ▪ should follow the specific times of inversions for various results and there is greater likelihood of contamination
peripheral
anticoagulants and risk of disease transmission than venipuncture
DEFIBRINATED WHOLE BLOOD blood
patient and/or specimen identification error skin puncture: carried out with needle or lancet, after use,
whole blood in which fibrin is removed 3
▪ once px identification is an error, everything follows they should be discarded in puncture-resistant containers
When serum is required urgently or when both serum and cells are delay in transit to laboratory for disposal or subsequent decontamination
required, (as in investigation of hemolytic anemia), the sample can 4 ▪ only takes for about 2 hours for the blood sample to be not used
1
be defibrinated – this involves the removal of fibrin from whole anymore capillary blood venous blood
blood. freely flowing, can be arteriolar in
This is done by placing the blood before it clots in a receiver (e.g. VENOUS BLOOD and CAPILLARY BLOOD origin
conical flask) containing a central glass rod on to which small pieces higher packed cell volume, red cell
necessary for most tests that:
2 of glass capillary or glass beads or paper clips have been fused. The count, & Hb
▪ require anticoagulation (macro-techniques)
blood is whisked around the central rod by moderate rapid rotation total leukocyte and neutrophil
▪ when requiring larger quantities of blood, plasma, or
of the rod or flask. counts higher by 12%, & almost
serum that cannot be provided by capillary blood
Coagulation is usually complete by 5-10 minutes, most of the fibrin 100% esp. in children
3 advantages:
collecting upon the central rod. platelet counts lower, due to
▪ multiple and repeated examinations can be platelet counts higher (9-32%
performed on the same specimen adhesion of platelets at site of skin
STANDARDIZED PROCEDURE higher than capillary blood)
▪ aliquots of specimen (plasma and serum) maybe puncture
The method for blood collection may affect the sample. The constituents Why is there a lower platelet count in capillary blood? Because it is in
frozen for future reference
of the blood may be altered by the following factors discussed in the next venous bloods that have a higher concentration of capillary. If there is a
▪ there is no variation in blood values if specimens are
table: bigger wound on the capillary, it causes more platelets to adhere at the
obtained from different veins: therefore, ankle veins
CAUSES OF MISLEADING RESULTS FROM DISCREPANCIES IN SPECIMEN can be used if arm veins are being used for IV site of the skin puncture.
COLLECTION medication HEMOLYSIS
1.0 PRE-COLLECTION NOTE: Never draw blood for any laboratory test from the
tests for FBS (fasting blood sugar) and cholesterol need same extremity that is being used for IV medication (blood the rupture of red cells that causes the release of
meal within 2 6 to 12 hrs fasting transfusion, glucose, etc.) hemoglobin from ruptured red cells into the plasma
hours ▪ 6 hrs for FBS disadvantages: hemolyzed red cells act as tissue thromboplastin in
hemolysis
▪ 12 hrs for cholesterol ▪ lengthy procedure and requires more preparation activating plasma clotting factors
smoking increases neutrophils (↑) ▪ technically difficult in children, obese, and patients in when this occurs in the blood drawing process,
shock technical errors are usually the cause
including fast walking
physical venous ▪ hemolyzed blood leads to:
activity within 20 minutes, it increases platelet count (↑): let PREVENTION OF HEMOLYSIS
patient rest first for 20 minutes blood o lowered RBC counts (↓), Use of sharp lancets and do not squeeze (or milk) the puncture site.
o interferes w/ many chemical tests (enzymes, K) 1
stress increased WBC count (↑) (Milking is the process of drawing blood from a very small wound.)
o coagulation studies
age Use sharp smooth needles of large diameter (gauge 20 or 21) in
▪ hematoma or blood clot formation inside and outside 2
also affects sample (so different normal levels for venipuncture.
gender the vein must be prevented
different groups) Tourniquet must not be too tight and should be released before
pregnancy ▪ avoid prolonged stasis: leads to hemoconcentration 3
blood is aspirated.
and other changes that make the blood unsuitable for
2.0 DURING COLLECTION 4 The syringe should be clean, dry, and suction gentle.
the following tests:
diurnal variance: some substances in the body o gas analysis (arterial blood) Remove needle when transferring blood to test tubes except when
increases/decreases at different times of the day 5
different o blood counts vacutainers are used.
▪ serum iron: decreases during day (↓) o blood pH determination (arterial blood) If an anticoagulant is used, mix blood gently by inversion of the test
times of day 6
▪ WBC count: lowest in the mornings, increases to o some coagulation tests tube. (e.g. figure of 8 motion)
mid-afternoon (↑) ▪ Anticoagulated blood should not be used for If serum is needed, do not rim the clot and do not centrifuge blood
lying or standing or sitting peripheral blood smears, as some anticoagulants 7 until a clot has formed completely. (it takes about 30 mins. to 1 hr
posture ▪ enzymes, CHONS, Ca, iron: increases (↑) with the produce changes in platelets that may cause to clot)
change of position clumping, and in WBCs that make identification
prolonged difficult
prolonged pressure causes hemoconcentration:
tourniquet o dermal or capillary blood: the most preferred
increase in total CHON (↑)
application sample for peripheral blood smears
excessive ▪ Some components are not stable in anticoagulated
when drawing blood into syringe
negative blood, like WBC counts, platelet counts, & ESR.
pressure causes sample hemolysis

AIRAH M.
Right tube: shows hemolysis
Middle and left tube: no hemolysis
When you look at platelets over a book
or a printed material, you can see the
print below it. Middle and left tubes have
an opaque appearance (text print not
seen, on this example).
SPECIMEN COLLECTION
skin puncture and venipuncture
METHODS OF BLOOD COLLECTION
skin puncture venipuncture arterial blood collection
THREE METHODS OF VENOUS BLOOD COLLECTION
usually used for pediatric patients connected to an
butterfly
adapter (holder) or syringe, uses butterfly wings with
infusion set
plastic tubings
use vacutainer 2-way needle (multi-sample needle), a
evacuated
plastic holder, and evacuated glass tube (have a pre-
tube system
determined vacuum)
syringe
barrel and plunger in which a needle is attached
method
method in which the phlebotomist can control the
vacuum by gently pulling back on the plunger while
drawing blood
syringe method of choice for small, fragile, or damaged veins
method because they easily collapse under the vacuum pressure
of evacuated tubes
method used mostly for venipuncture in our laboratory
exercises
ROUTINE VENIPUNCTURE: EQUIPMENTS
also called ETS collection tubes or vacutainer tubes
the tubes are designed to fill with a predetermined
volume of blood by vacuum
▪ 5ml tube can only collect 5ml blood
Evacuated the rubber stoppers are color-coded according to
Collection Tube the additive that the tube contains
various sizes are available
blood should NEVER be poured from one tube to
another since the tubes can have different additives
or coatings (causes contamination)
the gauge number indicates the bore size: the larger
the number, the smaller the needle bore
needles ▪ Gauge 23 has a smaller bore than Gauge 20
are available for evacuated systems and for use with
a syringe, single draw, or butterfly system
holder/adapter use with the evacuated collection system
tourniquet wipe off with alcohol and replace frequently
alcohol wipes 70% isopropyl alcohol
Notes: SPS (sodium polyanethol sulfonate); fluoride tube (double oxalate
tube).
PERFORMANCE OF A VENIPUNCTURE STEPS IN ETS
Obtain and examine the requisition form. (Usually given by the
doctor; for outpatients: lab secretary) (The requisition form is very
essential because it is part of the patient’s medical record. You
1 should not collect a sample without it because this will accompany
the sample to the lab.) (Has the patient’s information and the test
to be performed, so you can prepare yourselves and the supplies
needed for the warding.)
Greet and reassure the patient and explain the procedure to be
performed. (For the greeting, you are practicing professionalism.
Social skills are important. Always be polite and friendly, even if
some are being rude. You should always treat the patient as the
2 customer who is always right. The lab’s reputation rests on you
because you are the frontliner. So, the patient’s response on how
well the lab perform will not usually rest on sophisticated machines
alone, but on how skilled, polite, and very gentle the
phlebotomists.)
Identify the patient verbally by having him or her state both the
first name and last name and compare the information on the
patient’s ID band with the requisition form. (Identification of the
3 patient is very important because this is considered as the most
significant step in phlebotomy. The CLSI, CAP, and JC recommend
that the patient safety goals require a minimum of two patient
identifiers when collecting blood.)
Verify if the patient has fasted, has allergies to latex, or has had
4 previous problems with venipuncture. (Verification should always
be done.)
Select correct tubes and equipment for the procedure. Have extra
5 tubes available. (Before even approaching the patient, you already
know the equipment needed for the test.)
6 Wash hands and apply gloves.
Position the patient’s arm slightly bent in a downward position so
that the tubes fill from the bottom up. Do not allow to touch the
stopper puncturing needle. Do not let the patient hyperextend the
7 arm. Ask the patient to make a fist. (In the lab setting, we have a
special chair or a drawing station which is called the phlebotomy
chair. It has a movable arm in which you can place your patient’s
arm. The movable arm is designed as a stoppage if your patient falls
or pains. If there is too much history on venipuncture procedure,
you should let them lie down on a bed, or on a sofa.)
Apply the tourniquet 3 to 4 inches (in some books, 2-3 in) above
the antecubital fossa. Palpate the area in a vertical and horizontal
direction to locate a large vein and to determine the depth,
direction, and size. The median cubital is the vein of choice
followed by the cephalic vein. The basilic vein should be avoided if
possible. Remove the tourniquet and have the patient open his or
her fist. (Torniquet application can be right over left, or left over
right. What’s important is that when you pull it, it would be pulled
out at a single time. The ends should be facing up. It should only be
8 placed on the arm for 1 minute to avoid hemoconcentration.)
large, well-anchored, superficial, less
median movable
cubital vein
most preferred vein
second vein of choice
cephalic vein
farthest from the body
vein nearest to the body
basilic vein least preferred because it’s very near the
nerves and arteries
Clean the site with 70% isopropyl alcohol in concentric circles
9
moving inward going outward and allow it to air dry.
Assemble the equipment while the alcohol is drying. Attach the
multisample needle to the holder. (You can assemble your adapter
10
with the multisample needle. You can also insert the tube up to the
tube advancement mark.)
11 Insert the tube into the holder up to the tube advancement mark.
Reapply the tourniquet. Do not touch the puncture site with an
unclean finger. Ask the patient to remake a fist. Patient should be
12
instructed not to “pump” or “continuously clench” the fist to
prevent hemoconcentration.
Remove the plastic needle cap and examine the needle for defects
13
such as non-pointed or barbed ends.
Anchor the vein by placing the thumb of the non-dominant hand 1
14
to 2 inches below the site and pulling the skin taut.
Grasp the assembled needle and tube holder using your dominant
hand with the thumb on the top near the hub and your other
fingers beneath. Smoothly insert the needle into the vein at a 15-
15
to 30-degree angle with the bevel up until you feel a lessening of
resistance. Brace the fingers against the arm to prevent movement
of the needle when changing tubes.
Using the thumb, advance the tube onto the evacuated tube
16 needle, while the index and middle fingers grasp the flared ends of
the holder (to stop it from moving).
When blood flows into the tube, release the tourniquet, and ask
17
the patient to open the fist.
Gently remove the tube when the blood stops flowing into it.
Gently invert anticoagulated tubes promptly. Insert the next tube
18 using the correct order of draw. Fill tubes completely. (When you
insert the tube, make sure that the writing on the tube is located
below so that you can see the blood flow.)
19 Remove the last tube collected from the holder and gently invert.
Cover the puncture site with clean gauze. Remove the needle
20 smoothly and apply pressure or ask the patient to apply pressure.
(When you remove the needle, it should be done from the same
AIRAH M.
 angle it was inserted, and should be done in one, swift motion.
When you place or hold the area to stop the bleeding, the arm
should be straight, not bent, or it can be raised out stretched
upwards.)
21 Activate the safety device.
Dispose the needle/holder assembly with the safety device
22
activated into the sharps container.
Label the tubes before leaving the patient and verify information
with the patient ID band or verbally with an outpatient. Observe
23 any special handling procedures. Complete paperwork. (For the
labelling, always place the patient’s name, date of birth if asked,
and the phlebotomist’s initials with the current date.)
Examine the puncture site and apply bandage. Place bandage over
24 folded gauze for additional pressure. (You should not leave the
patient if he/she is bleeding.)
Prepare sample and requisition for transportation to the
25 laboratory. Dispose of used supplies. (The samples should be
delivered into the laboratory within 45 minutes to 2 hours.)
26 Thank the patient, remove gloves, and wash hands.
VENOUS BLOOD COLLECTION FOR INFANTS
Site Selection: The veins located in the antecubital fossa are the best
choice for children older than 2 years.
Do not use deep veins. Site selection and technique is similar to that used
for adults.
Dorsal hand venipuncture (dorsal hand vein technique) can be used for
children younger than 2 years of age. This technique, which needs
proper skill training, can be used to collect samples from a superficial
hand vein directly into the appropriate microsample containers. (Dorsal
veins are the ones used for IV therapy.)
▪ The advantage of this technique is that more blood can be collected
from the vein as compared with a heelstick and there is less chance
of hemolyzing the sample or contaminating the sample with tissue
fluid. Use of this technique requires additional training and is an
institutional decision, because saving all veins for IV therapy may be
preferred. Use extreme care when disposing of the contaminated
needle.
CORD BLOOD:
▪ This is only obtained at the time of delivery. An admixture of cord
jelly (Wharton’s jelly) must be carefully avoided. The placental
segment of the cord is either allowed to drain into a test tube or the
umbilical vein (preferable) is aspirated with needle and syringe.
EXTERNAL JUGULAR VEIN PROCEDURE
▪ Infant is wrapped in sheet so that the arms are immobilized alongside
the body. The child is placed on his back on the examining table so
that his head hangs over the edge of the table as his body is steadied
by an assistant. His head is supported and turned to one side. When
the child cries, the external jugular stands out distinctly, running the
angle of the mandible to the mid-clavicular area. The area is
disinfected and treated after the procedure as described in the
discussion on obtaining venous blood in adults. (with the use of a
butterfly infusion set)
▪ Whether capillary or venous blood is obtained, the patient must not
be left unattended until all the bleeding has stopped and there is no
evidence of hematoma. (The reason why this method is not mostly
used nowadays and why doctors are usually the ones performing it.
MTs can only assist in the procedure.)
LANCETS
SKIN/DERMAL PUNCTURE ▪ to prevent contact with bone, the depth of the puncture is critical
the method of choice for collecting blood from infants and children ▪ CLSI recommends that the incision depth should not exceed 2.0 mm
younger than 2 years for the following reasons: in a device sued to perform heelsticks
▪ locating superficial veins that are large enough to accept even a ▪ the length of lancets and the spring release mechanisms control the
small-gauge needle is difficult in thee patients, and available veins puncture depth with automatic devices
may need to be reserved for intravenous therapy
▪ to produce adequate blood flow, the depth of the puncture is actually
use of deep veins (e.g. femoral vein) can be dangerous and may cause much less important than the width of the incision
complications, including:
o this is because the major vascular area of the skin is located at
▪ cardiac arrest the dermal subcutaneous junction, which in a newborn is only
▪ venous thrombosis
0.35 to 1.6 mm below the skin and can range to 3.0mm in a large
▪ hemorrhage adult
▪ damage to surrounding tissue and organs o the number of severed capillaries depends on the incision width
▪ infection o incision widths vary from needle stabs to 2.5mm
▪ reflex arteriospasm (that can possibly result to gangrene) o sufficient blood flow should be obtained form incision widths no
▪ injury (to the child) caused by restraining the child larger than 2.5mm
drawing excessive amounts of blood from premature and small infants o several color-coded lancets are available in varying depths and
can rapidly cause anemia, because a 2-pound infant may have a total widths to accommodate low, medium, and high blood flow
blood volume of only 150ml requirements
Certain tests require capillary blood, such as newborn screening tests, o the type of device selected depends on the:
from newborn and infants for: ✓ age of the patient
▪ neonatal bilirubin ✓ the amount of blood sample required
▪ capillary blood gases ✓ the collection site
▪ point of care testing ✓ the puncture depth
various kinds of lancets for the dermal puncture procedure:
DERMAL PUNCTURES MAY BE PREFERABLE OVER VENIPUNCTURE
Tenderlet toddler, junior and adult, Quick heel and Unistik
(ADULT PATIENT)
1 burned or scarred patients
patients receiving chemotherapy who require frequent tests and
2
whose veins must be reserved for therapy
3 patients with thrombotic tendencies
4 geriatric or other patients with very fragile veins
5 patients with inaccessible veins
6 obese patients
7 apprehensive patients LASER LANCETS (Lasette Plus, Cell Robotics International, Inc.,
Albuquerque, NM)
8 patients requiring home glucose monitoring
9 point-of-care tests ▪ are available for clinical and home use, and are approved by the FDA
for adults and children older than 5 years
blood collected by dermal puncture comes from ▪ the lightweight, portable, battery-operated device eliminates the
the capillaries, arterioles, and venules risks of accidental punctures and the need for sharps containers
it is a mixture of arterial and venous blood and ▪ the laser light penetrates the skin 1 to 2 mm, producing a small hole
may contain small amounts of interstitial and by vaporizing water in the skin
intracellular fluids ▪ this creates a smaller wound, reduces the pain and soreness
capillary blood because of arterial pressure, the composition of associated with capillary puncture, and allows up to 100uL of blood
composition this blood more closely resembles arterial rather to be collected
than venous blood MICROSAMPLE CONTAINERS
warming the site before sample collection ▪ containers come in microcollection tubes,
increases blood flow as much as sevenfold, capillary tubes, and micropipets
producing a sample that is very close to the ▪ some containers are designed for a specific test,
composition of arterial blood and others serve multiple purposes
▪ the type of container chosen is usually related
DERMAL PUNCTURE DEVICES to laboratory preference, because advantages
for use in performing dermal punctures, a phlebotomy collection tray or & disadvantages can be associated with each
drawing station should contain: system
▪ skin puncture devices
▪ microsample collection containers
▪ glass slides, and possibly
▪ a heel warmer
AIRAH M.
CAPILLARY TUBES Select the puncture site in the fleshy areas located off center of HEEL PUNCTURE SITES
▪ are frequently referred to as microhematocrit tubes 8 the third or fourth fingers on the palmar side of the nondominant ▪ The heel is used for dermal punctures on infants
▪ are small tubes used to collect approximately 30 to 75 uL of blood for hand. Do not use the side or tip of the finger. younger than 1 year because it contains more
the primary purpose of performing a Warm the puncture site if necessary (if patient’s hand is cold). This tissue than the fingers and has not yet become
microhematocrit test 9 is done by massaging the area, or by using the heel warmer of the callused from walking.
▪ the tubes are designed to fit into a towel. ▪ Acceptable areas for heel puncture are shown in
hematocrit centrifuge and its Cleanse and dry the puncture site with 70% isopropyl alcohol in and are described as the medial and lateral areas
corresponding hematocrit reader 10 of the plantar (bottom) surface of the heel.
concentric circles and allow to air dry.
▪ tubes are available in plain or coated with Prepare the lancet by removing the lancet locking device and open ▪ These areas can be determined by drawing
ammonium heparin, and they are color 11 imaginary lines extending back from the middle of the large toe to
the cap to the microcollection container.
coded, with a red band for heparinized Hold the finger between the nondominant thumb and index finger, the heel and from between the fourth and fifth toes to the heel.
tubes and a blue band for plain tubes 12 with the palmar surface facing up and the finger pointing ▪ It is in these areas that the distance between the skin and the
ADDITIONAL DERMAL PUNCTURE SUPPLIES downward. calcaneus (heel bone) is greatest.
alcohol pads, gauze, and sharps containers are required for the dermal Place the lancet firmly on the fleshy area of the finger ▪ Punctures should not be performed in other areas of the foot, and
puncture just as they are for the venipuncture perpendicular to the fingerprint and depress the lancet trigger. particularly not in the arch (in the middle), where they may cause
▪ warming the puncture site increases blood flow to the area 13 (When you do the puncture, the lancet should already be near the damage to nerves, tendons, and cartilage.
o this can be accomplished by warm skin, but not touching it. If it is far, it will produce a very small FINGER PUNCTURE SITES
washcloths or towels, or a commercial wound.) ▪ Finger punctures are performed on adults and
heel warmer 14 Discard lancet in the approved sharps container. children over 1 year of age.
o heel warmer: a packet containing ▪ Fingers of infants younger than 1 year many not
Gently squeeze the finger and wipe away the first drop of blood
sodium thiosulfate and glycerin that contain enough tissue to prevent contact with
15 that may contain alcohol residue and tissue fluid which causes
produces heat when the chemicals are the bone.
sample contamination.
mixed together by gentle squeezing of ▪ The fleshy areas located near the center of the
Collect rounded drops into microcollection containers in the third and fourth fingers on the palmar side of the
the packet (or you can do this by 16 correct order of draw without scraping the skin. Do not milk the
heating a towel at 42°C: not higher nondominant hand are the sites of choice for
site. Collect the sample within 2 minutes to prevent clotting. finger puncture
because it can cause burns) Cap the microcollection container when the correct amount of
17 ▪ should be off center perpendicular to the ridges of the fingerprint
COLLECTION OF BLOOD FROM FINGERSTICK blood has been collected. (against the lines of the fingerprints: because if you puncture parallel
Dermal Puncture Procedure Mix tubes 5 to 10 times by gentle inversion as recommended by to it, there’s a tendency for the wound to close up easily and also,
EQUIPMENT: the manufacturer. blood will follow the ridges of the fingerprint, giving us a hard time
18
▪ 70% isopropyl ▪ They may have to be gently tapped throughout the procedure collecting the blood)
▪ indelible pen ▪ gauze to mix the blood with the anticoagulant.
alcohol pad or o wound easily opens up
▪ sharps container ▪ warming device Place gauze on the site and ask the patient or parent to apply
cotton (wet & dry) o collect more blood
▪ microcollection ▪ bandage 19 pressure until the bleeding stops (takes about 5 minutes for
▪ finger puncture ▪ This is the site chosen because the tip and sides of the finger contain
container ▪ gloves coagulation to happen).
device only about one half the tissue mass of the central area, the possibility
PROCEDURE Label the tubes before leaving the patient and verify identification of bone injury is increased in these areas.
1 Obtain and examine the requisition form. No sample without form. 20 with the patient ID band or verbally with an outpatient. Observe ▪ Problems associated with use of the other fingers include:
Greet the patient and explain the procedure to be performed. any special handling procedures. o possible calluses on the thumb and index finger
2 (Never tell the patient that the procedure will not hurt, same as Examine the site for stoppage of bleeding and apply bandage if the o increased nerve endings in the index finger
with venipuncture.) 21 patient is older than 2 years. (not younger because it can cause o decreased tissue in the fifth finger
Identify the patient verbally by having him or her state both the choking to the child) ▪ A swollen or previously punctured site is unacceptable because the
first name and last name and compare the information on the 22 Dispose of used supplies in biohazard containers. increased tissue fluid will contaminate the blood sample.
3 o swollen site: increased tissue fluid
patient’s ID band with the requisition form. A parent or guardian 23 Thank the patient.
may do this for a child. o previously punctured site: cause infection
24 Remove gloves and wash hands.
Prepare the patient and/or parents and verify diet restrictions, as HEEL STICK PROCEDURE
4 appropriate, allergies to latex, or previous problems with blood 25 Complete paperwork.
We follow the first steps on the venipuncture procedure. Do the greeting
collection. 26 Deliver sample to the laboratory. and identification of the patient with the guardian.
Position the patient’s arm on a firm surface with the hand palm Hold the foot with a firm grip, grasp heel with thumb placed below
up. The child (should be restrained) may have to be held in either SITE SELECTION 1
the puncture site and index finger placed over the arch.
5 the vertical or horizontal restraint. (Ask permission from the ▪ Punctures should never be made through previous puncture sites
2 Puncture site at a 90-degree angle parallel to the heel.
guardian that you’ll get blood from the child. Never take blood with because this practice can easily introduce microorganisms into the
3 Use a quick continuous motion.
their permission.) puncture and allow them to reach the bone
▪ Do not collect blood from the fingers on the side of a mastectomy WARMING THE SITE:
Select equipment according to the age of patient, the type of test
6 without a health-care provider’s order (Why? In mastectomy, aside ▪ for optimal blood flow, the finger or heel from which the sample is
ordered, and the amount of blood to be collected.
from the breast tissue, the lymph nodes are also removed. Hence, to be taken may be warmed
7 Wash hands and put on gloves.
there is a greater chance of infection to occur.) ▪ this is primarily required:
o for patients with very cold or cyanotic fingers
o for heelsticks to collect multiple samples, and

AIRAH M.
 o for the collection of capillary blood gases ORDER OF COLLECTION FOR DERMAL PUNCTURE peripheral smears should be obtained from fresh
✓ warming dilates the blood vessels and increases arterial ▪ the order of draw for collecting multiple samples from a dermal non-anticoagulated blood
blood flow puncture is important because of the tendency of platelets to too much liquid dilutes the blood sample and thus interferes with
▪ moistening a towel with warm water (42°C) or activating a accumulate at the site of a wound anticoagulant quantitative determinations
commercial heel warmer and covering the site for 3 to 5 minutes ▪ blood to be used for tests for the evaluation of platelets (e.g. blood
effectively warms the site smear, platelet count, CBC) must be collected first ANTICOAGULANTS
▪ use caution in moistening the towel to ensure water temperature is ▪ the blood smear should be made first, followed by the lavender EDTA citrate inhibits blood clotting by binding calcium in a
not greater than 42°C to avoid burning the patient tube soluble complex
▪ the site should not be warmed for longer than 10 minutes or test order of
used for many coagulation studies
results may be altered blood collection tube cap color routine use sample for some tests (prothrombin time & partial
PERFORMING THE PUNCTURE: collection thromboplastin time), this is the anticoagulant of
▪ while the puncture is performed, the heel or finger should be well pink or for haematology sodium citrate choice, because factor V (proaccilerin/labile factor) is
1 relatively stable in citrated blood
supported and held firmly, without squeezing the puncture area lavender (e.g. CBC, HCT, HGB)
▪ massaging the area before the puncture may increase blood flow to for tests requiring sodium citrate 3.8%
the area light or dark = 3.8g sodium citrate to 100ml distilled water
plasma (e.g. Chemistry 2
▪ the heel is held between the thumb and index finger of the green
K+ and Glucose) Dispense 0.5ml into test tube. Add 4.5 ml blood and
nondominant hand, with the index finger held over the heel and the for tests requiring mix gently by inversion of the stoppered tube.
thumb below the heel red or gold serum (e.g. Chemistry 3 the potassium salt is the preparation of choice and is
COLLECTION OF SAMPLES: K+, Na+, bilirubin, BB) commercially available under trade name Sequester
▪ make sure there are no air bubbles: the presence of air bubbles limits Sol.
the amount of blood that can be collected per tube and will interfere SOURCES OF ERROR FOR SKIN PUNCTURE since EDTA prevents platelet aggregation, it is used
with blood gas determinations ▪ blood collected by skin puncture consist of mixture of capillary, as an anticoagulant for:
▪ to prevent the introduction of air bubbles, capillary tubes and venous and arterial blood, interstitial and intracellular fluids ▪ platelet counts
micropipettes are held horizontally while being filled (laboratory values differ from venous blood), so “skin puncture” ▪ platelet function tests, and
▪ place the end of the tube into the drop of blood and maintain the should be noted in the requisition slip potassium salt ▪ almost all hematological tests
tube in a horizontal position to fill by capillary action during the ▪ Hemolysis: common source of error since infants’ RBCS are more of EDTA optimal conc. of 1.5 mg of EDTA/ml of blood does not
entire collection fragile than adults cause distortion of cell if read within 2 hours but
▪ removing the microhematocrit tube from the drop of blood causes ▪ other sources include: excessive amount of this induces red cell shrinkage
air bubbles in the sample o failure to dry the site completely after cleansing with alcohol causing decrease of hematocrit (↓) and ESR values
▪ when the tubes are filled, they are sealed with sealant clay or o very deep puncture (↓)
designated plastic caps: recommended tubes are plastic or coated o failure to wipe away the first drop of bloos NOTE: when you are collecting blood samples using
with a puncture-resistant film o vigorous massaging or milking of area (gives more pressure to a EDTA, you should perform the test within the 2-hour
▪ when using a sealant tray, place the end of the tube (specifically, the small wound to produce more blood) period from the time of collection
end that has no color band) into the clay taking care to not break the o accidental capturing of air bubbles in capillary tubes or pipettes a powerful anticoagulant by virtue of its anti-
tube for collecting blood thrombic and anti-thromboplastic activity
▪ remove the tube with a slight twisting action to firmly plug the inhibits thrombin
microhematocrit tube CHOICE OF ANTICOAGULANTS
Coagulation of blood can be prevented by the following: not used for coagulation studies
BANDAGING THE PATIENT: the anticoagulant of choice for:
▪ when sufficient blood has been collected, pressure is applied to the ▪ removing calcium by the addition of oxalates, citrates, and
▪ osmotic fragility test: if defibrinated blood is
puncture site with the gauze ethylenediaminetetraacetic acid (EDTA) heparin
not used
▪ the finger or heel is elevated, and bleeding pressure is applied until ▪ inactivating thrombin and thromboplastin by the addition of heparin
blood and bone marrow smears prepared from
the bleeding stops ▪ removing fibrin by defibrination heparinized material exhibit a light bluish
▪ confirm that bleeding has stopped before removing the pressure
The correct choice and the correct amount of anticoagulant is important/ background when stained with Wright-Giemsa stain:
▪ bandages are not used for children younger than 2 years because
▪ Too little anticoagulant leads to partial clotting, which interferes with: it causes morphologic distortions of platelets and
the children may remove the bandages, place them in their mouth,
o WBC and RBC counts leukocytes, causes errors in automated cell counting
and possibly aspirate the bandages
o platelet counts potassium oxalate: shrinks RBC
▪ adhesive may also cause irritation to or tear sensitive skin,
o ESR, etc. ammonium oxalate: swelling of the cells
particularly the fragile skin of a newborn or older adult patient
if used alone, these anticoagulants are unsatisfactory
LABELLING:
The incorrect anticoagulant may interfere with biochemical investigation of but combine as a double oxalate mixture, they do not
▪ microsamples must be labelled with the same information required
the plasma: affect the shape of the red cells and therefore, do not
for venipuncture samples
potassium salts oxalates influence the hematocrit
▪ labels can be wrapped around microcollection tubes or groups of interfere with K assay
capillary pipettes of EDTA Double Oxalate Mixture
▪ for transport, capillary pipettes are then placed in a large tube interferes with BUN (blood urea nitrogen) ammonium oxalate 1.2 g
because the outside of the capillary pipettes may be contaminated ammonium determinations potassium oxalate 0.8 g
with blood oxalate both these tests should be performed in serum and neutral formaldehyde, 38% USP 1ml
▪ this procedure also helps to prevent breakage not on plasma distilled water 100ml
oxalates affect white cell morphology

AIRAH M.
6842_Ch07_155-190 14/01/19 4:21 PM Page 157 6842_Ch07_155-190 14/01/19 4:21 PM Page 158

7
158 SECTION 3 ✦ Phlebotomy Techniques

conveniently present in the collection area. Main-

INTRODUCTION
CHAPTER The first step in learning to perform a venipuncture is
knowledge of the needed equipment. Considering the
many types of blood specimens that may be required
taining a well-equipped blood collection tray that
you carry into the patient’s room is the ideal way to
prevent unnecessary errors during blood collection.
Phlebotomy Tray

Venipuncture Equipment
Learning Outcomes Key Terms
Upon completion of this chapter, the reader will be able to: Acid citrate dextrose (ACD)
Additive
7.1 Discuss the use of a blood collection tray, mobile phlebotomy
Anticoagulant
workstations, and drawing stations.
Antiglycolytic agent
7.2 List the items that should be carried on a blood collection tray.
Antiseptic
7.3 Differentiate among the various safety needle sizes as to gauge,
Bevel
length, and purpose.
Clot activator
7.4 Describe the correct methods to safely dispose of contaminated
needles.
Ethylenediaminetetraacetic
acid (EDTA)
7.5 Differentiate among an evacuated tube system (ETS), a syringe
Evacuated tube
system, and a winged blood collection set, and state the advantages
Gauge
and disadvantages of each for blood collection.
Heparin
7.6 Identify the types of evacuated tubes by color code, and state the
Holder
anticoagulants and additives present, any special characteristics, and
Hub
the purpose of each.
Hypodermic needle
7.7 State the mechanism of action, advantages, and disadvantages of the
Lumen
anticoagulants ethylenediaminetetraacetic acid (EDTA), sodium
Multisample needle
citrate, potassium oxalate, and heparin.
Plasma preparation tube
7.8 List the correct order of draw when collecting multiple tubes of
(PPT)
blood.
Plasma separator tube (PST)
7.9 Describe the purpose and types of tourniquets.
Polymer barrier gel
7.10 Name the substances used to cleanse the skin before venipuncture.
Potassium oxalate
7.11 Discuss the use of gauze, bandages, gloves, and slides when
Rapid serum tube (RST)
performing venipuncture.
Serum separator tube (SST)
7.12 Describe the quality control of venipuncture equipment.
Shaft
7.13 Correctly select and assemble venipuncture equipment when
Silica
presented with a clinical situation.
Sodium citrate
Sodium fluoride
Sodium polyanethol
sulfonate (SPS)
Winged blood collection set
For additional resources please visit
http://davisplus.fadavis.com
for laboratory testing and the risks to both patients and
Trays designed to organize and transport collection
health-care personnel associated with blood collection,
equipment are available from several manufacturers
it is understandable that a considerable amount of
(Fig. 7-1). The phlebotomy tray provides a convenient
equipment is required for the procedure. This chapter
way for you to carry equipment to the patients’ rooms,
covers the current types of equipment used when per-
except in isolation situations, which require a differ-
forming venipunctures with evacuated tube systems
ent protocol. In a non-isolation patient’s room, you
(ETSs), syringe systems, and winged blood collection sets.
The discussion includes the advantages and disadvan-
should place your tray on a solid surface, such as a
nightstand, and not on the patient’s bed, where it can
tages of the various pieces of equipment, the situations
in which they are used, and when appropriate, the
be knocked off. Bring only the needed equipment di-
rectly to the patient’s bed.
mechanisms by which the equipment works.
Equipment necessary to perform venipunctures
includes needles, sharps disposal containers, holders, Technical Tip 7-1. A well-organized tray instills
evacuated blood collection tubes, syringes, winged
confidence in the patient.
blood collection sets, tourniquets, antiseptic cleansing
solutions, gauze pads, bandages, and gloves. Box 7-1
lists the routine venipuncture equipment. Phlebotomy Workstations
Mobile phlebotomy workstations with swivel caster
wheels have replaced the traditional phlebotomy tray
in many facilities. With the increased amounts of equip-
ORGANIZATION OF EQUIPMENT
ment necessary for safe phlebotomy, these versatile
mobile workstations can be configured to accommo-
An important key to successful blood collection is
date phlebotomy trays, laptop computers, identification
making sure that all the required equipment is
band scanners, label printers, hazardous waste contain-
ers, sharps containers, and storage drawers and shelves.
The cart is designed to be wheeled around the hospital
BOX 71 Routine Venipuncture Equipment
and up to the patient’s bedside to eliminate placing
equipment or a phlebotomy tray on the patient’s bed
Phlebotomy collection tray
(Figs. 7-2A and B).
Evacuated tube system holders
Syringes
Winged blood collection sets
Needles
Needle disposal sharps containers
Evacuated collection tubes
Transfer devices
Tourniquets
Gloves
70 percent isopropyl alcohol, iodine swabs,
chlorhexidine gluconate swabs
2-in. × 2-in. gauze pads
Bandages
Slides
Antimicrobial hand gel
Marking pen
FIGURE 71 Phlebotomy collection tray.

157
6842_Ch07_155-190 14/01/19 4:21 PM Page 159
A dles used to collect units of blood for transfusion to
B and disposable and are used only once. Needle size
FIGURE 72 Mobile phlebotomy workstation. A, Workstation
with laptop. B, Workstation showing laptop and phlebotomy
supplies.
Drawing Stations
In outpatient settings, a more permanent arrange-
ment can be located at the drawing station (Fig. 7-3).
A blood drawing chair has a stand that is attached
or placed nearby to hold equipment. Drawing
chairs have an armrest that locks in place in front
of the patient to provide arm support and protect
the patient from falling out of the chair if he or she
faints. A reclining chair or bed should be available
for special procedures or for patients who feel faint
or ill.
Infant Cradle Phlebotomy Station
Infant cradle pads or portable infant phlebotomy
stations are available for collection of blood from an
infant (Fig. 7-4). These include Velcro safety straps,
a removable pad, and a plastic tray to hold your sup-
plies for easy access when performing procedures on
infants.
6842_Ch07_155-190 14/01/19 4:21 PM Page 160
CHAPTER 7 ✦ Venipuncture Equipment 159
FIGURE 73 Phlebotomy drawing station, including a
reclining chair.
FIGURE 74 Portable infant phlebotomy station.
Equipment Maintenance
Your duties will include the cleaning, disinfecting, and
restocking of the phlebotomy trays, workstations, and
outpatient drawing stations. Be sure to empty trays
completely and disinfect them on a weekly basis. Trays
also contain equipment for performing the microcol-
lection techniques discussed in Chapter 11, arterial
160 SECTION 3 ✦ Phlebotomy Techniques
puncture equipment discussed in Chapter 12, and
point-of-care equipment discussed in Chapter 13,
so you will need to ensure that all equipment needed
for these procedures is restocked after you clean the
trays.
EVACUATED TUBE SYSTEM
The ETS (Fig. 7-5) is the method used most frequently
for venipuncture. You collect blood directly into the
evacuated tube, eliminating the need for transfer
of specimens and minimizing the risk of biohazard
exposure. The ETS consists of a double-pointed nee-
dle with one point to puncture the patient’s vein and
the other point to puncture the collection tube stop-
per, a holder to hold the needle and blood collection
tube, and color-coded evacuated tubes.
NEEDLES
Venipuncture needles include multisample needles,
hypodermic needles, and winged blood collection set
needles. All needles used in venipuncture are sterile
varies by both length and gauge (diameter). For rou-
tine venipuncture, 21- to 23-gauge needles with 1- and
1.5-in. lengths are commonly used. You will choose
the type and gauge of needle to use on the basis of
the size and condition of the patient’s vein, the
amount of blood required to collect, and the blood
collection system that you are using.
Needle Length
Needle lengths vary from 1 to 1.5 in. for hypodermic
and multisample needles. Winged blood collection
Needle Safety shield Holder Evacuated tube
FIGURE 75 Evacuated tube system.
set needles are 0.5 to 0.75 in. long. You will choose the
length of the needle according to the depth of the vein.
Technical Tip 7-2. Many phlebotomists believe
that a 1-in. needle gives better control and is
less frightening to the patient.
Needle Gauge
Needle gauge refers to the diameter of the needle bore.
The smaller the gauge number, the bigger the diameter
of the needle. Needles vary from large (16-gauge) nee-
much smaller (25-gauge) needles used for children
and patients with very small veins. A 25-gauge needle
is not used routinely for drawing blood specimens
because it can cause hemolysis (the exceptions are
specially designed red cell–friendly 25-gauge needles,
which have thinner walls and larger interior dia-
meters). A 25-gauge needle is used most frequently for
injections and IV infusions.
Technical Tip 7-3. Although a 20-gauge needle
allows blood to flow more quickly into the tube, it
is not recommended for routine blood collection.
Many patients are taking blood thinners, and use of
a 20-gauge needle can result in postpuncture
bleeding and hematomas because of the larger
opening in the patient’s vein.
Technical Tip 7-4. Using 25-gauge needles usually
is not recommended because of the longer time
the needle is in the vein, causing the tube to fill
more slowly; the formation of microclots; and the
increased frequency of hemolysis.
Technical Tip 7-5. You will use a 21-gauge needle
for most adult antecubital venipunctures.
Manufacturers package needles individually in
sterile twist-apart sealed shields that are color coded
by gauge for easy identification. Typically, 20-gauge
needles are yellow, 21-gauge are green, 22-gauge are
black, and 23-gauge are pink; however, this can vary
among manufacturers. Regardless of the size, never
use a needle if the seal on the package has been bro-
ken (Fig. 7-6). Syringe hypodermic needles and
winged blood collection set needles are packaged
individually in sterile packets.
6842_Ch07_155-190 14/01/19 4:21 PM Page 161
CHAPTER 7 ✦ Venipuncture Equipment 161
the rubber stopper of the evacuated blood collection
tube. A retractable rubber sheath covers the back end
of the needle to prevent leakage of blood as tubes are
changed or removed. This allows multiple tubes to be
collected from one venipuncture.
Safety Tip 7-1. The Needlestick Prevention and
Safety Act mandates the evaluation and use of safety
needle devices. State mandates also have been
issued.
Various safety shields and blunting devices are avail-
able from different manufacturers. Safety features
FIGURE 76 Multisample needles with color-coded caps,
both traditional and BD Eclipse™ safety needle with the safety include devices that blunt or retract the needle after
shield attached, black 22-gauge and green 21-gauge, and use and shields that cover the needle after use. The
Greiner Bio-One black 22-gauge and green 21-gauge. BD Vacutainer® Eclipse™ blood collection needle
(Becton, Dickinson, and Company, Franklin Lakes,
NJ) uses a shield that locks over the needle tip after
Needle Structure completion of the venipuncture (Fig. 7-8). The
As shown in Figure 7-7, needle structure varies for Greiner Bio-One VACUETTE® VISIO PLUS Needle
adaptation to the type of collection equipment used. (Monroe, NC) has a translucent plastic hub that func-
All needles consist of a bevel (angled point), shaft, tions as a view window. If the venipuncture is successful,
lumen, and hub. You should visually examine all needles you can see the blood flow in the window (Fig. 7-9).
before use to determine if any structural defects, such
as nonbeveled points or bent shafts, are present. Do
not use defective needles. Never recap a needle once NEEDLE HOLDERS
the shield has been removed, regardless of whether the
needle has or has not been used. Multisample needles used with the ETS attach to a
holder that holds the collection tube. Holders are
Multisample Needles made of clear, rigid plastic and are available with or
Multisample needles used with an ETS are threaded in without safety features. Complete units are available
the middle and have a beveled point at each end; one that include the holder and a preattached, sterile
end is for venipuncture, and the other end punctures multisample needle with safety shield. Various types
of holders are shown in Figure 7-10. As discussed in
Point
Bevel
Shaft
Point
Bevel
Shaft Hub
Stopper-
puncturing end
Hub
Sleeve
Point
Syringe Evacuated tube
needle needle
FIGURE 77 Needle structure. FIGURE 78 Eclipse™ blood collection needle.
6842_Ch07_155-190 14/01/19 4:21 PM Page 162
162 SECTION 3 ✦ Phlebotomy Techniques
FIGURE 79 VACUETTE® VISIO PLUS needle with transparent
hub. (Courtesy of Greiner Bio-One International AG, Kremsmunster
Austria.)
FIGURE 710 Types of tube holders. VACUETTE®,
Venipuncture Needle Pro®, Monoject, and Becton Dickinson.
Chapter 3, the Occupational Safety and Health
Administration (OSHA) directs that holders be dis-
carded with the used needle.
The one-use holder by Becton, Dickinson, and
Company is available with different threading to allow
a needle to be threaded into the holder only one time
(Fig. 7-11). After use, you can discard the entire
needle/holder assembly in a sharps container. You
must use a multisample needle with a safety device.
The JELCO® Venipuncture Needle-Pro® safety
tube holder (Smiths Medical, Weston, MA) consists
of a plastic safety sheath attached by a hinge to the
end of the evacuated tube holder. The shield hangs
One use holder
Venipuncture Vanishpoint
needle-pro
FIGURE 711 One-Use Holder (Becton, Dickinson, and
Company, Franklin Lakes, NJ), Venipuncture Needle-Pro®
(Smith Medical), and VanishPoint (Retractable Technologies,
Little Elm, TX) holders.
free during the venipuncture, and then you engage
the shield over the needle using a single-handed tech-
nique against a flat surface after you perform the
puncture. You can rotate the plastic shield to obtain
a better view of the venipuncture site and needle
placement. When the puncture is complete, you can
discard the entire device in the sharps container
(Fig. 7-12).
Holders that retract the needle and offer back-end
protection include The ProGuard™ II (Covidien,
Mansfield, MA) and the VanishPoint® tube holder
(Retractable Technologies, Little Elm, TX). The Pro-
Guard II safety needle holder uses a one-handed
method to retract the needle into the holder and a
cover for the end that is open to the stopper-puncturing
needle. The VanishPoint tube holder automatically re-
tracts the needle by securely closing the end cap while
the needle is still in the patient’s vein (Fig. 7-13).
The VACUETTE QuickShield Safety Tube Holder
(see Fig. 7-10) comes with a protective cap and is
designed to be used with VACUETTE multisample
needles. The VACUETTE QuickShield Complete style
includes both the holder and a sterile, preattached
needle (Fig. 7-14). After you complete the blood col-
lection, you remove the needle from the patient’s
vein and press the protective cap over the needle
against a hard surface using a one-handed technique.
The VACUETTE QuickShield Complete PLUS system
includes a holder and VACUETTE VISIO PLUS multi-
sample needle. With this combination, you observe a
“flash” that confirms penetration of the vein (Fig. 7-15).
6842_Ch07_155-190 14/01/19 4:21 PM Page 163
A A
FIGURE 712 A, JELCO® Venipuncture Needle-Pro® Holder
with safety shield. B, JELCO Venipuncture Needle-Pro with
safety shield activated.
The BD Vacutainer Passive Shielding Blood Collec-
tion Needle (Becton, Dickinson, and Company) and
the VACUETTE Premium Safety Needle System
(Greiner Bio-One) are the new generation of safety
devices. The systems include a preassembled multi-
sample needle with a safety device and holder. In both
systems, when you insert the first tube into the holder,
the safety shield is released, which then rests against
the patient’s skin. As you remove the needle from the
patient’s vein after blood collection, a spring in the
holder causes the safety shield to move forward auto-
matically to cover the needle. An advantage to these
systems is that the needle will be covered immediately
when it moves out of the patient’s vein after an unex-
pected move by the patient. The BD Vacutainer Passive
Shielding Blood Collection Needle (Fig. 7-16) has a
safety shield indicator arrow that judges the depth of
needle insertion. The holders have a flat side to lay
against the patient’s skin for shallow angle of needle
entry.
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CHAPTER 7 ✦ Venipuncture Equipment 163 164 SECTION 3 ✦ Phlebotomy Techniques
FIGURE 715 The VACUETTE® QuickShield Complete PLUS
system.
B
FIGURE 713 VanishPoint® Tube Holder. A, Tube in holder.
B, Tube removed and needle retracted and sealed.
FIGURE 716 BD Vacutainer Passive Shielding Blood
Collection Needle. (Courtesy of Becton, Dickinson, and Company,
Franklin Lakes, NJ.)
Holders are available to accommodate collection
tubes of different sizes. To provide proper puncturing
of the rubber stopper and maximum control, tubes
should fit securely in the holder.
FIGURE 714 VACUETTE® QuickShield Complete PLUS Safety
Tube Holder. The rubber-sheathed puncturing end of an ETS
needle screws securely into the small opening at
one end of the holder; you then place the evacuated
blood collection tube into the large opening at
the opposite end of the holder. You can advance
the first tube partially onto the stopper-puncturing
needle in the holder. A marking near the top of
the holder indicates the distance that you can
advance an evacuated tube into the stopper-
puncturing needle without entering the tube and
losing the vacuum (Fig. 7-17). You will advance the
tube fully to the end of the holder when the needle
is in the patient’s vein. Blood will flow into the tube
once the needle penetrates the stopper. To pre-
vent movement of the needle in the vein in multiple-
tube collections, use the flanges of the holder
during the changing of tubes. Remove the tubes
with a slight twist to help disengage them from the
needle.
Safety Tip 7-2. If the evacuated tube needle does
not have a safety device, the tube holder must
have one.
Needle
Tube
advancement
mark
Rubber
sleeve
Holder
Assembled
system
FIGURE 717 Diagram of a basic needle holder.
6842_Ch07_155-190 14/01/19 4:21 PM Page 165
Technical Tip 7-6. Loss of tube vacuum is the
primary cause of failure to obtain blood. You
can perform the venipuncture before placing
the tube on the needle. Practice both methods,
and choose the one that is most comfortable
for you.
NEEDLE DISPOSAL SYSTEMS
To protect yourself from accidental needlesticks by
contaminated needles, you must have a means of
safe disposal available whenever you perform phle-
botomy. In recent years, because of increased con-
cern over exposure to bloodborne pathogens and
mandates by OSHA, many disposal systems have
been developed.
Needles with safety devices activated must always
be placed in rigid, puncture-resistant, leakproof dis-
posable “sharps” containers labeled BIOHAZARD
that are easily sealed and locked when full. Syringes
with the needles attached, winged blood collection
sets, and holders with needles attached are disposed
of directly into puncture-resistant containers. Many
styles and sizes of sharps containers are available
(Fig. 7-18).
Phlebotomist Alert Under no circumstances
should you recap a needle.
Safety Tip 7-3. Fill sharps containers only to the
designated mark and never above it.
FIGURE 718 Sharps disposal containers.
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CHAPTER 7 ✦ Venipuncture Equipment 165
Safety Tip 7-4. To prevent accidental punctures
from contaminated needles, become thoroughly
familiar with the operation of your needle safety
system before performing blood collection.
COLLECTION TUBES
Blood collection tubes (Fig. 7-19A and B) are avail-
able from a number of different manufacturers in a
variety of sizes and volumes, ranging from 1.8 to 15 mL.
Tubes used for blood collection are called evacuated
tubes because they contain a premeasured amount of
vacuum. The amount of blood collected is deter-
mined by the size of the tube and the amount of
vacuum present. With the ETS, evacuated tubes with
their corresponding needles and holders provide a
means of collecting blood directly into the tube.
Laboratory instrumentation is also available for direct
sampling from the evacuated tubes, providing addi-
tional protection for laboratory workers. When using
a syringe system, you must transfer the blood quickly
into the evacuated tubes.
A
B rubber stopper provide additional protection against
FIGURE 719 Examples of evacuated tubes. A, BD Vacutainer
tubes (Becton, Dickinson, and Company, Franklin Lakes, NJ).
B, VACUETTE® evacuated tubes (Greiner Bio-One, Monroe, NC).
166 SECTION 3 ✦ Phlebotomy Techniques
As shown in Figure 7-19, a wide variety of sizes is
available to accommodate adult, pediatric, and geri-
atric patients. When selecting the appropriate size
tube, you must consider the amount of blood needed,
the age of the patient, and the size and condition
of the patient’s veins. Using a 23-gauge needle with
a large evacuated tube can produce hemolysis be-
cause red blood cells (RBCs) are damaged when the
large amount of vacuum causes them to be pulled
through the small lumen of the needle too rapidly.
Therefore, if it is necessary to use a small-gauge needle,
you should collect two small tubes instead of one
large tube.
Both glass and plastic evacuated tubes are avail-
able, but glass tubes are less desirable because of
the risk of breakage and exposure to bloodborne
pathogens.
Safety Tip 7-5. For safety reasons, glass tubes are
rarely used.
Tubes are sterile and many are silicone coated to
prevent cells from adhering to the tube or to prevent
the activation of clotting factors in coagulation studies.
Tubes may also contain anticoagulants and additives.
The tubes are labeled with the type of anticoagulant
or additive, the draw volume, and the expiration date.
The manufacturer guarantees the integrity of the
anticoagulant and vacuum in the tube until the expi-
ration date (Fig. 7-20).
Technical Tip 7-7. You should verify the
information written on the tube label before
blood collection.
As shown in Figure 7-21, evacuated tubes have
thick rubber stoppers with a thinner central area to
allow puncture by the needle. Tubes also may have
a color-coded plastic safety shield covering the stop-
per to provide additional protection against blood
splatter (e.g., BD Hemogard™ Vacutainer System,
Becton, Dickinson, and Company). The stoppers
FIGURE 720 Collection tube label.
FIGURE 721 Cutaway view of a vacuum tube stopper
(Hemogard closure). (Adapted from product literature, Becton,
Dickinson, and Company, Franklin Lakes, NJ.)
are color-coded to help identify the many types of
evacuated tubes. The color of the Hemogard closures
varies slightly from that of the rubber stoppers.
Color coding for routinely used tubes is generally
universal; however, it may vary slightly by manufacturer,
and instructions for specimen collection usually refer
to the tube color. This reference to tube color is found
on most computer-generated forms. Each laboratory
department has specified sample requirements for
the analysis of particular blood constituents. Testing
methodologies and types of instrumentation vary
among laboratories. Therefore, the type of tube used
for a particular test may not be the same in all facili-
ties. Direct sampling instrumentation also may be
designed to accept only a specific type of tube, such
as a rubber stopper and not a Hemogard closure or
vice versa.
Many instruments in the laboratory are designed
to identify a blood tube by its bar-coded label and will
directly pierce the stopper to aspirate blood into the
instrument for testing.
Safety Tip 7-6. Removing the rubber stoppers
from evacuated tubes can be hazardous to
laboratory personnel because an aerosol of blood
can be produced when the stopper is quickly
“popped off.” Cover a stopper with a gauze pad,
and then slowly loosen it with the opening facing
away from your body.
Plastic safety shield closures covering the top of the
blood splatter by allowing the stoppers to be easily
twisted and pulled off. The plastic shield provides
6842_Ch07_155-190 14/01/19 4:21 PM Page 167
protection from blood that remains on the stopper
after the tubes are removed from the needle.
As stated previously, evacuated tubes fill automat-
ically because a premeasured vacuum is present in
the tube. This causes some tubes to fill almost to
the top, whereas other tubes fill only partially. BD
partial-fill tubes are distinguished from regular-fill
tubes by translucent colored Hemogard closures in
the same color as regular-fill tubes. VACUETTE
partial-draw tubes are indicated by a white ring in the
cap color. The draw volume is written on the tube
label. When a tube has lost its vacuum, it cannot fill
to the correct level. Loss of vacuum can be caused
by dropping the tube, opening the tube, improper
storage, manufacturer error, using the tube past its
expiration date, prematurely advancing the tube
onto the stopper-puncturing needle in the holder,
or pulling the needle bevel out of the skin during
venipuncture.
Principles of Color-Coded Tubes
Color coding indicates the type of specimen that
you will obtain when you use a particular tube. As dis-
cussed in Chapter 2, tests may be run on plasma,
serum, or whole blood. Tests also may require the
presence of preservatives, inhibitors, clot activators, or
barrier gels. To produce these necessary conditions,
some tubes contain anticoagulants or additives, and
others do not. You must be able to relate the color of
the collection tubes to the types of specimens needed
and to any special techniques, such as tube inversion,
that may be required. This section discusses the anti-
coagulants and additives used routinely as well as
the types of tests for which they are used and special
handling that they require.
Anticoagulants
Tests requiring whole blood or plasma are collected
in tubes containing an anticoagulant to prevent clot-
ting of the specimen. Anticoagulants prevent clotting
by binding calcium or inhibiting thrombin in the
coagulation cascade (Fig. 7-22). Ethylenediaminete-
traacetic acid (EDTA), citrates, and oxalates are the
most common anticoagulants that work by binding
calcium. Heparin prevents clotting by inhibiting the
formation of thrombin, which is necessary to convert
fibrinogen to fibrin in the coagulation process. You
must gently invert all tubes containing an anticoagu-
lant three to eight times immediately after collection
to mix the contents and to avoid formation of micro-
clots (Fig. 7-23).
6842_Ch07_155-190 14/01/19 4:21 PM Page 168
CHAPTER 7 ✦ Venipuncture Equipment 167 168 SECTION 3 ✦ Phlebotomy Techniques
Intrinsic Extrinsic For hematology procedures that require whole
pathway pathway Technical Tip 7-8. Observing an air bubble
blood, such as a complete blood count (CBC), K2EDTA
moving through the tube from top to bottom
is the anticoagulant of choice because it maintains
Factor XII Tissue thromboplastin during inversion ensures proper mixing.
cellular integrity better than other anticoagulants, in-
hibits platelet clumping, and does not interfere with
Before use, gently tap tubes with powdered anti-
routine staining procedures.
coagulant to loosen the powder from the tube for
Factor XI
PF3 better mixing with the blood. Fill tubes containing an
Factor VII anticoagulant to the designated volume draw to Preexamination Consideration 7-2.
ensure the correct blood-to-anticoagulant ratio and The Clinical and Laboratory Standards Institute
Factor IX accurate test results. When a short draw is anticipated, (CLSI) recommends spray-coated K2EDTA for
EDTA
Ca++
use a partial collection tube. Also, gently mix tubes hematology tests because liquid K3EDTA dilutes
Na citrate
Ca++ containing additives to ensure effectiveness.
K oxalate the specimen and can result in lower hemoglobin
Factor VIII SPS values; RBC, white blood cell (WBC), and platelet
Phlebotomist Alert Never transfer blood collected counts; and packed cell volumes.
in a tube containing an anticoagulant or additive
EDTA
Na citrate into a tube containing a different anticoagulant or
K2EDTA tubes are also used for immunohematol-
K oxalate additive.
ogy testing and blood donor screening. As shown in
SPS Factor X
Figure 7-22, lavender stopper tubes cannot be used
for coagulation studies because EDTA interferes with
++
Ca Technical Tip 7-9. For anticoagulants to totally factor V and the thrombin-fibrinogen reaction.
Factor V prevent clotting, you must thoroughly mix
specimens immediately after collection.
Prothrombin Thrombin Heparin
Preexamination Consideration 7-3.
Technical Tip 7-10. Shaking an anticoagulated You should fill the lavender stopper tube
tube rather than gently inverting the tube may completely to avoid excess EDTA, which may
Thrombin shrink the RBCs and decrease the hematocrit level,
cause hemolysis and specimen rejection.
RBC indices, and erythrocyte sedimentation rate
(ESR) results.
Fibrinogen Fibrin (clot)
Color-Coded Tubes
FIGURE 722 The role of anticoagulants in the coagulation Lavender (Purple) Top
cascade. (Ca++ = calcium; PF3 = platelet factor 3.) Lavender (purple) stopper tubes contain the anticoagu- Pink Top
lant EDTA in the form of liquid tripotassium (K3EDTA) Pink stopper tubes also contain a spray-coated
(glass) or spray-coated dipotassium ethylenediaminete- K2EDTA anticoagulant and are used specifically for a
traacetic acid (K2EDTA) (plastic). Coagulation is pre- blood bank.
vented by the binding of calcium in the specimen to
sites on the large EDTA molecule, thereby preventing
the participation of the calcium in the coagulation Preexamination Consideration 7-4.
cascade (see Fig. 7-22). After blood collection, you Using a designated tube for a blood bank is
should gently invert lavender stopper tubes eight times believed to help prevent testing of specimens
for adequate mixing of the anticoagulant with the from the wrong patient.
blood.
The tubes are designed with a special label for
Preexamination Consideration 7-1. patient information required by the American Asso-
ciation of Blood Banks. After blood collection, you
= 1 inversion Without adequate mixing, microclots can form in a
should invert these tubes eight times.
FIGURE 723 Evacuated tube inversion. lavender stopper tube used for hematology
testing and can result in erroneously lower cell
White Top
counts. The specimen will be rejected and must
be recollected. White tubes containing a spray-coated K2EDTA anti-
coagulant and a separation gel are called plasma
6842_Ch07_155-190 14/01/19 4:21 PM Page 169
preparation tubes (PPTs). This differentiates them from
plasma separator tubes (PSTs) that contain heparin as
the anticoagulant. White-top tubes are primarily used
for molecular diagnostics. After blood collection, you
should invert these tubes eight times. Greiner Bio-One
VACUETTE EDTA gel tubes have purple plastic stop-
pers and white plastic stoppers with yellow tops.
Light Blue Top
Light blue stopper tubes contain the anticoagulant
sodium citrate, which also prevents coagulation by binding
calcium. Centrifugation of the anticoagulated light blue
stopper tubes provides the plasma used for coagulation
tests. Sodium citrate (3.2% or 3.8%) is the required
anticoagulant for coagulation studies because it pre-
serves the labile coagulation factors. After blood collec-
tion, you should invert these tubes three to four times.
The ratio of blood to liquid sodium citrate is critical and
should be 9 to 1 (e.g., 4.5 mL of blood and 0.5 mL of
sodium citrate). Therefore, you must completely fill
light blue stopper tubes to ensure accurate results.
When collecting blood for coagulation tests on
patients with polycythemia or hematocrit readings
greater than 55 percent, you need to decrease the
amount of citrate anticoagulant to prevent an increased
amount of citrate in the plasma. The increased citrate
in the specimen will interfere with the coagulation
tests. The CLSI recommends the use of tubes contain-
ing 3.2 percent sodium citrate to prevent this prob-
lem. If necessary, you can specially prepare the
needed tubes as described in the CLSI guideline.
Special glass citrate, theophylline, adenosine, and
dipyridamole (CTAD) tubes with light blue stoppers
are designed for specialized platelet testing of citrated
plasma. These minimize in vitro platelet activation
and the artificial entry of platelet factors into the
plasma. Greiner Bio-One VACUETTE CTAD tubes
have blue stoppers with yellow tops.
When you are drawing blood from a patient to pro-
vide serum to test for fibrin degradation products, use
a navy blue stopper tube containing thrombin and a
soybean trypsin inhibitor.
Technical Tip 7-11. The laboratory always rejects
light blue stopper tubes that are not completely
filled.
Technical Tip 7-12. Overmixing a light blue
stopper tube can activate platelets and cause
erroneous coagulation test results.
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CHAPTER 7 ✦ Venipuncture Equipment 169
Black Top
Black stopper tubes containing buffered sodium citrate
are used for Westergren sedimentation rates. They
differ from light blue–top tubes in that they provide
a ratio of blood to liquid anticoagulant of 4 to 1. Spe-
cially designed tubes for Westergren sedimentation
rates are available.
Green Top
Green stopper tubes contain the anticoagulant he-
parin combined with sodium, lithium, or ammonium
ion. Heparin prevents clotting by inhibiting thrombin
in the coagulation cascade (see Fig. 7-22). Green stop-
per tubes are used primarily for chemistry tests per-
formed on whole blood or plasma, particularly STAT
tests or tests that require a fast turnaround time. Be
careful to choose the correct green stopper tube to
avoid interference by sodium and lithium heparin
with their corresponding chemical tests and by am-
monium heparin in blood urea nitrogen (BUN) deter-
minations. In general, lithium heparin has been
shown to produce the least interference. After blood
collection, you should invert these tubes eight times.
Green stopper tubes are not used for hematology
because heparin interferes with the Wright’s stained
blood smear. Heparin causes the stain to have a blue
background on the blood smear, making it difficult
to interpret the differential cell identification.
Light Green Top
Light green Hemogard closure tubes and green/black
stopper tubes containing lithium heparin and a sepa-
ration gel are called PSTs. PSTs are used for plasma
determinations in chemistry. They are well suited for
potassium determinations because heparin prevents
the release of potassium by platelets during clotting,
and the gel prevents contamination by RBC potassium.
After blood collection, you should invert these tubes
eight times. Greiner Bio-One VACUETTE heparin gel
tubes have green plastic stoppers with yellow tops.
Technical Tip 7-13. Tubes containing a gel barrier
are referred to as PST and SST tubes (BD) or as
plasma/serum gel barrier tubes (VACUETTE)
depending on the manufacturer.
Lime Green Top
Lime green Hemogard closure BD Barricor™ Tubes
(Becton, Dickinson, and Company) containing lithium
heparin and a mechanical separator instead of gel to
170 SECTION 3 ✦ Phlebotomy Techniques
separate cells from plasma are used for chemistry de-
terminations, therapeutic drug monitoring, and zinc
testing. They are well suited for zinc testing because
the tubes are certified to contain less than 50 !L of
zinc. After blood collection, you should invert these
tubes eight times. The mechanical separation process
requires a shorter tube centrifugation time of only
3 minutes. Because the mechanical separator permits
separation to continue throughout centrifugation far
longer than gel separators, Barricor tubes can reduce
cellular contamination by 50 to 65 percent compared
to gel tubes (Fig. 7-24).
Gray Top
Gray stopper tubes are available with a variety of
anticoagulants and additives for the collection of
blood specimens for testing of glucose, blood alcohol
(ethanol), and lactic acid. All gray stopper tubes con-
tain the glucose preservative (antiglycolytic agent)
sodium fluoride. Sodium fluoride maintains glucose
stability for 24 hours. Sodium fluoride is not an anti-
coagulant; therefore, when plasma is needed for
FIGURE 724 BD Barricor™ Lithium Heparin Plasma
Collection Tube.
analysis, an anticoagulant must also be present, and
you must invert the tubes eight times. In gray stop-
per tubes, the anticoagulant is potassium oxalate, or
Na2EDTA, which prevents clotting by binding cal-
cium. Gray tubes with only sodium fluoride for
serum testing are available.
Preexamination Consideration 7-5.
When monitoring patient glucose levels, do not
interchange tubes for the collection of plasma
and serum.
Sodium fluoride interferes with some enzyme analy-
ses; therefore, do not use gray stopper tubes for other
chemistry analyses except lactic acid and blood alcohol
levels. Gray stopper tubes are not used in hematology
because oxalate distorts cellular morphology.
Draw a specimen for testing for blood alcohol levels
in gray stopper tubes containing sodium fluoride to
inhibit microbial growth, which could produce alco-
hol as a metabolic end product. You can use tubes with
or without potassium oxalate, depending on the need
for plasma or serum in the test procedure.
Royal Blue Top
Royal blue tubes are used for toxicology, trace metal,
and nutritional analyses. Because many of the elements
analyzed in these studies are significant at very low
levels, you must use tubes that are chemically clean and
have rubber stoppers that are specially formulated to
contain the lowest possible levels of metal. Royal blue
stopper tubes are available with a spray-coated silica
clot activator for serum or with K2EDTA or sodium
heparin (Greiner Bio-One VACUETTE) for plasma to
conform to a variety of testing requirements. After
blood collection, you must invert these tubes with an
anticoagulant present eight times.
Tan Top
Tan tubes are available for lead determinations. They
are certified to contain less than 0.1 !g/mL of lead.
The tubes contain the anticoagulant K2EDTA, and
after collection, you must invert them eight times.
Yellow Top
Yellow stopper tubes are available for two different
purposes and contain different additives. Yellow stop-
per tubes containing the RBC preservative acid citrate
dextrose (ACD) are used for cellular studies in blood
bank, human leukocyte antigen phenotyping, and
6842_Ch07_155-190 14/01/19 4:21 PM Page 171
DNA and paternity testing. The acid citrate prevents
clotting by binding calcium, and dextrose preserves
the RBCs.
Sterile yellow stopper tubes containing the anti-
coagulant sodium polyanethol sulfonate (SPS) are used to
collect specimens to be cultured for microorganisms.
SPS also prevents coagulation by binding calcium (see
Fig. 7-22). SPS aids in the recovery of microorganisms
by inhibiting the actions of complement, phagocytes,
and certain antibiotics. As with other tubes, after
blood collection, you should invert yellow stopper
tubes eight times.
Light Blue/Black Top
Light blue/black rubber stopper glass tubes contain
the anticoagulant sodium citrate, a polyester gel, and
a density gradient liquid. These tubes are called cell
preparation tubes (CPTs). CPTs are special single-
tube systems used for whole blood molecular diagnos-
tic testing so that mononuclear cells can be separated
from whole blood and transported without removing
them from the tube. The mononuclear cells and
platelets are separated from the granulocytes and
RBCs by the polyester gel and dense gradient liquid
when centrifuged. After blood collection, you should
invert these tubes eight times (Fig. 7-25).
Red/Green Top
Red/green rubber stopper glass tubes contain the
anticoagulant sodium heparin, a polyester gel, and
density gradient liquid. These tubes are also CPTs. This
tube is used for whole blood molecular diagnostic
Before After
centrifugation centrifugation
Whole blood
Plasma
Mononuclear cells
and platelets
Polyester gel
Dense solution
Granulocytes
Red blood
cells
FIGURE 725 Centrifuged and uncentrifuged cell preparation
tubes for molecular diagnostic tests.
6842_Ch07_155-190 14/01/19 4:22 PM Page 172
CHAPTER 7 ✦ Venipuncture Equipment 171
testing when the methodology requires heparinized
blood. For mixing, you must invert these tubes eight
times.
Orange Top
Orange stopper tubes contain the clot activator throm-
bin. Notice in Figure 7-22 that thrombin is generated
near the end of the coagulation cascade; addition of
thrombin to the tube results in faster clot formation,
usually within 5 minutes. After blood collection, you
should invert these tubes eight times. Tubes contain-
ing thrombin are used for STAT serum chemistry
determinations and for collecting specimens from
patients receiving anticoagulant therapy.
Orange stopper tubes containing a thrombin-based
clot activator with a separation gel are called rapid
serum tubes (RSTs) (Becton, Dickinson, and Company).
RSTs clot within 5 minutes and are centrifuged for
10 minutes at a high speed, yielding serum in a short
time, which is ideal for STAT serum chemistry testing.
After blood collection, you should invert these tubes
five times.
Red/Gray and Gold Top
Red/gray stopper tubes and gold BD Hemogard
closures are found on tubes containing a clot activa-
tor and a separation gel. They are frequently referred
to as serum separator tubes (SSTs) (Becton, Dickinson,
and Company). The tubes are spray coated with the
clot activator silica to increase platelet activation,
thereby shortening the time required for clot forma-
tion. You should invert these tubes five times to expose
the blood to the clot activator. A polymer barrier gel
that undergoes a temporary change in viscosity during
centrifugation is located at the bottom of the tube. As
shown in Figure 7-26, when the tube is centrifuged,
the gel forms a barrier between the cells and the
serum to prevent contamination of the serum with
cellular materials. To produce a solid separation bar-
rier, specimens must be allowed to clot completely
before centrifuging. Clotting time is approximately
30 minutes. Specimens should be centrifuged as
soon as clot formation is complete. Greiner Bio-One
serum gel tubes have red plastic stoppers with
yellow tops.
Preexamination Consideration 7-6.
Centrifugation of incompletely clotted SSTs can
produce a nonintact gel barrier and possible
cellular contamination of the serum.
172 SECTION 3 ✦ Phlebotomy Techniques
FIGURE 726 VACUETTE® serum gel tubes before and after
centrifugation.
Technical Tip 7-14. Fibrin fibers in the serum of
incompletely clotted, centrifuged SSTs may cause
blockages in the tubing of analyzers.
SSTs are used for most chemistry tests and pre-
vent contamination of the serum by cellular chemi-
cals and products of cellular metabolism. They are
not suitable for use in the blood bank and for cer-
tain immunology and serology tests because the gel
may interfere with the immunological reactions. SSTs
are also not recommended for certain therapeutic
drug testing.
Red Top
Red stopper plastic tubes contain silica as a clot acti-
vator. They are used for serum chemistry tests, for
serology tests, and in the blood bank, where the gel
from the SST tube may interfere with testing. You
need to invert these tubes five times to initiate the
clotting process. Blood clotting time is 30 minutes.
Red stopper glass tubes are often referred to as clot
or plain tubes because they contain no anticoagulants
or additives. Blood collected in red stopper glass tubes
clots by the normal coagulation process in about
60 minutes. Centrifugation of the specimen then
yields serum as the liquid portion. Red glass tubes
are used for the same purpose as the red plastic tubes.
There is no need to invert red stopper glass tubes.
Red/Light Gray and Clear Top
Red/light gray stoppers with clear BD Hemogard
closures are plastic “discard tubes” because they con-
tain no anticoagulants, additives, or gel. They are
used as discard tubes for coagulation studies, when
using a winged blood collection set, or as a second-
ary specimen collection tube. You do not need to
invert the tubes.
Technical Tip 7-15. Serum tubes with clot
activator cannot be used as a discard tube for
coagulation studies.
Evacuated tubes are summarized in Table 7-1.
Appendix I lists laboratory tests and the required types
of anticoagulants and volumes of blood required.
Figures 7-27 and 7-28 list the tube guides from the
major manufacturers.
Order of Draw
Often, several tests are ordered on patients, and you will
have to collect blood in different tubes. The order in
which you draw these tubes is one of the most impor-
tant considerations when collecting blood specimens
because this can affect some test results (Fig. 7-29). You
must collect tubes of blood in a specific order to pre-
vent invalid test results caused by microorganisms, tis-
sue fluid, or carryover of additives or anticoagulants
between tubes.
Preexamination Consideration 7-7.
It is essential that you follow the correct order of
draw to ensure accurate test results.
Technical Tip 7-16. CLSI standards state that a
discard tube is not required for routine coagulation
tests (activated partial thromboplastin time [APTT]
and prothrombin time [PT]) unless you are collecting
special factor assays or are using a winged blood
collection set.
You must avoid transfer of anticoagulants among
tubes because of possible contamination of the
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CHAPTER 7 ✦ Venipuncture Equipment 173 174 SECTION 3 ✦ Phlebotomy Techniques

TABLE 71 ● Summary of Evacuated Tubes TABLE 71 ● Summary of Evacuated Tubes—cont’d
STOPPER COLOR ANTICOAGULANT/ADDITIVE SAMPLE TYPE LABORATORY USE STOPPER COLOR ANTICOAGULANT/ADDITIVE SAMPLE TYPE LABORATORY USE
Lavender Ethylenediaminetetraacetic acid Whole blood/plasma Hematology Black Sodium citrate Whole blood Hematology
(EDTA) sedimentation
Pink EDTA Whole blood/plasma Blood bank rates
White EDTA and gel Plasma Molecular Red/light gray, clear None Discard tube
diagnostics Light blue/black Sodium citrate, gel Plasma Molecular
Light blue Sodium citrate Plasma Coagulation diagnostics
BD: red/gray, gold Clot activator and gel Serum Chemistry Red/green Sodium heparin, gel Plasma Molecular
diagnostics
VACUETTE®: red with
yellow ring
Green Ammonium heparin Whole blood/plasma Chemistry stopper-puncturing needle (Box 7-2). Blood remain- ● Serum tubes with or without gel: red/gray SST,
Lithium heparin ing on the needle after puncturing a tube can be gold SST, red stopper plastic tubes (clot activator),
Sodium heparin transferred to the next tube. When one considers the red stopper glass tubes, orange RST (thrombin
BD: light green, Lithium heparin and gel Plasma Chemistry mechanisms of anticoagulation and the chemical com- clot activator with gel), and royal blue stopper
green/black position of the various anticoagulants, it is understand- tubes (clot activator)
able that the results of several frequently requested ● Green stopper tubes and light green PST
VACUETTE: green with tests could be compromised by contamination. This tubes (heparin), royal blue stopper tubes with
yellow ring is why tubes containing other anticoagulants or clot heparin
Lime green Lithium heparin and mechanical Plasma Chemistry activators are drawn after the light blue stopper tube. ● Lavender, pink, white (PPT), tan, and royal blue
separator EDTA and heparin contamination can cause falsely stopper tubes (EDTA)
Red (glass) None Serum Blood bank, increased PT and APTT time results that might cause ● Gray stopper tubes (oxalate, fluoride)
chemistry, serology a health-care provider to change the dosage of a med- ● Yellow stopper tubes (ACD)
Red (plastic) Clot activator Serum Chemistry, serology ication or misdiagnose a coagulation disorder. Tubes
You should draw tubes with other colored stoppers
containing EDTA, which can bind calcium and iron,
Orange Thrombin and gel Serum Chemistry that contain EDTA, such as pink, white, royal blue,
should not be drawn before a tube testing for these
Gray Potassium oxalate and sodium Plasma Chemistry glucose and tan stoppers, in the same order as the lavender
substances. Contamination of a tube with a green,
fluoride tests, alcohol and stopper tube. When the royal blue stopper tube con-
gold, or red stopper designated for sodium, potas-
lactic acid tests tains the anticoagulant sodium heparin, you should
sium, and calcium determinations with EDTA, sodium
draw it in the same order as the green stopper tubes.
Sodium fluoride Serum citrate, or potassium oxalate will falsely decrease the
When the royal blue stopper tube does not contain
Disodium ethylenediaminetetra- Plasma calcium results and elevate the sodium or potassium
an anticoagulant, you should draw it in the same
acetic acid (Na2EDTA) and result. Tubes containing heparin should not be drawn
order as serum tubes.
sodium fluoride before a tube for serum specimens. Holding blood col-
lection tubes in a downward position so that the tube
Tan Spray-coated dipotassium Plasma Chemistry lead tests fills from the bottom up helps avoid the carryover of
ethylenediaminetetraacetic
acid (K2EDTA)
anticoagulants from tube to tube. SYRINGE SYSTEM
When you need to collect sterile specimens, such
Royal blue Sodium heparin Plasma Chemistry trace as blood cultures, you must consider them in the
elements, You may prefer to use a syringe system over an evacu-
order of draw. Such specimens are always drawn first
toxicology, and ated tube system when you are drawing blood from
in a sterile bottle or tube to prevent microbial con-
nutrient analyses patients with small or fragile veins. The advantage of
tamination of the stopper-puncturing needle from
this system is that you can control the amount of suc-
K2EDTA Plasma the unsterile stoppers of tubes used for the collection
tion pressure on the vein by slowly pulling back the
Clot activator Serum of other tests. Here is the order of draw as recom-
syringe plunger.
mended by the CLSI for both the ETS and when fill-
Yellow Sodium polyanethol sulfonate Whole blood Microbiology blood ing tubes from a syringe:
(SPS) cultures
● Sterile specimens: blood culture bottles or yellow Syringes
Acid citrate dextrose (ACD) Whole blood Blood bank
(SPS) stopper tubes Syringes come in individually wrapped sterile pack-
Continued ● Light blue stopper tubes (sodium citrate) ages in a variety of sizes. Syringes consist of a barrel
6842_Ch07_155-190 14/01/19 4:22 PM Page 175 6842_Ch07_155-190 14/01/19 4:22 PM Page 176

CHAPTER 7 ✦ Venipuncture Equipment 175 176 SECTION 3 ✦ Phlebotomy Techniques

Hemogard™ Conventional Laboratory Cap Number of Testing

Additive Inv* Notes Color Additive Inversions Disciplines Comments
Closure Stopper Use
• Clot activator and 5 For serum determinations Discard tube
Red/ gel for serum in chemistry. No additive 5–10 Transport/Storage
Gold Gray Immunohematology
separation Blood clotting time: Viral Markers
30 minutes.
If a winged blood collection
• Lithium heparin and 8 For plasma determinations set is used AND the
Light Green/ gel for plasma in chemistry. coagulation specimen is
Green Gray separation Sodium Citrate drawn first, a discard tube is
3.2% (0.109 M) 4 Coagulation
recommended to be drawn
• Silicone coated 0 For serum determinations in 3.8% (0.129 M)
(glass) chemistry. prior to this tube to ensure
Red Red • Clot activator, 5 Blood clotting time, glass: the proper anticoagu-
silicone coated 60 minutes. lant-to-blood ratio.*
(plastic) Blood clotting time, plastic:
30 minutes. For complete clotting, 30
Chemistry
For stat serum Immunochemistry minutes minimum clotting
• Thrombin-based clot 5 Clot Activator 5–10 time is required. Incomplete
activator with gel for to determinations in Immunohematology
Orange serum separation 6 chemistry. Viral Markers or delayed mixing may result
Blood clotting time: in delayed clotting.
5 minutes. For complete clotting, 30
For stat serum Chemistry minutes minimum clotting
• Thrombin-based 8 Clot Activator
clot activator determinations in 5–10 Immunochemistry time is required. Incomplete
Orange w/Gel
chemistry. TDMs or delayed mixing may result
Blood clotting time: in delayed clotting.
5 minutes.
Lithium Heparin
• Clot activator (plastic 5 For trace-element,
Royal toxicology, and Lithium Heparin 5–10 Chemistry
serum) w/Gel Immunochemistry
Blue nutritional-chemistry
• K2EDTA (plastic) 8 determinations. Sodium Heparin

• Sodium heparin 8 For plasma determinations

in chemistry. Hematology
Green Green • Lithium heparin 8 K 3EDTA Immunohematology
8–10
K 2EDTA Molecular Diagnostics
Viral Markers
• Potassium oxalate/ 8 For glucose
sodium fluoride determinations.
Gray Gray • Sodium fluoride/ 8
Na2 EDTA K 2EDTA gel 8–10 Molecular Diagnostics
• Sodium fluoride 8
(serum tube) Sodium
Fluoride/
For lead determinations. 5–10 Chemisty
• K2EDTA (plastic) 8 Potassium
Oxalate
Tan
Sodium Heparin 5–10 Trace Elements
No Additive
• Liquid K 3EDTA 8 For whole blood
Lavender (glass) hematology
Lavender determinations. Centrifugation Recommendations
• Spray-coated 8
K2EDTA (plastic)
VACUETTE® Serum Tubes (Clot Activator, No Additive) Min. 1500 g 10 min.
• Sodium polyanethol 8 SPS for blood culture VACUETTE® Serum Clot Activator w/Gel Tubes 1800 g 10 min.
Yellow sulfonate (SPS) specimens in microbiology.
• Acid citrate dextrose ACD for blood bank VACUETTE® K 2EDTA w/Gel Tubes 1800 – 2200 g 10 min.
additives (ACD): studies, HLA phenotyping, VACUETTE® Plasma Tubes (Lithium or Sodium Heparin, NaF/KO) 2000 - 3000 g 15 min.
Solution A 8 and DNA and paternity
22.0 g/L trisodium testing. VACUETTE® Lithium Heparin w/Gel Tubes 2200 g 15 min.
citrate, 8.0 g/L citric VACUETTE® Coagulation Tubes (Sodium Citrate)
acid, 24.5 g/L
dextrose
Platelet tests (PRP) 150 g 5 min.
Solution B 8 Platelet tests (PRP) 1500 - 2000 g 10 min.
13.2 g/L trisodium
citrate, 4.8 g/L citric
Preparation for deep freeze plasma (PFP) 2500 - 3000 g 20 min.
acid, 14.7 g/L
dextrose R in g I nd i c at o r yellow black white
Gel Separation Standard Draw Pediatric Draw
• K 2EDTA and gel for 8 For use in molecular (2 mL or less)
White plasma separation diagnostic test methods.
*CLSI H3-A6 Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture;
Approved Standard – 6th Edition FIGURE 728 VACUETTE® Tube Guide.
• Spray-coated 8 For whole blood
K 2EDTA (plastic) immunohematology
Pink Pink testing.
Special cross-match label.

• Buffered sodium citrate 3–4 For coagulation

graduated in milliliters (mL) and a plunger that fits range from 21- to 23-gauge sizes with 1- and 1.5-in.
Light
Blue
Light
Blue
0.105 M (3.2%) glass determinations. tightly within the barrel, creating a vacuum when lengths.
0.109 M (3.2%) plastic
• Citrate, theophylline, 3–4 retracted (Fig. 7-30). Syringes routinely used for
adenosine,
venipuncture range from 2 to 20 mL, and you should
Clear Light dipyridamole (CTAD)
Technical Tip 7-17. An advantage when using
Blue
choose a size corresponding to the amount of blood
syringe needles is that blood will appear in the hub
• None (plastic) 0 For use as a discard tube needed and the condition of the patient’s vein.
Clear
Red/
Light or secondary specimen of the needle when you have entered the vein
FIGURE 727 BD Vacutainer Venous Blood Collection tube.
Gray successfully.
Tube Guide.
*Inversions at blood collection Syringe Needles
Needles used with syringes are attached to a plastic Needle protection devices are available for hypo-
hub designed to fit onto the barrel of the syringe. dermic syringe needles similar to evacuated tube nee-
They are also individually packaged, sterile, and color dles. The JELCO Hypodermic Needle-Pro® (Smiths
coded as to gauge size. Routinely used syringe needles Medical North America) is a syringe needle with a
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CHAPTER 7 ✦ Venipuncture Equipment 177 178 SECTION 3 ✦ Phlebotomy Techniques

Order Tube Color Additive disposable plastic sheath attached by a hinge (Fig. 7-31).
BOX 72 Tests Affected by Anticoagulant/Additive Contamination—cont’d
SPS The sheath hangs free during the venipuncture, and
1 Yellow
Sterile media bottles then you engage it over the needle by pressing the Bilirubin Gamma-GT
2 Light blue Sodium citrate sheath against a flat surface after the procedure is Calcium Glucose
Red plastic Clot activator complete. CK-MB High-density lipoprotein (HDL) cholesterol
Red glass No additive The BD SafetyGlide™ hypodermic needle (Becton, Copper Iron
Red and
gray SST
Gel separator tube
with clot activator
Dickinson, and Company) (Fig. 7-32) has a movable Creatine kinase (CK) Phosphorus
3 Gold SST Gel separator tube shield that you push along the cannula with the Gamma-GT Sodium
with clot activator thumb to enclose the needle tip after the venipunc- Insulin Triglycerides
Orange RST Gel separator tube
with thrombin ture. Becton, Dickinson, and Company also has an Iron Uric acid
Royal blue Clot activator Eclipse™ hypodermic needle with a shield that you Lactate dehydrogenase (LDH) Sodium fluoride
Light green Gel separator tube lock over the needle tip after completion of the Lipid electrophoresis Acid phosphatase
4
PST with heparin venipuncture procedure (Fig. 7-33). Then you dis- Lithium Alanine aminotransferase (ALT)
Green Heparin
card the entire needle and syringe assembly in the Low-density lipoprotein (LDL) cholesterol Alkaline phosphatase
Royal blue Heparin
designated sharps container. The technique for use Potassium Amylase
Lavender EDTA
Pink
of syringes is discussed in Chapter 9. Protein electrophoresis Aspartate aminotransferase (AST)
EDTA
Tan EDTA PT Bilirubin
5
Royal blue EDTA Blood Transfer Devices Red blood cell morphology BUN
White PPT Gel separator
When you draw blood in a syringe, you must transfer Sodium Cholesterol
with EDTA
it immediately to appropriate evacuated tubes to pre- Triiodothyronine (T3) Cholinesterase
Potassium oxalate
6 Gray
Sodium fluoride vent the formation of clots. It is not acceptable to Triglycerides CK-MB
puncture the rubber stopper with the syringe needle Vitamin B12 Copper
7 Yellow ACD
and allow the blood to be drawn into the tube. A Sodium citrate Creatine kinase (CK)
blood transfer device provides a safe means for blood Acid phosphatase Creatinine
FIGURE 729 Clinical and Laboratory Standards Institute
(CLSI) recommended order of draw. transfer without using the syringe needle or removing Alkaline phosphatase Gamma-GT
Alpha-1-antitrypsin HDL cholesterol
Amylase LDH
Bilirubin Sodium
Calcium Triglycerides
BOX 72 Tests Affected by Anticoagulant/Additive Contamination Cholesterol Uric acid
CK-MB Clot activator (silica)
EDTA Heparin
Copper APTT
Acid phosphatase Acid phosphatase
Creatine kinase (CK) PT
Activated partial thromboplastin time (APTT) Activated clotting time
Creatinine
Alkaline phosphatase APTT
Alpha-1-antitrypsin Albumin
Amylase Ammonia (ammonium heparin)
Calcium Blood urea nitrogen (BUN) (ammonium heparin)
Ceruloplasmin Cholinesterase
Cholinesterase CK-MB
Copper Erythrocyte sedimentation rate (ESR)
Creatine kinase-MB (CK-MB) Gamma-glutamyl transferase (Gamma-GT) Luerlock tip Barrel Plunger
Creatinine Iron
Iron Lithium (lithium heparin)
Iron binding capacity PT
Lipase Sodium (sodium heparin)
Lipids Potassium oxalate
Potassium Acid phosphatase
Prothrombin time (PT) APTT
Sodium Alkaline phosphatase
FIGURE 731 JELCO® Hypodermic Needle-Pro® safety
Uric acid Amylase FIGURE 730 Diagram of a syringe. needle.

Continued
6842_Ch07_155-190 14/01/19 4:22 PM Page 179
FIGURE 732 BD SafetyGlide™ hypodermic needle.
FIGURE 733 BD Eclipse™ hypodermic needle.
the tube stopper (Fig. 7-34). It is an evacuated tube
holder with a rubber-sheathed needle inside. After
blood collection, insert the syringe tip into the hub
of the device and fill the evacuated tubes by pushing
them onto the rubber-sheathed needle in the holder
as in an ETS, as shown in Figure 7-35.
Technical Tip 7-18. It is important that you hold
the syringe and tube in a vertical position when
using the blood transfer device to prevent
carryover of anticoagulants or additives from
previously filled tubes.
CHAPTER 7 ✦ Venipuncture Equipment
FIGURE 734 Types of blood transfer devices.
FIGURE 735 BD blood transfer device with syringe and
evacuated tube.
Discard the entire syringe/holder assembly in the
sharps container after use. Use only syringes with
needle safety devices with this system. Be sure to
activate the needle safety device immediately when
you remove the needle from the patient’s vein to
avoid accidental needle sticks.
6842_Ch07_155-190 14/01/19 4:22 PM Page 180
179 180 SECTION 3 ✦ Phlebotomy Techniques
Technical Tip 7-19. Let the vacuum in the
evacuated tube draw the appropriate amount of
blood into the tube. Discard any extra blood left in
the syringe; do not force it into the tube.
Safety Tip 7-7. Do not unthread the syringe from
the blood transfer device. Place the entire assembly
in a sharps container. Use a safety needle device with
this system.
When you fill tubes from a syringe, the CLSI rec-
ommends that you fill the tubes in the same order as
recommended for the order of draw for the ETS.
Preexamination Consideration 7-8. B
According to the current CLSI recommendation,
you may not use syringes for collecting specimens
for testing cobalt and chromium because the
A
plunger tip may contaminate the specimen with
these trace elements.
FIGURE 736 Winged blood collection sets. A, Attached to a
syringe. B, Attached to an evacuated tube system ETS holder.
WINGED BLOOD COLLECTION
SETS Technical Tip 7-20. In the interest of cost
containment and safety, you should not become
dependent on the use of winged blood collection
Winged blood collection sets (or “butterflies” as they
sets for patients with veins that can be accessed
are routinely called) are used for the infusion of IV
with a standard ETS.
fluids and for performing venipuncture from very
small or very fragile veins, often seen in oncology,
The flexible tubing can make the winged blood col-
pediatric, and geriatric populations. Winged blood
lection set more difficult to manage. The length of the
collection needles used for phlebotomy are usually
tubing also results in approximately 0.5 mL less blood
21- or 23-gauge with lengths of 0.5 to 0.75 in. Plastic
entering the first collection tube, which can interfere
attachments to the needle that resemble butterfly
with coagulation tests. It is more expensive to use the
wings are used for holding the needle during inser-
winged blood collection set than the standard ETS, and
tion and to secure the apparatus during IV therapy.
you should avoid becoming overly dependent on the
They also allow lowering of the needle insertion angle
winged blood collection set for specimen collection.
when working with very small veins. To accommodate
the dual purpose of venipuncture and infusion, the
needle is attached to flexible 5- to 12-in. plastic tubing Technical Tip 7-21. You should draw a clear
that then can be attached to an IV setup, syringe, or “discard” tube or another tube with the same
evacuated tube holder (Fig. 7-36). additive before tubes that are affected by an
incorrect blood-to-anticoagulant ratio. Air in the
winged blood collection set tubing will cause the
Safety Tip 7-8. Take extreme care when working
first tube collected to underfill.
with winged blood collection needles to avoid
accidental needle punctures. Always hold the
There are several winged blood collection sets with
apparatus by the needle wings and not by the
built-in safety devices (Fig. 7-37). The BD Vacutainer
tubing.
Safety-Lok™ blood collection set (Becton, Dickinson,
6842_Ch07_155-190 14/01/19 4:22 PM Page 181
C
B A variety of portable devices are available to locate
A The tourniquets used most frequently are flat, one-
FIGURE 737 Examples of winged blood collection needles.
A, VACUETTE® safety blood collection set (Greiner Bio-One,
Kremsmunster, Austria). B, BD Vacutainer Safety-Lok™ blood
collection set (Becton, Dickinson, and Company, Franklin
Lakes, NJ). C, BD Vacutainer Push Button Blood Collection
Set (Becton, Dickinson and Company, Franklin Lakes, NJ).
and Company) has a translucent protective shield that
covers the needle immediately after removal from the
vein. After use, the needle is completely retracted into
the shield and locked in place by pushing the shield
forward (Fig. 7-37B). The BD Vacutainer Push
Button Blood Collection Set uses in-vein activation of
the needle. The needle is retracted into the device
automatically when you push the activation button
using your index finger while the needle is still in the
vein (Fig. 7-37C). The BD Vacutainer Ultratouch™
Push Button Blood Collection Set employs BD patented
Penta Point™ Comfort and RightGauge™ UltraThin
Wall technology, which increases the needle’s inner
diameter without increasing the outer diameter. This
new device reduces penetration forces by up to 32 per-
cent without compromising specimen quality and blood
flow. The advantage of this design is the ability to use
smaller-gauge needles for patients with difficult or frag-
ile veins. The flatter, thinner surface minimizes patient
discomfort during blood collection.
The VACUETTE safety blood collection set (Greiner
Bio-One, Kremsmunster, Austria) is activated by depre-
ssing both sides of the stopper and sliding it until the
tip of the needle is retracted and covered by the protec-
tive shield (Fig. 7-37A). The Punctur-Guard Winged
Blood Collection Set (Bectdon, Dickinson, Franklin
Lakes, NJ) produces a safety device that blunts the
needle before you withdraw it from the vein (Fig. 7-38).
6842_Ch07_155-190 14/01/19 4:22 PM Page 182
CHAPTER 7 ✦ Venipuncture Equipment 181
FIGURE 738 Punctur-Guard Winged Blood Collection Set.
(With permission from Gaven Medical, Vernon, CT.)
The Monoject Angel Wing safety needle (Kendall,
Mansfield, MA) utilizes a stainless-steel safety shield
that locks in place to cover the needle when you with-
draw it from the vein.
The technique for use of winged blood collection
sets is covered in Chapter 9.
COMBINATION SYSTEMS
The S-Monovette® Blood Collection System (Sarstedt,
Inc., Newton, NC) is an enclosed multisampling
blood collection system that includes the blood
collection tube and collection device. Blood is
collected using either an aspiration or vacuum prin-
ciple and multisampling needles with preassem-
bled holders, needle protection devices, and a
safety winged blood collection set (Fig. 7-39). The
FIGURE 739 S-Monovette® Blood Collection System
(Sarstedt, Inc., Newton, NC).
182 SECTION 3 ✦ Phlebotomy Techniques
advantage to this system is that no specimen trans-
fers are required.
TOURNIQUETS
Tourniquets are used during venipuncture to make it
easier to locate patients’ veins. Tourniquets work by
impeding venous but not arterial blood flow in the
area just below where the tourniquet is applied. The
distended vein then becomes more visible or palpable.
Tourniquets are available in both adult and pediatric
sizes.
time-use, nonlatex strips (nitrile or vinyl) (Fig. 7-40).
Latex-free tourniquets are available on a roll that is
perforated. After you use a stretch tourniquet, you
discard it.
Blood pressure cuffs can be used as tourniquets.
They are used primarily for veins that are difficult to
locate. In these situations, inflate the cuff to a pressure
FIGURE 740 Latex-free tourniquet.
of just below the diastolic blood pressure number.
This allows blood to flow into but not out of the
affected veins.
The application of tourniquets and their effects
on blood tests are discussed in Chapters 8 and 9.
VEINLOCATING DEVICES
veins that are not easily visible, particularly in the in-
fant, pediatric, and elderly patient in whom every
attempt should be made to avoid multiple venipunc-
tures. The Venoscope® II (Fig. 7-41) and Neonatal
Transilluminator (Venoscope, L. L. C., Lafayette, LA)
use high-intensity LED lights that shine through the
patient’s subcutaneous tissue to highlight the veins by
absorbing the light rather than reflecting it. The vein
stands out as a dark line, enabling you to note its di-
rection, which allows you to mark the vein for needle
insertion. The Wee-Sight Transilluminator (Philips
Children’s Medical Ventures, Monroeville, PA) is de-
signed for a baby’s tiny veins. It does not emit heat,
making it safe for an infant’s delicate skin. The Vein
Entry Indicator Device (VEID™) (Vascular Technolo-
gies, Ness-Ziona, Israel) uses sensor technology to in-
dicate correct insertion of a catheter needle into a
vein. The device emits a continuous beeping signal,
indicating a change of pressure when the needle
penetrates a vein. The beeping signal stops when the
needle exits the vein.
GLOVES
OSHA and the Centers for Disease Control/Healthcare
Infection Control Practices Advisory Committee man-
dates that you wear gloves when collecting blood, and
you must change the gloves after each patient. Under
routine circumstances, gloves do not need to be sterile.
To provide maximal manual dexterity, they should fit
securely.
Gloves are available in several varieties. You may
use nonlatex nitrile, neoprene, polyethylene, and
vinyl gloves for phlebotomy (Fig. 7-42). Gloves with
powder should never be used because the powder
can contaminate patient specimens and cause falsely
elevated calcium values. The glove powder can also
cause a sensitization to latex. Allergenic latex proteins
are absorbed on the glove powder, which become
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CHAPTER 7 ✦ Venipuncture Equipment 183 184 SECTION 3 ✦ Phlebotomy Techniques

Gauze Pads Biohazard Bags

FIGURE 742 Gloves.
PUNCTURE SITE PROTECTION
SUPPLIES
The recommended antiseptic used for cleansing the
skin in routine phlebotomy is 70 percent isopropyl al-
cohol. This is a bacteriostatic antiseptic used to prevent
contamination by normal skin bacteria during the
short period required for collection of the specimen.
A
For collections that require additional antisepsis,
such as blood cultures, use stronger antiseptics such as
iodine or chlorhexidine gluconate (for patients allergic
to iodine) to cleanse the area (Fig. 7-43). To prevent
skin discomfort, always remove iodine from the patient’s
skin with alcohol after a phlebotomy procedure.
Use gauze pads that are 2 in. × 2 in. for applying
pressure to the puncture site after you have re-
moved the needle. Gauze pads can also serve as
additional protection when folded in quarters and
placed under a bandage. Cotton balls are not rec-
ommended because they stick to the site and dis-
rupt the platelet plug when removed, which may
reinitiate bleeding.
Bandages
Place latex-free bandages or adhesive tape over the
puncture site when the bleeding has stopped. Self-
adhesive gauze is preferred for patients who are aller-
gic to adhesive bandages and for the elderly with thin
skin or when more pressure is required after arterial
puncture or blood collection in patients with exces-
sive bleeding (Fig.7-44).
ADDITIONAL SUPPLIES
Slides
You may need glass microscope slides to prepare
blood films for certain hematology tests. This proce-
dure is discussed in Chapter 11.
Biohazard bags should be available for transport of
specimens according to facility protocol. They must
be leakproof and clearly show a biohazard label. Most
have an outside pocket for the requisition forms.
Handheld Sanitizers
Alcohol-based hand sanitizers are an acceptable sub-
stitute for hand sanitizing when your hands are not
visibly soiled. Wall-mounted hand sanitizers with either
gels or foams are available in all health-care settings.
Carrying personal bottles of hand sanitizers provides
a convenient, readily available method of decontami-
nation (Fig. 7-45).
Pen
The final piece of equipment you will need is an in-
delible pen for labeling tubes, initialing computer-
generated labels, or noting unusual circumstances on
the requisition form.

Technical Tip 7-22. When using either iodine or

chlorhexidine gluconate, ask the patient about
allergies. Increasing numbers of patients are
B allergic to iodine or chlorhexidine gluconate.

FIGURE 741 A, Venoscope® II transilluminator device. (With

permission from Di Lorenzo, MS, and Strasinger, SK: Blood
Collection: A Short Course, ed. 2. FA Davis, Philadelphia, 2010.)
B, A vein appears as a dark line between the light-emitting
arms of the Venoscope. (Courtesy of Venoscope, LLC.)

airborne and can be inhaled when the gloves are put

on and taken off.

Safety Tip 7-9. You must sanitize your hands after

removing gloves to prevent the transmission of
bloodborne pathogens. Cotton glove liners can be
worn under gloves for people who develop an
allergic dermatitis to gloves.
FIGURE 743 Antiseptics. FIGURE 744 Bandages. FIGURE 745 Handheld personal hand sanitizer.
6842_Ch07_155-190 14/01/19 4:22 PM Page 185
QUALITY CONTROL
Ensuring the sterility of needles and puncture de-
vices and the stability of evacuated tubes, anticoagu-
lants, and additives is essential to patient safety and
specimen quality. Disposable needles and puncture
devices are individually packaged in tightly sealed
sterile containers.
Safety Tip 7-10. You should never use puncture
equipment when the seal has been broken.
Visual inspection for nonpointed or barbed nee-
dles may detect manufacturing defects. Manufacturers
of evacuated tubes must ensure that tubes, anticoagu-
lants, and additives meet the standards established by
the CLSI. Evacuated tubes produced at the same time
are referred to as a lot and have a distinguishing lot
number printed on the package. An expiration date
is also printed on each package. The expiration date
represents the last day the manufacturer guarantees
the stability of the specified amount of vacuum in the
tube and the reactivity of the anticoagulants and ad-
ditives. Check the expiration date each time a new
package of tubes is opened, and never use outdated
tubes.
Technical Tip 7-23. Use of expired tubes
may cause incompletely filled tubes (short
draws), clotted anticoagulated specimens,
improperly preserved specimens, and insecure
gel barriers.
Failure to completely fill tubes (short draws)
containing anticoagulants and additives affects
specimen quality because the amount of anticoag-
ulant or additive present in the tube is based on
the assumption that the tube will be filled com-
pletely. Possible errors include excessive dilution of
the specimen by liquid anticoagulants and distor-
tion of cellular structure by increased chemical
concentrations.
Preexamination Consideration 7-9.
Underfilled sodium citrate tubes (light blue
stopper) will have an incorrect anticoagulant-to-
blood ratio, which can cause a falsely lengthened
APTT result.
CHAPTER 7 ✦ Venipuncture Equipment
Preexamination Consideration 7-10.
Underfilled EDTA tubes cause RBC shrinkage,
which affects hematology tests.
Technical Tip 7-24. Avoid manual filling of tubes
with anticoagulant to maintain the correct blood-
to-anticoagulant ratio.
BIBLIOGRAPHY
BD Vacutainer® Barricor™ Lithium Heparin Plasma Blood
Collection Tubes. Becton, Dickinson and Company.
barricor.bd.com/eu/barricor-product-overview.xml.
Accessed July 27, 2018.
Becton, Dickinson and Company. BD Receives FDA 510(k)
Clearance for New Blood Collection Device to Help
Enhance Patient and Clinician Experience. www.bd.com/
en-us/company/news-and-media/press-releases/feb-17-
2016-bd-receives-fda-510-k-clearance-for-new-blood-
collection-device-to-help-enhance-patient-and-clinician-
experience. Accessed February 17, 2016.
Becton, Dickinson Vacutainer Evacuated Blood Collection
System. www.bd.com/vacutainer/productinserts.
CLSI. Collection of Diagnostic Venous Blood Specimens,
ed. 7. CLSI Standard GP41. Clinical and Laboratory
Standards Institute, Wayne, PA, 2017.
CLSI. Procedures for the Handling and Processing of Blood
Specimens, ed. 4. Approved Guideline, GP44-A4. CLSI,
Wayne, PA, 2010.
CLSI. Tubes and Additives for Venous and Capillary Blood
Specimen Collection, ed. 6. Approved Standard GP39-A6.
CLSI, Wayne, PA, 2010.
Greiner Bio-One. Venous Blood Collection. shop.gbo.com/
en/usa/products/preanalytics/venous-blood-collection/.
Accessed July 27, 2018.
Greiner Bio-One. Widespread Errors Made During Blood
Collection. https://www.gbo.com/fileadmin/user_upload/
Downloads/Brochures/Brochures_Preanalytics/English/
980183_Preanalytics_Manual_e_rev05_0216_lowres.pdf.
Accessed July 27, 2018.
International Sharps Injury Prevention Society. Safety Products.
www.isips.org/page/needlesticks. Accessed July 27, 2018.
Occupational Safety and Health Administration. Disposal
of Contaminated Needles and Blood Tube Holders Used
in Phlebotomy. Safety and Health Information Bulletin,
www.osha.gov/dts/shib/shib101503.html.
Phlebotomy Today Stat! 2016 Center for Phlebotomy Edu-
cation, Inc., October 2016. www.phlebotomy.com/pt-stat/
stat1016.html. Accessed July 27, 2018.
Smiths Medical. Jelco®. www.smiths-medical.com/brands/
jelco. Accessed July 27, 2018.
VanishPoint Safety by Design. http://b2icontent.irpass.cc/
577/166726.pdf. Accessed November 20, 2018.
Venoscope. Home page. www.venoscope.com. Accessed
July 27, 2018.
6842_Ch07_155-190 14/01/19 4:22 PM Page 186
185 186 SECTION 3 ✦ Phlebotomy Techniques
Key Points
✦ A well-stocked phlebotomy tray contains
racks with evacuated blood collection tubes,
tube holders and multisample needles,
syringes with safety hypodermic needles,
winged blood collection sets, blood transfer
devices, tourniquets, alcohol pads, gauze,
bandages, gloves, microcollection equipment,
and a biohazard sharps container. Mobile
phlebotomy workstations, containing all blood
collection supplies, laptop or personal digital
assistant (PDA), scanner to identify patients,
and a label printer, are wheeled to patients’
rooms. Drawing stations are permanent
outpatient blood collection centers.
✦ Needle size varies by length and gauge.
The needle gauge refers to the diameter of
the needle lumen; the lower the number, the
larger the needle. Needles used for blood
collection range from 16- to 25-gauge sizes.
Standard needles used for venipuncture are
21- and 22-gauge needles with a 1- or 1.5-in.
length. Needles of 23 gauge with a 0.75-in.
length may be used for children and patients
with small, fragile veins.
✦ Needles for venipuncture have a bevel (angled
point), a hollow shaft, and a hub that attaches
to a holder or syringe. Double-pointed needles
are used with the ETS.
✦ OSHA requires the use of safety needles or
holders with engineered safety devices that
include self-sheathing, retractable, and blunting
needles. You must follow all manufacturer’s
recommendations in the correct operation of
the safety device. Never manually recap a needle
or remove it from the holder. Dispose of needles
in an approved sharps container.
✦ The ETS consists of a double-pointed
multisample needle, a holder, and color-coded
evacuated blood collection tubes. You collect
the blood directly into the tube, eliminating the
need to transfer specimens.
✦ Syringes attach to a hypodermic needle and are
used for small and fragile veins. They allow you
to control the suction on the vein.
✦ Winged blood collection sets (butterflies) can be
attached to a holder, a syringe, or an IV setup.
They are used for performing venipuncture
from very small fragile veins and often are used
with children and the elderly. You can use the
wings to guide the needle in the vein and to
lower the needle insertion angle.
✦ Color-coded evacuated tubes are labeled with
the type of anticoagulant or additive, the
draw volume, and the expiration date. Each
laboratory department has specific specimen
requirements for the analysis of particular
blood constituents.
✦ EDTA, sodium citrate, and potassium oxalate
prevent clotting by binding or chelating calcium.
Heparin prevents clotting by inhibiting thrombin
in the coagulation cascade. You must invert these
tubes gently three to eight times to ensure
adequate mixing.
✦ You should collect blood in collection tubes
in a specific order to prevent carryover
of anticoagulants or additives that cause
contamination of the specimen. The correct
order is (1) blood culture (SPS); (2) light blue
(sodium citrate); (3) clot tubes: gold, red/gray
(serum gel separator tube), red (glass or
plastic), royal blue with clot activator, and
orange (thrombin); (4) heparin tubes: green,
light green, green/black (plasma gel separator
tube with heparin), and royal blue with heparin;
(5) EDTA tubes: lavender, pink, white (plasma
gel separator tube with EDTA), tan, and royal
blue; (6) gray (sodium fluoride and potassium
oxalate); and (7) yellow (ACD).
✦ Tourniquets are used to make the vein more
visible by impeding venous blood flow but not
arterial blood flow. You may use flat, nonlatex
strips and blood pressure cuffs. Portable vein-
locating devices are available.
✦ Substances used to cleanse the skin before
venipuncture include 70 percent isopropyl
alcohol for routine venipuncture and iodine or
chlorhexidine gluconate for collections for
blood cultures.
✦ OSHA mandates that gloves be worn when
collecting blood and be changed after each
patient.
✦ Use gauze pads to apply pressure to the
puncture site after you have removed the
needle. Then you can place latex-free bandages,
paper tape, or self-adhering gauzelike material
over the gauze after bleeding has stopped.
6842_Ch07_155-190 14/01/19 4:22 PM Page 187
✦ Additional blood collection supplies include a
pen, slides, alcohol-based hand sanitizers, and
biohazard bags.
✦ Quality control of venipuncture equipment is
essential to patient safety and specimen quality.
You must visibly inspect needles for nonbeveled
Study Questions
1. A reclining phlebotomy chair is part of a
a. phlebotomy collection tray.
b. mobile phlebotomy workstation.
c. phlebotomy drawing station.
d. portable infant phlebotomy station.
2. Which of the following is not routinely carried
on a phlebotomist’s tray?
a. Evacuated tubes
b. Tourniquets
c. Syringes
d. Urine collection cups
3. Which of these needles has the smallest
diameter?
a. 16-gauge needle
b. 21-gauge needle
c. 22-gauge needle
d. 23-gauge needle
4. Before disposing of a contaminated needle, you
must
a. recap the needle.
b. remove the needle from the ETS holder.
c. activate the safety device.
d. always use two hands.
5. The advantage of an ETS system is that
a. blood is directly collected into the evacuated
tube.
b. blood is placed in the tube using a transfer
device.
c. you can control the suction pressure on the
vein.
d. the angle of the needle can be lowered.
6. The winged blood collection set is used
primarily for
a. heel sticks.
b. large antecubital veins.
c. fingersticks.
d. hand veins.
CHAPTER 7 ✦ Venipuncture Equipment
points or bent shafts and ensure they are sterile.
Check the expiration date each time you open a
new package of tubes. Use of expired tubes may
cause short draws, clotted anticoagulated
specimens, improperly preserved specimens,
and insecure gel barriers.
7. Which of the following tubes contains an
anticoagulant that inhibits thrombin?
a. Tube with a lavender stopper
b. Tube with a white stopper
c. Tube with a light blue stopper
d. Tube with a green stopper
8. EDTA, sodium citrate, and potassium oxalate
anticoagulants prevent blood clotting in blood
collection tubes by
a. binding calcium.
b. binding fibrinogen.
c. acting as an antithrombin agent.
d. releasing heparin.
9. Which of the following can be used to obtain a
serum specimen?
a. PPT
b. PST
c. SST
d. EDTA tube
10. Which tube additive preserves glucose?
a. Sodium citrate
b. Sodium heparin
c. Sodium polyanethol sulfonate
d. Sodium fluoride
11. Which tube must always be filled to the correct
ratio?
a. Light blue stopper tube
b. Light green PST
c. Gold SST
d. Tan stopper tube
12. According to the CLSI, which of the following is
an acceptable order of tube draw?
a. Light blue, light green, and lavender
b. Red, light blue, and lavender
c. Lavender, red, and yellow
d. Yellow, green, and light blue
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187 188 SECTION 3 ✦ Phlebotomy Techniques
13. A tourniquet is used in routine venipuncture to 15. Using evacuated tubes past their expiration date
a. impede venous blood flow. may result in
b. impede arterial blood flow. a. clotted anticoagulated tubes.
c. harden the vein. b. completely filled tubes.
d. flatten the vein. c. secure gel barriers.
d. clotted serum tubes.
14. The primary antiseptic for routine venipuncture is
a. iodine.
b. chlorhexidine gluconate.
c. isopropyl alcohol.
d. soap and water
Clinical Situations
1 At Healthy Hospital laboratory, the information on a requisition form requesting a liver
panel, an amylase level, and a theophylline level tells you to collect a gold SST and a red
stopper tube.
a. Which test must be performed on the red stopper tube?
b. Serum from which tube could be used by the serology department if an additional test
was requested?
c. Why is a gold SST preferred over a red stopper tube for most chemistry tests requiring
serum?
d. State a reason why a different laboratory might require a green PST instead of a gold SST.
2 Katia, the phlebotomy supervisor, is investigating the following complaints. State a
technical phlebotomy error that could be the cause of each problem.
a. The coagulation laboratory rejects a light blue stopper tube for a PT. The
phlebotomist used a winged blood collection set.
b. The chemistry laboratory rejects an SST into which blood from a syringe has been
transferred.
c. The phlebotomy team complains about getting short draws with lavender stopper
tubes but not red stopper tubes during morning collections.
d. The hematology supervisor rejected a lavender stopper tube because of a clot in the
specimen.
3 Jacob, the phlebotomist, was called to the emergency department (ED) to collect blood for
a glucose and CBC from a patient. Jacob collected lavender stopper and gray stopper
tubes. The doctor then suspected the patient was having a myocardial infarction (MI) and
ordered an MI panel, PT, APTT, and type and crossmatch. Because George had a difficult
time obtaining the first specimens, the nurse asked if the tests could be performed on
blood already collected.
a. Can a lavender stopper tube be used to perform a PT and APTT? Why or why not?
b. Can a glucose and an MI panel be performed on a gray stopper tube? Why or why not?
c. What tube is used to perform a crossmatch?
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CHAPTER 7 ✦ Venipuncture Equipment 189

4 Janeen was asked to draw blood for a CBC and a basic metabolic panel (BMP) from a
patient with very small, fragile veins. Janeen chose a syringe with a 25-gauge needle to use
for the blood draw. The chemistry supervisor questioned the potassium results and asked
that the blood specimen be redrawn.
a. What tubes should be used to collect blood for the CBC and BMP tests?
b. What is the correct order of fill for a syringe?
c. Name two reasons why the potassium results will be incorrect.
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8
192 SECTION 3 ✦ Phlebotomy Techniques

where the laboratory staff generates a requisition form.

INTRODUCTION
CHAPTER The procedure that is performed most frequently in
blood collection is the venipuncture. Your ability to
perform this technique in an organized, patient-
In some health-care providers’ offices, the health-care
provider uses a prescription pad to write the laboratory
tests ordered. The patient then takes the prescription
to a clinical laboratory where the requisition form is
prepared following the health-care provider’s orders.

Routine Venipuncture
Learning Outcomes
Upon completion of this chapter, the reader will be able to:
8.1 List the required information on a test requisition form.
8.2 Discuss the appropriate procedure to follow when greeting and
reassuring a patient.
8.3 Describe correct identification procedures for inpatients and
outpatients.
8.4 Describe patient preparation and positioning.
8.5 Correctly assemble venipuncture equipment and supplies.
8.6 Identify the three veins used most frequently for venipuncture.
8.7 Correctly apply a tourniquet, and state why the tourniquet can be
applied for only 1 minute.
8.8 Describe vein palpation.
8.9 Discuss the procedure for cleansing the venipuncture site.
8.10 State the steps in a venipuncture procedure, and correctly perform a
routine venipuncture using an evacuated tube system (ETS).
8.11 Demonstrate safe disposal of contaminated needles and supplies.
8.12 List the information required on a specimen tube label.
8.13 Explain the importance of delivering specimens to the laboratory in a
timely manner.
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considerate manner is the key to success. Each phle- Inpatient requisition forms may be delivered to the
botomist develops his or her own style for dealing laboratory, sent by pneumatic tube system, or entered
with patients and performing the actual venipuncture. into the hospital computer at the nursing station and
Administrative protocols vary among facilities, and of printed out by the laboratory computer or accessed by
course, every patient is different. However, many basic a computer at the patient’s bedside.
rules are the same in all situations. You must follow You should carefully examine all requisition forms
these basic rules to ensure your safety and the safety before leaving the laboratory. Review each requisition
Key Terms of the patient, produce specimens that are represen- form to verify the tests to be collected and the time and
tative of the patient’s condition, and create an efficient date of collection, as well as to determine whether any
Antecubital fossa phlebotomy service for the facility. special conditions or patient preparation requirements,
Bar codes In this chapter, the routine venipuncture technique
such as fasting, must be met before the venipuncture.
Basilic vein is presented for the beginning phlebotomist in a step-
You should check that all requisition forms for a partic-
Cephalic vein by-step procedure as recommended by the Clinical
ular patient are together so that all the tests are col-
Hematoma and Laboratory Standards Institute (CLSI) standards.
lected with one venipuncture and that you have all the
Hemoconcentration The procedure is outlined again in Chapter 9 with
necessary equipment.
Hemolysis a presentation of the complications that may occur at
Identification (ID) band each step. Manual Requisition Forms
Median cubital vein
The actual format of a requisition form may vary.
Palpation
Patient information may be handwritten or imprinted
Radio frequency Preexamination Consideration 8-1. on color-coded forms with test check-off lists for dif-
identification (RFID) According to the CLSI, a standardized venipuncture
ferent departments (Fig. 8-1). There may be multiple
Requisition form procedure can reduce or eliminate errors that can
copies for purposes of record-keeping and billing.
Taut affect specimen quality and the patient’s test
Venipuncture results.
VENIPUNCTURE PROCEDURE
Requisition Form
All phlebotomy procedures begin with the receipt of
a test requisition form that is generated by or at the
request of a health-care provider. The requisition
form becomes part of the patient’s medical record
and provides the information needed to correctly
identify the patient, organize the necessary equip-
ment, collect the appropriate specimens, and provide
legal protection. You should not collect a specimen
without a requisition form, and this form must accom-
pany the specimen to the laboratory.
Methods for receiving a requisition form vary with
the setting. Requisition forms from outpatients may
be hand carried by the patient, or lab orders may be
telephoned or faxed to the specimen processing or
accessioning area by the health-care provider’s office, FIGURE 81 Manual requisition form.

191
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CHAPTER 8 ✦ Routine Venipuncture 193 194 SECTION 3 ✦ Phlebotomy Techniques

Computer Requisition Forms Table 8-1). The required information on a requisition TABLE 81 ● Standard and Military Time Comparison
manner the patient can understand. It is helpful to
Computer-generated forms can include not only is listed in Box 8-1. explain to the patient that his or her health-care
STANDARD MILITARY provider has ordered the laboratory tests. Then the
patient information and tests requested but also more
information or instructions. You may also find tube 12:00 midnight 0000 patient can give you permission to collect the speci-
Technical Tip 8-1.You should never collect men. Carefully listen to the patient, and observe the
labels and bar codes for specimen processing, the num- specimens before receiving or generating the
1:00 a.m. 0100
ber and type of collection tubes needed, and special patient’s body language. Consent may be verbal or
requisition form. 6:00 a.m. 0600
collection instructions (Fig. 8-2). Figure 8-3 shows a nonverbal, which is indicated by the patient extend-
11:00 a.m. 1100 ing his or her arm or rolling up his or her sleeve. In
computer-generated specimen requisition form with
12:00 noon 1200 the outpatient setting, the patient usually knows what
accompanying labels. Technical Tip 8-2. All required patient and test
Requisition forms must contain certain basic infor- 1:15 p.m. 1315 is about to occur (Fig. 8-5).
information is provided on labels generated by
mation to ensure that the specimen drawn and the the computer information system. 5:00 p.m. 1700
test results are correlated with the appropriate patient
10:00 p.m. 2200
and that these can be correctly interpreted regarding Technical Tip 8-3. The more relaxed and trusting
special conditions, such as the time of collection (see 11:59 p.m. 2359
ENTERING A PATIENT’S ROOM your patient is, the greater the chance of a
successful, atraumatic venipuncture.

FIGURE 82 Computer requisition forms printed in the
laboratory.
When entering a patient’s room, it is polite to knock
lightly on the open or closed door to make your
presence known. If the curtain is closed around the
bed, speak to the patient first through the curtain.
This will avoid any embarrassment or invasion of the
patient’s privacy if he or she happens to be bathing
or using the bedpan. In the hospital setting, a variety
of other circumstances may be present that require
additional considerations when greeting the patient.
These circumstances are discussed in Chapter 9.
Room Signs
Observe any signs on the patient’s door or in the
patient’s room that relay special instructions, such as
an allergy to latex, nothing by mouth (NPO), do not
resuscitate (DNR), do not draw blood from (a partic-
ular) arm, infection control precautions, or patient
expired (Fig. 8-4). A sign with a picture on it may be
used in place of written warnings.
Greeting the Patient
Your professional demeanor instills confidence and
trust in the patient, which can effectively ease his or
her apprehension about the procedure. When ap-
proaching patients, you should introduce yourself
and say that you are from the laboratory. If you are a
student, you must tell the patient. Explain the in-
tended procedure in nontechnical terms and in a
PATIENT IDENTIFICATION
The most important procedure in phlebotomy is cor-
rect identification of the patient. Serious diagnostic
or treatment errors and even death can occur when
blood is drawn from the wrong patient. The CLSI
recommends two identifiers for patient identification.
The College of American Pathologists (CAP) and The
Joint Commission (TJC) patient safety goals require
a minimum of two patient identifiers when collecting
blood. To ensure that blood is drawn from the right
patient, compare information obtained verbally and

BOX 81 Information Required on a Requisition Form

• Patient’s first and last names (middle if applicable or
available)
• Identification number (The identification number may
be a hospital-generated number that is also present on
the patient’s wrist identification (ID) band and in all
hospital documents; in an outpatient setting, it may be a
laboratory-assigned number.)
• Patient’s sex
• Patient’s date of birth or age (according to facility policy)
• Patient’s location
• Name of ordering health-care provider
• Tests requested
• Requested date and time of specimen collection (When
the specimen is collected, you must write the actual
date and time on the requisition form and the specimen
FIGURE 83 Specimen requisition form label. Most hospitals have adopted the military time
and labels.
system because they operate continuously for 24 hours.
Standard time and military time are similar between
midnight and noon. Afternoon standard time repeats,
but afternoon military time is standard time plus 12 (see
Table 8-1).
• Status of specimen (STAT, timed, routine)
• Other information that may be present including the
following:
• Number and type of collection tubes
• Special collection information (such as fasting
specimen or latex sensitivity)
• Special patient information (such as areas that should
not be used for venipuncture)
• Billing information and International Classification of
Diseases, Ninth Revision ICD-9-CM codes
6842_Ch08_191-222 17/01/19 11:45 AM Page 195
FIGURE 84 Warning sign in patient’s room to not use latex.
FIGURE 85 Phlebotomist greeting a patient in an
outpatient setting.
from the patient’s wrist identification (ID) band with
information on the requisition form (Fig. 8-6). It is
highly recommended that you perform a third iden-
tification check that includes comparing the labeled
specimen with the patient’s ID band or showing the
labeled specimen to the patient to confirm that the
information is correct. This ensures that specimens
are labeled correctly at the patient’s bedside.
FIGURE 86 Phlebotomist comparing information from the
requisition form with an inpatient’s identification band.
6842_Ch08_191-222 17/01/19 11:45 AM Page 196
CHAPTER 8 ✦ Routine Venipuncture 195
Inpatient Identification
Verbal identification is made after greeting patients by
asking them to state their full name, spell the last name,
and give their date of birth. Always have patients state
their names. Do not ask, “Are you Juan Jimenez?”
because many patients who are medicated, seriously
ill, or hard of hearing have a tendency to say “yes” to
anything. After verbal identification, be sure to examine
the information on the patient’s wrist ID band, which
should always be present on hospitalized patients.
Information on the wrist ID band should include the
patient’s name, hospital identification number, date of
birth or age, and physician. All information on the wrist
ID band should match the information on the requisi-
tion form and computer-generated specimen labels.
Pay particular attention to the hospital identification
number because it is possible for two patients to have
the same name, date of birth, and physician; however,
they will not have the same identification number.
Technical Tip 8-4. When identifying patients, pay
close attention to high-risk identification situations,
such as siblings or twins, newborns, common
names (John Smith), sound-alike names, and
patients who share a room.
Preexamination Consideration 8-2.
You must verify any discrepancies between the
patient’s ID band and the requisition before you
draw blood. It is estimated that 16 percent of ID
bands contain erroneous information.
It is essential that you identify hospitalized patients
from an ID band attached to the patient. Sometimes
wristbands are removed when IV fluids are being ad-
ministered in the wrist or when fluids have infiltrated
the area. They should be reattached to the patient’s
ankle. Frequently, ankle bands are used with pediatric
patients and newborns. You cannot use a wristband
lying on the bedside table for identification—it could
belong to anyone. Likewise, you cannot rely on a sign
over the patient’s bed or on the door because the
patient could be in the wrong bed.
Outpatient Identification
In an outpatient setting, after calling a patient back
to the drawing area, ask him or her to state his or her
full name; spell the last name; and give his or her
196 SECTION 3 ✦ Phlebotomy Techniques
address, birth date, and/or unique identification
number. Compare the verbal information with the
information on the requisition form and specimen
labels to verify the patient’s identification. A person
who is hard of hearing or nervous about the proce-
dure may stand and follow you to the blood collection
area from the waiting room just because you looked
at him or her when calling a patient’s name, even
when it is a different person’s name. Outpatients tra-
ditionally have not worn ID bands; however, facilities
are beginning to assign an ID band for outpatient
procedures to avoid patient identification errors. The
CLSI standard GP41 recommends that patients with-
out ID bands provide a photo ID with a patient-specific
identifier for proof of identification. Photo identifi-
cation may be a requirement for certain legal tests.
Clinics may provide a patient ID card that can be im-
printed or scanned for patient identification and to
generate a requisition form and specimen labels. Writ-
ten policies must be available for outpatient centers.
Preexamination Consideration 8-3.
The CLSI requires that a caregiver or family
member provide information on behalf of a
patient who is cognitively impaired to avoid
misidentification before you collect a specimen.
Document the name of the verifier.
Bar Code Technology
Positive patient identification using bar code technol-
ogy is becoming standard practice in many facilities.
Using a wireless handheld computer, you can identify
the patient by scanning the bar code on the patient’s
hospital ID band. You can match the patient’s identi-
fication against a blood collection order on the mobile
computer. This verifies that a blood specimen has
been ordered and the correct patient has been iden-
tified. The system, which is interfaced with the labo-
ratory information system (LIS), specifies the tests
ordered, the kind of tube to be used, and special
handling instructions. After confirmation of the patient
identification and test requests, the mobile computer
directs a lightweight handheld printer to create a
bar-coded label that is affixed to the tube before you
leave the bedside. The system detects duplicate draw
orders, new test requests, or cancellation of tests.
Labels for a specific patient are printed only after the
patient has been identified, therefore eliminating the
possibility of placing the wrong label on a specimen.
Another technology is radio frequency identification
(RFID). This is an automated wireless technology
that uses radio waves to transmit data for patient
identification and specimen tracking. The advantage
of RFID is that patient data can be updated at any
time, unlike with a bar code, for which the data are
set and nothing can be added until a new wristband
is created.
Technical Tip 8-5. You must always identify a
hospitalized patient correctly by an ID band that is
attached to the patient before you perform the
venipuncture.
Safety Tip 8-1. Even though you may be familiar
with a patient, you must never become lax with
regard to patient identification.
Preexamination Consideration 8-4.
Failure to properly identify a patient may result in
mismanagement of his or her medication and
treatment.
PATIENT PREPARATION
Reassurance of the patient actually begins with the
greeting and continues throughout the procedure.
You must demonstrate concern for the patient’s
comfort as well as confidence in your ability to
perform the procedure. Provide patients with a
brief explanation of the procedure, including any
nonroutine techniques to be used, such as addi-
tional site preparation for collection of blood cul-
tures. Never tell patients that the procedure will be
painless.
Patients often will question you about what tests
are being performed or why their blood is being
drawn so frequently. The best policy is to politely
suggest that they ask their health-care provider
these questions. Even listing the names of tests can
cause problems because many medical books and
internet sites are available to the general public.
The patient may reach erroneous conclusions be-
cause many tests have several diagnostic purposes;
or the patient may misunderstand the test name
and look up an inappropriate test associated with a
very severe condition.
6842_Ch08_191-222 17/01/19 11:45 AM Page 197
When patients must undergo repeated bedside
tests, such as glucose tests, they may ask for the result.
Often, it is written on a paper in the room that is
visible to the patient. Confirm the facility’s protocol
before telling the patient the test results.
While talking with the patient, verify that he or she
has completed any pretest preparation, such as fasting
(nothing to eat or drink except water for 8 to 12 hours
before the procedure) or abstaining from medica-
tions that can interfere with laboratory testing. When
the patient has not completed these procedures,
you should report this problem to the nurse before
drawing the blood. If the specimen is still required
after consultation with the nurse or health-care
provider, you should make note of the irregular con-
dition, such as “not fasting,” on the requisition form
and the specimen. Ask the patient if he or she has a
latex sensitivity. Use latex-free supplies when appro-
priate. Other preexamination variables are discussed
in Chapter 9.
Technical Tip 8-6. When necessary, write down
information or use sign language or an interpreter
to help the patient understand the procedure and
help him or her give permission for the blood
collection.
Technical Tip 8-7. Good verbal, listening, and
nonverbal skills are very important for patient
reassurance and trust.
Positioning the Patient
When patient identification is completed, position
the patient conveniently and safely for the procedure.
As mentioned previously, always ask the patient if he
or she is allergic to latex. If the patient is allergic to
latex, be prepared to use latex-free supplies (gloves,
tourniquets, bandages, or adhesives) and do not
bring latex items into his or her room.
Safety Tip 8-2. Never draw blood from a patient
who is in a standing position.
Situate an outpatient in a seated or reclining posi-
tion at the drawing station, as shown in Figure 8-7.
In some drawing stations, the movable arm serves
the dual purposes of providing a solid surface for the
patient’s arm and preventing him or her from falling
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CHAPTER 8 ✦ Routine Venipuncture 197
FIGURE 87 Patient seated in a blood drawing chair.
out of the chair after fainting. Be sure the patient’s
arm is firmly supported and extended downward in a
straight line from the shoulder to the wrist, allowing
the tubes to fill from the bottom up to prevent reflux
and anticoagulant carryover between tubes. Ask the
patient to make a fist with the hand of the arm not
being used and place it behind the elbow in order to
provide support and make the vein easier to locate
(Fig. 8-8). In outpatient settings, a phlebotomy wedge
is often used to correctly position the arm and pro-
vide support.
You should always be alert for any changes in the
patient’s condition while the procedure is being per-
formed. Some patients know that they experience dif-
ficulties (such as fainting) during venipuncture, and
you should allow them to lie down for the procedure.
When collecting a blood specimen in a home set-
ting, you should seat the patient in a chair with armrests
and have the patient place his or her arm on a hard sur-
face. You may use a sofa or bed if the patient is anxious
or has had difficulties during previous venipunctures.
Safety Tip 8-3. Do not collect specimens from
patients who are sitting upright on a surface
that does not have armrests or other barriers to
prevent falls.
Technical Tip 8-8. When supporting the patient’s
arm, do not hyperextend the elbow. This may make
vein palpation difficult. Sometimes, bending the
elbow very slightly aids in vein location.
It may be necessary to move a hospitalized patient
slightly so the arm is more accessible or to place a
198 SECTION 3 ✦ Phlebotomy Techniques
A
B
FIGURE 88 Positioning the patient’s arm. A, Using the
patient’s fist. B, Using a phlebotomy wedge.
pillow or towel under the arm for better support and
to position the arm in a straight line downward. If
you need to lower the bed rail in order to get ade-
quate access to the venipuncture site, you must
always return it to the raised position before you
leave the room.
Patients should remove any objects, such as food,
a drink, gum, or a thermometer, from their mouths
before you perform the venipuncture. Any foreign
object in the patient’s mouth could cause choking.
EQUIPMENT SELECTION
Before approaching the patient for the actual veni-
puncture, you should collect all necessary supplies
(including collection equipment, antiseptic pads,
gauze, bandages, and a needle disposal system) and
place them close to the patient (Fig. 8-9). Do not
place the blood collection tray on the bed or on the
patient’s eating table. Place supplies on the same side
as your free hand during blood collection to avoid
reaching across the patient and causing unnecessary
movement of the needle in the patient’s vein.
Reexamine the requisition form, and select the
appropriate blood collection system (ETS, syringe
system, or winged blood collection set) and the num-
ber and type of collection tubes, taking into consid-
eration the age of the patient and the amount of
blood to be collected. Check supplies for defects and
the expiration date on each tube. Discard any tube
that is expired.
Place the tubes in the correct order for specimen
collection, and have additional tubes readily available
for possible use during the venipuncture. It is not
uncommon to find an evacuated tube that does not
contain the necessary amount of vacuum to collect a
full tube of blood. Accidentally pushing a tube past
the indicator mark on the tube holder before the vein
is entered also results in loss of vacuum.
FIGURE 89 Venipuncture collection equipment.
6842_Ch08_191-222 17/01/19 11:45 AM Page 199
Phlebotomist Alert Do not preassemble
collection devices before you have identified the
patient.
SANITIZE HANDS AND APPLY
GLOVES
Go back to DavisPlus for Videos 3-1 and 3-2
(Hand Hygiene).
Hand hygiene is the most important factor
in preventing healthcare-associated infections (HAIs).
In front of the patient, you should sanitize your hands
using the procedure described in Chapter 3 and
apply clean gloves. Pull the gloves over the cuffs of
protective clothing (lab coat) for maximum protection.
Remember to change your gloves between patients.
Phlebotomist Alert You must use soap and
water for hands that are visibly soiled and for
patients known to be infected with Clostridium
difficile.
Safety Tip 8-4. Occupational Safety and Health
Administration (OSHA) regulations mandate that
gloves be worn when performing a venipuncture
procedure.
Technical Tip 8-9. Patients are often reassured
that proper safety measures are being followed
when you put on gloves in their presence.
TOURNIQUET APPLICATION
The tourniquet serves two functions in the veni-
puncture procedure. By impeding venous (but not
arterial) blood flow, the tourniquet causes blood to
accumulate in the veins, helping you locate them
more easily and providing a larger amount of blood
for collection. However, use of a tourniquet can alter
some test results by increasing the ratio of cellular
elements, protein-based analytes, and packed cell
volume to plasma (hemoconcentration) and by causing
hemolysis. Therefore, the maximum amount of time
that you should leave the tourniquet in place is
6842_Ch08_191-222 17/01/19 11:45 AM Page 200
CHAPTER 8 ✦ Routine Venipuncture 199 200 SECTION 3 ✦ Phlebotomy Techniques
1 minute. This requires that you apply the tourniquet
twice during the venipuncture procedure, first when
you are selecting the vein and then immediately be- PROCEDURE 81 ✦ TOURNIQUET APPLICATION
fore you perform the puncture. When you use the
EQUIPMENT: Step 3. Bring the two sides together, and hold both ends
tourniquet during vein selection, the CLSI recom- between the thumb and forefinger of one hand
mends that you release it for 2 minutes before you Latex-free strip tourniquet
close to the arm.
reapply it.
PROCEDURE:
Place the tourniquet on the patient’s arm 3 to 4 in.
above the venipuncture site. Application of the com- Step 1. Position the latex-free strip 3 to 4 in. above the
monly used flat latex-free strip requires practice to venipuncture site. Avoid areas with a skin lesion,
develop a smooth technique and can be difficult when or apply the tourniquet over the patient’s gown.
you are not wearing gloves that fit properly. Proce-
dure 8-1 shows the technique used with latex-free
strip tourniquets.
To achieve adequate pressure, you must grasp
both sides of the tourniquet near the patient’s arm,
and while maintaining tension, tuck the left side
under the right side. The loop that forms should
face downward toward the patient’s antecubital area,
and the free end should be away from the venipunc-
ture area but in a position that will allow you to pull Step 4. Tuck a portion of the left side under the right side
it easily to release the pressure. Left-handed people to make a partial loop facing the antecubital area.
would reverse this procedure. The tourniquet
should be flat around the patient’s arm and not
rolled or twisted.
Step 2. Grasp one side of the tourniquet with each hand,
and while maintaining tension, cross the
Technical Tip 8-10. Applying the tourniquet over tourniquet over the patient’s arm.
the patient’s clothing or other barrier, such as a
washcloth or gauze, prevents pinching of the skin
and discomfort to the patient.
Tourniquets that are folded or applied too tightly
are uncomfortable for the patient and may obstruct
blood flow to the area. The appearance of small, red-
dish discolorations (petechiae) on the patient’s arm,
blanching of the skin around the tourniquet, and the
inability to feel a radial pulse are indications that a
tourniquet is tied too tightly.
Technical Tip 8-11. A tourniquet applied too close
to the venipuncture site may cause the vein to
collapse as blood is removed.
Safety Tip 8-5. The use of disposable, one-time-
use, latex-free tourniquets is advised as part of good
infection control practice to avoid HAIs in patients.
Return to DavisPlus for Video 8-1 (Applying
the Tourniquet).
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CHAPTER 8 ✦ Routine Venipuncture 201 202 SECTION 3 ✦ Phlebotomy Techniques

Medial cubital Medial cubital

PROCEDURE 81 ✦ TOURNIQUET APPLICATION (Continued) nerve nerve
Subclavian Subclavian
Step 5. A properly applied tourniquet will have the ends Step 6. Pull the end of the loop to release the tourniquet vein vein
pointing up, away from the venipuncture site. with one hand. Remember, the tourniquet should
be on for only 1 minute. Basilic vein Basilic vein
Cephalic Cephalic
vein vein
Brachial Anterior median Brachial Anterior median
artery cutaneous nerve artery cutaneous nerve
Posterior median Posterior median
cutaneous nerve Accessory cutaneous nerve
cephalic vein
Median cubital Basilic vein
Accessory vein
cephalic vein Median
Basilic vein cephalic vein Median basilic
Cephalic vein Cephalic vein vein
Median vein Median vein

H M
Cephalic
vein
Cephalic vein
Median Median basilic vein
cubital
Basilic vein
vein
SITE SELECTION Brachial Median vein
artery Basilic
Cephalic vein Median
vein
The preferred site for venipuncture is the antecubital cephalic
Basilic vein vein
fossa, located anterior to and below the bend of the
elbow. As shown in Figure 8-10, three major veins— FIGURE 811 Major antecubital veins showing the H- and M-shaped patterns.
Median
the median cubital, the cephalic, and the basilic—are antebrachial Median
located in this area, and in most patients, at least one cutaneous cephalic vein
nerves
of these veins can be located easily. Vein patterns Accessory or tendons. Veins on the side of the wrist above the
vary among individuals. The arrangements of veins Median cephalic vein
thumb also must not be used to avoid nerve injury.
seen most often in the antecubital fossa are referred cubital vein
Lateral antebrachial
to as the “H-shaped” and “M-shaped” patterns. The cutaneous nerve
H-shaped pattern includes the cephalic, median Phlebotomist Alert According to the CLSI
Basilic vein
cubital, and basilic veins in a pattern that looks like a standard, you must never use the veins on the lateral
Dorsal venous
slanted H. The most prominent veins in the M-shaped network Cephalic vein (sides) and palmar (underside) of the wrist.
pattern are the cephalic, median cephalic, median
basilic, and basilic veins. The H-shaped pattern is
seen in approximately 70 percent of the population
Median Cubital Vein
FIGURE 810 Veins in the arm most often chosen for Of the three veins located in the antecubital area, the
(Fig. 8-11). Notice that the veins continue down venipuncture.
the forearm to the wrist area; however, in these areas, median cubital is the vein of choice for venipuncture
they become smaller and less well anchored, and because it is large and tends not to move when a needle
punctures are more painful to the patient. Small allow the patient more arm flexibility. Frequent is inserted. It is in the median (center) of the antecu-
Dorsal bital fossa. It is often closer to the surface of the skin,
prominent veins are also located in the back of the venipuncture in these veins could make them unsuit- metacarpal
hand (Fig. 8-12). When necessary, these veins can be able for IV use. Some facilities have special ID bands veins isolated from underlying structures, and the least
used for venipuncture, but they may require a smaller that indicate the restricted use of veins that are being painful to puncture because there are fewer nerve
needle or winged blood collection set (Fig. 8-13). used for other procedures. Veins on the underside of FIGURE 812 Veins on the back of the hand and wrist. endings in this area. Because the median cubital vein
The veins of the lower arm and hand are also the the wrist must not be used for venipuncture because
preferred site for administering IV fluids because they of the risk of accidentally puncturing arteries, nerves,
6842_Ch08_191-222 17/01/19 11:45 AM Page 203
Dorsal hand
veins
FIGURE 813 Prominent hand and wrist veins.
overlies the bicipital aponeurosis, a fibrous membrane
that provides protection to underlying structures
such as nerves and arteries, there is also less chance
of nerve injury or accidental artery puncture.
Technical Tip 8-12. According to the CLSI
standards, you should try to locate the median cubital
veins on both arms before considering other veins.
Cephalic Vein
The cephalic vein located on the thumb side of the
arm (lateral area of the antecubital fossa) is usually
more difficult to locate, except possibly in larger pa-
tients, and has tendencies to move. The cephalic vein
should be the second choice when the median cubital
is inaccessible in both arms. Avoid the most lateral as-
pect of the cephalic vein to prevent accidental injury
to the lateral cutaneous nerve.
Technical Tip 8-13. Because the cephalic vein is
usually close to the surface, a blood spurt is
possible when you insert the needle into the vein.
This can often be controlled by decreasing the
angle of needle insertion to 15 degrees.
Basilic Vein
The basilic vein is located on the inner (medial) edge
of the antecubital fossa near the median nerve and
brachial artery. The basilic vein is the least firmly
anchored; therefore, it has a tendency to “roll” as well
as a high likelihood of hematoma formation. The
CHAPTER 8 ✦ Routine Venipuncture
basilic vein should be the last choice because the
median nerve, medial cutaneous nerve, and brachial
artery are in close proximity to it, increasing the risk
of permanent injury. Take care to avoid accidentally
puncturing the brachial artery.
Technical Tip 8-14. Use of the basilic vein is
discouraged; however, if no other vein can be
accessed, always locate the brachial pulse before
puncturing the basilic vein to prevent an accidental
arterial puncture.
Safety Tip 8-6. Only superficial veins should be
used in children.
Phlebotomist Alert Collecting blood from the
basilic vein has caused more complaints, injuries,
and legal actions against phlebotomists than any
other vein.
Two routine steps in the venipuncture procedure
aid in locating a suitable vein: applying a tourniquet
and asking the patient to make a fist. The difference
in vein prominence before and after these procedures
is usually remarkable, making the veins easier to locate
and puncture. However, you should not permit the
patient to clench or pump his or her fist (vigorously
opening and closing the hand) continuously because
it will result in hemoconcentration and alter some test
results. As discussed earlier, the tourniquet can be
applied for only 1 minute; therefore, after you have
6842_Ch08_191-222 17/01/19 11:46 AM Page 204
203 204 SECTION 3 ✦ Phlebotomy Techniques
located the vein, you should remove the tourniquet
while you are cleansing the site, and then reapply it
immediately before performing the venipuncture.
Technical Tip 8-15. Patients often think they
are helping by pumping their fists because this
is an acceptable practice when donating blood.
Although a donated unit of blood is best when
the number of red blood cells, white blood cells,
and platelets is hemoconcentrated, in contrast,
hemoconcentration in laboratory specimens
adversely affects test results.
FIGURE 814 Palpating for a vein using the fingers, not the
thumb.
Preexamination Consideration 8-5.
Asking the patient to pump his or her fist may
Technical Tip 8-17. Leaving an alcohol pad on the
cause elevated potassium levels in the specimen.
patient’s arm below the venipuncture site, with the
On the basis of such erroneous results, the
corner of the pad pointing to the insertion site, can
patient’s medication may be changed in a way
that adversely affects him or her. help you relocate a vein that is not visible.
Veins are located by sight and by touch, referred
Technical Tip 8-18. Palpating for a vein that is
to as palpation. The ability to feel a vein is much more
important than the ability to see a vein—a concept not visible is easier when you are not looking
that is often difficult for beginning phlebotomists to directly at the site. Your sense of touch is
accept. Perform a palpation using the tip of the index enhanced when you cannot see the site.
finger of your nondominant hand to probe the ante- Continuing to look at and converse with the
cubital area with a pushing motion rather than a patient while palpating for the vein often leads
stroking motion. Feel for the vein in both vertical and to more successful results.
horizontal directions. Use palpation to determine the
size, depth, and direction of the vein to help direct
the needle during insertion. The pressure that you
apply by palpating locates deep veins; distinguishes Safety Tip 8-7. You should wear gloves
veins, which feel like spongy, resilient, tubelike struc- when palpating veins to prevent contact with
tures, from rigid tendon cords; and differentiates microorganisms, such as methicillin-resistant
veins from arteries, which produce a pulse (Fig. 8-14). Staphylococcus aureus (MRSA) and vancomycin-
Therefore, do not use your thumb to palpate because resistant enterococci (VRE).
it has a pulse beat.
Turning the patient’s arm slightly helps you distin-
guish veins from other structures. Select a vein that is
easily palpated and large enough to support good
CLEANSING THE SITE
blood flow. It is often helpful to find a visual reference
for the selected vein, such as its location near a mole, When you have located an appropriate vein, release
freckle, or skin crease, to assist you in relocating the the tourniquet and cleanse the area using a 70 per-
vein after you have cleansed the site. cent isopropyl alcohol prep pad to prevent bacterial
contamination of either the patient or the speci-
men. Use a back-and-forth motion, creating friction
Technical Tip 8-16. Often, veins are more
to clean an area 2 to 3 in. in diameter. For skin that
prominent in the patient’s dominant arm.
is particularly dirty, repeat this procedure using a
6842_Ch08_191-222 17/01/19 11:46 AM Page 205
new alcohol pad. For maximum bacteriostatic
action to occur, allow the alcohol to dry for 30 to
60 seconds on the patient’s arm rather than wiping
it off with a gauze pad. The drying process helps kill
the bacteria. Performing a venipuncture before
the alcohol has dried will cause a stinging sensation
for the patient and may hemolyze the specimen. Do
not reintroduce microbial contaminants by touch-
ing the site, blowing on the site, or fanning the area
to dry the alcohol or dry the area with nonsterile
gauze.
Preexamination Consideration 8-6.
Alcohol contamination may cause hemolysis,
affecting the integrity of the specimen.
Technical Tip 8-19. Patients are quick to
complain about a painful venipuncture. The
stinging sensation caused by undry alcohol
is a frequent cause of complaints that is easily
avoided.
Technical Tip 8-20. The current CLSI standard
states that cleansing with back-and-forth friction is
superior to circular concentric cleansing, which was
recommended previously.
Technical Tip 8-21. If you must feel for the vein
after cleansing, then you must cleanse the site
again.
ASSEMBLY OF PUNCTURE
EQUIPMENT
While the alcohol is drying, make a final survey of the
supplies at hand to be sure everything required for the
procedure is present, and then assemble the equipment.
Technical Tip 8-22. Place assembled venipuncture
equipment within easy reach of your nondominant
hand; however, do not place the collection tray on
the patient’s bed.
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CHAPTER 8 ✦ Routine Venipuncture 205
Screw the stopper-puncturing end of the double-
ended evacuated tube needle into the ETS holder. The
needle and holder may come preassembled by the
manufacturer. Do not remove the sterile colored cap
from the other end of the needle. Insert the first tube to
be collected into the needle holder up to the designated
mark. After the tube is pushed up to the mark, it may re-
tract slightly when pressure is released. This is acceptable.
Technical Tip 8-23. Visual examination cannot
detect defective evacuated tubes; therefore, be
sure you have extra tubes nearby. It is not
uncommon for the vacuum in a tube to be lost.
PERFORMING THE VENIPUNCTURE
Reapply the tourniquet, and ask the patient to make
a fist again. Be careful to not touch the cleaned punc-
ture site.
Examine the Needle
Hold the ETS holder securely in your dominant hand
with your thumb on top and the other fingers below.
Immediately before entering the vein, remove the
needle’s plastic cap and visually examine the point of
the needle for any defects, such as a bent or rough
(barbed) end. When defects are present, remove and
discard the needle and obtain a new one. Position the
needle or entry into the vein with the bevel facing up.
Safety Tip 8-8. Never lay an uncapped needle
down on the table or bed before venipuncture.
If a needle becomes contaminated before the
venipuncture, remove it and replace it with a new one.
Anchoring the Vein
Use the thumb of your nondominant hand to anchor
the selected vein while you insert the needle (Fig. 8-15).
Place your thumb 1 or 2 in. (2.5 to 5 cm) below and
slightly to the left of the insertion site. Place your
four fingers on the back of the patient’s arm, and pull
the skin taut, which will keep the skin tight and help
prevent the vein from slipping to the side when the
needle enters. A vein that moves to the side is said to
have “rolled.” Patients often state that they have
“rolling veins”; however, all veins will roll if they are
206 SECTION 3 ✦ Phlebotomy Techniques
FIGURE 815 Placement of the fingers when anchoring FIGURE 816 Placement of the fingers when anchoring and
the vein. palpating a hand vein.
not anchored properly. These patients are really say- Technical Tip 8-24. Tell the patient that “there will
ing that they have had blood drawn in the past by be a little poke” before needle insertion to alert the
phlebotomists who were not sufficiently anchoring patient to hold very still.
the veins. As mentioned previously, the median cubital
vein is the easiest to anchor and the basilic vein the
most difficult. In general, the closer a vein is to the
surface, the more likely it is to roll.
Technical Tip 8-25. Entering the vein too slowly is
more painful for the patient and may cause a spurt
Anchor hand veins by having the patient make a
of blood to appear at the venipuncture site, which
fist or grasp the end of a table or the arm of the draw-
can be disconcerting for both you and the patient.
ing chair. Pull the patient’s skin tightly over his or her
knuckles with the thumb of your nondominant hand
(Fig. 8-16). Filling the Tubes
Once the needle has entered the vein, move the hand
Phlebotomist Alert Anchoring the vein above anchoring the vein and use it to push the evacuated
and below the site using your thumb and index tube completely into the holder. Use your thumb to
finger is not an acceptable technique because push the tube onto the back of the evacuated tube
needle while your index and middle fingers grasp the
sudden patient movement could cause you to
flanges of the holder to stabilize the device. As blood
puncture your index finger accidentally.
begins to flow into the tube, ask the patient to open
his or her fist, and you can release the tourniquet; if
Inserting the Needle the procedure does not last more than 1 minute, you
Place the ETS holder securely in your dominant hand can leave the tourniquet on until the last tube is filled.
Some phlebotomists prefer to change hands at this
with your thumb on top, close to the needle hub, and
point so that the dominant hand is free for perform-
your remaining fingers below the holder. When you
have the vein anchored securely, align the needle with ing the remaining tasks. This method of operating is
usually better suited for use by experienced phle-
the vein and insert it, bevel up, at an angle of 15 to
botomists because holding the needle steady in the
30 degrees depending on the depth of the vein. This
patient’s vein is often difficult for beginners.
should be done in a smooth, quick movement so the
patient feels the stick only briefly. You will notice a
feeling of lessening of resistance to the needle move- Preexamination Consideration 8-7.
ment when the needle has entered the vein. After in-
Leaving the tourniquet on for more than 1 minute
sertion, brace the fingers holding the ETS holder
causes hemoconcentration that may adversely
against the patient’s arm to provide stability while you
affect test results.
change tubes in the holder.
6842_Ch08_191-222 17/01/19 11:46 AM Page 207
Keep the hand holding the needle assembly
braced on the patient’s arm. This is particularly im-
portant when you are inserting evacuated tubes into
the holder or removing tubes from the holder, be-
cause a certain amount of resistance is encountered
and can cause the needle to be pushed through or
pulled out of the vein. Gently twist tubes on and off
the puncturing needle using the flanges of the holder
as an additional brace.
Technical Tip 8-26. Pulling up or pressing down
on the needle while it is in the vein can cause pain
to the patient or hematoma formation if blood
leaks from the enlarged hole.
To prevent any chance of blood refluxing back
into the needle, hold the tubes at a downward angle
and apply slight pressure while the tubes are being
filled. Be sure to follow the correct order of draw
when multiple tubes are being collected, and allow
the tubes to fill completely (until the vacuum is ex-
hausted) to ensure the correct ratio of blood to ad-
ditive before removing them. Visually assess the tubes
to ensure adequate filling. Tubes do not fill com-
pletely to the top. Gently invert the evacuated tubes
three to eight times, depending on the type of tube.
This should be done as soon as the tube is removed
and before another tube is placed in the holder.
The few seconds that this procedure requires do
not cause additional discomfort to the patient and
ensure that the specimen will be acceptable to the
laboratory.
When the last tube has been filled, remove it
from the holder and mix it before completing the
procedure. Failure to remove the evacuated tube
before removing the needle causes blood to drip
from the end of the needle, resulting in unnecessary
contamination and possible damage to the patient’s
clothes.
Technical Tip 8-27. Vigorous mixing of
the specimen can cause hemolysis and
can make the specimen unacceptable for
testing.
Technical Tip 8-28. Poor mixing may produce a
specimen with microclots that can yield erroneous
test results.
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CHAPTER 8 ✦ Routine Venipuncture 207
Technical Tip 8-29. Allow tubes to fill until the
vacuum is exhausted to ensure the correct ratio of
blood to anticoagulant.
REMOVAL OF THE NEEDLE
If the tourniquet is still on the patient’s arm or hand,
remove the tourniquet by pulling on the free end be-
fore removing the needle and tell the patient to open
his or her fist. Failure to remove the tourniquet be-
fore removing the needle may produce a bruise
(hematoma).
Activate the needle safety device if it is designed to
function while the needle is in the vein. If it is de-
signed to function after the needle has been removed
from the vein, place folded gauze over the venipunc-
ture site, withdraw the needle in a smooth swift mo-
tion, and activate the safety device. Apply pressure to
the site as soon as you have withdrawn the needle. Do
not apply pressure while the needle is still in the vein.
To prevent blood from leaking into the surround-
ing tissue and producing a hematoma, apply pressure
until the bleeding has stopped, usually about 2 to
3 minutes. The patient should hold his or her arm in
a raised, outstretched position. Bending the elbow to
apply pressure allows blood to leak more easily into the
tissue, causing a hematoma. A capable patient can be
asked to apply the pressure, thereby freeing you to dis-
pose of the used needle and label the specimen tubes.
If this is not possible, you must apply the pressure and
perform the other tasks after the bleeding has stopped.
DISPOSAL OF THE NEEDLE
On completion of the venipuncture, immediately
dispose of the contaminated needle and ETS holder
as a single unit in an acceptable sharps container
conveniently located near the patient. Under no
circumstance should the needle be removed, bent, cut,
placed on a counter or bed, or manually recapped.
Technical Tip 8-30. Follow manufacturer’s
guidelines when activating needle safety devices.
Some are activated when the needle is still in the
vein, and some must be activated immediately
upon removal of the needle from the vein.
208 SECTION 3 ✦ Phlebotomy Techniques
LABELING THE TUBES
Label the tubes by writing with an indelible pen
on the attached label or by applying a computer-
generated label that may also contain a designated
bar code. You must label the tubes at the time of
collection, before leaving the patient’s room or
before accepting another outpatient requisition
form. You must label the tubes after the specimen
has been collected to prevent confusion of speci-
mens when additional tubes are needed because
of lost vacuum in a faulty tube, if a re-stick is neces-
sary, or when more than one patient is having
blood drawn. Carefully check all preprinted labels
with the patient’s identification before attaching
them to the specimens. Mislabeled specimens, just
like misidentified patients, can result in serious
patient harm.
The following information must be included on
the specimen label:
● Patient’s first and last names
● Patient’s identification number (inpatient) or
date of birth (outpatient)
● Date and time of collection
● Phlebotomist’s initials
Additional information may be present on computer-
generated labels. Specimens for the blood bank may
require an additional label obtained from the patient’s
blood bank ID band.
After labeling the tubes and before leaving the pa-
tient, compare the information on each labeled tube
with the patient’s ID band. For an outpatient, verify
correct labeling of the tube by showing the labeled
tube to the patient and verbally asking him or her to
confirm the information on the label.
Place specimens that are to be sent to the labora-
tory via a pneumatic tube system into a biohazard bag.
Place specimens that require special handling, such
as cooling or warming, in the appropriate container
when labeling is complete.
Phlebotomist Alert Never turn your back to
the patient while labeling the tubes. Continue to
observe the patient for an adverse reaction after
the venipuncture.
BANDAGING THE PATIENT’S ARM
Bleeding at the venipuncture site should stop within
5 minutes. Before applying the adhesive bandage, ex-
amine the patient’s arm to be sure the bleeding has
stopped. Use paper tape for patients who are allergic
to adhesive bandages. For additional pressure, apply
an adhesive bandage or tape over a folded gauze
square. For patients with fragile skin or when addi-
tional pressure is needed, you can place a self-adher-
ing gauzelike material (Coban) over the folded gauze
square and wrap it around the arm. Instruct the pa-
tient to remove the bandage after a minimum of 15
minutes to avoid irritation and to avoid using the arm
to carry heavy objects for a minimum of 1 hour.
Technical Tip 8-31. The practice of quickly
applying tape over the gauze without checking the
puncture site frequently produces a hematoma.
Safety Tip 8-9. The CLSI GP41 standard
recommends that you observe for prolonged or
subcutaneous bleeding for at least 5 to 10 seconds
before applying a bandage. Hematoma formation
caused by subcutaneous bleeding can place
pressure on the nerves and cause a disabling
compression nerve injury.
DISPOSING OF USED SUPPLIES
Before leaving the patient’s room, dispose of all con-
taminated supplies, such as alcohol pads, gauze, and
gloves, in a biohazard container. Place needle caps
and paper in the regular waste container. Sanitize
your hands before leaving the area.
LEAVING AND THANKING THE
PATIENT
Return the bed and bed rails to their original position
if you had to move them. Failure to replace bed rails
can result in patient injury and subsequent legal action.
6842_Ch08_191-222 17/01/19 11:46 AM Page 209
In the outpatient setting, release the patient once
you have bandaged his or her arm and labeled the
tubes. If the patient has been fasting and no more
procedures are scheduled, instruct him or her to eat.
Before calling the next patient, clean up the area as
described earlier. In both the inpatient and outpatient
settings, thank the patient for his or her cooperation.
COMPLETING THE
VENIPUNCTURE PROCEDURE
The venipuncture procedure is complete when you
have delivered the specimen to the laboratory in sat-
isfactory condition and completed all appropriate
paperwork. These procedures vary depending on
facility protocol (personal delivery, pneumatic tube
system, courier service) and the types of specimens
collected. You must be familiar with procedures,
such as verifying collection in the computer system,
making entries manually in the logbook, stamping
the time of specimen arrival in the laboratory on the
requisition form, and informing the nursing station
that you have completed the procedure.
Transporting Specimens
to the Laboratory
Deliver each specimen to the laboratory as soon as pos-
sible. Follow procedures for specimens that require
special handling, which are covered in the following
chapters, and in STAT situations. When possible, try to
organize your patients’ collection times so that your
last collection is a specimen requiring special handling.
Use designated biohazard containers for transport,
and securely attach the requisition forms with the spec-
imen when using the pneumatic tube system. Verify
that the pneumatic tube has been sent before leaving
the area.
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CHAPTER 8 ✦ Routine Venipuncture 209 210 SECTION 3 ✦ Phlebotomy Techniques
Transport blood specimens to the laboratory for
processing in a timely manner. The stability of ana-
lytes varies greatly, as do the accepted methods of PROCEDURE 82 ✦ VENIPUNCTURE USING AN ETS
preservation. This is why timely delivery to the labo-
EQUIPMENT: Step 2. Greet and reassure the patient. Explain the
ratory or following laboratory-prescribed specimen- procedure to be performed, and obtain the
handling protocols is essential to protect specimen Requisition form
Gloves patient’s consent.
integrity.
Tourniquet
70 percent isopropyl alcohol pad
Technical Tip 8-32. You must store and Evacuated tube needle with safety device
transport gel separation tubes in an upright Evacuated tube holder with safety device if the needle
position to facilitate clotting and prevent does not have one
hemolysis. Evacuated tubes
2 in. × 2 in. gauze pads
The CLSI recommends centrifugation of clotted Sharps container
tubes and anticoagulated tubes and separation of Indelible pen
the serum or plasma from the cells within 2 hours. Bandage
Ideally, the specimen should reach the laboratory Biohazard bag
within 45 minutes and be centrifuged on arrival.
Tests affected by improper processing most fre- PROCEDURE:
quently include tests for glucose, potassium, and Step 1. Obtain and examine the requisition form. Step 3. Identify the patient verbally by having him or her
coagulation. Glycolysis caused by the use of glucose
state both the first and last names, spell the last
in cellular metabolism causes glucose values that are
name, and give the date of birth. Compare
falsely low. Hemolysis and leakage of intracellular
the information on the patient’s ID band with the
potassium into the serum or plasma falsely elevates
information on the requisition form.
potassium results. Coagulation factors are destroyed
in specimens remaining at room temperature for
extended periods of time. Appendix A summarizes
the requirements of some analytes that are encoun-
tered routinely. The routine venipuncture procedure
is illustrated in Procedure 8-2.
Technical Tip 8-33. Verification of the
specimen collection recorded either on the
computer or in a logbook completes the
collection process.
Head to DavisPlus for Video 8-2 (Venipunc-
ture Using an Evacuated Tube System).
6842_Ch08_191-222 17/01/19 11:46 AM Page 211
PROCEDURE 82 ✦ VENIPUNCTURE USING AN ETS (Continued)
Step 4. Verify whether the patient has fasted (if required
for test), has allergies to latex, or has had previous
problems with venipunctures.
Step 5. Select the correct tubes and equipment for the
procedure. Have extra tubes available.
Step 6. Sanitize your hands, and apply gloves.
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CHAPTER 8 ✦ Routine Venipuncture 211
Step 7. Position the patient’s arm slightly bent in a
downward position so that the tubes fill from
the bottom up. Do not allow blood to touch the
stopper-puncturing needle. Do not let the patient
hyperextend the arm. Ask the patient to make a fist.
Step 8. Apply the tourniquet 3 to 4 in. above the
antecubital fossa. Palpate the area in vertical
and horizontal directions to locate a large vein
and to determine its depth, direction, and size.
The median cubital is the vein of choice followed
by the cephalic vein. Avoid the basilic vein if
possible. Remove the tourniquet, and have the
patient open his or her fist.
Continued
212 SECTION 3 ✦ Phlebotomy Techniques
PROCEDURE 82 ✦ VENIPUNCTURE USING AN ETS (Continued)
Step 9. Cleanse the site with 70 percent isopropyl Step 12. Reapply the tourniquet. Do not touch the
alcohol in a back-and-forth motion, moving puncture site. Ask the patient to remake a fist,
outward 2 to 3 in., and allow the area to air-dry. and instruct the patient not to “pump” or
“continuously clench” his or her fist to prevent
hemoconcentration.
Step 10. Assemble the equipment while the alcohol is
drying. Attach the multisample needle to the ETS
holder. Step 13. Remove the plastic needle cap and examine the
needle for defects, such as bent or barbed ends.
Step 11. Insert the tube into the holder up to the tube
advancement mark.
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CHAPTER 8 ✦ Routine Venipuncture 213 214 SECTION 3 ✦ Phlebotomy Techniques

PROCEDURE 82 ✦ VENIPUNCTURE USING AN ETS (Continued) PROCEDURE 82 ✦ VENIPUNCTURE USING AN ETS (Continued)
Step 14. Anchor the vein by placing the thumb of your Step 16. Using your thumb, advance the tube onto the Step 18. Gently remove the tube when the blood stops Step 20. Cover the puncture site with clean gauze.
nondominant hand 1 to 2 in. below the site and evacuated tube needle while your index and flowing into it. Gently invert anticoagulated Remove the needle smoothly, and apply
pulling the patient’s skin taut. middle fingers grasp the flanges of the holder. tubes promptly. Insert the next tube using the pressure or ask the patient to apply pressure.
correct order of draw. Fill tubes completely.

Step 15. Grasp the assembled needle and tube holder Step 17. When blood flows into the tube, release the
using your dominant hand with the thumb on the tourniquet, and ask the patient to open his or Step 19. Remove the last tube collected from the holder,
top near the hub and your other fingers beneath. her fist. and gently invert it.
Smoothly insert the needle into the vein at an
angle of 15 to 30 degrees with the bevel up until
you feel a lessening of resistance. Brace your
fingers against the patient’s arm to prevent Step 21. Activate the safety device.
movement of the needle when you change
tubes.

Continued
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CHAPTER 8 ✦ Routine Venipuncture 215 216 SECTION 3 ✦ Phlebotomy Techniques

BIBLIOGRAPHY CLSI. Procedures for the Handling and Processing of

Blood Specimens for Common Laboratory Tests.
PROCEDURE 82 ✦ VENIPUNCTURE USING AN ETS (Continued) CLSI. Accuracy in Patient and Sample Identification.
Approved Guideline GP33-A. Clinical and Laboratory
Approved Guideline, ed. 4. CLSI document GP44-A4.
Clinical and Laboratory Standards Institute, Wayne,
Step 22. Dispose of the needle/holder assembly with the Step 24. Examine the puncture site, and apply a bandage. Standards Institute, Wayne, PA, 2010. PA, 2010.
safety device activated into the sharps container. Place the bandage over a piece of folded gauze CLSI. Collection of Diagnostic Venous Blood Specimens,
for additional pressure. ed. 7. CLSI standard GP41. Clinical and Laboratory
Standards Institute, Wayne, PA, 2017.

Step 23. Label the tubes before leaving the patient, and
verify identification with the patient ID band or Step 25. Prepare the specimen and requisition form for trans-
verbally with an outpatient. Observe any special portation to the laboratory. Dispose of used supplies.
handling procedures. Complete the paperwork.

Step 26. Thank the patient, remove your gloves, and

sanitize your hands.
6842_Ch08_191-222 17/01/19 11:46 AM Page 217
Key Points
✦ The information that is required on a
requisition form includes the patient’s name and
identification number, patient’s date of birth or
age, patient’s location, name of the health-care
provider ordering the test(s), tests requested,
requested date and time of specimen collection,
number and type of collection tubes, status of the
specimen, special collection information, special
patient information, and billing information.
✦ Introduce yourself to the patient, say that you
are from the laboratory, and explain that you
will be collecting a blood specimen for a test
that the patient’s health-care provider has
requested. You must obtain permission from the
patient before collecting the specimen.
✦ Patient identification is the most important step
in the venipuncture procedure. The CAP, TJC,
and CLSI require a minimum of two identifiers.
Identifiers may include comparing the patient’s
name and ID number on the requisition form
with information on the patient’s ID band and
having the patient verbally state his or her first
and last names, spell the last name, and give his
or her date of birth.
✦ The patient must be seated or reclining with his
or her arm in a downward position for blood
collection. Verify that the patient has completed
any pretest preparation, such as fasting and
abstaining from medications when required. Ask
the patient if he or she has a latex sensitivity. Use
nonlatex supplies when appropriate.
✦ Choose the appropriate blood collection system
(ETS, syringe, or winged blood collection set)
and the number and type of collection tubes
and other supplies, taking into consideration
the age of the patient and the amount of blood
to be collected.
✦ The three major veins for venipuncture are the
median cubital, the cephalic, and the basilic.
The median cubital is the vein of choice for
venipuncture, followed by the cephalic vein
located on the thumb side, and lastly, the basilic
vein located on the inner edge of the antecubital
fossa near the median nerve and brachial artery.
The dorsal veins of the hand may be used.
✦ Place a tourniquet snugly on the patient’s arm 3 to
4 in. above the venipuncture site with the loop
facing toward the patient’s antecubital area and
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CHAPTER 8 ✦ Routine Venipuncture 217
the free end facing up away from the venipuncture
area in a position that allows you to pull it easily
to release the pressure. Leaving the tourniquet
on for longer than 1 minute results in hemocon-
centration, which can adversely affect test results.
✦ Perform the palpation using the tip of the index
finger of your nondominant hand to probe the
antecubital area with a pushing motion rather
than a stroking motion to determine the size,
depth, and direction of the vein. Feel the area in
both vertical and horizontal directions to
differentiate veins, which feel bouncy and
resilient, from rigid tendon cords and from
arteries that produce a pulse. Do not use your
thumb to palpate because it has a pulse beat.
✦ Cleanse the area with 70 percent isopropyl
alcohol in a back-and-forth motion, starting at
the inside of the venipuncture site and working
outward about 2 to 3 in., and allow it to dry for
30 to 60 seconds. Confirm the alcohol has dried
before you perform the venipuncture in order
to avoid specimen hemolysis and a stinging
sensation for the patient.
✦ The steps of the venipuncture are as follows:
remove the cap and examine the needle, anchor
the vein 2 to 3 in. below the site with the thumb of
your nondominant hand, insert the needle at an
angle of 15 to 30 degrees, collect the blood tubes
in the correct order, remove the tourniquet,
remove the last tube in the holder, cover the
needle with gauze, remove the needle and activate
the safety feature, apply pressure to the site, and
apply a bandage when bleeding has stopped.
✦ Dispose of contaminated needles and holders
with the safety feature activated in an acceptable
sharps container conveniently located near the
patient.
✦ Label tubes at the time of collection—before
leaving the patient’s room or before accepting
another outpatient requisition form—with the
patient’s name and ID number, the date and
time, and your initials.
✦ Deliver specimens to the laboratory in a timely
manner because some analytes are affected by
glycolysis (glucose) or hemolysis (potassium). The
CLSI recommends centrifugation of clotted tubes
and anticoagulated tubes and separation of the
serum or plasma from the cells within 2 hours.
218 SECTION 3 ✦ Phlebotomy Techniques
Study Questions
1. What information is required on a requisition
form?
a. Patient’s first and last names
b. Patient’s identification number
c. The test requested
d. All of the above
2. When greeting a patient, you must
a. identify yourself.
b. tell the patient the name of the tests
requested.
c. rely on the bed sign for the patient’s name.
d. use technical terms to describe the
10. Which of the following is correct when
procedure.
3. Before you draw a blood specimen from a
patient, you must always
a. check the patient’s ID band number and
name.
b. ask the patient his or her first and last names.
11. To prevent rolling veins, the venipuncture step
c. tell the patient what type of blood test you
are going to perform.
d. a. and b.
4. Which of the following is correct for positioning
the patient for a venipuncture procedure?
a. Hyperextending the arm
b. Asking the patient to stand
12. The needle is inserted into the vein with the
c. Extending the arm down from the shoulder
d. Confirming the elbow is straight
5. What must be considered when choosing the
correct equipment for venipuncture?
a. Type of blood collection system
b. Age of the patient
13. Before bandaging the puncture site, you should
c. Amount of blood to be collected
d. All of the above
6. The vein of choice for venipuncture is the
a. basilic.
b. cephalic.
14. Contaminated needles must be placed in the
c. median cubital.
d. radial.
7. A properly tied tourniquet
a. permits arterial flow and blocks venous flow.
b. blocks arterial and venous flow.
c. prevents backflow.
d. permits venous flow and blocks arterial flow.
8. The maximum length of time the tourniquet
should be applied is
a. 1 minute.
b. 3 minutes.
c. 5 minutes.
d. 10 minutes.
9. Correct palpation of a vein excludes
a. determining the depth of the vein.
b. detecting a pulse using the thumb.
c. determining the direction of the vein.
d. probing with the index finger.
cleansing the venipuncture site with alcohol?
a. Cleansing with a circular motion
b. Blowing on the site to dry it
c. Drying the site with gauze
d. Cleansing with a back-and-forth motion
of primary importance is
a. tightly applying the tourniquet.
b. selecting the median cubital vein.
c. using a 23-gauge needle.
d. anchoring the vein while inserting the
needle.
bevel
a. up at an angle of 45 to 50 degrees.
b. up at an angle of 15 to 30 degrees.
c. down at an angle of 15 to 30 degrees.
d. down at an angle of 45 to 50 degrees.
a. thank the patient.
b. instruct a fasting patient to eat.
c. examine the site for bleeding.
d. apply pressure for at least 5 minutes.
a. biohazard container.
b. sharps container after removing the needle
from the holder.
c. sharps container with the safety device
activated.
d. sharps container after recapping.
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CHAPTER 8 ✦ Routine Venipuncture 219 220 SECTION 3 ✦ Phlebotomy Techniques

15. When should you label blood collection tubes?
a. Before entering the patient’s room
b. In the presence of the patient
c. In the laboratory
d. At the nursing station
16. The information that must be present on a
specimen label is
a. patient’s first and last names.
b. date and time of collection.
c. phlebotomist’s initials.
d. All of the above
Clinical Situations
17. After collection and delivery to the laboratory,
when must clotted and anticoagulated tubes be Summary of the Procedure for Tourniquet Application and Vein Selection
centrifuged?
a. Within 5 minutes 1. Position the arm correctly for vein selection.
b. Within 1 hour
2. Select an appropriate tourniquet application site.
c. Within 2 hours
d. Within 4 hours 3. Place the tourniquet in a flat position behind the arm.
4. Smoothly position the hands when crossing and tucking the tourniquet.
5. Fasten the tourniquet with the appropriate tightness.
6. Observe that the tourniquet is not folded into the arm.
7. Confirm that the loop and loose end do not interfere with the puncture site.
8. Ask the patient to make a fist.
9. Select the antecubital area to palpate.

1 Jaime, the phlebotomist, enters a patient’s room. She asks, “Are you Sabina Jung?” The
patient answers “Yes.” Jaime applies the tourniquet, selects a vein, assembles the equipment,
10. Perform palpation using the correct fingers.
11. Palpate the entire area or both arms if necessary.
labels the tubes, cleanses the site, blows on the site to dry the alcohol, and performs the
venipuncture. 12. Check the size, depth, and direction of the veins.
a. What is wrong with this situation? 13. Remove the tourniquet smoothly.
b. State three ways the patient or specimen in this scenario could be affected. 14. Remove the tourniquet in a timely manner.

2 Jonas Wilke, an outpatient, arrived at the Physician’s Clinic for a blood draw. The clerk
checked him in and ordered the test. Alyssa, the phlebotomist, prepared to draw his blood
using the computer label handed to her by the clerk. The label indicated that a complete Summary of the Procedure for Venipuncture Using an Evacuated Tube System (ETS)
blood count (CBC) was ordered, and Alyssa organized her equipment. Alyssa called Jonas
from the waiting room to the draw station. Alyssa collected a lavender stopper tube and 1. Examine the requisition form.
applied the computer label to the tube. Then Jonas was released. When the specimen was
2. Greet the patient, state the procedure to be done, and obtain informed consent.
received in the laboratory for testing, it was questioned because there was not a laboratory
order for Jonas Wilke. After further investigation, it was determined that the clerk had 3. Ask the patient to state his or her first and last names and date of birth and to spell the last name.
printed the test requisition form using another patient’s name: Jonas Wendt. The blood
4. Examine the patient’s identification (ID) band.
was drawn on the correct patient but had the wrong label. The patient had to return to
the laboratory for another specimen collection. 5. Compare the requisition form information with the ID band and the patient’s statement.
a. How could this mistake have been avoided? 6. Select the correct tubes and equipment for the procedure.
b. What assumption was made by Alyssa? 7. Sanitize your hands.
c. What might Jonas Wilke’s reaction have been when he found out that he had to have
another blood collection? 8. Put on gloves.
9. Position the patient’s arm.
3 Raakel is assigned to pre-op, post-op, and emergency department (ED). She collected a
light blue stopper tube and a plasma separator tube (PST) on a patient in post-op and then
10. Apply the tourniquet.

was called to the ED for a STAT collection before taking care of several pre-op patients. 11. Identify the vein by palpation.
Raakel forgot about the specimen she drew at 7 a.m. in post-op, and it is now 10 a.m. 12. Release the tourniquet.
a. Name two tests that will have falsely decreased values after the 3-hour wait. 13. Cleanse the site and allow it to air-dry.
b. Name a test that will have a falsely increased value.
14. Assemble the equipment.
c. What is the recommended time frame for delivering specimens to the laboratory?
15. Reapply the tourniquet.
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CHAPTER 8 ✦ Routine Venipuncture 221

16. Do not touch the puncture site with unclean fingers.

17. Remove the needle cap and examine the needle.
18. Anchor the vein below the puncture site.
19. Smoothly enter the vein at the appropriate angle with the bevel up.
20. Release the tourniquet and ask the patient to open the fist.
21. Do not move the needle when changing tubes.
22. Collect the tubes in the correct order.
23. Mix the tubes promptly.
24. Fill the tubes to the correct level.
25. Remove the last tube collected from the holder.
26. Cover the puncture site with gauze.
27. Remove the needle smoothly and apply pressure.
28. Activate any safety features.
29. Dispose of the needle in a sharps container with the safety device activated and attached to the holder.
30. Label the tubes.
31. Confirm the labeled tube with the patient ID band or have the patient verify that the information is
correct.
32. Examine the puncture site.
33. Apply the bandage.
34. Dispose of the used supplies.
35. Remove your gloves, and sanitize your hands.
36. Thank the patient.
37. Converse appropriately with the patient during the procedure.
38. Provide post-puncture instructions.
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9
224 SECTION 3 ✦ Phlebotomy Techniques

CHAPTER Learning Outcomes—cont’d

9.16 State reasons why blood may not be obtained immediately from a venipuncture, and describe
the procedures to follow to obtain blood.

Preexamination Variables 9.17 List venipuncture errors that may produce hemolysis as well as the tests affected.
9.18 List causes of hematomas.
9.19 List reasons for rejecting a specimen.

and Venipuncture Complications INTRODUCTION Unconscious Patients

Learning Outcomes
Upon completion of this chapter, the reader will be able to:
9.1 Explain the procedure for coordinating requisition forms, patient
identification, and labeling of tubes for unidentified patients.
9.2 Discuss the procedures to follow when patients are asleep, not in their
rooms, or being visited by a physician, member of the clergy, or friend.
9.3 Describe the identification procedure for patients who are too young,
are cognitively impaired, or whose first language is not English.
9.4 Explain the preexamination variables that affect laboratory test results.
9.5 Identify patient complications, and describe methods to handle each
situation.
9.6 Discuss the procedure to follow when a patient develops syncope
during the venipuncture procedure.
9.7 State the facility policy regarding patients who refuse to have their
blood drawn.
9.8 List the reasons why a tourniquet can be applied for only 1 minute.
9.9 Describe methods used to locate veins that are not prominent.
9.10 Describe conditions in which it is not advisable to draw from veins in
the legs or feet.
9.11 Explain the reasons why blood should not be drawn from a hematoma,
a burned or scarred area, or an arm adjacent to a mastectomy.
9.12 State the procedure to follow when drawing blood from a patient with
an arteriovenous fistula.
9.13 Describe the venipuncture procedure using a syringe, including
equipment preparation, technique for exchanging syringes, transfer
of blood to evacuated tubes, and disposal of the equipment.
9.14 Describe the venipuncture procedure using a winged blood collection
set, the technique involved, and disposal of the equipment.
9.15 Identify technical complications during venipuncture, and describe
remedies for each situation.
Continued
For additional resources please visit
http://davisplus.fadavis.com
The venipuncture procedure discussed in Chapter 8
is conducted under normal circumstances; however,
Key Terms complications to the routine procedure can occur
at any step. You must be aware of your surroundings
Arteriovenous (AV) fistula
and the patient conditions that warrant a change in
Arteriovenous (AV) graft the routine procedure. In this chapter, the venipunc-
Basal state ture procedure is reviewed in the same order but
Edema with an emphasis on the complications that may be
Heparin lock encountered.
Hyperventilation
Iatrogenic
Lipemia
Lymphostasis REQUISITION FORMS
Mastectomy
Occluded In the emergency department or other emergency
Petechiae situations, the request for phlebotomy may be tele-
Preexamination variable phoned to the laboratory and the labels printed
Reference range automatically for you to take to the patient’s location.
Sclerosed When you pick up a requisition form in an emergency
Syncope situation, it still must contain all the pertinent infor-
Vasovagal mation for patient identification. When a temporary
identification system is being used, you may have to
Venous catheter
write in the identification number from the patient’s
wristband on the requisition form.
GREETING THE PATIENT
Sleeping Patients
Frequently, patients are asleep, and you must awaken
them gently and give them time to become oriented
and have their identity verified before you perform a
venipuncture. Blood collection from a sleeping pa-
tient may result in identification errors or physical in-
jury to the patient. A sleeping patient is also not able
to give informed consent for the procedure, which
could result in a charge of assault and battery.
223
You should greet a patient who is unconscious in the
same manner as a patient who is conscious because
he or she may be capable of hearing and understand-
ing even though he or she cannot respond. In this cir-
cumstance, nursing personnel are often present and
can assist with the patient if necessary.
Safety Tip 9-1. A patient who is sleeping or
unconscious may move or jerk unexpectedly when
you insert a needle into a vein or while the needle is
in the vein during the venipuncture procedure. This
can cause injury to you or the patient.
Psychiatric Units
It is usually preferable to have a nurse assist with
patients on the psychiatric unit. Often, these patients
are anxious about the venipuncture procedure and
feel more comfortable in the presence of a familiar
caregiver. Be sure to place blood collection equip-
ment away from the patient in these units.
Physicians, Clergy, Visitors
Physicians, members of the clergy, and visitors may be
present when you enter the room. When a physician
or clergy member is with the patient, it is preferable
to return at another time, unless the request is for a
STAT or timed specimen. When this occurs, you
should explain the situation and request permission
to perform the procedure at that time.
You should greet visitors and family members in
the same manner as the patient and give them the
option of stepping outside. If they choose to stay,
you should assess their possible reactions, and you
may elect to pull the curtain around the bed. Visi-
tors and family members can sometimes be helpful
in the case of pediatric patients or those who are
very apprehensive.
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CHAPTER 9 ✦ Preexamination Variables and Venipuncture Complications
Unavailable Patients
Patients are not always in their room when you arrive.
You should attempt to locate the patient by checking
with nursing personnel. The patient may be in the
lounge or walking in the hall, or the patient may have
been taken to another department. If you must col-
lect the specimen at a particular time, it may be pos-
sible to draw blood from the patient in the area where
he or she has been taken. If this is not possible, you
must notify nursing personnel and be sure the appro-
priate forms are completed so that the test can be
rescheduled. Usually, you would leave the requisition
form at the nursing station and use the message
board in the patient’s room to alert the nurse to call
the laboratory for blood collection when the patient
returns to the room.
Patients in Long-Term Care Facilities
Patients in long-term care facilities may need assis-
tance or have certain restrictions. Before drawing
blood on these patients, you should check in at the
nursing station and inquire about recommendations
for assistance or restrictions concerning the patient.
You must knock on the door before entering or other-
wise announce your entry.
Home Collections
With increased home health care, you will often be
collecting blood specimens in the patient’s home.
Before arriving, contact the patient to schedule a con-
venient time and request that pets be isolated in a
room away from the location for specimen collection.
Always alert the patient by ringing the doorbell or
knocking on the door. Do not enter the home with-
out permission unless instructed beforehand to do so
by a patient, caregiver, or guardian.
PATIENT IDENTIFICATION
Missing Identification (ID) Band
You will occasionally encounter a patient who has
no ID band on either the wrist or the ankle. In this
circumstance, you must contact the nurse and re-
quest that the patient be banded before the drawing
of blood. The nurse’s signature on the requisition
form verifying identification should be accepted in
only emergency situations or according to hospital
policy.
6842_Ch09_223-260 17/01/19 11:47 AM Page 226
225
Patients in psychiatric units or long-term care
facilities often do not wear an ID band according to
facility policy. You can make positive identification by
asking the patient to state and spell his or her first and
last names and provide his or her date of birth as well
as a photo identification. If the patient is unable to
do this, you can acquire the required information
from the nursing staff or a family member. Follow
strict facility protocol in all special situations.
Unidentified Patients in the
Emergency Department
Sometimes unidentified patients are brought into the
emergency department, and a system must be in
place to ensure that they are correctly matched with
their laboratory work. The American Association of
Blood Banks (AABB) requires that the patient be pos-
itively identified with a temporary but clear designa-
tion attached to the body. Some hospitals generate ID
bands with a number and a tentative name, such as
John Doe or Patient X. When the patient’s identity
becomes known, a permanent identification number
is assigned to him or her. Health-care personnel can
cross-reference the temporary identification number
to the permanent number for patient identification
and correlation of patient and test result information.
Technical Tip 9-1. Both the temporary and
permanent ID bands must be attached to the
patient and confirmed before you collect blood.
Commercial identification systems are particularly
useful when blood transfusions are required (Fig. 9-1)
and units of blood are designated for the patient.
Many hospitals use this type of system in addition to
FIGURE 91 Blood bank identification bracelet.
226 SECTION 3 ✦ Phlebotomy Techniques
the routine identification system for all patients
receiving transfusions. In some facilities, patients are
required to wear the blood bank ID band for 48 hours
during their inpatient stay to indicate how long the
specimen that has been drawn can be used. Follow
facility protocol.
Identification of Young, Cognitively
Impaired, or Unconscious Patients or
Patients Whose First Language is not
English
When a patient is too young to identify himself or
herself, cognitively impaired, or unconscious or does
not speak a language that you understand, ask the
patient’s nurse, relative, or friend to identify the patient
by name, address, and identification number or date
of birth. Document the name of the verifier. You must
compare this information with the information on the
requisition form and the patient’s ID band. You must re-
solve any discrepancies before you collect the specimen.
PATIENT PREPARATION
The preexamination stage of laboratory testing in-
volves processes that occur before testing of the speci-
men. Errors that occur during this stage often happen
during blood collection. Numerous variables in patient
preparation can affect specimen quality, and you can-
not be expected to control and monitor all variables.
However, you should be aware of the critical variables
that can affect specimen quality and consequently
laboratory results and report them to the nursing staff
or phlebotomy supervisor. You should also be able to
recognize various patient conditions and complica-
tions that may occur during or after blood collection.
Numerous preexamination variables associated with
the patient’s activities before specimen collection can
affect the quality of the specimen. These variables
include diet, posture, exercise, stress, alcohol, smoking,
time of day, and medications. Physiological variables,
such as age, and sex affect normal values for test results.
Other patient conditions that may influence labora-
tory test results are altitude, dehydration, fever, and
pregnancy.
Basal State
The ideal time to collect blood from a patient is when
he or she is in a basal state. This is early in the morning,
when the patient has refrained from strenuous
exercise and has not ingested food or beverages
except water for 12 hours (fasting). Reference ranges
(normal values) for laboratory tests are determined
from a normal, representative sample of volunteers
who are in a basal state. Not all tests are affected
by fasting and exercise, as evidenced by the collec-
tion and testing of specimens throughout the day,
and many diagnostic results can be obtained at
any time. However, the best comparison of a patient’s
results with the reference ranges can be made while
the patient is in the basal state. This explains why
you begin blood collection in the hospital very early
in the morning while the patient is in a basal state
and why the majority of outpatients arrive in the
laboratory as soon as the drawing station opens.
Table 9-1 summarizes the major tests affected by
variables that change the basal state. You should
be aware of the effects these conditions have on
test results and document them to help avoid a
misdiagnosis.
PREEXAMINATION VARIABLES
Diet
The ingestion of food and beverages alters the level of
certain blood components. The tests most affected are
glucose and triglycerides. Glucose levels increase after
a meal and return to normal within 2 hours. Serum or
plasma collected from patients shortly after a meal
may appear cloudy or turbid (lipemic) because of the
presence of fatty compounds such as meat, cheese,
butter, and cream. Lipemia will interfere with many
test procedures (see Fig. 2-7). Patients on high-protein
diets may have elevated ammonia, urea, and uric acid
levels.
Certain beverages can also affect laboratory tests.
Alcohol consumption can cause a transient elevation
in glucose levels, and chronic alcohol consumption
affects tests associated with the liver and increases
triglycerides. Caffeine has been found to affect hor-
mone levels (adrenocorticotropic hormone [ACTH]
and cortisol levels), whereas hemoglobin levels and
electrolyte balance can be altered by drinking too
much liquid.
Because of these dietary interferences in laboratory
testing, fasting specimens are often requested. When
a fasting specimen is requested, it is your responsibility
to determine whether the patient has been fasting for
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CHAPTER 9 ✦ Preexamination Variables and Venipuncture Complications
TABLE 91 ● Major Tests Affected by Patient Preexamination Variables
VARIABLE INCREASED RESULTS
Age Cholesterol and triglycerides
Alcohol Glucose, aldosterone, prolactin, cortisol, cholesterol,
triglycerides, luteinizing hormone (LH),
catecholamine, aspartate aminotransferase (AST),
alanine transaminase (ALT), estradiol, mean
corpuscular volume (MCV), high-density lipoprotein
(HDL), and iron
Altitude Red blood cells (RBCs), hemoglobin, and hematocrit
Caffeine Fatty acids, hormone levels, glycerol, lipoproteins,
and serum gastrin
Dehydration Calcium, coagulation factors, enzymes, iron, RBCs,
and sodium (NA)
Diurnal variation (a.m.) Cortisol, testosterone, bilirubin, hemoglobin, insulin,
potassium, renin, RBCs, thyroid-stimulating
hormone (TSH), LH, follicle-stimulating hormone
(FSH), estradiol, aldosterone, and serum iron
Long-term exercise Aldolase, creatinine, sex hormones, AST, creatine
kinase (CK), and lactic dehydrogenase (LD)
Nonfasting Glucose, triglycerides, AST, bilirubin, blood urea
nitrogen (BUN), phosphorus, uric acid, growth
hormone (GH), cholesterol, lipoproteins (HDL),
and low-density lipoprotein (LDL)
Posture Albumin, aldosterone, bilirubin, calcium, cortisol,
enzymes, cholesterol, total protein, triglycerides,
RBCs, white blood cells (WBCs), iron thyroxine (T4),
plasma renin, serum aldosterone, and
catecholamines
Pregnancy Erythrocyte sedimentation rate (ESR) and factors II, V,
VII, IX, and X
Prolonged fasting Bilirubin, ketones, lactate, fatty acids, glucagon, and
triglycerides
Short-term exercise Creatinine, fatty acids, lactic acid, AST, CK, insulin, LD,
uric acid, bilirubin, HDL, hormones, aldosterone,
renin, angiotensin, potassium, and WBCs
Smoking Glucose, BUN, triglycerides, cholesterol, ALP,
catecholamines, GH, cortisol, immunoglobulin (Ig)E,
hemoglobin, hematocrit, RBCs, and WBCs
Stress Adrenal hormones, aldosterone, renin, TSH, GH,
prolactin, partial pressure of oxygen (PO2),
and WBCs
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227 228 SECTION 3 ✦ Phlebotomy Techniques
the required length of time. If the patient has not, you
must report this to a supervisor or the nurse and
DECREASED RESULTS
note it on the requisition form. For most tests, the
Hormones patient is required to fast for 8 to 12 hours. As shown
Testosterone in Table 9-1, however, prolonged fasting also can
alter certain blood tests.
Posture
Changes in patient posture from a recumbent (lying
down) to an upright position cause variations in
some blood constituents, such as cellular elements,
plasma proteins, compounds bound to plasma pro-
teins, and high molecular weight substances. The
large size of these substances prevents their move-
ment between the plasma and tissue fluid when
body position changes. For example, protein-bound
Eosinophils, creatinine, compounds are too large to pass through the capil-
glucose, phosphate, and
lary walls and remain in the bloodstream. There-
triglycerides fore, when a person moves from lying down to an
upright position and water leaves the plasma to
efflux into the tissue, the concentration of these high
molecular weight substances increases in the plasma.
Tests most noticeably elevated by decreased plasma
volume are aldosterone, bilirubin, blood cells, cal-
cium, cholesterol, iron, protein, renin, triglycerides,
and enzymes. The concentration of these analytes
can increase 4 to 15 percent within 10 minutes after
changing from lying down to standing. After the
patient returns to lying down from a standing posi-
tion, it takes about 30 minutes for the analytes to
decrease to the original level. Plasma renin, serum
aldosterone, and catecholamines can double in
Protein, alkaline 1 hour; therefore, patients are required to be lying
phosphatase (ALP),
down for 30 minutes before blood collection. The
estradiol, free fatty acids, increase is most noticeable in patients with disor-
RBCs, and iron
ders such as congestive heart failure and liver dis-
Glucose, insulin, cholesterol, eases that cause increased fluid to remain in the
and thyroid hormones tissue. When inpatient and outpatient results are
Arterial pH and partial being compared, the physician may request that
pressure of carbon dioxide an outpatient lie down before specimen collection.
(PCO2) For plasma renin levels, you must document the
IgA, IgG, and IgM patient’s position during blood collection.
Preexamination Consideration 9-1.
Serum iron and PCO2 Laboratory results in elderly patients may be most
affected by changes in posture. Asking patients to
sit while you are checking their identification and
arranging the equipment can allow their blood to
stabilize.
Technical Tip 9-2. The National Institutes of Health
recommends that patients be lying or sitting for
5 minutes before blood collection for lipid panels
to minimize the effects caused by posture.
Exercise
Moderate or strenuous exercise affects laboratory test
results by increasing the blood levels of creatinine, fatty
acids, insulin, lactic acid, aspartate aminotransferase
(AST), creatine kinase (CK), lactic dehydrogenase
(LD), aldolase, hormones (antidiuretic hormone, cat-
echolamines, growth hormone, cortisol, aldosterone,
renin, angiotensin), bilirubin, uric acid, high-density
lipoprotein (HDL), potassium, and white blood cell
(WBC) count. Arterial (potential hydrogen) pH and
PCO2 are decreased.
The effects of exercise depend on the physical fit-
ness and muscle mass of the patient, the strenuousness
and intensity of the exercise, and the time between the
exercise and blood collection. Vigorous exercise has
been associated with a temporary activation of coagu-
lation factors, platelet function, and total cholesterol.
Transient short-term exercise and prolonged exer-
cise or weight training affect test results differently. In
short-term exercise, muscle contents are released into
the blood. Anaerobic glycolysis and metabolic changes
interfere with laboratory results. Short-term exercise
elevates the enzymes associated with muscles (AST, CK,
LD) and the WBC count because WBCs attached to the
venous walls are released into the circulation. In a
healthy person, the values usually return to normal
within several hours of relaxation; however, skeletal
muscle enzymes, aldosterone, renin, and angiotensin
may be elevated for 24 hours. Prolonged exercise also
increases the muscle-related waste products (AST, CK,
and LD) and hormones, and they will remain more
consistently elevated.
Preexamination Consideration 9-2.
Well-trained athletes are more resistant to
exercise-related changes because of their
consistently elevated level of skeletal muscle
enzymes.
Preexamination Consideration 9-3.
Vigorous exercise before blood collection can
transiently increase total cholesterol levels by
6 percent or more.
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CHAPTER 9 ✦ Preexamination Variables and Venipuncture Complications
Stress
Failure to calm a frightened, nervous patient before
specimen collection may increase the patient’s levels
of ACTH, cortisol, and catecholamines; increase WBC
counts; decrease serum iron levels; and markedly
affect arterial blood gas (ABG) results. It has been
shown that WBC counts collected from a violently cry-
ing infant may be markedly elevated. This is caused
by the release of WBCs attached to the blood vessel
walls into the circulation. In contrast, WBC counts
on early morning specimens collected from patients
in a basal state are decreased until normal activity is
resumed. Elevated WBC counts return to normal
within 1 hour.
Preexamination Consideration 9-4.
For an accurate WBC count, discontinue blood
collection from a crying child until after the child
has been calm for at least 1 hour.
Severe anxiety that results in hyperventilation may
cause acid-base imbalances and increased levels of
lactate and fatty acid.
Smoking
The immediate effects of nicotine include increases
in plasma catecholamine, cortisol, glucose, growth
hormone, blood urea nitrogen (BUN), cholesterol,
and triglyceride levels. The extent of the effect
depends on the type and the number of cigarettes
smoked and the amount of smoke inhaled. Glucose
and BUN levels can increase by 10 percent and
triglyceride levels by 20 percent. Chronic smoking
increases hemoglobin, the mean corpuscular volume
(MCV), and immunoglobulin (Ig) E levels as well
as red blood cell (RBC) counts. IgA, IgG, and IgM
levels are decreased, lowering the effectiveness of
the immune system.
Altitude
RBC counts as well as hemoglobin (Hgb) and hema-
tocrit (Hct) levels are increased in high-altitude areas,
such as the mountains, where there are reduced oxy-
gen levels. The body produces increased numbers of
RBCs to transport oxygen throughout the body. Nor-
mal ranges for RBC parameters must be established
for populations living at 5,000 to 10,000 ft above sea
level. It is important to note this information if, when
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229
speaking with the patient, you realize he or she has
just traveled from another geographical area.
Age and Sex
Laboratory results vary among patients in infancy,
childhood, and adulthood and the elderly because of
the gradual change in the composition of body fluids.
Hormone levels vary with age and sex. For example,
RBC, Hgb, and Hct values are higher for males than
for females. Normal reference ranges are established
for the different patient age and sex groups; therefore,
you should confirm the age and sex of the patient on
the requisition form.
Pregnancy
Pregnancy-related differences in laboratory test re-
sults are caused by physiological changes in the body,
including increases in plasma volume. Increased
plasma volume may cause a dilutional effect and
lower RBC counts and protein, alkaline phosphatase,
estradiol, free fatty acid, and iron values. The erythro-
cyte sedimentation rate (ESR) and coagulation
factors II, V, VII, VIII, IX, and X may be increased.
Other Factors Influencing Patient Test
Results
Other factors caused by certain medical conditions,
such as shock, malnutrition, fever, burns, and trauma,
may influence blood and body fluid composition and
can affect laboratory test results. Malnutrition may
cause increased ketone, bilirubin, lactate, and triglyc-
eride levels and decreased glucose, cholesterol, thy-
roid hormone, total protein, and albumin levels. Fever
may cause increases in insulin, glucagon, and cortisol
levels.
Environmental factors associated with geographi-
cal location, such as temperature and humidity, can
change body fluid composition and laboratory test
results. Acute exposure to heat that causes sweating
may cause dehydration and hemoconcentration.
Diurnal Variation
The concentration of some blood constituents is af-
fected by the time of day. Diurnal rhythm is the normal
fluctuation in blood levels at different times of the day
based on a 24-hour cycle of eating, sleeping, activity,
darkness, and daylight. Blood analytes are released into
the bloodstream intermittently. Levels of cortisol, aldos-
terone, renin, luteinizing hormone, follicle-stimulating
230 SECTION 3 ✦ Phlebotomy Techniques
hormone, estradiol, thyroid-stimulating hormone
(TSH), testosterone, bilirubin, hemoglobin, insulin,
potassium, RBC count, and serum iron are highest in
the morning, whereas eosinophil counts and levels of
creatinine, glucose, triglycerides, and phosphate are
lower.
Preexamination Consideration 9-5.
Cortisol, TSH, and iron levels can differ by 50 percent
between 8 a.m. and 4 p.m.; therefore, it is important
to collect specimens for analytes that exhibit diurnal
variation at the correct scheduled time.
Medications
Administration of medication before specimen col-
lection may affect tests results, either by changing a
metabolic process within the patient or by interfering
with the testing procedure. IV administration of dyes
used in diagnostic procedures, including radiographic
contrast media for kidney disorders and fluorescein
used to evaluate cardiac blood vessels, can interfere
with testing procedures. In general, understanding
the effect of medications and diagnostic procedures
on laboratory test results is the responsibility of the
health-care provider, pathologist, or clinical labora-
tory testing personnel. However, you should be aware
of any procedures being performed at the time you
are collecting a specimen and note this on the requi-
sition form. For example, specimens collected while
a patient is receiving a blood transfusion may not
represent the patient’s true condition.
A variety of medications, both prescription and
over-the-counter, can influence laboratory test results.
Physicians frequently order tests to evaluate the effect
of certain prescribed medications on body systems. In
other cases, test results may be affected by over-the-
counter medications not reported to the physician by
the patient. The following examples are included:
● Medications that are toxic to the liver can cause
an increase in blood liver enzymes and abnormal
coagulation tests.
● Elevated BUN levels or imbalanced electrolyte
levels may be noted in patients taking medica-
tions that impair renal function.
● Patients taking corticosteroids, estrogens, or
diuretics can develop pancreatitis and will have
elevated serum amylase and lipase levels.
● Chemotherapy drugs cause a decrease in WBC
counts and platelets.
● Patients taking diuretics may have elevated levels
of calcium, glucose, and uric acid as well as de-
creased potassium levels.
● Oral contraceptives can cause a decrease in levels
of apoprotein, cholesterol, HDL, triglycerides,
and iron (Table 9-2).
● Aspirin, medications that contain salicylate, and
certain herbs can interfere with platelet function
or Coumadin anticoagulant therapy and may
cause increased risk of bleeding. Herbs, vitamins,
and dietary supplements that have been reported
to affect coagulation by the National Institutes of
Health are listed in Box 9-1.
Preexamination Consideration 9-6.
The College of American Pathologists (CAP)
recommends that drugs known to interfere
with blood tests be discontinued 4 to 24 hours
before blood tests and 48 to 72 hours before
urine tests.
Technical Tip 9-3. Patients taking herbs often
do not realize the side effect of bleeding that
can occur. When excessive post-venipuncture
bleeding occurs, question the patient about
herbal medications, and document this on the
requisition form.
Technical Tip 9-4. Patients taking blood thinners
will usually mention this; however, it is a good
practice to ask patients whether they are taking a
blood thinner, indicating that additional pressure
may be needed after collection.
PATIENT COMPLICATIONS
Apprehensive Patients
It is common to encounter patients who are ex-
tremely apprehensive. Enlisting the help of the nurse
who has been caring for the patient may help to calm
the person’s fears. It may also be necessary to ask the
nurse for assistance in holding the patient’s arm
steady during the procedure. Assistance from a nurse
or parent is frequently required when working with
children. You also may require nursing assistance
when encountering patients in fixed positions, such
as those in traction or body casts.
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CHAPTER 9 ✦ Preexamination Variables and Venipuncture Complications 231 232 SECTION 3 ✦ Phlebotomy Techniques

TABLE 92 ● Common Medications Affecting Laboratory Tests

should have blood collected only when emergency head. Watch the patient carefully because patients
procedures, such as cardiopulmonary resuscitation have a tendency to fall forward while fainting and can
MEDICATION AFFECTED TESTS/SYSTEMS (CPR) or use of a defibrillator, are available. easily slip out of the phlebotomy chair. Ask the patient
Acetaminophen and certain antibiotics Elevated liver enzymes and bilirubin levels to continue to take deep breaths, exercise the legs
Aspirin, salicylates, and herbal supplements Prolonged PT and bleeding time Fainting (Syncope) gently, and point and unpoint the toes. If possible, lay
the patient flat and loosen tight clothing. You can
Certain antibiotics Elevated BUN and creatinine levels and electrolyte imbalance Fainting (syncope) is the spontaneous loss of conscious-
apply cold compresses to the patient’s forehead and
Chemotherapy Decreased RBCs, WBCs, and platelet levels ness caused by insufficient blood flow to the brain. A
back of the neck to help revive him or her. For outpa-
part of the involuntary nervous system that regulates
Cholesterol-lowering drugs Prolonged PT and APTT tients who have been fasting for prolonged periods,
heart rate and blood pressure malfunctions in re-
Corticosteroids and estrogen diuretics Elevated amylase and lipase levels give them something sweet to drink (if you have col-
sponse to a trigger that causes a vasovagal reaction. In
lected the blood) and ask them to remain in the area
Diuretics Increased calcium, glucose, and uric acid levels and decreased response, the heart rate suddenly drops; blood vessels
for 15 to 30 minutes. You must document all incidents
sodium and potassium levels in the legs dilate, causing blood to pool in the legs and
of syncope following facility policy.
Fluorescein dye Increased creatinine, cortisol, and digoxin levels reduce blood pressure. Triggers, such as the sight of
blood, having blood drawn, fear of bodily injury, stand-
Opiates Increased liver and pancreatic enzyme levels ing for long periods, heat exposure, and exertion, can Technical Tip 9-5. Patients frequently mention
Oral contraceptives Decreased apoprotein, transcortin, cholesterol, HDL, triglyceride, cause vasovagal syncope. Other conditions that can previous adverse reactions. When these patients
LH, FSH, ferritin, vitamin B12, and iron levels cause a person to faint include postural hypotension, are sitting up, it may be wise to have them
Elevated erythrocyte sedimentation rate (ESR) dehydration, low blood pressure, heart disease, ane- lie down instead before collection. It is not
Radiographic contrast media Routine urinalysis mia, hypoglycemia, and neurological disorders. uncommon for patients with a history of fainting
Symptoms before fainting or a syncope episode to faint again.
APTT = Activated partial thromboplastin time; BUN = blood urea nitrogen; FSH = follicle-stimulating hormone; HDL = high-density lipoprotein; include paleness of the skin, hyperventilation, light-
LH = luteinizing hormone; PT = prothrombin time; RBC = red blood cell; WBC = white blood cell.
headedness, dizziness, vertigo, tunnel vision, nausea,
a feeling of warmth, or cold, clammy skin. You must Technical Tip 9-6. According to Clinical and
be aware of these symptoms in your patients and Laboratory Standards Institute (CLSI) standards, the
BOX 91 Herbs, Vitamins, and Dietary Supplements That Have Effects on Coagulation and Blood Clotting use of ammonia inhalants may be associated with
watch for them in the patient throughout the entire
Alfalfa Ginkgo biloba venipuncture procedure. adverse effects and is not recommended.
Anise Ginseng Apprehensive patients and fasting patients may be
Bilberry Grape seed prone to fainting, and you should be alert to this pos- Safety Tip 9-2. Never turn your back on a patient.
Bladder wrack Green tea sibility. It is sometimes possible to detect such patients Patients can have a delayed syncope response.
Bromelain Guarana during vein palpation because their skin feels cold Continue to monitor a patient after he or she
Cat’s claw Horse chestnut seed and damp. Before beginning the venipuncture, you stands up.
Celery Horseradish should ask the patient if he or she has had problems
Coenzyme Q10 Horsetail rush with blood collection or a tendency to faint. When the
Coleus Licorice patient indicates a history of syncope, have him or her Seizures
Cordyceps Omega-3 fatty acids in fish oil lie down in a recliner with his or her feet elevated to It is rare for patients to develop seizures during
Danshen Prickly ash chest level, or use a blood collection chair with a venipuncture. When this situation occurs, remove the
Dong Quai Red clover locked armrest that will prevent the patient from tourniquet and needle, apply pressure to the site, and
Evening primrose Reishi falling and injuring himself or herself. Ask the patient summon help. Restrain the patient only to the extent
Fenugreek St. John’s wort to take deep breaths, clench and unclench the mus- that injury is prevented. If possible, move the patient
Feverfew Sweet clover cles of the thigh and lower legs, point his or her toes, to the floor, loosen tight clothing, cushion the pa-
Fucus Turmeric and rotate his or her ankles in a circle. Distracting the tient’s head, and turn his or her head to the side to
Garlic Vitamin E patient through conversation may also be helpful. keep the airway clear. Do not attempt to place any-
Ginger White willow When possible, ask another employee for assistance thing in the patient’s mouth. Report to the physician
to help distract and comfort the patient. any very deep puncture caused by the patient’s sud-
If a patient begins to faint during the procedure, den movement. Stay with the patient, and talk calmly
immediately remove the tourniquet and needle, and and reassuringly during and after the seizure. Do not
Needle Phobia venipuncture. Needle-phobic patients have a height- apply pressure to the venipuncture site. In the inpa- allow the patient to leave the area or drive a car until
Approximately 10 percent of the population suffers ened sensitivity to the pain associated with the tient setting, notify nursing personnel as soon as he or she has been examined by trained first-aid per-
from an intense fear of needles (needle phobia) venipuncture. Patients experience symptoms similar possible. Ensure that an outpatient who is not in a sonnel. Document the time the seizure started and
that causes a shock type of reaction and, in severe to fainting that include pallor, light-headedness, bed is supported and that he or she lowers his or her stopped according to facility policy.
cases, arrhythmia or cardiac arrest during or after profuse sweating, and nausea. Needle-phobic patients
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CHAPTER 9 ✦ Preexamination Variables and Venipuncture Complications
Technical Tip 9-7. In both syncope and seizure
situations, notify designated first-aid–trained
personnel immediately.
Petechiae
Patients who present with small, nonraised red hem-
orrhagic spots (petechiae) may have prolonged bleed-
ing after venipuncture. Petechiae appear when blood
leaves the capillaries, leaking under the skin. Pe-
techiae can be caused by a coagulation disorder, such
as a low platelet count or abnormal platelet function,
medications (aspirin), and infections. A tourniquet
that is tied extremely tight may cause petechiae to
appear. In patients with petechiae, you should apply
additional pressure to the puncture site after needle
removal.
Allergies
Patients are occasionally allergic to alcohol, iodine,
chlorhexidine gluconate, latex, or the glue used in
adhesive bandages. You must observe necessary pre-
cautions by using alternative antiseptics, paper tape or
self-adhering wrap (Coban), and nonlatex products.
Nausea and Vomiting
A patient may experience nausea or vomiting before,
during, or after blood collection. When the patient is
nauseated, provide an emesis basin or carton, instruct
the patient to breathe deeply and slowly, and apply
cold compresses to his or her forehead. If the patient
vomits, stop the blood collection and provide him or
her with an emesis basin or wastebasket and tissues.
Give an outpatient water to rinse out his or her mouth
and a damp washcloth to wipe the face. Notify the
patient’s nurse or designated first-aid personnel.
Additional Patient Observations
You must be alert for changes in a patient’s condition
and notify nursing personnel. Such changes include
the presence of vomitus, urine, or feces; infiltrated or
removed IV fluid lines; extreme difficulty breathing;
and possibly a patient who has expired.
Patient Refusal
Some patients may refuse to have their blood drawn,
and they have the right to do this. Stress to the patient
that the results are needed by the health-care
provider for treatment, and discuss the problem with
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233
the nurse, who may be able to convince the patient to
have the test performed. When the patient continues
to refuse, you should document this decision accord-
ing to the facility policy.
Phlebotomist Alert Carefully listen to the
patient, and observe his or her body language.
The patient has the right to refuse to have his or
her blood drawn. You may be guilty of assault if
the patient perceives that his or her refusal is being
ignored.
EQUIPMENT ASSEMBLY
When positioning the needed equipment and sup-
plies within easy reach, you should include extra evac-
uated collection tubes. Occasionally, an evacuated
tube does not contain the correct amount of vacuum
necessary to collect a full tube of blood. Accidentally
pushing a tube past the indicator mark on the needle
holder before the vein is entered will also result in loss
of vacuum.
Rarely, you may encounter an evacuated tube that
pops off the back of the holder needle while blood is
being collected. Re-advancing the tube onto the nee-
dle in the holder and holding it in this position until
the tube is filled will remedy this situation. When
using the evacuated tube system, always screw the nee-
dle onto the holder tightly. Needles have become
unscrewed from the holder during venipuncture.
When this happens, release the tourniquet immedi-
ately, and carefully remove the needle and activate
the safety device.
As discussed in Chapter 3, remember that
only the necessary amount of equipment is brought
into isolation rooms. For patients on the psychiatric
unit, leave the phlebotomy tray at the nursing sta-
tion and take only the necessary equipment into
the room. Do not leave any type of equipment in
the patient’s room.
TOURNIQUET APPLICATION
As discussed in Chapter 7, sometimes a blood
pressure cuff is used to locate veins that are difficult
to find. Inflate the cuff to just below the patient’s
234 SECTION 3 ✦ Phlebotomy Techniques
diastolic blood pressure. Too much pressure affects
the flow of arterial blood. Only trained personnel
should perform blood pressure readings. You can
obtain the patient’s diastolic pressure from the
patient’s caregiver.
When dealing with patients with skin conditions or
sensitivity and open sores, it may be necessary to place
the tourniquet over the patient’s gown or to cover the
area with gauze or a dry cloth before application. When
possible, select another area for the venipuncture.
Technical Tip 9-8. Consider routinely using latex-
free, single-use tourniquets.
Hemoconcentration
Application of the tourniquet for more than 1 minute
will interfere with some test results, which is why the
CLSI set the limit on tourniquet application time as
1 minute and states that the tourniquet should be
released as soon as the vein is accessed. Prolonged
tourniquet time causes hemoconcentration because the
plasma portion of the blood passes into the tissue, which
results in an increased concentration of protein-based
analytes in the blood. Tests most likely to be affected
are those measuring large molecules, such as plasma
proteins and lipids; RBCs; and substances bound to
protein such as iron, calcium, and magnesium; or ana-
lytes affected by hemolysis, including potassium, lactic
acid, and enzymes. Fist clenching is not recommended
when drawing specimens for lactic acid determina-
tions. Follow facility protocol for tourniquet use.
Releasing the tourniquet as soon as blood begins
to flow into the first tube can sometimes result in the
inability to fill multiple collection tubes. You may have
to make a decision about immediately removing the
tourniquet on the basis of the size of the patients’
veins or the difficulty of the puncture. Regardless of
the situation, do not leave the tourniquet in place for
longer than 1 minute.
Other causes of hemoconcentration are excessive
squeezing or probing of a site, long-term IV therapy,
drawing from sclerosed or occluded veins, drawing from
edematous sites, and vigorous fist pumping (Box 9-2).
Preexamination Consideration 9-7.
Repeated fist pumping can increase the blood
potassium level by 1 to 2 mmol/L (20 percent). It
also can increase levels of lactic acid and ionized
calcium and decrease blood pH.
BOX 92 Cellular Elements Increased by
Hemoconcentration
Albumin
Ammonia
Bilirubin
Calcium
Cholesterol
Coagulation factors
Enzymes
Iron
Lactic acid
Lipids
Potassium
Red blood cells
Total protein
Preexamination Consideration 9-8.
Prolonged tourniquet application can increase
hemoglobin levels 3 percent after 1 minute and
7 percent after 3 minutes, which can mislead
health-care providers when diagnosing anemia.
Preexamination Consideration 9-9.
Cholesterol levels can increase 2 to 5 percent after
the tourniquet has been applied for 2 minutes and
up to 10 to 15 percent after 5 minutes.
Technical Tip 9-9. According to the CLSI standard,
tourniquet use is recommended unless it interferes
with test results.
SITE SELECTION
Not all patients have a median cubital, cephalic, or
basilic vein that becomes prominent immediately when
you apply a tourniquet. In fact, a high percentage of
patients have veins that are not easily located, and you
may have to use a variety of techniques to locate a suit-
able puncture site. Many patients have prominent veins
in one arm and not in the other; therefore, checking
the patient’s other arm should be the first thing you
do when a site is not easily located. Patients with veins
that are difficult to locate often point out areas where
they remember previous successful phlebotomies. Pal-
pation of these areas may prove beneficial and is also
good for patient relations.
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CHAPTER 9 ✦ Preexamination Variables and Venipuncture Complications
Technical Tip 9-10. Never be reluctant to check
both arms and to listen to the patient’s
suggestions. Often, veins in the dominant arm are
more prominent.
Other techniques to enhance the prominence of
veins include:
● Massaging the patient’s arm upward from the
wrist to the elbow
● Briefly hanging the patient’s arm down
● Applying heat to the site for 3 to 5 minutes
Remember that when performing these techniques,
you should not leave the tourniquet tied for more than
1 minute at a time.
When no palpable veins are found in the antecu-
bital area, you should examine the patient’s wrist and
hand (Fig. 9-2A). Re-tie the tourniquet on the pa-
tient’s forearm. Because the veins in these areas
are smaller, it may be necessary to change equip-
ment and use a smaller needle with a syringe, winged
blood collection set, or smaller evacuated tube. You
must tightly anchor the patient’s wrist veins because
they tend to roll to the side easily. Never use veins on
the underside of the patient’s wrist because nerves,
tendons, and the ulnar and radial arteries lie close to
the veins and can be injured when accidentally punc-
tured (Fig. 9-2B).
Safety Tip 9-3. Nerve damage caused by drawing
on the underside of the wrist may cause a patient to
lose his or her ability to open or close the hand.
A B
FIGURE 92 Alternate site for venipuncture. A, The back
(posterior side) of the hand. B, Do not use the underside of
the wrist.
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235
Sometimes veins in the legs and feet are used as
venipuncture sites when veins in the arms or hands are
unsuitable (Fig. 9-3). You should use these veins only
with physician permission. Leg or foot veins are more
susceptible to infection, tissue necrosis, and the forma-
tion of thrombi (clots), particularly in patients with di-
abetes, cardiac problems, and coagulation disorders.
Areas to Be Avoided
Certain areas must be avoided for venipuncture be-
cause of the possibility of decreased blood flow, infec-
tion, hemolysis, or specimen contamination. Specimen
contamination affects the integrity of the specimen,
causing invalid test results. Laboratory personnel may
not know that contamination has occurred and conse-
quently can report erroneous test results that adversely
affect overall patient care. Incorrect blood collection
techniques that can cause contamination include:
● Blood collected from edematous areas (potential
for altered test results)
● Blood collected from veins with hematomas
(may cause discomfort to the patient and poten-
tially alter test results)
● Blood collected from arms containing an IV
(contamination of specimens with IV fluids)
● Sites contaminated with alcohol or iodine (poten-
tial for altered test results)
● Infected sites (potential for altered test results
and patient discomfort)
● Anticoagulant carryover between tubes (poten-
tial for altered test results)
Damaged Veins
Veins that contain thrombi or have been subjected to
numerous venipunctures often feel hard (sclerosed),
FIGURE 93 Veins in the foot.
236 SECTION 3 ✦ Phlebotomy Techniques
and you should avoid them because they may be
blocked (occluded) and may have impaired circula-
tion that can cause invalid test results. Chemotherapy
patients, chronically ill patients, and illegal IV drug
users may have hardened veins. Probing or using a
lateral needle direction when redirecting the needle
also can cause vein damage. Areas that appear blue
or are cold may also have impaired circulation.
Hematoma
The presence of a hematoma indicates that blood has
leaked out of the vein and has accumulated in the tis-
sue surrounding the vein during or after venipunc-
ture. It may appear as a nonswollen, purple bruise or
may be a swollen, raised bruise near the venipuncture
site (Fig. 9-4). Puncturing into a hematoma is not only
painful for the patient but also results in the collec-
tion of old, hemolyzed blood from the hematoma
rather than circulating venous blood that is represen-
tative of the patient’s current condition. When you
must use a vein containing a hematoma, be sure to
collect blood below the hematoma to ensure sam-
pling of free-flowing blood.
Technical Tip 9-11. Remove the tourniquet and
needle immediately and apply pressure to the site
when a hematoma begins to form during a
venipuncture.
Edema
Drawing from areas containing excess tissue fluid
(edema) also is not recommended because the specimen
FIGURE 94 Hematoma formed from venipuncture.
will be contaminated with tissue fluid and yield in-
accurate test results. Edema may be caused by heart
failure, renal failure, inflammation, or infection.
Edema also may be caused by IV fluid infiltrating
into the surrounding tissue. Notify nursing person-
nel when you encounter this situation.
Burns, Scars, and Tattoos
Areas that are burned and scarred extensively, in-
cluding inflamed tattoos, are more susceptible to
infection. Healed areas that are burned and scarred
also have decreased circulation and can yield inac-
curate test results. Veins in these areas are difficult
to palpate and penetrate. The CLSI recommends
avoiding inflamed or new tattoos because of the
risk of infection, patient discomfort, and possible
complications.
Mastectomy
Applying a tourniquet to or drawing blood from an arm
located on the same side of the body as a recent mastec-
tomy can be harmful to the patient and has the potential
to produce erroneous test results. Removal of lymph
nodes in the mastectomy procedure interferes with the
flow of lymph fluid (lymphostasis) and increases the
blood level of lymphocytes and waste products normally
contained in the lymph fluid. Patients are in danger of
developing lymphedema in the affected area, and this
can be increased by application of a tourniquet. Be-
cause the lymph nodes have been removed, the protec-
tive functions of the lymphatic system also are lost,
making the area more prone to infection. For these
reasons, you should draw blood from the other arm. In
the case of a patient with a double mastectomy, you
should consult with the physician as to an appropriate
site for the draw, such as the patient’s hand. It may be
possible to perform the tests from a finger puncture but
only with the physician’s permission.
Technical Tip 9-12. Most mastectomy patients
have been told never to have blood drawn from
the affected side. Drawing blood from the arm
on the side of a mastectomy with a patient’s
permission may have legal ramifications for you
because a patient may not know the risks involved.
Obesity
Veins on obese patients are often deep and difficult
to palpate. First, check the antecubital area of both
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CHAPTER 9 ✦ Preexamination Variables and Venipuncture Complications
arms for a median cubital vein. When a median cu-
bital vein is not palpable, next check for a cephalic
vein. Often, the cephalic vein is more prominent and
easier to palpate. A blood pressure cuff may work
better as a tourniquet when a typical tourniquet is too
short. Another option is to use a bariatric tourniquet
(longer tourniquet). It is important to avoid probing
to find the vein because that can be painful to the
patient and cause hemolysis by destroying RBCs that
can alter test results. Using a syringe with a 11⁄2-in.
needle may offer more control.
IV Therapy
Frequently, you will encounter patients receiving
IV fluids in an arm vein. Whenever possible, you should
draw blood from the other arm because the specimen
may be contaminated with IV fluid. When you must
use an arm containing an IV for specimen collection,
you must select a site below the IV insertion point and
preferably in a different vein. The CLSI recommends
having the nurse turn off the IV infusion for 2 min-
utes before venipuncture; then you may apply the
tourniquet between the IV and the venipuncture site
and perform the venipuncture. Alert the nurse that
the specimen has been collected and the infusion
may be restarted. Document the location of the
venipuncture (right or left arm) and that it was drawn
below an infusion site. Certain “add-on tests” may not
be acceptable from this specimen. However, a dermal
puncture is preferred to collect the specimen when
possible.
Technical Tip 9-13. Avoid drawing blood from the
site of a previous IV for 24 hours after the IV was
disconnected to avoid a potential error in testing.
Preexamination Consideration 9-10.
Inappropriate collection of blood from an
arm containing an IV is a major cause of
erroneous test results. Unless the specimen
is highly contaminated, the error may not
be detected.
Heparin and Saline Locks
Heparin or saline locks are winged infusion sets con-
nected to a stopcock or cap with a diaphragm that can
be left in a vein for up to 48 hours for administering
medications required frequently and for obtaining
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237
blood specimens. The devices must be flushed with
heparin or saline periodically and after use to prevent
blood clots from developing in the line. The first
5 mL of blood drawn must be discarded from either
device. It is not recommended to collect blood through
these devices for coagulation testing because residual
heparin or dilution with saline can adversely affect
test results. Only specifically trained personnel are au-
thorized to draw blood from heparin and saline locks.
Vascular Grafts, Fistulas,
and Catheters
Three types of venous access devices are available for
patients undergoing renal dialysis. The most common
is a permanent surgical fusion of the radial artery and
the cephalic vein, called an arteriovenous (AV) fistula in
one arm. It is visible under the skin as a large bulging
area of the vein. The second venous access device is an
arteriovenous graft (AV graft) that connects the artery to
the vein using looped artificial tubing implanted under
this skin. You should avoid using this arm for venipunc-
ture because of the possibility of infection or clotting.
Accidental puncture of the area around the fistula or
graft can cause prolonged bleeding.
The patient on dialysis also may have a temporary
external venous catheter, which is a plastic tube that is
inserted into a large vein, usually in the neck, to access
venous blood for dialysis. Only specifically trained per-
sonnel are authorized to draw blood from a fistula,
graft, or catheter.
Technical Tip 9-14. Be sure to check for the
presence of an AV fistula or AV graft before
applying a tourniquet to the patient’s arm because
this can compromise the patient and threaten the
integrity of the fistula and vascular graft.
CLEANSING THE SITE
Certain procedures, primarily blood cultures, require
that you cleanse the site with a stronger antiseptic
than isopropyl alcohol (see Chapter 10). The solu-
tions used most frequently are povidone-iodine and
tincture of iodine or chlorhexidine gluconate for
patients who are allergic to iodine.
Alcohol should not be used to cleanse the site be-
fore drawing a specimen for a blood alcohol level
test. Thoroughly cleansing the site with soap and
water ensures the least amount of interference. Some
238 SECTION 3 ✦ Phlebotomy Techniques
facilities use benzalkonium chloride (Zephiran Chlo-
ride) to cleanse the site or find povidone-iodine to
be acceptable.
EXAMINATION OF PUNCTURE
EQUIPMENT
When using a syringe, pull back the plunger and then
push it forward while the protective cap is still on the
needle to ensure that it will move freely when the nee-
dle has entered the vein. Just before insertion, remove
the protective cap on the needle, and examine the
needle point for imperfections. Examine syringe and
winged blood collection needles for flaws in the same
manner as evacuated tube needles.
PERFORMING THE
VENIPUNCTURE
Although you will perform venipuncture most fre-
quently using an evacuated tube system (ETS), you
may need to use a syringe or winged blood collection
set to better control the pressure applied to the deli-
cate veins found in pediatric and elderly patients or
when drawing from hand veins.
Using a Syringe
Except for a few minor differences, the procedure for
drawing blood using a syringe is the same as when
using an ETS. Withdraw blood from the vein by slowly
pulling on the plunger of the syringe, using your free
hand after the needle has entered the anchored vein.
The advantage of using a syringe is that when the pa-
tient’s vein is entered, blood appears in the hub of
the needle; then you can pull back the plunger at a
speed that corresponds to the rate of blood flow into
the syringe. Pulling the plunger back faster than the
rate of blood flow may cause the walls of the vein to
collapse and can cause hemolysis. It is important to
anchor the hand holding the syringe firmly on the pa-
tient’s arm so that the needle will not move when you
pull back the plunger.
Technical Tip 9-15. Pulling the plunger of the
syringe back too slowly can cause the blood to
begin to clot before the collection is completed.
Ideally, the size of the syringe used should corre-
spond with the amount of blood needed. However,
with small veins that easily collapse, it may be necessary
to fill two or more smaller syringes. This procedure
will require assistance because you will need to transfer
blood from the filled syringe to the appropriate tubes
while the second syringe is being filled. It is important
that the blood be added to the anticoagulated tubes
as soon as possible. Before exchanging syringes, place
gauze on the patient’s arm under the needle because
blood will leak from the hub of the needle during the
exchange.
Technical Tip 9-16. In many circumstances, the
use of small evacuated tubes with a winged blood
collection set instead of a syringe can prevent the
need to change syringes.
As discussed in Chapter 7, use a blood trans-
fer device to transfer blood from the syringe to evac-
uated tubes following the correct order of fill. After
removing the needle from the vein, activate the nee-
dle safety device, and remove the needle and dis-
card it in the sharps container. Attach the blood
transfer device to the syringe, and push the evacu-
ated tubes onto the internal rubber-sheathed needle.
Allow the tubes to fill according to the vacuum in
the tube. After the tubes are filled, discard the
syringe and blood transfer device into a sharps con-
tainer. For hypodermic needles without a safety
shield, insert the needle into a JELCO® Point-Lok®
Needle Protection Device and remove the needle.
Then, using the blood transfer device, place the
specimen into tubes. After transferring the speci-
men, discard the needle, Point-Lok device, syringe,
and transfer device into a sharps container. The
venipuncture procedure using a syringe is shown in
Procedure 9-1.
Safety Tip 9-4. Pushing on the plunger of the
syringe can hemolyze the RBCs or cause the tube
stopper to pop off, risking an aerosol spray.
Technical Tip 9-17. Transfer the blood quickly
from the syringe to the evacuated tube to avoid
the possibility of blood clotting. Do not lay the
syringe aside to complete the venipuncture
procedure before transferring the blood.
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CHAPTER 9 ✦ Preexamination Variables and Venipuncture Complications 239 240 SECTION 3 ✦ Phlebotomy Techniques

PROCEDURE 91 ✦ VENIPUNCTURE USING A SYRINGE PROCEDURE 91 ✦ VENIPUNCTURE USING A SYRINGE (Continued)
EQUIPMENT: of blood will appear in the syringe hub when the Step 7. Release the tourniquet, and have the patient bottom up to avoid cross-contamination. Do not
Requisition form needle has entered the vein. Brace your fingers open his or her fist. push on the plunger.
Gloves against the patient’s arm to prevent movement of Step 8. Cover the puncture site with gauze, remove the
Tourniquet the needle when you pull back on the plunger. needle smoothly, activate the safety shield, and
70 percent isopropyl alcohol pad apply pressure.
Syringe needle with safety device
Syringe
Blood transfer device
Evacuated tubes
2 in. × 2 in. gauze
Sharps container
Indelible pen
Bandage
Biohazard bag

PROCEDURE:
Step 12. Fill the tubes in the correct order. Gently invert
Step 1. Perform steps 1 to 9 of Procedure 8-2, anticoagulated tubes as soon as you remove
“Venipuncture Using an ETS.” Step 6. Pull back the syringe plunger slowly using your them from the transfer device.
Step 2. Assemble the equipment as the alcohol is drying. nondominant hand to collect the appropriate Step 9. Remove the needle from the syringe, and discard Step 13. After the tubes are filled, discard the entire
Attach the hypodermic needle to the syringe. Pull amount of blood. it in the sharps container. syringe and blood transfer device into a sharps
the plunger back to ensure that it moves freely, container.
Step 10. Attach a blood transfer device to the syringe.
and then push it forward to remove any air in the
syringe.
Step 3. Reapply the tourniquet, remove the needle cap,
and inspect the needle.
Step 4. Ask the patient to remake a fist, and anchor the
vein by placing the thumb of your nondominant
hand 1 to 2 in. below the site and pulling the
patient’s skin taut.
Step 5. Hold the syringe in your dominant hand with your
thumb on top near the hub and your other fingers
underneath. Smoothly insert the needle into the
vein at an angle of 15 to 30 degrees with the bevel
up until you feel a lessening of resistance. A flash
Step 11. Holding the syringe vertically with the blood Step 14. Label the tubes before leaving the patient’s
Continued room, and verify identification with the patient
transfer device at the bottom, advance the
evacuated tube onto the internal needle in the ID band or verbally with an outpatient. Observe
blood transfer device. The tubes will fill by the any special handling procedures. Complete any
vacuum in the tube. Keep the tube in a vertical required paperwork.
position to ensure that the tubes fill from the Step 15. Examine the puncture site and apply a bandage.
Place the bandage over folded gauze for
additional pressure on the site.
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CHAPTER 9 ✦ Preexamination Variables and Venipuncture Complications
PROCEDURE 91 ✦ VENIPUNCTURE USING A SYRINGE (Continued)
Using a Winged Blood Collection Set
All routine venipuncture procedures used with
evacuated tubes and syringes also apply to blood
collection using a winged blood collection set (but-
terfly). This method is used for difficult venipunc-
ture and often is less painful to patients. You can
reduce the angle of needle insertion to 10 to 15 de-
grees, facilitating entry into small veins by folding
the plastic needle attachments (“wings”) upward
while inserting the needle. Blood will appear in the
tubing when the needle enters the vein. You can
thread the needle securely into the vein and keep
it in place by holding the plastic wings against the
patient’s arm.
Depending on the type of winged blood collection
set that you use, you can collect blood into evacuated
tubes or into a syringe. The tubing contains a small
amount of air (0.5 mL) that will cause underfilling of
the first tube; therefore, you should collect a discard
tube before an anticoagulated tube to maintain the
correct blood-to-anticoagulant ratio.
To prevent hemolysis when using a small (23-gauge)
needle, you should use partial-draw evacuated tubes.
Position the tubes downward to fill from the bottom
up and in the same order of draw as in routine
venipuncture. If you have collected blood into a
syringe, activate the safety device on the winged
blood collection needle and then remove it from
the syringe. Attach a blood transfer device to the
syringe, and then fill the evacuated tubes in the
correct order.
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241 242 SECTION 3 ✦ Phlebotomy Techniques
PROCEDURE 92 ✦ VENIPUNCTURE USING A WINGED BLOOD
Step 16. Prepare the specimen and requisition form for
COLLECTION SET
transportation to the laboratory. Dispose of used EQUIPMENT: Step 3. Apply the tourniquet 3 to 4 in. above the patient’s
supplies in the appropriate waste container. wrist bone.
Requisition form
Step 17. Remove your gloves, and sanitize your hands. Gloves
Step 18. Provide post-puncture instructions, and thank Tourniquet
the patient. 70 percent isopropyl alcohol pad
Winged blood collection set
Syringe or evacuated tube system (ETS) holder
Blood transfer device
Evacuated tubes
2 in. × 2 in. gauze
Sharps container
Indelible pen
Bandage
Biohazard bag
Safety Tip 9-5. When using a winged blood collection PROCEDURE:
set, be sure to attach the holder and do not just push Step 4. Palpate the top of the patient’s hand or wrist.
the tubes onto the back of the rubber-sheathed Step 1. Perform steps 1 to 6 of Procedure 8-2, Select a vein that is large and straight and that
needle. This will avoid an accidental needlestick “Venipuncture Using an ETS.” can be anchored easily.
exposure from the stopper-puncturing needle. Step 2. Support the patient’s hand on the bed or armrest of
When disposing of the winged blood collection set,
the drawing chair, and have the patient make a
use extreme care because many accidental sticks result
loose fist.
from unexpected movement of the tubing. You can pre-
vent an accidental stick by immediately activating the
needle safety device and placing the needle into a sharps
container before removing the syringe, and then allow-
ing the tubing to fall into the container when the syringe
is removed. Always hold a winged blood collection set
by the wings, not by the tubing. To prevent accidental
needle punctures, it is recommended that you use an
apparatus with automatic re-sheathing capability or ac-
tivate a device on the needle set that advances a safety
blunt before removing the needle from the vein. Do not
push the apparatus manually into a full sharps container.
The venipuncture procedure using a winged blood
collection set is shown in Procedure 9-2.
Safety Tip 9-6. When removing the winged blood
collection needle from the vein, always hold the base
of the needle or the wings until it has been placed in
the biohazard sharps container. You should activate
the needle safety mechanism immediately.
Return to DavisPlus for Video 9-1 (Venipunc-
ture Using a Winged Blood Collection Set).
6842_Ch09_223-260 17/01/19 11:48 AM Page 243
CHAPTER 9 ✦ Preexamination Variables and Venipuncture Complications
PROCEDURE 92 ✦ VENIPUNCTURE USING A WINGED BLOOD
COLLECTION SET (Continued)
Step 5. Release the tourniquet and have the patient relax his
or her fist. Clean the site with 70 percent isopropyl
alcohol using friction, and allow it to air-dry.
Step 10. To collect blood, pull back on the plunger of
Step 6. Assemble the equipment as the alcohol is drying.
Attach the winged blood collection set to the
evacuated tube holder or the syringe. Stretch out
the coiled tubing. Pull the plunger back to ensure
that it moves freely, and then push it forward to
remove any air in the syringe. If you are using an
evacuated tube holder, insert the first tube to the
tube advancement mark.
Step 7. Reapply the tourniquet, remove the needle cap,
and inspect the needle. Lay the syringe and
tubing next to the patient’s hand.
Step 8. Anchor the vein by placing the thumb of your
nondominant hand below the patient’s knuckles
and pulling the patient’s skin taut. Having the
patient make a loose fist can be helpful.
Step 9. Grasp the needle between your thumb and index
finger by holding the back of the needle or by
folding the wings together. Smoothly insert the
needle into the vein at a shallow angle of 10 to
15 degrees with the bevel up. Thread the needle
into the lumen of the vein until the bevel is firmly
Step 11. Release the tourniquet, and ask the patient to
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243
“seated” in the vein. A flash of blood will appear in
the tubing when the needle has entered the vein.
the syringe slowly and smoothly with your
nondominant hand. Do not pull back on the
syringe plunger if a blood flash does not appear.
When using an evacuated tube holder, insert the
tubes in the correct order of draw. Use a discard
tube when collecting anticoagulated tubes to
prime the tubing and maintain the correct
blood-to-anticoagulant ratio. Gently invert
anticoagulated tubes immediately.
relax his or her fist.
Continued
244 SECTION 3 ✦ Phlebotomy Techniques
PROCEDURE 92 ✦ VENIPUNCTURE USING A WINGED BLOOD
COLLECTION SET (Continued)
Step 12. Cover the puncture site with gauze, and remove
the needle smoothly or activate the safety device
on needles designed to be retracted while the
needle is in the vein.
Step 13. Activate the safety shield for needles designed to
be shielded when the needle is out of the vein,
and apply pressure.
TECHNICAL COMPLICATIONS
Technical complications with the venipuncture pro-
cedure result in the inability to obtain blood, a re-
jected specimen, or discomfort to the patient. By
identifying the types of complications encountered,
you usually can remedy the situation without having
to puncture the patient again.
Step 14. Remove the winged blood collection set from the
syringe, and discard it in the sharps container.
Step 15. Attach a blood transfer device to the syringe,
and fill the evacuated tubes in the correct order.
Step 16. After you have filled the tubes, discard the syringe
and blood transfer device into a sharps container.
Step 17. Label the tubes before leaving the patient’s room,
and verify identification with the patient’s ID band
or verbally with an outpatient. Observe any special
handling procedures. Complete any paperwork.
Step 18. Examine the puncture site, and apply a bandage.
Place the bandage over folded gauze for
additional pressure on the site.
Step 19. Prepare the specimen and requisition form for
transportation to the laboratory. Dispose of used
supplies in the appropriate waste container.
Step 20. Remove your gloves, and sanitize your hands.
Step 21. Provide post-puncture instructions, and thank
the patient.
Failure to Obtain Blood
Pop over to DavisPlus for Animation 9-1: Possible
Reasons for Failure to Obtain Blood and the
Remedies.
Needle Position
Not all venipunctures result in the immediate ap-
pearance of blood; however, in many instances, this
6842_Ch09_223-260 17/01/19 11:48 AM Page 245
CHAPTER 9 ✦ Preexamination Variables and Venipuncture Complications
is only a temporary setback that can be corrected by
slight movement of the needle. It is important for
you as a beginning phlebotomist to know these tech-
niques so that you are not tempted to remove the
needle immediately when blood does not appear.
Then you have to puncture the patient again when
it may not have been necessary. However, you should
reposition the needle only when you have established
vein location. Never try to find a vein by blind prob-
ing. Figure 9-5 illustrates possible causes of failure to
obtain blood.
Bevel Against the Wall of the Vein
As shown in Figure 9-5B and C, the bevel of the
needle may be resting against the upper or lower
wall of the vein, obstructing blood flow. Often this
occurs because the angle of the needle is incorrect;
an angle that is too shallow can cause the needle to
lay against the upper wall of the vein, and an angle
that is too steep can cause the needle to lay against
the lower wall of the vein. Failure to insert the
needle with the bevel up also can obstruct blood
flow into the needle. Removing the evacuated tube
and rotating the needle a quarter of a turn will
allow blood to flow freely into a new evacuated tube
(Figure 9-5D).
Phlebotomist Alert To avoid damage to the vein
and pain for the patient, before rotating the needle
it is important to remove the tube from the holder
and pull the needle back until it is just beneath
the skin.
Needle Too Deep
When the angle of needle insertion is too steep
(greater than 30 degrees) or while advancing the
evacuated tube onto the tube stoppering needle when
the tube holder is not firmly braced against the pa-
tient’s skin, the needle may penetrate through the
vein into the tissue. Blood can leak into the tissues,
forming a hematoma. Gently pulling the needle back
may produce blood flow (Fig. 9-5E).
Technical Tip 9-18. Failure to keep the holder
steady by bracing your hand against the patient’s
arm may cause you to push the needle through the
vein or pull the needle out of the vein when you
are changing tubes.
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245 246 SECTION 3 ✦ Phlebotomy Techniques
Needle Too Shallow
If the needle angle is too shallow (less than 15 degrees),
the needle bevel may only partially enter the lumen Skin Vein
of the vein, causing blood to leak into the tissues,
forming a hematoma. Often you can detect this when
15 to 30 Skin Vein
you see blood flowing very slowly into the tube. Slowly degree
advancing the needle into the vein may correct the angle
problem. If a hematoma appears under the skin,
remove the tourniquet and needle immediately, and
apply pressure to the site. Continuing to draw the
specimen may result in injury to the patient and a
Correct insertion technique Bevel on upper wall of vein
specimen contaminated with tissue fluid and hemolysis A (blood flows freely into needle) B (does not allow blood to flow)
(Figure 9-5F).
Collapsed Vein
Using an evacuated tube that is too large or pulling
back on the plunger of a syringe too quickly creates suc- Skin Vein Skin Vein
tion pressure that can cause a vein to collapse and can
stop blood flow (Fig. 9-5G). Veins also can collapse
when you apply the tourniquet too tightly or too close
to the site. When it appears that the vein has collapsed,
release the vacuum pressure by removing the tube from
the holder, or release the plunger of the syringe. Wait a Bevel on lower wall of vein Needle rotated 45°
few seconds for the vein to fill and try another tube. C (Does not allow blood to flow) D (allows blood to flow)
Using an evacuated tube that requires a smaller volume
may remedy the situation. If it does not, you must per-
form another puncture, possibly using a syringe or
winged blood collection set with a smaller needle.
Skin Hematoma Vein
Skin Vein
Needle Beside the Vein
A frequent reason for the failure to obtain blood oc-
curs when a vein is not well anchored before the punc-
ture. The needle may slip to the side of the vein
without actual penetration (“rolling vein”) (Fig. 9-5H).
You may be able to determine the positions of the vein Needle inserted too far Needle partially inserted
and needle by gently touching the area around the E F (causes blood to leak into tissue)
needle with your cleansed, gloved finger. This may
allow you to redirect the needle slightly. To avoid hav-
ing to puncture the patient again, withdraw the needle
until the bevel is just under the skin, anchor the vein Skin Vein
again, and redirect the needle into the vein. Skin Vein
When moving the needle, you should never vigor-
ously probe the area because this is not only painful
to the patient but also enlarges the puncture site so
that blood can leak into the tissues and form a
hematoma or cause an accidental nicking of an artery.
The CLSI recommends never moving the needle in a Collapsed vein When the vein rolls, the needle
may slip to the side of the vein
lateral direction to access the basilic vein because of
G H without penetrating it.
the close proximity of the brachial artery and ante-
FIGURE 95 Possible reasons for failure to obtain blood. A, Correct insertion technique. B, Bevel on upper wall of
brachial cutaneous nerve.
vein (does not allow blood to flow). C, Bevel on lower wall of vein (does not allow blood to flow). D, Needle rotated
45 degrees (allows blood to flow). E, Needle inserted too far. F, Needle partially inserted (causes blood to leak into
tissue). G, Collapsed vein. H, When the vein rolls, the needle may slip to the side of the vein without penetrating it.
6842_Ch09_223-260 17/01/19 11:48 AM Page 247
CHAPTER 9 ✦ Preexamination Variables and Venipuncture Complications
Phlebotomist Alert Repositioning the needle
without establishing vein location is considered
blind probing; you should never do so.
Faulty Evacuated Tube
If the needle appears to be in the vein but blood flow is
slow or absent, a faulty evacuated tube (either by man-
ufacturer error, age of the tube, dropping and cracking
of the tube, or accidental puncture when assembling
the equipment) may be the problem. You should use a
new tube. Occasionally, an evacuated tube will lose its
vacuum if the needle bevel moves out of the patient’s
skin during venipuncture. You can detect this by observ-
ing a splash of blood into the tube and sometimes hear-
ing a hissing sound before the blood flow stops.
Technical Tip 9-19. Remember always to have
extra tubes within reach.
Collection Attempts
When you do not obtain blood from the initial
venipuncture, you should select another site, either
in the other arm or below the previous site, and repeat
the procedure using a new needle. When the second punc-
ture is not successful, you should not make another
attempt. Following facility policy, you should notify
nursing personnel and request that another phle-
botomist perform the venipuncture.
Technical Tip 9-20 . Never attempt to stick a
patient unless you can see and/or feel a vein.
Technical Tip 9-21. Blind probing can be painful
to the patient and result in nerve damage, arterial
puncture, or hematoma formation. Needle
redirection is limited to a forward or backward
movement in a straight line.
Nerve Injury
Temporary or permanent nerve damage can be
caused by incorrect vein selection or improper
venipuncture technique and may result in loss of
movement to the arm or hand and the possibility of a
lawsuit. The most critical permanent injury in the
venipuncture procedure is damage to the median
antebrachial cutaneous nerve.
Damage to the nerve can occur when a nerve is
nicked during venipuncture. The patient may expe-
rience a shooting pain, electric-like shock or burning
6842_Ch09_223-260 17/01/19 11:48 AM Page 248
247
sensation, or tingling or numbness running up or
down his or her arm or in the fingers of the arm used
for venipuncture. When you observe any of these
symptoms or the patient verbalizes any of them, you
must remove the tourniquet and needle immediately.
Complications from nerve damage can be perma-
nently disabling and include lack of limb mobility,
lack of grip strength, and lingering pain. The factors
associated with nerve injury in venipuncture tech-
nique are preventable and are included in Box 9-3.
The pressure from a hematoma, infiltrations of IV
fluid, or a tourniquet that is on for too long or too
tightly can cause a nerve compression injury. Swelling
and numbness may occur 24 to 96 hours later.
The symptoms of nerve injury are treated with a
cold ice pack initially and then warm compresses to
the area. Document the incident, and direct the pa-
tient to medical evaluation when indicated according
to facility policy.
Phlebotomist Alert You must terminate the
venipuncture procedure immediately whenever a
patient complains of a tingling, burning sensation,
numbness, or pain—even when the patient urges
you to continue.
Iatrogenic Anemia
Iatrogenic anemia pertains to a condition of blood loss
caused by treatment. Anemia can occur when large
amounts of blood are removed for testing at one time
or over a period of time. This is especially dangerous
for pediatric or elderly patients or those who are
critically ill. Removal of more than 10 percent of a
patient’s blood can be life-threatening in these
BOX 93 Errors in Technique That Can Cause
Nerve Injury
Blind probing
Excessive manipulation of the needle
Inserting the needle too far (angle greater than
30 degrees)
Lateral redirection of the needle
Movement by the patient while the needle is in
the vein
Selecting high-risk venipuncture sites (underside of
the wrist, basilic vein)
Using jerky movements
248 SECTION 3 ✦ Phlebotomy Techniques
patients. Collecting the minimum amount of blood,
Technical Tip 9-23. Hemolysis that is not evident
monitoring collection orders for duplicate requests,
to the naked eye can elevate critical potassium
and avoiding redraws can reduce excessive blood
values.
collections. Some facilities have instituted a blood
conservation program to minimize blood loss that can
cause iatrogenic anemia. Technical Tip 9-24. Potassium values are
higher in serum than in plasma because of
Hemolyzed Specimens the release of potassium from platelets during
clotting.
You may detect hemolysis by the presence of pink or
red plasma or serum (Fig. 9-6). Rupture of the RBC
Errors in performance of the venipuncture ac-
membrane releases cellular contents into the serum
count for the majority of hemolyzed specimens and
or plasma and interferes with many test results so that
include the following:
the specimen may need to be recollected. Hemolysis
that is not visibly noticeable may be present and will
1. Using a needle with a diameter that is too
affect test results of analytes such as potassium and
small (above 23 gauge)
lactic acid, which are particularly sensitive to hemoly-
2. Using a small needle with a large evacuated tube
sis. Table 9-3 summarizes the major tests affected by
3. Using a needle that is improperly attached on
hemolysis.
a syringe so that frothing occurs as the blood
enters the syringe
Technical Tip 9-22. Specimens collected after 4. Pulling back the plunger of a syringe too quickly
vigorous probing are frequently hemolyzed and 5. Drawing blood from a site containing a
must be recollected. hematoma
6. Vigorously mixing tubes
7. Forcing blood from a syringe into an evacu-
ated tube
8. Collecting specimens from IV lines when not
Slight Moderate Gross
hemolysis hemolysis hemolysis recommended by the manufacturer
9. Applying the tourniquet too close to the punc-
ture site or for too long a time
10. Using fragile hand veins
11. Performing venipuncture before the alcohol
is allowed to dry
12. Collecting blood through different internal di-
ameters of catheters and connectors
13. Partially filling sodium fluoride tubes
14. Readjusting the needle in the vein (probing)
or using occluded veins
Factors in processing, handling, or transporting
the specimen also can result in hemolyzed specimens
and include:
1. Rimming clots
2. Prolonged contact of serum/plasma with cells
3. Centrifuging at a speed that is higher than rec-
ommended and with increased heat exposure
in the centrifuge
4. Elevated or decreased temperatures of blood
5. Using pneumatic tube systems with unpadded
canisters, speed acceleration and/or decelera-
FIGURE 96 Slight, moderate, and gross serum hemolysis. tion, and excessive agitation
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CHAPTER 9 ✦ Preexamination Variables and Venipuncture Complications 249 250 SECTION 3 ✦ Phlebotomy Techniques

TABLE 93 ● Laboratory Tests Affected by Hemolysis

SERIOUSLY AFFECTED NOTICEABLY AFFECTED
Aspartate aminotransferase (AST) Thyroxine (T4)
Complete blood count (CBC) Prothrombin time (PT)
Lactic dehydrogenase (LD) Alanine aminotransferase (ALT)
Potassium (K) Serum iron (Fe)
Troponin (T) Activated partial thromboplastin
time (APTT)
Creatine kinase (CK)
C-peptide
Various patient physiological factors can cause he-
molysis and include:
1. Metabolic disorders (liver disease, sickle cell
anemia, autoimmune hemolytic anemia, blood
transfusion reactions)
2. Chemical agents (lead, sulfonamides, anti-
malarial drugs, analgesics)
3. Physical agents (mechanical heart valve, third-
degree burns)
4. Infectious agents (parasites, bacteria)
Head to DavisPlus for Animation 9-2
(Hemolysis).
Reflux of Anticoagulant
Reflux of a tube anticoagulant can occur when there is
blood backflow into a patient’s vein from the collection
tube. This can cause adverse reactions in patients. You
can eliminate the problem by keeping the patient’s arm
and the tube in a downward position, which allows the
collection tubes to fill from the bottom up.
Technical Tip 9-25. To ensure prevention of
reflux, make sure that blood in the tubes does
not come in contact with the stopper during
collection.
Partially Filled Tubes
Partially filled collection tubes deliver the wrong ratio
of blood to anticoagulant, resulting in an inadequate
specimen for laboratory testing. An incorrect ratio of
SLIGHTLY AFFECTED
Albumin
Magnesium (Mg)
Total protein (TP)
Phosphorus (P)
Calcium (Ca)
Alkaline phosphatase
Rapid plasma
reagin (RPR)
Haptoglobin
Bilirubin
blood to anticoagulant can be due to the following
causes:
● Excessive liquid anticoagulant in light blue stop-
per tubes dilutes the plasma and causes pro-
longed coagulation results.
● Excessive ethylenediaminetetraacetic acid (EDTA)
in lavender stopper tubes shrinks the RBCs and af-
fects the Hct, RBC count, Hgb, RBC indices, and
ESR rates.
● Underfilled green stopper tubes adversely affect
ionized calcium test results.
● Underfilled gray stopper tubes cause hemolysis
of RBCs.
Serum separator tubes (SSTs) and red stopper
tubes usually are not affected by partially filled collec-
tion tubes providing there is an adequate amount of
specimen to perform the test. “Partial-draw” tubes are
available for situations in which it is difficult to obtain
a full tube. A line is present on each tube to indicate
the proper fill level.
REMOVAL OF THE NEEDLE
Hematoma Formation
Improper technique during removal of the needle is a
frequent (although not the only) cause of a hematoma
appearing on the patient’s arm. The skin discoloration
and swelling that accompany a hematoma are often a
cause of anxiety and discomfort to the patient and, in
severe cases, can cause disabling compression injury to
nerves.
Errors in technique that cause blood to leak or
be forced into the surrounding tissue, producing
hematomas, include:
1. Failure to remove the tourniquet before remov-
ing the needle
2. Applying inadequate pressure to the site after
removal of the needle
3. Bending the patient’s arm while applying
pressure
4. Excessive probing to obtain blood
5. Failure to insert the needle far enough into
the vein
6. Inserting the needle through the vein
7. Selecting a needle that is too large for the
vein
8. Using veins that are small and fragile
9. Accidentally puncturing the brachial artery
Under normal conditions, the elasticity of the
vein walls prevents the leakage of blood around the
needle during venipuncture. A decrease in the elas-
ticity of the vein walls in older patients makes them
more prone to developing hematomas. Using small-
bore needles and firmly anchoring the veins before
needle insertion may prevent a hematoma in older
patients. When a hematoma begins to form while
you are collecting blood, immediately remove the
tourniquet and needle, and apply pressure to the
site for 2 minutes. Apply pressure longer (3 to
5 minutes) when an accidental arterial puncture has
occurred. You may offer a cold compress to the pa-
tient to minimize hematoma swelling and pain for
the first 24 hours, and then the patient should use
warm compresses after that. Acetaminophen or
ibuprofen may help with the pain. Follow facility
policy. Choose an alternative site for the repeat
venipuncture; when none is available, you must per-
form the venipuncture below the hematoma. The
goals of successful blood collection are not only to
obtain the specimen but also to preserve the site for
future venipunctures. It is critical to prevent
hematoma formation.
DISPOSAL OF THE NEEDLE
You should not deviate from the methods for needle
disposal discussed in Chapter 8.
LABELING THE TUBES
You must follow facility protocol for information
contained on the labels of tubes from unidentified
patients to provide a temporary but clear designa-
tion of the patient. When available, attach stickers
from the patient’s ID band to all specimens for the
blood bank.
If you are using preprinted labels, it is important
to double-check the name on the label while attach-
ing it to the tube.
BANDAGING THE PATIENT’S ARM
Patients receiving anticoagulant medications or large
amounts of aspirin or herbs and patients with coagu-
lation disorders may continue to bleed after you have
applied pressure for 5 minutes. You should continue
to apply pressure until the bleeding stops. Notify the
nurse in cases of excessive bleeding. For patients who
have bleeding problems, you can place a self-adhering
gauze (Coban) over a folded gauze to form a pressure
dressing. Never leave the patient until the bleeding
has stopped.
Compartment Syndrome
Some patients who are receiving anticoagulants or
who have a coagulation disorder (hemophilia) may
continue to bleed large amounts of blood into the
subcutaneous tissue surrounding the puncture site.
The blood can accumulate within the tissues of the
muscles that surround the arm or hand and cause
pressure to build in the area, which can interfere with
blood flow and can injure the muscle. This condition,
called “compartment syndrome,” can cause pain,
swelling, numbness, and permanent injury to the
nerves. This is a serious condition that requires a sur-
gical procedure to open the compartment to relieve
the pressure and stop the bleeding. This syndrome
can be prevented by checking the venipuncture site
for bleeding and hematoma formation before you
apply the bandage.
Technical Tip 9-26. You should routinely ask
patients if they are taking blood thinners
(anticoagulant therapy) and take extra care to
maintain pressure on the venipuncture site until
bleeding has stopped.
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CHAPTER 9 ✦ Preexamination Variables and Venipuncture Complications
Accidental Arterial Puncture
In the case of an accidental arterial puncture, which
you can usually detect by the appearance of unusually
red blood that spurts into the tube, you—not the
patient—should apply pressure to the site for 5 minutes
(10 minutes may be required if the patient is receiv-
ing anticoagulant therapy). A nick to the artery also
can cause compartment syndrome and compression
nerve injury owing to the accumulation of blood in
the tissue. The fact that the specimen is arterial blood
should be recorded on the requisition form because
some test values are different for arterial blood than
for venous blood.
Technical Tip 9-27. Probing and lateral movement
of the needle, particularly near the basilic vein, are
the main causes of accidental arterial punctures.
Allergy to Adhesives
Some patients are allergic to adhesive bandages, and
it may be necessary to wrap gauze around the pa-
tient’s arm before applying the adhesive tape or to use
paper tape. Omitting the bandage in these patients
and those with hairy arms is another option, particu-
larly when the patient requests it. Alternatively, you
may use self-adhering bandages, such as Coban. Con-
firm that bleeding has stopped completely before
leaving the patient. Bandages are not recommended
for children younger than 2 years because they may
put the bandages in their mouth.
Infection
Instruct the patient to keep the bandage on for at
least 15 minutes post venipuncture to avoid the pos-
sibility of infection. Do not open bandages ahead of
time and place them on the table or in your lab coat.
Technical Tip 9-28. Practicing aseptic technique
throughout the venipuncture procedure minimizes
the risk of infection.
LEAVING THE PATIENT
Patients often request that you change the position of
their bed or provide them with a drink of water.
Because this may not be in the best interest of the
6842_Ch09_223-260 17/01/19 11:48 AM Page 252
251 252 SECTION 3 ✦ Phlebotomy Techniques
patient, you should tell the patient that you will CLSI. Collection, Transport, and Processing for Testing org/apps/portlets/contentViewer/show.do?content
inform the nurse of the request. Leave the room in Plasma-Based Coagulation Assays and Molecular Hemo- Reference=cap_today%2Ffeature_stories%2F0604
stasis Assays; Approved Guideline—Fifth Edition. CLSI Phlebotomy.html. Accessed July 31, 2018.
the condition in which you found it (bed and bed
document H21-A5. Clinical and Laboratory Standards Ogden-Grable, H, and Gill, GW: Phlebotomy puncture
rails in the original position).
Institute, Wayne, PA, 2008. juncture, preventing phlebotomy errors–potential for
CLSI. Procedures for the Handling and Processing of Blood harming your patients. Lab Medicine 36(7):430-433, 2005.
Specimens for Common Laboratory Tests, ed. 4. Ap- Patton, MT: Addressing nerve damage. Advance for Medical
COMPLETING THE proved Guideline GP44-A4. Clinical and Laboratory Laboratory Professionals April 21, 2003, 25-26.
Standards Institute, Wayne, PA, 2012. Proytcheva, MA: Issues in neonatal cellular analysis.
VENIPUNCTURE PROCEDURE Ernst, DJ, and Ernst, C: The Lab Draw Answer Book, ed. 2. Am J Clin Pathol 131:560-573, 2009.
Center for Phlebotomy, Inc., Corydon, IN, 2017. Wyan, RL, Meiller, TF, and Crossley, HL: Drug Information
Specimens brought to the laboratory may be re- Holmes, WE: The interpretation of laboratory tests. In Handbook for Dentistry, ed. 10. Lexi-Comp, Inc.,
jected if conditions are present that will compro- McClatchey, KD: Clinical Laboratory Medicine, ed. 2. Hudson, NY, 2005.
Lippincott Williams & Wilkins, Philadelphia, 2002.
mise the validity of the test results. Rejection of a
Lusky, K.: Safety Net: Juggling the Gains, Losses of
specimen has clinical consequences because it
Phlebotomy Routines. CAP Today, June, 2004. www.cap.
delays making laboratory results available for the
health-care provider, delays patient treatment, and
causes inconvenience and discomfort for the pa-
tient. Major reasons for specimen rejection include
the following:
1. Unlabeled or mislabeled specimens
2. Inadequate volume
3. Collection in the wrong tube
4. Hemolysis
5. Lipemia
6. Clotted blood in an anticoagulant tube
7. Improper handling during transport, such as
not chilling the specimen
8. Specimens without a requisition form
9. Contaminated specimen containers
10. Delays in delivering the specimen
11. Use of outdated blood collection tubes
It is your responsibility to make sure that none of
these conditions exist in the specimens that you
deliver to the laboratory to ensure that they can
be processed and tested in the appropriate time
frame.
BIBLIOGRAPHY
An examination of the bleeding complications associated
with herbal supplements, antiplatelet and anticoagulant
medications. Journal of Dental Hygiene 81(3), July 2007.
https://pdfs.semanticscholar.org/b3b1/d670c7eb55c9ff
30fb32495956ef5440ff78.pdf. Accessed July 31, 2018.
Anderson, SC, and Cockayne, S: Method evaluation and
preanalytical variables. In Clinical Chemistry, Concepts
and Applications. McGraw-Hill Professional, New York,
2003.
CLSI. Collection of Diagnostic Venous Blood Specimens,
ed. 7. CLSI standard GP41. Clinical and Laboratory
Standards Institute, Wayne, PA, 2017.
6842_Ch09_223-260 17/01/19 11:48 AM Page 253
CHAPTER 9 ✦ Preexamination Variables and Venipuncture Complications
Key Points
✦ Unidentified patients must be identified with a
temporary ID band that includes an identifica-
tion number and tentative name. The requisi-
tion form may be obtained at the emergency
situation. The tubes are labeled with the tempo-
rary information. Patients who are not wearing
an ID band must be positively identified by the
nursing staff and their signature documented.
Follow facility policy.
✦ The patient’s nurse, relative, or friend must
identify anyone who is too young or cognitively
impaired or whose first language is not English.
Document the name of the verifier.
✦ When a patient is sleeping, you should awaken
him or her gently before venipuncture to
ensure proper identification and informed con-
sent. Do not interrupt a visit between a physi-
cian or clergy member and a patient to collect
blood unless it is a STAT or timed test. Give visi-
tors the option of stepping outside the room
during the venipuncture. You should attempt
to locate a patient who is not in the room, par-
ticularly when the request is timed or STAT;
otherwise, notify the nursing staff.
✦ Preexamination variables that can affect labora-
tory tests include diet, posture, exercise, stress,
alcohol, smoking, time of day, medications, sex,
age, altitude, dehydration, fever, and pregnancy.
✦ A patient is in the basal state when he or she has
refrained from strenuous exercise and has not
ingested food or beverages except water for
12 hours.
✦ When a patient faints during the venipuncture
procedure, immediately remove the tourniquet
and needle, apply pressure to the site, lower the
patient’s head, and keep the patient in the area
for 15 to 30 minutes. Document the incident.
✦ When a patient develops a seizure during a
venipuncture procedure, immediately remove
the tourniquet and needle, apply pressure
to the site, and situate the patient in a safe
position. Document the time the seizure
started and stopped.
✦ Notify nursing personal for all patient complica-
tions and document the incidents. Follow
facility policy.
✦ Document on the requisition form any refusal
by a patient to have blood drawn and notify the
nursing staff. Follow facility policy.
6842_Ch09_223-260 17/01/19 11:48 AM Page 254
253
✦ Tourniquet application of longer than 1 minute
can alter test results by causing hemoconcentra-
tion and hemolysis. Tests primarily affected are
plasma proteins, cholesterol, hemoglobin, iron,
calcium, magnesium, potassium, lactic acid, and
enzyme levels.
✦ Useful techniques for locating veins that are not
prominent include massaging the patient’s arm
upward from the wrist to the elbow, hanging the
patient’s arm down, and applying heat to the
site for 3 to 5 minutes.
✦ It is not advisable to draw blood from a patient’s
leg or foot veins because they are susceptible to
infection and the formation of thrombi (clots),
particularly in patients with diabetes, cardiac
problems, and coagulation disorders. A draw
from these locations requires physician
approval.
✦ Unacceptable sites for venipuncture include
damaged (sclerosed) veins; hematomas; edema-
tous areas; burns; scars; inflamed tattoos; the
area above an IV; arms with an AV fistula, vascu-
lar graft, or catheter; and arms adjacent to a
mastectomy because of specimen contamina-
tion, decreased blood flow, and risk of patient
infection.
✦ A syringe or winged blood collection set can be
used for difficult venipuncture to better control
the pressure applied to the delicate veins found
in pediatric and elderly patients or when draw-
ing from hand veins.
✦ Failure to obtain blood can be caused by incor-
rect needle position in the vein (bevel on lower
wall of vein, bevel on upper wall of vein, needle
inserted through the vein, needle partially in-
serted into the vein), a collapsed vein, a
“rolling” vein, or a faulty evacuated tube.
✦ Venipuncture technique errors account for the
majority of hemolyzed specimens and include
using a needle with a diameter that is too small,
using a small needle with a large evacuated
tube, using an improperly attached needle on a
syringe so that frothing occurs as the blood en-
ters the syringe, pulling the plunger of a syringe
back too quickly, drawing blood from a site
containing a hematoma, vigorously mixing
tubes, forcing blood from a syringe into an evac-
uated tube, collecting specimens from IV lines
when not recommended by the manufacturer,
254 SECTION 3 ✦ Phlebotomy Techniques
applying the tourniquet too close to the punc-
ture site or for too long, using fragile hand
veins, performing venipuncture before the
alcohol is allowed to dry, collecting blood
through different internal diameters of a
catheter and connectors, partially filling sodium
fluoride tubes, and readjusting the needle in
the vein or using an occluded vein.
✦ The laboratory tests affected most seriously by
hemolysis are potassium, LD, and AST levels
and the CBC.
✦ A hematoma is caused by the leakage of blood
into the tissues and is characterized by a black
and blue discoloration and swelling at the site.
Errors in technique associated with needle in-
sertion and removal are the primary causes of
hematomas and include failure to remove
Study Questions
1. What is the correct identification procedure
when an unidentified person is brought to the
emergency department?
a. You may not draw blood from an unidenti-
fied person.
b. You must attach an ID band with a tentative
name and identification number.
c. You must wait until the identity of the patient
has been confirmed before collecting the
blood.
d. You must cross-reference the temporary iden-
tification number to the permanent identifi-
cation number assigned to the patient.
2. A phlebotomist who encounters a comatose
patient with no ID band should
a. notify the phlebotomy supervisor.
b. check the patient’s identity with the patient’s
roommate.
c. leave the requisition at the nurse’s station.
d. ask the nurse to band the patient.
3. What should a phlebotomist do when a patient
is sleeping?
a. Postpone the collection.
b. Gently wake the patient and allow him or her
to become oriented.
c. Ask the nurse to wake him or her.
d. Wait until a family member is present.
the tourniquet before removing the needle,
applying inadequate pressure to the site after
removal of the needle, bending the arm while
applying pressure, excessive probing to obtain
blood, failure to insert the needle far enough
into the vein, inserting the needle through the
vein, selecting a needle that is too large
for the vein, using veins that are small and
fragile without additional precautions, and ac-
cidentally puncturing the brachial artery.
✦ Reasons that the laboratory rejects compro-
mised specimens include unlabeled or misla-
beled specimens, inadequate volume, collection
in the wrong tube, hemolysis, lipemia, clotted
blood in an anticoagulant tube, improper han-
dling during transport, lack of a requisition
form, and contaminated specimen containers.
4. When must a phlebotomist document the name
of the person who has verified a patient’s
identity?
a. When the patient is a teenager
b. When the patient is elderly
c. When the patient is cognitively impaired
d. When the patient is combative
5. Why do phlebotomists perform their routine
blood collections early in the morning?
a. The physician needs the results early.
b. Patients are in a basal state.
c. Patients will have had breakfast.
d. Patients have a lower chance of fainting.
6. Match the following patient variables with their
possible effect on test results.
Effect Variable
_____ a. Increased 1. Prolonged fasting
Hgb level
_____ b. Decreased 2. Stress
glucose level
_____ c. Increased 3. Erect posture
WBC count
_____ d. Increased 4. Long-term exercise
skeletal
enzyme level
_____ e. Increased 5. Tobacco
cholesterol
level
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CHAPTER 9 ✦ Preexamination Variables and Venipuncture Complications
7. A patient who appears pale and has cold, damp
skin may develop
a. coagulation problems.
b. septicemia.
c. sclerosis.
d. syncope.
8. When a patient develops a seizure, the
phlebotomist should
a. continue to collect the blood.
b. forcibly restrain the patient.
c. place an applicator stick against the patient’s
tongue.
d. document the time the seizure started and
ended.
9. When a patient refuses to have his or her blood
drawn, the phlebotomist should
a. obtain help to hold the patient down.
b. cancel the test.
c. document the patient’s decision and notify
nursing personnel.
d. call the physician.
10. Hemoconcentration can be caused by
a. a tourniquet applied for longer than 1
minute.
b. failure by the patient to clench his or her fist.
c. inadequate mixing of tubes.
d. vigorously mixing the tubes.
11. Which of the following methods can be used to
locate veins that are not prominent?
a. Massaging the patient’s arm downward
b. Tapping the patient’s arm
c. Applying heat for 3 minutes
d. Applying a cold compress
12. Physician approval is required when collecting
blood from
a. patients with diabetes.
b. a patient’s lower arm veins.
c. a patient’s foot and leg veins.
d. pediatric patients.
13. Which of the following areas should be used for
venipuncture?
a. Hematomas
b. Deep cephalic veins
c. Edematous tissue
d. Sclerosed veins
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255 256 SECTION 3 ✦ Phlebotomy Techniques
14. What complication can occur when you draw 20. A patient verbalizes a shooting, burning, and 24. Which of the following is most critically affected
blood from an arm located on the same side of tingling pain when the needle is inserted. This in a hemolyzed specimen?
the body as a patient’s mastectomy? could be caused by a a. Potassium
a. Hemoconcentration a. nicked nerve. b. Albumin
b. Decreased blood flow b. vasovagal reaction. c. Total protein
c. Lymphedema c. collapsed vein. d. Calcium
d. Hemolysis d. sclerosed vein.
25. A puncture site may require additional pressure
15. When encountering a patient with an AV fistula, 21. What should you do first when a patient to stop bleeding when the patient
the phlebotomist should develops syncope? a. has low blood pressure.
a. apply the tourniquet below the fistula. a. Lower the patient’s head. b. has high blood pressure.
b. use the other arm. b. Apply cold compresses to the patient’s neck. c. frequently takes aspirin.
c. collect the blood from the fistula. c. Remove the tourniquet and needle. d. has a clotting tendency.
d. attach a syringe to the T-tube connector. d. Place the patient on a bed.
26. Which of these would cause a laboratory to
16. If the plunger of a syringe is pulled back too 22. Which of the following techniques will avoid reject a specimen?
quickly causing a hematoma? a. Clots in a lavender stopper tube
a. the patient feels a stinging sensation. a. Removing the tourniquet after removing the b. Collection in a partial-draw tube
b. the specimen may be hemolyzed. needle c. An incompletely filled SST
c. the patient develops a hematoma. b. Bandaging the patient’s arm immediately d. Clots in a red stopper tube
d. excess needle movement is prevented. after needle removal
c. Firmly anchoring the vein during needle in-
17. Which of the following is acceptable when
sertion
collecting blood using a winged blood
d. Having the patient bend his or her elbow
collection set?
and applying pressure
a. Raising the angle of needle insertion to 45
degrees 23. What error in technique can hemolyze a blood
b. Collecting blood into a syringe specimen?
c. Using a 15-mL evacuated tube a. Using a needle with too small of a diameter
d. Filling the SST before the light blue stopper b. Inserting the needle through the vein
tube c. Bending the arm while applying pressure
d. Using a needle with too large of a diameter
18. What can cause blood to flow slowly into the
tube while leaking into the tissue, causing a
hematoma?
a. Bevel of the needle is against the wall of
the vein Clinical Situations
b. Needle insertion angle is too deep
c. Needle is beside the vein 1 Tania, an outpatient, enters the blood drawing station, properly identifies herself, and
states that she had a mastectomy 3 months ago. She holds her left arm out for Trevor, the
d. Needle insertion angle is too shallow
phlebotomist.
19. Which of the following techniques is acceptable
when blood is not obtained after needle
a. What should Trevor ask Tania?
insertion? b. If blood is drawn from the wrong arm, state two possible dangers to Tania.
a. Laterally moving the needle c. If blood is drawn from the wrong arm, state two possible effects on laboratory tests.
b. Gently pulling the needle back and redirect-
ing the needle in a forward motion
c. Using a larger tube in the holder
d. Pulling the needle out of the skin and rein-
serting it
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CHAPTER 9 ✦ Preexamination Variables and Venipuncture Complications 257 258 SECTION 3 ✦ Phlebotomy Techniques

10. Identify the vein by palpation.

2 While blood for a CBC is being collected, Jessica develops syncope. Gerald, the
phlebotomist, immediately removes the needle and lowers Jessica’s head. Once Jessica has
11. Release the tourniquet.
recovered, Gerald labels the lavender stopper tube, which fortunately contains enough 12. Cleanse the site and allow it to air-dry.
blood, and delivers it to the clinical laboratory. Many results from this specimen are
13. Assemble and conveniently place the equipment.
markedly lower than those from Jessica’s previous CBC test.
a. How might the quality of the specimen have caused this discrepancy? 14. Reapply the tourniquet.
b. How could a venipuncture complication have contributed to this error? 15. Do not touch the puncture site with an unclean finger.
c. Could Gerald have done anything differently? Explain your answer. 16. Check the plunger movement.
17. Remove the needle cap and examine the needle.
3 Charlotte has a requisition form to collect blood from Nathan for two serology tests and a
prothrombin time. Charlotte is unable to obtain any blood from Nathan’s left antecubital 18. Anchor the vein below the puncture site.
area. She then moves to the right antecubital area and obtains a full red stopper tube, but 19. Smoothly enter the vein at an appropriate angle with the bevel up.
she cannot fill the light blue stopper tube.
20. Do not move the needle when the plunger is retracted.
a. What should Charlotte do next?
b. State two things that Charlotte should do before deciding that the needle must be 21. Collect the appropriate amount of blood.
removed without filling the second tube. 22. Release the tourniquet.
23. Cover the puncture site with gauze.
4 Jerome, an extremely overweight man, came to the outpatient station to have blood drawn
for a basic metabolic panel (BMP). Stephanie, the phlebotomist, had a difficult time 24. Remove the needle smoothly, activate the safety device, place the needle in the sharps container, and
finding a good median cubital or cephalic vein; however, she did feel a deep basilic vein. apply pressure.
After inserting the needle at an angle greater than 30 degrees, Stephanie was able to 25. Use a blood transfer device to fill the tubes.
obtain the blood after much probing. Jerome complained of a burning, tingling sensation
up and down his arm. 26. Fill the tubes in the correct order.
a. What likely caused the tingling sensation? 27. Mix the tubes promptly.
b. What is the CLSI recommendation for needle angle and vein selection? 28. Dispose of the needle, transfer device, and syringe in the sharps container.
c. What other complication may have occurred that will cause the laboratory to reject the 29. Label the tubes.
specimen?
30. Confirm the labeled tube with the patient’s ID band or have the patient verify that the information is
correct.
31. Examine the puncture site.
32. Apply the bandage.
Summary of the Procedure for Venipuncture Using a Syringe System 33. Dispose of used supplies.
34. Remove your gloves, and sanitize your hands.
1. Examine the requisition form.
35. Thank the patient.
2. Greet the patient, state the procedure to be done, and obtain informed consent.
36. Converse appropriately with the patient during the procedure.
3. Ask the patient to state his or her first and last names and date of birth and spell the last name.
37. Provide post-puncture instructions.
4. Examine the patient’s identification (ID) band.
5. Compare the requisition form information with the ID band and the patient’s statement.
6. Select tubes and equipment for the procedure.
7. Sanitize your hands and put on gloves.
8. Position the patient’s arm.
9. Apply the tourniquet.
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CHAPTER 9 ✦ Preexamination Variables and Venipuncture Complications 259 260 SECTION 3 ✦ Phlebotomy Techniques

32. Confirm the labeled tube with the patient’s ID band or have the patient verify that the information is
Summary of the Procedure for Venipuncture Using a Winged Blood Collection correct.
Set in a Hand Vein 33. Examine the puncture site.

1. Examine the requisition form. 34. Apply the bandage.

2. Greet the patient, state the procedure to be done, and obtain informed consent. 35. Dispose of used supplies.

3. Ask the patient to state his or her first and last names and date of birth and spell the last name. 36. Remove your gloves, and sanitize your hands.

4. Examine the patient’s ID band. 37. Thank the patient.

5. Compare the requisition form information with the ID band and the patient’s statement. 38. Converse appropriately with the patient during the procedure.

6. Select the tubes and equipment for the procedure. 39. Provide post-puncture instructions.

7. Sanitize your hands and put on gloves.

8. Position the patient’s hand.
9. Apply the tourniquet.
10. Identify the vein by palpation.
11. Release the tourniquet.
12. Cleanse the site and allow it to air-dry.
13. Assemble and conveniently place the equipment.
14. Reapply the tourniquet.
15. Do not touch the puncture site with an unclean finger.
16. Check the plunger movement if a syringe is attached.
17. Remove the needle cap and examine the needle.
18. Anchor the vein below the puncture site.
19. Hold the needle appropriately.
20. Enter the vein smoothly at the appropriate angle with the bevel up.
21. Maintain the needle securely in the vein.
22. Smoothly operate the syringe or evacuated tube holder.
23. Fill the tubes in the correct order.
24. Mix the tubes promptly.
25. Collect the appropriate amount of blood.
26. Release the tourniquet.
27. Cover the puncture site with gauze.
28. Remove the needle smoothly, activate the safety device, dispose of it in the sharps container, and apply
pressure.
29. Dispose of the apparatus in the sharps container.
30. Use a blood transfer device to fill the tubes in the correct order when the syringe is attached.
31. Label the tubes.
6842_Ch10_261-294 14/01/19 4:24 PM Page 261
CHAPTER
Special Blood Collection
Learning Outcomes
Upon completion of this chapter, the reader will be able to:
10.1 Explain the importance of various test collection priorities.
10.2 Define a fasting specimen, and name three tests affected by not
fasting.
10.3 List four reasons for requesting timed specimens.
10.4 Explain the requirements for oral glucose tolerance tests (OGTTs).
10.5 Discuss diurnal variation of blood constituents, and list substances
that are affected.
10.6 Differentiate between a trough level and a peak level in therapeutic
drug monitoring, and state the importance of collecting the
specimen at the prescribed time.
10.7 Discuss the timing sequences for the collection of blood cultures,
the reasons for selecting a particular timing sequence, and the
number of specimens collected.
10.8 Describe the aseptic techniques required when collecting blood
culture specimens.
10.9 Discuss blood collection from venous access devices.
10.10 Describe the procedure for collecting specimens for cold agglutinins
and cryoglobulins.
10.11 List tests that must be chilled immediately after collection and
methods for transporting specimens to the laboratory.
10.12 List tests for which the results are affected by exposure of the
specimen to light.
10.13 Define the chain of custody.
10.14 Describe the criteria for collection and processing of specimens
requested for forensic studies.
10.15 List tests frequently requested for molecular diagnostic studies.
10.16 Describe physical and emotional conditions in pediatric and
geriatric patient populations and the effects of these conditions on
blood collection.
For additional resources please visit
http://davisplus.fadavis.com
6842_Ch10_261-294 14/01/19 4:24 PM Page 262
10
262 SECTION 3 ✦ Phlebotomy Techniques
INTRODUCTION
Certain laboratory tests require techniques that are
not part of the routine venipuncture procedure.
These special techniques may involve patient prepa-
ration, timing of specimen collection, other blood
collection techniques, and specimen handling. You
must know when these techniques are required,
how to perform them, and how specimen integrity is
affected when they are not performed correctly.
Key Terms COLLECTION PRIORITIES
Aerobic
Anaerobic Each test order is designated as routine, asap, STAT, or
Aseptic timed. Collections lists and turnaround times (TATs)
Bacteremia for test results are based on these designations and vary
for different facilities. You must prioritize your workload
Central venous catheter
accordingly to accommodate the various test priorities.
(CVC)
Chain of custody
Diurnal variation Routine
Fasting Routine test collections are for tests that are ordered
Forensic by the health-care provider to diagnose and monitor
Geriatric a patient’s condition. Routine specimens are usually
Hyperglycemia
collected early in the morning, but you can collect
Hypoglycemia them throughout the day during scheduled “sweeps”
Peak level (collection times) on the floors or from outpatients.
Pediatric
Postprandial (pp)
Septicemia ASAP
ASAP means “as soon as possible.” The response time
Trough level
for the collection of this test specimen is determined by
Vascular access device (VAD)
each hospital or clinic and may vary by laboratory test.
STAT
“STAT” means the specimen is to be collected and an-
alyzed and the results reported immediately. STAT
tests have the highest priority and are usually ordered
from the emergency department (ED) or for a criti-
cally ill patient whose treatment will be determined
by the laboratory result. You must deliver these spec-
imens to the laboratory promptly and notify the
laboratory personnel of the delivery.
FASTING SPECIMENS
Certain laboratory tests must be collected from a
patient who has been fasting. Fasting differs from
261
the basal state in that the fasting patient must have
refrained from only eating and drinking (except water)
for 8 to 12 hours, whereas in the basal state, the patient
also must have refrained from exercise. A patient who
is classified as nothing by mouth (NPO) is not allowed
to have food or water because of possible complica-
tions with anesthesia during surgery or certain medical
conditions.
Test results most critically affected in a nonfasting
patient are those for glucose, cholesterol, triglyceride,
or lipid profiles. Prolonged fasting increases bilirubin
and triglyceride values and markedly decreases glucose
levels. When a fasting specimen is requested, it is your
responsibility to determine whether the patient has
been fasting for the required length of time. If the
patient has not, you must report this to a supervisor
or the nurse and note it on the requisition form if the
decision is made to collect the nonfasting specimen.
Technical Tip 10-1. A specimen that appears
lipemic is an indication that the patient was not
fasting. Lipemia may interfere with laboratory
testing.
Technical Tip 10-2. Patients should be encouraged
to drink water to avoid dehydration, which can
affect laboratory results.
TIMED SPECIMENS
Frequently, you will receive requisitions for blood to
be drawn at a specific time. Reasons for timed speci-
mens are shown in Box 10-1.
You should arrange your schedule to be available
at the specified time, and you should record the ac-
tual time of collection on the requisition form and
specimen tube. Results from specimens collected too
early or too late may be falsely elevated or decreased.
Misinterpretation of test results can cause improper
treatment of the patient.
The most frequently encountered timed specimens
are discussed in this chapter. Other diagnostic proce-
dures may also require timed specimens, and any re-
quest for a timed specimen should be strictly followed.
Glucose Tolerance Tests
A glucose tolerance test (GTT) is used to evaluate
the patient’s ability to metabolize glucose, which is
6842_Ch10_261-294 14/01/19 4:24 PM Page 263
BOX 101 Reasons for Timed Specimens
Determining blood levels of medications
Measuring cardiac markers after an acute myocardial
infarction
Measuring substances that exhibit diurnal variation
(normal changes in blood levels at different times of
the day)
Measuring the body’s ability to metabolize a particular
substance
Monitoring anticoagulant therapy
Monitoring changes in a patient’s condition (e.g., a
steady decrease in hemoglobin)
regulated by insulin. Disorders in glucose metabolism
include hyperglycemia (increased blood glucose levels),
as in diabetes mellitus, and hypoglycemia (decreased
blood glucose levels). For the test, the patient orally
ingests a measured load of glucose, and then you col-
lect specimens at specific times in order to measure
the patient’s blood glucose level. A variety of methods
have been available for the diagnosis of diabetes
mellitus and gestational diabetes (GDM). Originally
these included the 2-hour postprandial (pp) glucose
test and the classic GTT. The 2-hour pp glucose test
compares a patient’s fasting glucose level with the
glucose level 2 hours after eating a meal with a high
carbohydrate content. The classic GTT required
patients to drink a standard glucose load and return
for testing on an hourly basis for up to 6 hours.
The American Diabetes Association (ADA) and the
World Health Organization (WHO) have standardized
and revised the methods used for the diagnosis of
diabetes mellitus. Current diagnostic test results for
diabetes mellitus include a hemoglobin (Hgb) A1C
level equal to or greater than 6.5 percent or a fasting
plasma glucose level equal to or greater than 126 mg/dL
or a 2-hour plasma glucose level equal to or greater
than 200 mg/dL after a 75-g oral glucose tolerance
test (OGTT). GDM is diagnosed with the one-step and
two-step OGTT.
You need to be aware of the variation in these pro-
cedures and consistently follow your facility’s protocol
for instructing patients, administering the glucose
loads, and setting up the specimen collection schedule.
The type of evacuated tubes that you use for blood
collection must be consistent throughout the proce-
dure. You should use gray stopper tubes to collect
blood specimens that will not be tested until the end
CHAPTER 10 ✦ Special Blood Collection
of the sequence. You must maintain consistency of
venipuncture or dermal puncture because glucose
values differ between the two types of blood. Venous
blood specimens are preferred. Schedule OGTT pro-
cedures to begin between 0700 and 0900 because
glucose levels exhibit a diurnal variation. The basic
instructions for these procedures are similar and are
shown in Procedure 10-1.
OGTT Preparation
Before the OGTT, give patients both verbal and
written instructions that must be followed exactly.
The patient must:
● Eat a balanced diet containing 150 g per day of
carbohydrates for 3 days before the test
● Fast for 8 hours but not more than 16 hours
before the test
● Abstain from food and drinks, including coffee
and unsweetened tea, except water
● Avoid smoking, chewing tobacco, alcohol, and
sugarless gum before and during the test because
they stimulate digestion and may cause inaccurate
test results
● Avoid vigorous exercise for 12 hours before
the test
● Refrain from certain medications that can inter-
fere with the test results (Box 10-2)
Technical Tip 10-3. You should ask the patient
about medications he or she is taking before
beginning the OGTT.
Technical Tip 10-4. Note on the requisition form if
the patient is chewing gum.
During scheduled specimen collections, observe
patients for any changes in their condition, such as dizzi-
ness, which might indicate a reaction to the glucose, and
report any changes to a supervisor. Some patients may
not be able to tolerate the glucose solution; if vomiting
occurs, you must report the time of the vomiting to a
supervisor. Contact the health-care provider for a deci-
sion concerning whether to continue the test. Vomiting
early in the procedure is considered the most critical
factor, and in most situations, the OGTT is discontinued.
Technical Tip 10-5. It is your responsibility to
determine the appropriate timing of inpatient
OGTT collections.
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263 264 SECTION 3 ✦ Phlebotomy Techniques
PROCEDURE 101 ✦ OGTT PROCEDURE
EQUIPMENT: Step 5. Timing for the remaining collection times begins
when the patient finishes drinking the glucose
Requisition form
Flavored glucose solution solution (Table 10-1). Give outpatients a copy of
the schedule, and instruct them to continue
Gloves
Tourniquet fasting, to drink water, and to remain in the
Alcohol pads drawing station area.
Evacuated tube holder and needles
TABLE 101 ● Sample Oral Glucose Tolerance Test
Evacuated tubes
Schedule for a 3-Hour Test
2 in. × 2 in. gauze
Sharps container TEST PROCEDURE 3HOUR TEST
Indelible pen Fasting blood 0700
Bandage Patient finishes glucose 0800
Biohazard bag
1-Hour specimen 0900
PROCEDURE: 2-Hour specimen 1000
3-Hour specimen 1100
Step 1. Identify the patient using the normal protocol,
explain the procedure, and obtain informed consent.
Step 2. Confirm that the patient has fasted for 8 hours and Step 6. Collect the remaining specimens at the scheduled
not more than 16 hours. times. Timing of specimen collection is critical
because test results are related to the scheduled
Step 3. Draw a fasting glucose specimen. Test the fasting
times; make note of any discrepancies on the
blood specimen before continuing the procedure
requisition form.
to determine whether the patient can safely be
given a large amount of glucose. Step 7. Place corresponding labels containing routinely
required information and specimen order in the
Step 4. Ask the patient to drink the appropriate flavored
test sequence, such as 1-hour, 2-hour, and 3-hour,
glucose solution within 5 minutes. Small adults
on the blood specimen tube label.
and children may have adjusted amounts based on
1 g of glucose per kilogram of body weight. Oral Step 8. Transport the specimens to the laboratory
immediately. Specimens not collected in gray
glucose loads may vary when testing for GDM.
stopper tubes must be centrifuged or tested
within 2 hours of collection for reliable results.
6842_Ch10_261-294 14/01/19 4:24 PM Page 265
BOX 102 Medications That May Interfere
With an Oral Glucose Tolerance Test
Alcohol
Anticonvulsants
Aspirin
Birth control pills
Blood pressure medications
Corticosteroids
Diuretics
Estrogen-replacement pills
Technical Tip 10-6. Some health-care providers
still request that a 1/2-hour blood specimen and
urine specimens be collected and tested with each
specimen.
Technical Tip 10-7. Instruct outpatients on the
importance of adhering to the scheduled blood
collection times for accurate results.
Technical Tip 10-8. When collecting OGTT
specimens, closely observe the patient for
symptoms of hyperglycemia or hypoglycemia.
2-Hour OGTT
The 2-hr OGTT is now the recommended method
for the diagnosis of diabetes mellitus. The procedure
requires the collection of a fasting glucose specimen
and having the patient drink a 75-g glucose solution
within 5 minutes and return for a second glucose test
in 2 hours. A result equal to or greater than 200 mg/dL
is considered indicative of diabetes mellitus.
One- and Two-Step Methods for GDM
Timing for these tests may vary with facilities and
health-care providers. It is important to check with
a supervisor for any requests that you are not familiar
with.
One-Step Method
The one-step method used to diagnose GDM uses
the same procedure as the diagnostic 2-hour OGTT,
except that you need to draw and test blood when the
patient is fasting and at both 1 and 2 hours after she
drinks the 75-g glucose solution. The diagnosis of
6842_Ch10_261-294 14/01/19 4:24 PM Page 266
CHAPTER 10 ✦ Special Blood Collection 265
GDM is made when any of the following plasma
glucose values are met or exceeded:
● Fasting: 92 mg/dL (5.1 mmol/L)
● 1 hour: 180 mg/dL (10.0 mmol/L)
● 2 hour: 153 mg/dL (8.5 mmol/L)
Two-Step Method
The two-step method requires that the patient receive
two tests. In the first step, the nonfasting patient
receives a 50-g glucose challenge, with plasma glucose
testing performed at 1 hour. When the plasma glu-
cose level is equal to or greater than 140 mg/dL, step
2 is performed. The second test is administered on a
different day and consists of a 100-g, 3-hour OGTT
when the patient is fasting. The diagnosis of GDM is
made when at least two of the following levels are met
or exceeded:
● Fasting: 95 mg/dL (5.3 mmol/L)
1 hour: 180 mg/dL (10.0 mmol/L)
●
● 2 hour: 155 mg/dL (8.6 mmol/L0
● 3 hour: 140 mg/dL (7.8 mmol/dL)
Lactose Tolerance Test
A lactose tolerance test evaluates a patient’s ability
to digest lactose, a milk sugar. The enzyme mucosal
lactase converts lactose into glucose and galactose.
Patients without this enzyme are unable to break
down lactose from milk and milk products, which may
result in gastrointestinal discomfort and diarrhea.
Avoiding milk can reduce the symptoms.
Lactose intolerance can be diagnosed by a lactose
tolerance test. For the test, the patient is asked to drink
a standardized amount of lactose solution based on
body weight in place of glucose. The blood collection
schedule is similar to that of a 2-hour OGTT. When
the patient is lactose intolerant, glucose levels increase
no more than 20 mg/dL from the fasting specimen.
Diurnal Variation
Substances and cell counts primarily affected by diur-
nal variation are cortisol, testosterone, estradiol,
progesterone, renin, thyroid-stimulating hormone
(TSH), serum iron, and white blood cells (most often
eosinophils), and the levels of these substances fluc-
tuate noticeably throughout the day. This is why
you are often asked to draw specimens for these tests
at specific times, usually corresponding to the peak
diurnal level. Certain variations can be substantial.
Plasma cortisol levels drawn between 0800 and 1000
266 SECTION 3 ✦ Phlebotomy Techniques
are twice as high as levels drawn at 1600. Consequently,
requests for plasma cortisol levels frequently specify
that the test be drawn between 0800 and 1000, or at
1600. If the specimen cannot be collected at the spec-
ified time, you must notify the health-care provider and
have the test rescheduled for the next day.
Technical Tip 10-9. You must stress to the
outpatient the importance of adhering to the
scheduled blood collection times for accurate results.
Therapeutic Drug Monitoring
The fact that medications affect all patients differently
frequently results in the need to change dosages or
medications. Some medications can reach toxic levels
in patients who do not metabolize or excrete them
within an expected time frame. Likewise, some patients
metabolize and excrete medications at an increased
rate. The use of multiple medications also can inter-
fere with the action of the medication being tested. To
ensure patient safety and medication effectiveness, the
blood levels of many therapeutic drugs are monitored.
Therapeutic drugs that are monitored frequently
are shown in Box 10-3. Random specimens are re-
quested occasionally; however, the most beneficial
levels are those drawn before the next dosage is given
(trough level) and shortly after the medication has
been given (peak level). Trough levels are collected
30 minutes before the drug is to be given; they repre-
sent the lowest level in the blood and ensure that the
drug is in the therapeutic (effective) range. Ideally,
trough levels should be tested before administering
BOX 103 Frequently Monitored
Therapeutic Drugs
Amikacin
Digoxin
Dilantin
Gentamicin
Lithium
Methotrexate
Phenobarbital
Theophylline
Tobramycin
Valproic acid
Vancomycin
Various antibiotics
the next dose to ensure that the level is low enough
for the patient to receive more medication safely. The
time for collecting peak levels varies with the medica-
tion and the method of administration. Peak levels
should be collected approximately 30 minutes after
IV administration, 1 hour after intramuscular (IM)
administration, or 1 to 2 hours after oral dosing; this
ensures that the drug is not at a toxic level. Informa-
tion from drug manufacturers provides the half-life,
the toxicity level, and the recommended times for
collection of peak levels.
To ensure correct documentation of the peak
and trough levels, be sure that requisition forms and
specimen tube labels include the medication dose,
the time and method the last dose was administered,
and the specimen collection time. Therapeutic drug
monitoring collections are often coordinated with the
pharmacy, laboratory, and nursing staff.
Preexamination Consideration 10-1.
Collection of blood in gel serum separator tubes
(SSTs) has caused falsely low levels of certain
medications. Refer to the manufacturer’s package
insert to determine whether the gel serum tube
can be used.
Technical Tip 10-10. Depending on the half-life
of a medication, the timing of peak levels in
therapeutic drug monitoring can be critical.
Technical Tip 10-11. Red stopper tubes are
recommended for therapeutic drug monitoring,
and you should transport specimens in an upright
position.
BLOOD CULTURES
One of the most difficult phlebotomy procedures is
collection of blood cultures. This is because of the
strict aseptic technique required and the need to
collect multiple specimens in special bottles. The skin
is covered with bacteria. If the venipuncture needle
is contaminated with skin bacteria, the microorgan-
isms can be inoculated into the collection bottles. A
positive blood culture could be from skin contamina-
tion and not from an actual patient infection in the
6842_Ch10_261-294 14/01/19 4:24 PM Page 267
blood. Bacteria in the circulatory system is called bac-
teremia. Blood cultures are requested on patients when
symptoms of fever and chills indicate a possible infec-
tion of the blood by pathogenic microorganisms and
their toxins (septicemia). The patient’s initial diagnosis
is often fever of unknown origin (FUO). A blood cul-
ture test can determine the microorganism causing
the infection and the most effective antibiotic to treat
the infection.
Timing of Specimen Collection
Usually blood cultures are ordered STAT or as timed
collections. A blood culture set consists of blood
from a single venipuncture that is inoculated into
both an aerobic (with air) bottle and an anaerobic
(without air) bottle. It is often difficult to isolate
microorganisms from the blood because of the
small number of organisms needed to cause symp-
toms. Specimens are usually collected in sets of two
drawn 30 or 60 minutes apart or just before the pa-
tient’s temperature reaches its highest point (spike);
however, timing of specimen collections varies from
facility to facility. The concentration of microorgan-
isms fluctuates and is often highest just before the pa-
tient’s temperature spikes. This explains why collections
may be ordered at specific intervals or ordered STAT
when a pattern has been observed in the patient’s
temperature chart.
When antibiotics are to be started immediately, the
sets are drawn at the same time from different sites.
Specimens collected from different sites at the same
time serve as a control for possible contamination and
must be labeled by the collection site, such as right
arm antecubital vein, and their number in the series
(#1 or #2).
Collection Equipment
You can draw blood directly into bottles containing cul-
ture medium (nutrient broth) and the anticoagulant
sodium polyanethol sulfonate or into sterile, yellow
stopper evacuated tubes containing the anticoagulant
sodium polyanethol sulfonate, and transferred to cul-
ture medium in the laboratory. You should collect each
set in the same manner as the first set.
You can use a winged blood collection set with a
Luer adapter and a specially designed holder to trans-
fer blood directly from the patient to bottles contain-
ing culture medium. The Luer adapter on the winged
blood collection apparatus attaches to the transfer
device, which contains a stopper-puncturing needle.
Blood flows from the vein through the winged blood
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CHAPTER 10 ✦ Special Blood Collection 267
collection set tubing, Luer adapter, and stopper-
puncturing needle into the culture bottle.
You can collect blood in a syringe and aseptically
transfer it to blood culture bottles at the bedside
using a safety transfer device. Occupational Safety and
Health Administration (OSHA) regulations do not
allow direct inoculation from the syringe to the bottle.
A health-care provider may order blood cultures
on a patient who is on antibiotic therapy, which will
require you to collect the blood using special blood
collection systems. Some blood culture collection sys-
tems have antimicrobial removal devices (ARDs) con-
taining resin, which inactivates antibiotics. The
fastidious antimicrobial neutralization (FAN) blood
collection system uses bottles that contain activated
charcoal, which neutralizes the antibiotic.
Blood cultures may be collected from vascular
access devices (VADs), such as IV catheters and ports,
by specially trained personnel. However, there is a
greater contamination rate associated with VAD collec-
tion than with blood cultures obtained by venipuncture.
The recommended procedure is to collect one blood
culture from the VAD and a second culture by veni-
puncture. Be sure to document both sources accord-
ing to the facility’s policy.
Contaminated blood cultures remain a significant
problem in the diagnosis of bloodstream infections, in-
cluding sepsis. A new device developed by Magnolia
Medical Technologies, Inc., called the Steripath Initial
Specimen Diversion Device® (ISDD®) has substantially
reduced the rate of contaminated blood cultures to
0.2 percent, providing a 97 percent positive predictive
value. Steripath is a sterile mechanical ISDD that diverts
and sequesters the first 1.5 to 2 mL of blood, which can
contain contaminants from skin cells and microbes. This
sample of the blood is mechanically isolated into an
integrated diversion chamber. When the device is fully
actuated, a second independent sterile pathway directs
the blood into the blood culture bottle. This closed
system prevents contamination that can occur from
equipment preparation, remaining skin flora (you can
disinfect but not sterilize the skin), and microorganisms
on the skin plug created via venipuncture (Fig. 10-1).
Blood Culture Anticoagulation
An anticoagulant must be present in the tube or
blood culture bottle to prevent microorganisms from
being trapped within a clot, where they might be
undetected; therefore, you must invert blood culture
bottles after the blood has been added in order to mix
the contents. The anticoagulant sodium polyanethol
268 SECTION 3 ✦ Phlebotomy Techniques
FIGURE 101 SteriPath Initial Specimen Diversion Device®
(ISDD®).
sulfonate is used for blood cultures because it does not
inhibit bacterial growth and may, in fact, enhance it
by inhibiting the action of phagocytes, complement,
and some antibiotics. Do not use any other anti-
coagulants because they may inhibit bacterial growth.
Technical Tip 10-12. Be sure to transport blood
collection bottles to the laboratory for testing as
soon as possible, particularly the ARDs and FANs.
Cleansing the Site
The venipuncture technique for collecting blood cul-
tures follows the routine procedures, except for the
increased aseptic preparation of the puncture site.
Contamination of the blood culture bottles with skin
bacteria could interfere with the interpretation of
the test results. Antiseptics for disinfecting the blood
collection site include 2 percent iodine tincture,
povidone-iodine, multiple 70 percent isopropyl alco-
hol preps, chlorine-peroxidase, and chlorhexidine
gluconate, and all are equally effective in killing bac-
teria on the skin. Following facility policy and strict
adherence to aseptic technique during specimen
collection is essential to ensure that a positive blood
culture is not caused by external contamination.
The procedure for cleaning the arm depends on
the antiseptic that you use. When using the two-step
method with alcohol and iodine, cleansing of the site
typically begins with scrubbing of the site for 1 minute
using 70 percent isopropyl alcohol. Follow the alco-
hol scrub by scrubbing the site with 2 percent iodine
tincture or povidone-iodine for another minute,
starting in the center of the venipuncture site and
progressing outward 3 to 4 in., creating friction. Allow
the iodine to dry on the site for at least 30 seconds.
Iodine-containing preparations require sufficient
time to disinfect the skin. To prevent irritation of
the patient’s arm and iodine’s possible adverse effect
on the thyroid and liver, remove the iodine with
alcohol when the procedure is complete.
Chlorhexidine gluconate/isopropyl alcohol (Medi-
Flex ChloraPrep, Cardinal Health, Leawood, KS) is
the antiseptic used in many health-care facilities
because of the frequency of iodine sensitivity in pa-
tients. It is a one-step application using a commer-
cially prepared swab or sponge (ChloraPrep). Scrub
the venipuncture site for 30 to 60 seconds in a back-
and-forth motion, creating friction on the skin,
which is effective in skin antisepsis. It also requires
30 seconds to dry for skin disinfection. Chlorhexi-
dine gluconate is not recommended for infants
younger than 2 months because it can cause irrita-
tion or chemical burns.
Technical Tip 10-13. Follow the manufacturer’s
instructions when using commercially packaged
venipuncture site blood culture prep kits.
Phlebotomist Alert Take every precaution not to
retouch the puncture site after it has been cleaned.
If you must palpate the vein again, you must wear a
sterile glove or repeat the disinfection procedure.
You must clean the tops of the blood culture bottles
before inoculating them with blood. Remove the plastic
caps on the collection bottles, and clean the rubber stop-
pers using 70 percent alcohol; allow them to dry before
use or as recommended by the manufacturer. Be sure
to keep the alcohol pad on the bottles until inoculation.
Do not use iodine on the stoppers because it can enter
the culture during specimen inoculation and may cause
deterioration of some stoppers during incubation.
Specimen Collection
You should plan to collect two specimen bottles for each
blood culture set from one venipuncture, one to be
incubated aerobically and the other anaerobically.
6842_Ch10_261-294 14/01/19 4:24 PM Page 269
When you use a syringe, you should inoculate the
anaerobic bottle first to prevent possible exposure to
air. When you collect the specimen using a winged
blood collection set, you should inoculate the aerobic
bottle first so that the air in the tubing does not enter
the anaerobic bottle. It is not recommended that you
fill bottles directly through an evacuated tube needle
and holder system because of the possibility of broth
media refluxing back into the vein. It also is difficult
to ensure that you have collected the correct volume
of blood.
Preexamination Consideration 10-2.
Failure to follow the proper inoculation procedure
for aerobic and anaerobic specimens is most
critical for the anaerobic specimen because the
addition of air to the anaerobic bottle will kill any
anaerobic organisms present.
Pediatric blood culture volume requirements are
based on the child’s body weight, and pediatric bottles
PROCEDURE 102 ✦ BLOOD CULTURE SPECIMEN COLLECTION
EQUIPMENT:
Requisition form
Gloves
Tourniquet
Chlorhexidine gluconate (or other acceptable skin antiseptic)
Alcohol pads
Blood culture bottle set (aerobic and anaerobic)
Syringe
Hypodermic needle with safety device
Blood transfer device
Winged blood collection set and tube holder
2 in. × 2 in. gauze
Sharps container
Indelible pen
Bandage
Biohazard bag
PROCEDURE:
Step 1. Obtain and examine the requisition form.
Step 2. Greet the patient, explain the procedure to be
performed, and obtain informed consent.
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CHAPTER 10 ✦ Special Blood Collection 269
are inoculated. Draw 1 mL of blood for every 5 kg
(approximately 10 pounds) of patient weight. For a
child heavier than 45 kg, treat the specimen as that
of an adult. Draw 1 mL of blood on babies weighing
less than 5 kg, and place all the blood in one pediatric
bottle.
Because the number of organisms present in the
blood is often small, the amount of blood inocu-
lated into each container is critical. The ratio of
blood to media should be at least 1:10. Adult blood
culture bottles usually require 8 to 10 mL for each,
and pediatric bottles require 1 to 3 mL for each.
Read the bottle label for the volume of blood
required. Follow the instructions for the system
being used. Avoid overfilling bottles because
this may cause false-positive results with automated
systems. Underfilled blood culture bottles may
cause false-negative results. The specimen collec-
tion procedure for blood culture is described in
Procedure 10-2.
Head to DavisPlus for Video 10-1 (Blood Cul-
ture Using a Syringe).
Step 3. Identify the patient verbally by having him or her
state both the first and last names, spell the last
name, and give the date of birth. Compare the
information on the patient’s identification (ID)
band with the requisition form.
Step 4. Prepare the patient, and verify allergies.
Step 5. Select the equipment.
Continued
270 SECTION 3 ✦ Phlebotomy Techniques
PROCEDURE 10 2 ✦ BLOOD CULTURE SPECIMEN COLLECTION (Continued)
Step 6. Sanitize your hands, and put on gloves. Step 12. Clean the top of the bottles with a 70 percent
isopropyl alcohol pad, and allow them to dry.
Step 7. Apply the tourniquet, and locate the
venipuncture site.
Step 8. Release the tourniquet.
Step 9. Disinfect the site using chlorhexidine gluconate.
Creating friction, rub for 30 to 60 seconds over an
area of about 2 in., and allow it to air-dry for at
least 30 seconds for antisepsis.
Step 13. Reapply the tourniquet, and perform the veni-
puncture. Do not repalpate the site unless you
are wearing a sterile glove or you repeat the
disinfection procedure.
Step 10. Aseptically assemble equipment while the anti-
septic is drying. Attach the needle to the syringe.
Step 11. Remove the plastic cap on the collection bottle.
Confirm the volume of blood required from the
label.
Step 14. Release the tourniquet. Place gauze over the
puncture site, remove the needle, and apply
pressure.
Step 15. Activate the safety device or remove the syringe
needle using a point-lok device.
6842_Ch10_261-294 14/01/19 4:24 PM Page 271
PROCEDURE 10 2 ✦ BLOOD CULTURE SPECIMEN COLLECTION (Continued)
Step 16. Attach the safety transfer device.
Step 17. Inoculate the anaerobic blood culture bottle first
when using a syringe or second when using a
winged blood collection set.
Step 18. Dispense the correct amount of blood into the
bottles. Some facilities require documenting the
amount of blood dispensed.
CHAPTER 10 ✦ Special Blood Collection
Step 19. Mix the blood culture bottles by gentle inversion
eight times.
Step 20. Fill other collection tubes after the blood culture
tubes.
Step 21. Clean the iodine off the patient’s arm with
alcohol if necessary.
Step 22. Label the specimens appropriately, including the
site of collection. Verify identification with the
patient.
Step 23. Dispose of used equipment and supplies in a
biohazard container.
Step 24. Check the venipuncture site for bleeding, and
bandage the patient’s arm.
Step 25. Prepare the specimen and requisition form for
immediate transport to the laboratory.
Step 26. Remove your gloves, and sanitize your hands.
Step 27. Provide post-puncture instructions, and thank
the patient.
6842_Ch10_261-294 14/01/19 4:24 PM Page 272
271 272 SECTION 3 ✦ Phlebotomy Techniques
and flushing with heparin or saline are required
BLOOD COLLECTION FROM VADS maintenance for this type of catheter (Fig. 10-2).
Hickman catheters may be single lumen or
Blood specimens may be obtained from indwelling multilumen. The most common is the double
lines called central venous catheters (CVCs). However, lumen, which has two color-coded tails; the
this procedure must be performed by specially white port is for routine IV fluids and medica-
trained personnel, and physician authorization is tions, and the red port is for blood draws and
required. A CVC is a special type of catheter that is infusing blood products.
inserted by a physician or a certified health-care pro- The Groshong catheter is a clear silicone exter-
fessional either as an internal or an external catheter nal catheter with a blue radiopaque line running
into a large blood vessel. CVCs are used for adminis- alongside its length. This catheter has a three-
tration of fluids, drugs, blood products, and nutri- position valve at the end of the catheter tip. The
tional solutions as well as to obtain blood. There are valve opens to allow blood collection and fluid
numerous types of CVCs, and specific procedures infusion but does not allow backflow of blood.
must be followed for flushing the catheters with saline, Therefore, use of heparin is not needed with this
and possibly heparin, to prevent thrombosis when type of catheter and is not recommended.
blood collection is completed. Sterile techniques 3. Implanted port
must be strictly adhered to when entering CVCs The implanted port is a small chamber attached
because they provide a direct path for infectious to a catheter that is also considered more perma-
organisms to enter the patient’s bloodstream. nent. It is used for long-term access to the central
The four main types of CVCs are the following: venous system for a patient requiring frequent
IVs or receiving chemotherapy, but it can also be
1. Nontunneled, noncuffed CVC
used for blood collection. Using local or IV seda-
The nontunneled, noncuffed CVC is used for
tion, a surgeon implants the port in subcutaneous
short-term dwell times and is inserted through the
tissue usually at the collar bone, with the catheter
skin into the jugular, subclavian, or femoral vein
tip placed in the superior vena cava. It consists of
and threaded to the superior vena cava by a physi-
a self-sealing septum housed in a metal or plastic
cian during surgery or in a hospital room with
case. The port is palpated to locate the septum.
local anesthetic. It is commonly called a triple-
The self-sealing septum of the port withstands
lumen catheter, having one to three ports to access
1,000 to 2,000 needle punctures; however, only
with antireflux valve connector end caps on the
end of the ports. When multilumen catheters are
used, the proximal lumen is the preferred lumen
from which to obtain a blood specimen. The
lumens not being used should be clamped when
drawing blood to avoid contamination of the blood
specimen. After insertion, an occlusive waterproof
dressing covers the insertion site, and flushes are
necessary to maintain patency of the CVC.
2. Tunneled/cuffed CVC
The tunneled CVC is considered more perma-
nent and is used for long-term dwell times,
such as administration of chemotherapy. The
Broviac®, Hickman®, and Groshong® catheters
are examples of single-, double-, or triple-lumen
external catheters, respectively. A surgeon per-
forms a cutdown of the vein with local or IV se-
dation and tunnels the catheter in subcutaneous
tissue under the skin with the catheter tip in the
superior vena cava and some of the capped
catheter tubing protruding from the exit site on
the outside on the chest. A sterile dressing is ap-
plied over the insertion site. Dressing changes FIGURE 102 Triple-lumen catheter.
6842_Ch10_261-294 14/01/19 4:24 PM Page 273
specially designed noncoring needles can be
used. This needle has a deflected tip and is con-
figured at a 90-degree angle. This type of port
may be a single- or double-lumen catheter. The
advantages of this CVC are that there is no visible
catheter tubing and no site care is needed when
it is not being used. It is flushed monthly with
heparin or saline (Fig. 10-3).
4. Peripherally inserted central catheters (PICC
lines)
The PICC is placed in the basilic or cephalic vein
in the antecubital area of the arm, with the tip
threaded to the superior vena cava. PICCs can
be placed by IV team nurses or physicians and
can be left in for several weeks to months. The
catheter is threaded through an introducer
needle with about 6 to 10 in. of catheter exposed
and covered by an occlusive dressing. There is an
anti-reflux valve connector device attached to the
end of the lumen(s) of the catheter, where the IV
is connected or blood specimens are removed.
The advantages of a PICC are that it has few risks
and causes minimal discomfort to the patient. A
disadvantage of blood collection from a PICC is
that the catheter walls are easily collapsed.
To obtain blood from a PICC line, the catheter
size must be a 4 French (Fr) or greater in size. If
a PICC is being used for total parental nutrition
(TPN), it cannot be used for blood collection.
It is also important to never apply a tourniquet
or a blood pressure cuff to the arm above a PICC
insertion site because this may occlude or col-
lapse the catheter.
FIGURE 103 Implanted port.
CHAPTER 10 ✦ Special Blood Collection
Phlebotomist Alert PICC line catheters require
frequent observations. Assessment of the insertion
site and changing of dressing and the injection cap
are necessary to avoid infection. Follow your facility’s
policy regarding the use of PICC lines.
Blood Specimen Collection
Blood specimen collection for laboratory testing can
be routinely drawn from vascular access devices (VADs).
Blood specimens are not collected from indwelling
peripheral or midline catheters. Blood specimens
may not be drawn from an administration set or prox-
imal to an existing infusion site.
When IV fluids are being administered through
the CVC, the flow should be stopped for 1 minute be-
fore you collect the blood specimen. You should not
use syringes larger than 20 mL for blood collection
because the high negative pressure produced may col-
lapse the catheter wall. At all times, you must discard
or conserve the first 5 mL of blood (or two times the
dead space volume of the catheter) and use a new
syringe to collect the specimen. It is not recommended
that you draw specimens for coagulation tests from a
CVC; however, when this is necessary, you should col-
lect them after you have discarded 20 mL of blood
(or five to six times the dead space volume of the
catheter) or used that amount for other tests.
The order of tube fill may vary slightly to accommo-
date the amount of blood that must be drawn before
a coagulation test. As with other procedures, always
collect blood cultures first. Draw blood cultures from
CVCs primarily to detect infection of the catheter tip,
and then compare the cultures with results from blood
cultures drawn from a peripheral vein. If these are
ordered, the draw will satisfy the additional discard
needed for coagulation tests. Therefore, the order of
fill is as follows:
1. First syringe—5 mL, discard
2. Second syringe—blood cultures
3. Third syringe—anticoagulated tubes (light blue,
lavender, green, and gray)
4. Clotted tubes (red and SST)
When blood cultures are not ordered, you can
collect the coagulation tests (light blue stopper tube)
with a new syringe after you have collected the other
specimens, using the order shown earlier. You are
frequently responsible for assisting the nurse who is
collecting blood from the CVC and should understand
these specimen collection requirements. Be sure to
note the source of the specimen on the requisition
6842_Ch10_261-294 14/01/19 4:24 PM Page 274
273 274 SECTION 3 ✦ Phlebotomy Techniques
form and that it was collected with a VAD. Under
Technical Tip 10-14. When you collect blood
no circumstances should a person without special-
from a VAD, do not leave blood in the syringe
ized training collect specimens from a CVC. You
while extensive flushing of the VAD is performed.
must always follow facility policy. Blood specimen
Transfer the specimen to the correct tubes
collection from VADs is described in Procedures 10-3
immediately, and gently invert them for proper
and 10-4. anticoagulation of the specimen.
PROCEDURE 103 ✦ BLOOD SPECIMEN COLLECTION FROM A VASCULAR
ACCESS DEVICE
EQUIPMENT: draw is for a blood culture, scrub the injection
cap with an alcohol wipe for 30 seconds.
Requisition form
Gloves
Alcohol wipes or chlorhexidine gluconate sponge
Two 10-mL syringes filled with normal saline, for flush
Two 5-mL syringes
Three-way stopcock
Blood collection tubes
Syringes for blood collection
Blood transfer device
One or two 5-mL syringe(s) filled with heparinized saline,
for flushing after using the saline flush (optional)
PROCEDURE:
Step 1. Obtain and review the requisition form.
Step 2. Identify the patient verbally by having him or her Step 10. Attach a 10-mL prefilled saline syringe to a three-
state both the first and last names, spell the last way stopcock. Flush with 10 mL of normal saline
name, and give the date of birth. Compare the (if TPN or heparin was infusing, flush the line
information on the patient’s ID band with the with 20 mL of normal saline).
requisition form.
Step 3. Explain the procedure, and obtain the patient’s
informed consent.
Step 4. Position the patient in a supine position.
Step 5. Assemble your supplies, and place them within
easy reach of your position near the patient.
Step 6. Sanitize your hands, and put on gloves.
Step 7. Stop infusions in all lumens for 1 minute before
drawing the specimen. When the lumen to be used
for laboratory draws has an infusion, cap the tubing
with a male/female cap when disconnecting it.
Step 8. When using a multilumen catheter, clamp all
lumens and withdraw blood from the proximal Step 11. Using the same syringe, withdraw 5 mL of blood.
lumen of the catheter. Remove the syringe, and discard the syringe in a
Step 9. Cleanse the injection cap with an alcohol wipe. biohazard container. Wait 10 to 15 seconds to
Using vigorous friction, scrub on the top and in draw the specimen.
the grooves for 15 seconds. When the laboratory
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CHAPTER 10 ✦ Special Blood Collection 275 276 SECTION 3 ✦ Phlebotomy Techniques

PROCEDURE 10 3 ✦ BLOOD SPECIMEN COLLECTION FROM A VASCULAR
ACCESS DEVICE (Continued)
Step 12. Use a sterile syringe to collect the specimen.
Collect the smallest volume of blood required
for each test.
Step 13. Attach the syringe and blood collection tubes to
the blood transfer device, and fill the tubes in the
correct order.
Step 14. After the tubes are filled, mix them immediately by
gentle inversion for the appropriate number of
inversions.
Step 15. Label all tubes in front of the patient, and
confirm with the patient or the identification (ID)
band that the information is correct.
Step 16. Scrub the hub for 15 seconds with alcohol to
remove any blood.
Step 17. Attach a prefilled, nonsterile 10-mL saline syringe
and flush. Use two syringes for a total of 20 mL. If
there are lumens that are not being used, flush
each of these lumens with 10 mL of saline.
Step 18. Resume previous fluids if applicable.
Step 19. Prepare the specimen and requisition form for
transport to the laboratory.
Step 20. Dispose of used supplies in a biohazard container.
Step 21. Remove your gloves, sanitize your hands, and
thank the patient.
PROCEDURE 10 4 ✦ BLOOD COLLECTION FROM AN IMPLANTED PORT (Continued)
Step 6. Palpate the patient’s shoulder area to locate and
identify the septum of the access port.
Step 7. Prep the area with a vigorous scrub using a
chlorhexidine gluconate applicator. When using
alcohol and iodine pads, prep in a circular motion
from within to outward, approximately 4 to 6 in.,
first with the alcohol pad and then with the iodine
swab. Allow the disinfectant to dry completely
(30 to 60 seconds for antisepsis to occur).
Step 8. Connect the noncoring needle tubing on the
end of one 10-mL saline flush syringe, and prime
the needle with saline until it is expelled.
Step 9. Locate the septum of the port with your
nondominant hand; firmly anchor the port
between your thumb and forefinger.
Step 10. Holding the noncoring needle with your other
hand, puncture the patient’s skin and insert the
needle at a 90-degree angle into the septum
using firm pressure. Advance the needle until
resistance is met and the needle touches the
back wall of the port.
Step 11. Inject 1 to 2 mL of saline, observe the area for
swelling and ease of flow; if swelling occurs,
reposition the needle in the port without
withdrawing it from the skin. If there is not
swelling, aspirate for blood return. When blood
return is observed, continue to flush with saline.
Step 12. Using the same syringe, aspirate 10 mL of blood,
and discard it. When specimens will be collected
for coagulation studies, discard 20 mL.
Step 13. Attach the syringe or the evacuated tube holder
to the needle tubing, and collect the minimum
blood necessary for ordered laboratory tests.
Step 14. Dispense the blood into the appropriate blood
collection tubes (using a blood transfer device
when a syringe is used) in the correct order of fill.
Mix the blood by gentle inversion three to eight
times.
Step 15. Flush the needle and the port with 20 mL of saline.
Step 16. Change syringes, and flush with 3 mL of
heparinized saline or follow your facility’s policy.
Step 17. Remove the needle, and apply a sterile dressing
over the site.
Step 18. Label all tubes in front of the patient, and
confirm with the patient or ID band that the
information is correct.
Step 19. Prepare the specimen and requisition form for
transport to the laboratory.
Step 20. Dispose of used supplies in the appropriate
biohazard container.
Step 21. Remove your gloves, sanitize your hands, and
thank the patient.

Technical Tip 10-15. Flushing of CVCs is

SPECIAL SPECIMEN HANDLING
PROCEDURE 10 4 ✦ BLOOD COLLECTION FROM AN IMPLANTED PORT performed to ensure and maintain patency of the
PROCEDURES
catheter and to prevent mixing of medications and
EQUIPMENT: PROCEDURE: solutions that are incompatible. Follow the
Requisition form manufacturer’s instructions for correct use and Instructions for the collection, transportation, and
Step 1. Obtain and review the requisition form.
Sterile drape facility policy and procedure for flushing. storage of all laboratory specimens are available from
Step 2. Identify the patient verbally by having him or her the laboratory and should be strictly followed to main-
Sterile gloves
state both the first and last names, spell the last tain specimen integrity. Some tests require that the
Noncoring needle
name, and give the date of birth. Compare the Technical Tip 10-16. Potential test errors can occur specimen be kept warm, chilled, frozen, or protected
Two 10-mL syringes
information on the patient’s identification (ID) when you obtain blood from VADs because of from light.
Two 10-mL flush syringes filled with saline
band with the requisition form. hemolysis and incomplete flushing of the collection
One 10-mL syringe filled with heparinized flush solution
(follow facility protocol) Step 3. Explain the procedure, and obtain the patient’s site, causing contamination or dilution of the specimen. Cold Agglutinins
Chlorhexidine gluconate sponge or alcohol and iodine pads informed consent.
Cold agglutinins are autoantibodies produced by
One 5-mL syringe Step 4. Sanitize your hands, and put on sterile gloves. people infected with Mycoplasma pneumoniae (atypical
2 in. × 2 in. gauze pads Phlebotomist Alert Always wear sterile gloves
Step 5. Assemble your equipment. pneumonia) or with autoimmune hemolytic anemias.
Dressing to cover insertion site when accessing ports. Maintain sterile technique
The autoantibodies react with red blood cells at
throughout the procedure.
temperatures below body temperature.
Continued
6842_Ch10_261-294 14/01/19 4:24 PM Page 277
Because the cold agglutinins in the serum attach to
red blood cells when the blood cools to below body
temperature, you must ensure the specimen is kept
warm until the serum can be separated from the cells.
Collect the specimens in tubes that have been warmed
in an incubator at 37°C for 30 minutes and that con-
tain no additives or gels that can interfere with the test.
Carry the warmed tube to the patient’s room in a warm
container or possibly a tightly closed fist, collect the
specimen as quickly as possible, return the specimen
to the laboratory in the same manner, and place it back
in the incubator. Small portable heat blocks that have
been warmed to 37°C are available for transporting
specimens that must be maintained at body tempera-
ture. Failure to keep a specimen warm before serum
separation will produce falsely decreased test results.
Cryofibrinogen and cryoglobulin are two proteins
that precipitate when cold and must be collected and
handled in the same manner as cold agglutinins.
Chilled Specimens
Chilling a specimen inhibits metabolic processes that
continue after blood collection and can adversely
affect laboratory results. Examples of specimens that
require chilling to prevent deterioration are shown in
Box 10-4. Follow facility protocol.
Chilling is contraindicated for some analytes. Potas-
sium levels will be falsely increased if the specimen is
chilled; therefore, you must collect whole blood spec-
imens collected for electrolytes in a separate tube when
ordered with other tests that require chilling. Chilling
BOX 104 Examples of Analytes That May
Require Chilling
Acetone
Adrenocorticotropic hormone (ACTH)
Ammonia
Angiotensin-converting enzyme (ACE)
Arterial blood gases (if indicated)
Catecholamines
Free fatty acids
Gastrin
Glucagons
Homocysteine
Lactic acid
Parathyroid hormone (PTH)
Pyruvate
Renin
Some coagulation studies
6842_Ch10_261-294 14/01/19 4:24 PM Page 278
CHAPTER 10 ✦ Special Blood Collection 277
blood specimens for prothrombin time (PT) (interna-
tional normalized ratio [INR]) testing is unacceptable
because it may cause activation of factor VII and alter
the results. The Clinical and Laboratory Standards
Institute (CLSI) recommends not chilling arterial
blood gases (ABGs) when they have been collected in
plastic syringes and will be analyzed within 30 minutes
(see Chapter 12).
For adequate chilling, you must place the specimen
in either crushed ice or a mixture of ice and water or in
a uniform ice block at the patient’s bedside (Fig. 10-4).
Placing a specimen in or on large ice cubes is not
acceptable because uniform chilling will not occur
and may cause part of the specimen to freeze, resulting
in hemolysis. It is important that these specimens be
delivered immediately to the laboratory for processing.
Specimens Sensitive to Light
Exposure to artificial light or sunlight (ultraviolet) for
any length of time may decrease the concentration of
various analytes that are listed in Box 10-5. Follow facility
protocol. Wrapping the tubes in aluminum foil or using
an amber specimen container or the equivalent can pro-
tect specimens (Fig. 10-5). Tubes should be kept closed.
Technical Tip 10-17. Bilirubin is rapidly destroyed
in specimens exposed to light and can decrease up
to 50 percent after 1 hour of exposure to light.
FIGURE 104 Specimens placed in crushed ice and a uniform
ice block.
278 SECTION 3 ✦ Phlebotomy Techniques
BOX 105 Examples of Analytes Sensitive
to Light
Beta carotene
Bilirubin
Folate
Porphyrins
Vitamin A
Vitamin B6
Vitamin B12
FIGURE 105 Specimens protected from light.
Legal (Forensic) Specimens
When drawing specimens for test results that may
be used as evidence in legal proceedings, you must
use extreme care to follow the stated policies exactly.
Documentation of specimen handling, called the
chain of custody, is essential. It begins with patient iden-
tification and continues until testing is completed and
results reported. Special forms are provided for this
documentation, and special containers and seals may
be required (Fig. 10-6). For each person handling the
specimen, documentation must include the date, the
time, and the identification of the handler. Patient
identification and specimen collection should be
done in the presence of a witness, frequently a law en-
forcement officer. Identification may include finger-
printing or heel printing in paternity cases. Tests most
frequently requested are alcohol and drug levels and
DNA analysis.
Blood Alcohol Specimens
Blood alcohol levels may be requested on a patient
for medical or legal reasons or as part of employee
drug screening. In any case, you must follow the
chain-of-custody protocol exactly. When collecting
blood alcohol levels, cleanse the site with soap and
water or a nonalcoholic antiseptic solution, such as
aqueous benzalkonium chloride (Zephiran Chloride)
to prevent compromising the results.
Technical Tip 10-18. Do not use skin disinfectants
that contain alcohol, such as tincture of iodine and
chlorhexidine gluconate, to clean the site for a
blood alcohol level.
To prevent the escape of the volatile alcohol into the
atmosphere, fill tubes until the vacuum is exhausted,
and do not uncap them before delivery to the labora-
tory. Blood alcohol levels are frequently collected in
gray stopper tubes with sodium fluoride; however,
laboratory protocol should be strictly followed.
Molecular Diagnostics
The field of molecular diagnostic testing is rapidly
expanding from the original blood testing of DNA
primarily to determine paternity and body fluid DNA
in criminal cases. In addition to specimens collected
by swabs for the identification of microorganisms,
blood specimens are collected for HIV and hepatitis
C virus (HCV) viral loads, diagnosis of hematological
disorders, coagulation disorders, management of war-
farin (Coumadin) therapy, and identification of ge-
netic disorders. More tests are rapidly being developed.
Depending on the test requested and the labora-
tory performing the test, the type of evacuated tubes
collected will vary. Yellow stopper tubes containing
acid citrate dextrose (ACD) are commonly used for
DNA paternity testing. Two concentrations of ACD
tubes are available, and you must collect the specimen
in the tube with the required concentration. Other
procedures may require ethylenediaminetetraacetic
acid (EDTA) or sodium citrate as the anticoagulant.
A variety of specialized tubes is also available.
Technical Tip 10-19. Yellow stopper tubes
containing sodium polyanethol sulfonate and used
for blood cultures are not acceptable for molecular
diagnostic testing.
6842_Ch10_261-294 14/01/19 4:24 PM Page 279
FIGURE 106 Sample chain-of-custody form.
Drug Screening
Health-care systems, workplaces, and universities and
colleges may require scheduled or random drug
screening. Urine is the specimen of choice because
of the ease of collection and because the substance
remains in the urine for a long period of time.
You may be involved in the collection of urine spec-
imens as part of a screening process for the use of
illegal drugs. As before, following and documenting
the chain-of-custody procedures is essential. Speci-
men substitution, contamination, or dilution must
also be prevented (see Chapter 14).
CHAPTER 10 ✦ Special Blood Collection
Technical Tip 10-20. Technical errors and failure
to follow chain-of-custody protocol are primary
targets of the defense in legal proceedings.
SPECIAL PATIENT POPULATIONS
As a phlebotomist, you will encounter patients of all
ages, which will require technical and communication
skills appropriate for each age group. Sometimes you
will need to modify your blood collection techniques
6842_Ch10_261-294 14/01/19 4:24 PM Page 280
279 280 SECTION 3 ✦ Phlebotomy Techniques
and equipment to successfully accommodate the chal-
lenges of blood collection for pediatric and geriatric
populations. You must develop and increase your
knowledge and skills in working with patients of all age
groups while performing blood collection procedures.
Geriatric Population
Blood collection in the older patient population
presents a unique challenge. Physical and emotional
factors related to the aging process can cause diffi-
culty with the blood collection procedure and speci-
men integrity. The goal is to perform an atraumatic
venipuncture without bruising or excessive bleeding
and provide a quality specimen for analysis.
Physical Factors
Physical changes that occur in the geriatric patient
and affect blood collection include the following:
● Normal aging often results in gradual hearing loss.
You may have to speak louder or repeat instructions
while facing the patient. You must confirm that
the patient thoroughly understands the instruc-
tions and identification procedures. Use of non-
verbal methods or paper and pencil to explain the
procedure or obtain consent to draw blood may
be required before performing the venipuncture.
● Failing eyesight is common in the geriatric pa-
tient. You may have to guide the patient to the
blood-drawing chair or escort him or her to the
bathroom for a urine specimen collection.
● The senses of taste, smell, and feeling also are
affected. Malnourishment or dehydration may
result from a lack of appetite. Malnutrition or
dehydration because of not eating or drinking
adequately can decrease plasma volume and
make locating veins for venipuncture difficult;
this can also affect laboratory test results, with
inherently higher potassium levels.
● Muscle weakness may cause the patient to drop
things or be unable to make a fist before venipunc-
ture or to hold the gauze after the venipuncture.
● Memory loss may cause the older patient to not
remember medications he or she may have taken
that can affect laboratory test results. A patient’s
inability to remember when he or she has last
eaten can affect a test requiring fasting.
● Epidermal cell replacement in the aging patient
is delayed, increasing the chance of infection.
When the patient already has a weakened immune
system, he or she may not heal as quickly or have
the ability to fight bacteria that can be introduced
during venipuncture. You must take extra care
when preparing the site for venipuncture. Always
sanitize your hands before applying gloves, and
use gloves when palpating for the vein.
● The loss of collagen and subcutaneous tissue
makes the patient’s veins less elastic and fragile,
with a tendency to collapse. The veins are hard
to anchor and puncture and are more prone to
hematoma formation. You must firmly anchor
the vein below the site so that the vein does
not move when it is punctured. Pull any loose
skin taut by wrapping your hand around the
patient’s arm from behind. You may need to
decrease the angle of the needle for venipunc-
ture because the patient’s veins are often close
to the surface.
● Older patients often feel cold because of the
decreased fatty tissue layer, meaning you may be
required to warm up the site.
● Arteries and veins often become sclerotic in the
older patient, making poor sites for venipunc-
ture because of compromised blood flow.
Disease States
Certain disease states are found predominantly in the
geriatric population and contribute to the challenge
of venipuncture:
● A patient with Alzheimer’s disease may be con-
fused or combative, which can cause problems
with identification and performing the proce-
dure. You may need assistance from a family
member or the patient’s caregiver to calm the
patient and hold his or her arm steady.
● Stroke patients may have paralysis or speech im-
pairments, requiring assistance in positioning
and holding the arm as well as help with commu-
nication.
● Patients in a coma should be treated as if they
can hear what is being said. Again, you will need
assistance when holding the patient’s arm.
● Arthritic patients may be in pain or unable to
straighten the arm and may require assistance
gently positioning and holding the arm. Using a
winged blood collection set with flexible tubing
may help to access veins at awkward angles.
● Geriatric patients may have tremors, as evidenced
in Parkinson’s disease, and may not be able to
hold the arm still for the venipuncture procedure.
● Geriatric patients are often receiving anticoagu-
lant therapy for heart problems or stroke. To
6842_Ch10_261-294 14/01/19 4:24 PM Page 281
avoid excessive bleeding or hematoma forma-
tion, extra time is required to hold pressure on
the site until bleeding has stopped and the area
can be bandaged.
Emotional Factors
Patients are often embarrassed by these conditions,
which may cause anxiety or fear of blood collection.
As previously stated, emotional stress can alter blood
composition and laboratory test results. In addition
to the physical changes of aging, the older patient
often faces the loss of career, spouse, family members,
and friends. These life changes can bring about de-
pression, sadness, and anger. The fear of pain or the
expense associated with venipuncture may make the
patient anxious or even tearful. All of these physical
and emotional factors can alter test results. In prepar-
ing the patient for venipuncture, it is important to
take more time than usual to assist and reassure the
patient. Treat patients with respect and dignity, giving
them a sense of control.
Blood Collection
The venipuncture procedure is basically the same for
geriatric patients as for younger patients; however,
unique preparation and sometimes modifications
to the blood collection technique are necessary to
successfully accommodate the collection of blood.
Patient Identification
When identifying older patients without identifica-
tion (ID) bands, be sure to have them state their
names. An elderly patient who is confused or who has
difficulty hearing is very likely to answer “yes” to any
question. When identifying patients, address them
by the appropriate title and not by their first name.
Always be considerate, and thank the patient.
Equipment Selection
Because of the small, fragile veins frequently seen in
the older patient, the evacuated tube system (ETS) is
usually not the best choice of equipment. The
vacuum pressure in the collection tube may cause
fragile veins to collapse. A better choice is a winged
blood collection set with a 23-gauge needle attached
to a syringe, which will allow you to control the suction
pressure on the vein. A small-gauge needle with a
syringe also is an option. If you use an ETS, be sure to
fill the smallest possible tubes. Because older patients
have a tendency to develop anemia, try to collect the
minimum acceptable amount of blood.
6842_Ch10_261-294 14/01/19 4:24 PM Page 282
CHAPTER 10 ✦ Special Blood Collection 281
Tourniquet Application
Geriatric patients are prone to bruising when a
tourniquet is applied. You can help avoid injury by
placing the tourniquet over the patient’s sleeve. Do
not apply the tourniquet too tightly to avoid injury to
the patient or collapse of the vein. Gently release the
tourniquet after venipuncture without snapping it
against the patient’s skin to avoid bruising the area.
You can use blood pressure cuffs for the thin patient
with small, hard-to-find veins.
Site Selection
Because of the difficulty in locating and anchoring
veins and the presence of hematomas from previous
venipunctures in the geriatric patient, the antecubital
fossa may not be the best site for you to select. The
veins in the hand or forearm may be a better choice.
It may require a little extra time and use of techniques
for making the veins more prominent. Applying heat
compresses for 3 to 5 minutes and stimulating the
area with alcohol can make the vein more prominent.
To avoid bruising the patient, do not tap the vein.
Other techniques to enhance the prominence of
veins include massaging the arm upward from the
wrist to the elbow and having the patient briefly hang
his or her arm down. Remember that when perform-
ing these techniques, you should not leave the tourni-
quet tied for more than 1 minute at a time.
Performing the Venipuncture
Geriatric patients’ veins “roll” easily; therefore, be
sure to pull the skin taut, anchor the vein firmly, and
puncture the vein in a quick motion. Pull loose skin
taut by wrapping your hand around the patient’s arm
from behind. You may need to decrease the angle of
the needle for venipuncture because the patient’s
veins are often close to the surface of the skin.
Bandages
Geriatric patients may have increased sensitivities to ad-
hesive bandages and an increased tendency to bruise.
Therefore, it is preferable to use a self-adhering
pressure-dressing bandage on the fragile skin of older
patients (e.g., Coban) because adhesive bandages can
actually take off a layer of skin when they are removed
and can leave a raw wound that is susceptible to infec-
tion. A better alternative is to hold pressure on the site
for 3 to 5 minutes or until the bleeding has stopped.
Older patients are often on anticoagulant therapy
for heart problems or stroke. Before bandaging the
area, take extra time to hold pressure on the site until
282 SECTION 3 ✦ Phlebotomy Techniques
the bleeding has stopped to avoid excessive bleeding
or hematoma formation. Do not apply the bandage
until the bleeding has stopped. The extra time and
consideration given to the patient is well spent.
Technical Tip 10-21. Direct light on the
venipuncture sight may help locate hard-to-find
veins in the older patient.
Additional Considerations
When possible, perform dermal puncture on the geri-
atric patient as a way of avoiding complications, such
as hematomas, bruising, collapsed veins, and anemia.
Advances in point-of-care testing (see Chapter 13)
have made it possible to perform many tests on a
small amount of blood that can be obtained by a
dermal puncture.
Pediatric Population
Ideally, you should use a dermal puncture procedure
to collect blood from children younger than 2 years
(see Chapter 11). However, special tests for coag-
ulation, erythrocyte sedimentation rates, special
diagnostic studies, or blood cultures require more
blood than can be collected from a finger or heel stick
and must be collected by venipuncture.
Patient/Parent Preparation
Pediatric blood collection involves preparing both the
child and parent and using certain restraining proce-
dures and special equipment. Pediatric phlebotomy
presents emotional as well as technical difficulties
and should be performed only by experienced phle-
botomists. A negative experience can lead to a child’s
lifelong fear of needles. Often, there is only one
chance to attempt a venipuncture on a child.
You must develop interpersonal skills to successfully
gain the trust and cooperation of both the young
patient and the parents as well as become skilled with
the special equipment used for pediatric venipuncture.
It is important to keep the patient as calm as possible
during the procedure because, as previously discussed,
emotional stress and crying can affect blood analytes
and cause erroneous test results. Try to collect only the
minimum amount of blood required for testing be-
cause infants and children have smaller blood volumes.
Techniques for Dealing With Children
Techniques for dealing with children vary depending
on the child’s age. It is best to establish guidelines and
to be honest with both the patient and parent.
Infants
Newborns and infants are totally dependent on their
parents. You should introduce yourself to the parents,
explain the procedure, and obtain consent. Ask the
parents about the child’s previous experiences with
blood collection. When possible, have the parent hold
the child, and encourage the parent to use distraction
and comforting techniques. The parents must identify
the child if the collection is occurring in an outpatient
setting. Hospitalized patients will have an ID band.
Toddlers
Toddlers can be fearful of strangers and have limited
language skills. It is important to talk to the child
calmly and maintain eye contact. Demonstrate the
procedure using toys. Allow children to have their
comfort toys or blanket and develop strategies to
distract or entertain them. Again, it is helpful to have
the parents assist with holding and comforting the
child. Reward the child with praise and stickers. Thank
the child and parent for their cooperation.
Older Children
Older children are more willing to participate. Ex-
plain the steps of the procedure, and demonstrate the
equipment. Demonstrate and allow the child to touch
the tourniquet or other clean equipment. Answer
their questions honestly. Never tell a child that the
procedure will not hurt. Explain that “it will hurt a lit-
tle bit, but if you hold very still, it will be over quickly.”
Enlist the child’s help in holding the gauze. Give the
child permission to cry.
Teenagers
Teenagers are more independent and often embar-
rassed to show their emotions. Use adult language with
teenagers for identification and explanation of the pro-
cedure. Ask them if they have fainted or had any reac-
tion to a previous venipuncture procedure. Encourage
them to ask questions about the procedure. They may
or may not want their parents present.
Methods of Restraint
Usually older children can sit in a drawing chair by
themselves. An infant cradle pad (see Chapter 7) fa-
cilitates blood collection for infants. Never draw blood
from a small child without some type of assistance. Phys-
ical restraint may be required to immobilize the young
child and steady his or her arm for the venipuncture
procedure. This can be accomplished by having some-
one hold the child or by using a papoose board. Either
a vertical or horizontal restraint will work.
6842_Ch10_261-294 14/01/19 4:24 PM Page 283
Vertical Restraint
For vertical restraint, the parent holds the child in an
upright position on his or her lap. The parent places
an arm around the toddler to brace the arm not being
used against the child’s body. The parent’s other arm
holds the child’s venipuncture arm firmly from be-
hind, at the bend of the elbow, in a downward position
(Fig. 10-7).
Horizontal Restraint
In the horizontal restraint, the child lies down, with
the parent on one side of the bed and the phle-
botomist on the opposite side. The parent leans over
the child, holding the child’s closer arm and body
securely while reaching over the child’s body to hold
the child’s opposite arm for you to perform the veni-
puncture (Fig. 10-8). In some instances, a child may
become extremely combative. To avoid injury to you
or the patient, the procedure should be discontinued
and the health-care provider notified.
Equipment Selection
You should collect the minimum amount of blood
required for laboratory testing from infants and small
children because drawing excessive amounts of blood
can cause anemia. Because of the small blood volume
in newborns, the amount of blood collected within a
24-hour period is monitored. It is recommended that
FIGURE 107 An adult holding a child using a vertical
restraint.
CHAPTER 10 ✦ Special Blood Collection
FIGURE 108 An adult holding a child using a horizontal
restraint.
no more than 3 percent of a child’s blood volume be
collected at one time and no more than 10 percent
in a month. To quickly estimate a child’s blood
volume, divide the child’s weight in pounds by 2 to
convert to kilograms, and multiply the kilograms by
100 to get the estimated blood volume in milliliters.
When using an ETS, select the smallest evacuated
pediatric tubes available to collect the least amount
of blood and to avoid causing the vein to collapse.
Evacuated tubes as small as 1.8 mL are available. A
23-gauge winged blood collection set needle with a
syringe is recommended because of a child’s small,
fragile veins. When only a very small amount of blood
is collected, use a microcollection tube rather than
an evacuated tube. It is acceptable to use an ETS on
older children. Pediatric-sized tourniquets are also
available. Assemble equipment out of view of the
child and cover threatening-looking equipment when
approaching the pediatric patient.
Pain Interventions
A local topical anesthetic, eutectic mixture of local
anesthetics (EMLA) (Abraxis Pharmaceuticals), is ideal
for use on an apprehensive child before venipuncture.
You can apply this emulsion of lidocaine and prilocaine
directly to intact skin and cover it with an occlusive
dressing. EMLA penetrates to a depth of 5 mm
through the epidermal and dermal layers of the skin.
It takes 60 minutes to reach its optimal effect and
lasts for 2 or 3 hours. Because of the time necessary to
anesthetize the area, you must select the vein accurately
or consider treating more than one site. EMLA should
not be used on infants younger than 1 month or if the
child is allergic to local anesthetics. One side effect of
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283 284 SECTION 3 ✦ Phlebotomy Techniques
this emulsion may be pallor or a slight redness at
the site because of the adhesive covering. It is a pre-
scription medication and must be administered by a
nurse, health-care provider, or parent. Other topical
anesthetics include a nonprescription gel, L-M-X4
(4 percent lidocaine) (Ferndale Labs, Ferndale, MI),
which is effective 15 to 30 minutes after application,
and Ametop® gel (4 percent amethocaine) (Smith &
Nephew Healthcare, Andover, MA). Tetracaine, a top-
ical anesthetic patch, has been effective when applied
30 minutes before venipuncture.
Research has shown that solutions of glucose, dex-
trose, and sucrose have a calming effect on infants
up to 3 months of age. When administered before FIGURE 109 Sucrose pacifier.
or during venipuncture or heel puncture, pain was
substantially reduced as opposed to use of a topical
anesthetic. The duration of crying was lessened, which
minimized the temporary increase in the white blood Site Selection
cell counts. Commercial sucrose pacifiers or nipples The veins located in the antecubital fossa are the best
are available. A 24 percent solution of sucrose may choice in children older than 2 years. Do not use
be made by mixing 4 teaspoons of water with 1 tea- deep veins. Site selection and technique are similar
spoon of sugar. This sucrose solution may be given to to those used for adults (see Chapter 8).
the infant using a syringe, dropper, nipple, or pacifier Dorsal hand venipuncture can be used for chil-
(Fig. 10-9) about 2 minutes before venipuncture, and dren younger than 2 years (Procedure 10-5). You
the effects last for about 5 minutes. can use this technique to collect specimens from
Other methods for reducing pain and calming a a superficial hand vein directly into appropriate
child include a topical refrigerant spray, breastfeed- microcollection tubes. The advantage of this tech-
ing, and holding a child tightly swaddled in a blanket nique is that you can collect more blood from the
during heel puncture or venipuncture. vein than with a heel puncture, and there is less
chance of hemolyzing the specimen or contaminat-
Preexamination Consideration 10-3. ing the specimen with tissue fluid. Use of this tech-
Utilizing techniques to calm an infant and reduce nique requires additional training and is a facility
crying times will minimize the preexamination decision because saving all veins for IV therapy may
effect of transient elevated white blood cell counts. be preferred. Use extreme care when disposing of
the contaminated needle.
PROCEDURE 105 ✦ DORSAL HAND VEIN TECHNIQUE
EQUIPMENT: PROCEDURE:
Requisition form Step 1. Obtain and examine the requisition form.
Gloves
Step 2. Greet the parent, explain the procedure, confirm
Alcohol pads
the infant’s identification, and obtain informed
Gauze
consent.
23- to 25-gauge hypodermic needle
Microcollection tubes Step 3. Sanitize your hands, and put on gloves.
6842_Ch10_261-294 14/01/19 4:24 PM Page 285
PROCEDURE 10 5 ✦ DORSAL HAND VEIN TECHNIQUE (Continued)
Step 4. Immobilize/restrain the infant/child.
Step 5. Select the vein by encircling the patient’s wrist
and gently bending it downward. Bending the
wrist too much may cause the vein to flatten out
and be hard to see or may cause the vein to
collapse. Do not use a tourniquet.
Step 6. Cleanse the site with alcohol, and allow it to
air-dry.
Step 7. Select a 23- to 25-gauge hypodermic needle with a
clear hub and appropriate microcollection tubes.
Step 8. Encircle the vein with your thumb underneath
and your index and middle fingers on top of the
patient’s wrist; apply pressure with your index
finger.
Step 9. Insert the needle into the vein with the bevel up
at an angle of 15 degrees to the patient’s skin.
Stop advancing the needle as soon as blood
appears in the hub.
Step 10. Fill the microcollection tubes directly from the
blood that drips from the hub of the needle.
BIBLIOGRAPHY
American Diabetes Association: Diagnosis and classification
of diabetes mellitus. Diabetes Care 40(Suppl. 1):S11-S24,
2017.
CLSI. Collection of Diagnostic Venous Blood Specimens,
ed. 7. CLSI standard GP41. Clinical and Laboratory Stan-
dards Institute, Wayne, PA, 2017.
CLSI. Collection, Transport, and Processing of Blood Speci-
mens for Testing Plasma-Based Coagulation Assays and
Molecular Hemostasis Assays. Approved Standard H21-A5,
ed. 5. CLSI document H21-A5. Clinical and Laboratory
Standards Institute, Wayne, PA, 2008.
CLSI. Procedures for the Collection of Arterial Blood Spec-
imens. Approved Standard GP43-A4, ed. 4. Clinical and
Laboratory Standards Institute, Wayne, PA, 2004.
6842_Ch10_261-294 14/01/19 4:24 PM Page 286
CHAPTER 10 ✦ Special Blood Collection 285
Step 11. Release the finger pressure intermittently to
allow the blood to continue to flow.
Step 12. After collection of specimens, place gauze over
the needle but do not push down.
Step 13. Remove the needle, and apply pressure for 2 to
3 minutes or until the bleeding stops. Do not
apply a bandage.
Step 14. Label the tubes, and confirm the information
with the identification (ID) band.
Step 15. Perform appropriate specimen handling.
Step 16. Dispose of used supplies in biohazard containers.
Step 17. Thank the patient and the parent, remove your
gloves, and sanitize your hands.
Step 18. Enter the blood collection volume in the
infant’s/child’s chart or logbook.
Step 19. Deliver the specimens promptly to the
laboratory.
CLSI. Procedures for the Handling and Processing of Blood
Specimens for Common Laboratory Tests, ed. 4. Ap-
proved Guideline GP44-A4. Clinical and Laboratory
Standards Institute, Wayne, PA, 2012.
Ernst, DJ: Pain reduction during infant and pediatric phle-
botomy. Medical Laboratory Observer, July 2007. https://
www.mlo-online.com/articles/200707/0707cover_
bonus.pdf. Accessed August 2, 2018.
Infusion nursing standards of practice. J Infusion Nurs
34(Suppl.1), 2011.
Methodist Hospital Nursing Service Policy and Procedure
Manual: Blood Specimen Collection From Vascular
Access Device. Methodist Hospital, Omaha, NE, 2014.
SteriPath Eliminates Blood Culture Contamination. Magnolia
Medical Technologies, 2017. www.magnolia-medical.com.
Accessed August 2, 2018.
286 SECTION 3 ✦ Phlebotomy Techniques
Key Points
✦ Test collection priorities determine how
phlebotomists prioritize their workload to achieve
maximum TATs. Routine specimens are collected
throughout the day or at scheduled “sweep”
times. ASAPs are collected as soon as possible.
Timed specimens are drawn at a specific time.
STAT specimens have the highest priority and are
collected and analyzed immediately.
✦ A fasting specimen is collected from a patient
who has had nothing to eat or drink except
water for 12 hours. Test results affected in a
nonfasting patient are glucose, cholesterol,
triglyceride, and lipid profiles.
✦ Timed specimens are requested to measure the
body’s ability to metabolize a substance, monitor
changes in a patient’s condition, determine
blood levels of medications, measure analytes
that exhibit diurnal variation, measure cardiac
markers after a myocardial infarction, and
monitor anticoagulant therapy.
✦ Methods to diagnose hyperglycemia and
hypoglycemia include the 2-hour OGTT for
diabetes mellitus and the one-step and two-step
methods for diagnosing GDM. A specimen for a
fasting blood sugar measurement is collected
and tested before a glucose solution is given to
the patient. Blood specimens are drawn at
designated times.
✦ Substances that exhibit diurnal variation are at
different levels in the blood at certain times of
the day. For example, cortisol levels drawn
between 0800 and 1000 are twice as high as
levels drawn at 1600.
✦ Therapeutic drug levels are tested to monitor
the effectiveness and safety of a therapeutic
drug. The trough level is drawn before the next
dose is given, and the peak level is drawn at a
specified time after the medication has been
given. Peak levels vary with the medication and
the method of administration.
✦ Blood cultures are requested for a patient
with suspected septicemia. Two specimens
are collected for each blood culture set, one
to be incubated aerobically and the other
anaerobically. Blood cultures are ordered as
timed or STAT collections, and strict aseptic
technique is required.
✦ Blood specimens can be collected from VADs by
specially trained personnel. There are various
types of catheters, and the flush protocol must
be followed without variance. In addition, order
of fill for blood collection tubes must be
followed correctly.
✦ Specimens for cold agglutinins are collected
in tubes that have been warmed in a 37°C
incubator for 30 minutes and contain no
additive or gel. The blood is collected into the
warmed tube and returned to the laboratory as
soon as possible. The full tubes are placed back
into the incubator before testing.
✦ Chilling specimens prevents deterioration
of specific analytes, such as ammonia, lactic
acid, pyruvate, gastrin, adrenocorticotrophic
hormone (ACTH), renins, catecholamines,
and parathyroid hormone. Specimens should
be placed into a slurry of crushed ice and
water or placed in a uniform ice block
immediately after blood collection.
✦ Exposure to light destroys bilirubin; beta-
carotene; vitamins A, B6, and B12, and folate;
and porphyrins. Wrapping tubes in aluminum
foil or using amber-colored tubes protects the
specimen.
✦ Forensic studies are performed on specimens
for legal proceedings. The most common are
blood alcohol tests, urine drug tests, and DNA
analysis. Documentation of specimen handling,
or the chain of custody, must be strictly
followed.
✦ Molecular diagnostic tests are continuing
to be developed for the identification of
microorganisms, HIV and HCV viral loads,
diagnosis of hematological disorders,
coagulation disorders, management of warfarin
(Coumadin) therapy, and identification of
genetic disorders. Special collection tubes are
used. Follow facility protocol.
✦ Geriatric and pediatric patients may require
modifications in the venipuncture technique.
Technical and interpersonal skills for working
with each age group must be developed to
provide an atraumatic venipuncture and quality
specimens.
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Study Questions
1. At 0730, a phlebotomist receives requests for a
cortisol level on Unit 4B, a fasting blood sugar
(FBS) level on Unit 4A, and a STAT crossmatch
in the ED. In which order should the
phlebotomist collect these specimens?
a. Cortisol, FBS, crossmatch
b. FBS, cortisol, crossmatch
c. Crossmatch, FBS, cortisol
d. FBS, crossmatch, cortisol
2. What test result is markedly decreased when a
patient fasts for longer than 16 hours?
a. Glucose
b. Cholesterol
c. Triglycerides
d. Bilirubin
3. Why are specimens collected at specific times?
a. Convenience for the phlebotomist
b. To ensure that all laboratory test specimens
are collected when the patient is fasting
c. To measure the body’s metabolism of a test
substance
d. Because all laboratory tests exhibit diurnal
10. Blood cannot be drawn from a PICC line that is
variation
4. The timing for an OGTT begins when
a. the fasting specimen is drawn.
b. the test results are completed on the fasting
specimen.
c. the patient finishes drinking the glucose.
11. Which of the following has a self-sealing septum
d. 30 minutes after the patient finishes drinking
the glucose.
5. Which of the following exhibits diurnal
variation?
a. PT
b. Vitamin D
12. Specimens for cold agglutinins must be
c. Cholesterol
d. Cortisol
6. The trough level for therapeutic drug
monitoring is collected
a. 30 minutes after the medication is adminis-
13. Specimens that require chilling immediately
tered.
b. 30 minutes before the medication is adminis-
tered.
c. at the time specified by the manufacturer.
d. after the patient has fasted for 8 hours.
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CHAPTER 10 ✦ Special Blood Collection 287 288 SECTION 3 ✦ Phlebotomy Techniques
14. Specimens for ammonia levels must be 18. Which test would be collected for a forensic
a. transported on ice. analysis?
b. drawn in a light blue tube. a. CBC
7. Two blood culture sets from a patient requiring c. protected from light. b. Alcohol and drug level
STAT administration of antibiotics are collected d. kept warm. c. Hepatitis panel
a. immediately from two different sites. d. Theophylline levels
15. How will leaving a green stopper tube for a
b. 30 minutes apart.
bilirubin test on the counter for 1 hour affect 19. Yellow ACD blood collection tubes are used for
c. before and after the antibiotic is adminis-
the result? a. molecular diagnostic tests.
tered.
a. No effect on the result b. blood cultures.
d. before and after the fever spikes.
b. Specimen will clot c. alcohol levels.
8. For maximum antisepsis when blood cultures c. Result will be falsely decreased d. therapeutic drug levels.
are collected, how long must the chlorhexidine d. Result will be falsely increased
20. When venipuncture is performed on a crying
gluconate dry on the patient’s arm before
16. A falsely decreased blood alcohol level may be child, which analyte is transiently elevated?
venipuncture?
obtained when a. White blood cell count
a. No drying time is necessary.
a. blood is collected in a gray stopper tube. b. Red blood cell count
b. It must dry for 30 seconds.
b. the site is cleansed with Zephiran chloride. c. Bilirubin level
c. It must dry for 3 minutes.
c. the tube is only partially filled. d. Platelet count
d. It must dry for 5 minutes.
d. the tube is overfilled.
21. Geriatric patients are more prone to hematoma
9. When blood is inoculated into blood culture
17. Specimens collected for forensic studies require formation because
bottles using a winged blood collection set, the
a. drawing of blood by a physician only. a. they have smaller veins.
a. anaerobic bottle is inoculated first.
b. the presence of three witnesses. b. tourniquets must be tied tighter.
b. safety device is activated first.
c. the specimen be collected in a clot tube. c. their veins have decreased elasticity.
c. aerobic bottle is inoculated first.
d. a chain-of-custody form be completed. d. they have difficulty making a fist.
d. volume of blood inoculated is increased.
infusing
a. antibiotics.
b. TPN.
Clinical Situations
c. dextrose.
d. pain medication. 1 Jayson comes to the laboratory drawing station at 1300 with a requisition form for a lipid
profile.
that is accessed with a noncoring needle?
a. Before collecting the specimen, what should Erik, the phlebotomist, ask the patient?
b. What specific tests requested for Jayson are of concern to Erik?
a. Implanted port
b. PICC line c. State the instructions that Jayson should have received with the requisition form.
c. Hickman catheter
d. Peripheral IV
2 Two sets of blood cultures, each consisting of aerobic and anaerobic bottles, are drawn
1 hour apart from Alisha, a patient with sepsis. The first set is drawn using a syringe, and
a. transported on ice. the second set is drawn using a winged blood collection set.
b. drawn in a green stopper tube. a. Is this a common ordering pattern for blood cultures? Why or why not?
c. processed in a refrigerated centrifuge.
d. kept warm.
b. What error in technique could cause a positive anaerobic culture in the first set and a
negative anaerobic culture in the second set?
c. What is the significance of a known skin contaminant growing in the aerobic bottle
after collection are placed in from the first set and not in the aerobic bottle from the second set?
a. a container of large ice cubes.
b. a container of crushed ice and water.
d. Would failure to mix the bottles after the blood is added most likely cause a false-
positive or false-negative culture?
c. a bag of dry ice.
d. a flask of cold water.
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CHAPTER 10 ✦ Special Blood Collection 289 290 SECTION 3 ✦ Phlebotomy Techniques

8. Release the tourniquet.

3 While using an evacuated tube to collect blood from Kiesha, an elderly patient, the
phlebotomist, Kiley, notices that the puncture site is beginning to swell.
9. Scrub the site using chlorhexidine gluconate for 30 to 60 seconds, creating friction.

a. Why is this happening? 10. Allow the chlorhexidine gluconate to air-dry for at least 30 seconds for antisepsis.
b. What should Kiley do? 11. Assemble the equipment.
c. How could the specimen be collected? 12. Remove the plastic cap from the collection bottles.
13. Confirm the volume of blood required from the label.
14. Clean the top of the blood culture bottles with 70% alcohol and allow it to air-dry.
15. Reapply the tourniquet.
Summary of the Procedure for an OGTT 16. Do not re-palpate the site without sterile gloves.
1. Obtain and examine the requisition form. 17. Perform the venipuncture.
2. Greet the patient, explain the procedure to be performed, and obtain informed consent. 18. Release the tourniquet.
3. Identify the patient following normal protocol. 19. Place a gauze over the puncture site, remove the needle, and apply pressure.
4. Prepare the patient and verify any allergies. 20. Activate the safety device and remove the needle.
5. Confirm that the patient has fasted for 8 hours and not more than 16 hours. 21. Attach the safety transfer device.
6. Select the equipment. 22. Inoculate the anaerobic bottle first when using a syringe or second when using a winged blood
collection set.
7. Sanitize your hands, and put on gloves.
23. Dispense the correct amount of blood into bottles and document the amount of blood dispensed.
8. Draw a fasting glucose specimen using the correct protocol.
24. Mix the blood culture bottles by gentle inversion eight times.
9. Test the fasting blood specimen.
25. Fill the other collection tubes in the correct order.
10. Ask the patient to drink the appropriate amount of flavored glucose solution within 5 minutes.
26. Label the specimens appropriately; include the site of collection, and verify the identification with the
11. Begin the timing for the remaining collection times when the patient finishes drinking the glucose
patient.
solution.
27. Dispose of used equipment and supplies in a biohazard container.
12. Collect the remaining specimens using the correct protocol at the scheduled times and the
appropriate, consistent collection tube. 28. Check the venipuncture site for bleeding, and bandage the patient’s arm.
13. Place the corresponding labels on the tubes in the order of test sequence. 29. Thank the patient, remove your gloves, and sanitize your hands.
14. Transport the specimens to the laboratory immediately.

Summary of the Procedure for a Blood Culture Collection Summary of the Procedure for Blood Specimen Collection From a Vascular
Access Device
1. Obtain and examine the requisition form.
1. Obtain and examine the requisition form.
2. Greet the patient, explain the procedure to be performed, and obtain informed consent.
2. Greet the patient, explain the procedure to be performed, and obtain informed consent.
3. Identify the patient following normal protocol.
3. Identify the patient following normal protocol.
4. Prepare the patient and verify any allergies.
4. Position the patient in a supine position.
5. Select the equipment.
5. Assemble the supplies and place them within easy reach of the patient.
6. Sanitize your hands, and put on gloves.
6. Sanitize your hands.
7. Apply the tourniquet and locate the venipuncture site.
7. Put on gloves.
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CHAPTER 10 ✦ Special Blood Collection
8. Stop infusions in all lumens for 1 minute.
9. Cap the tubing with a male/female cap when disconnecting.
10. Clamp all lumens and withdraw from the proximal lumen of the catheter to obtain the specimen.
11. Cleanse the injection cap with an alcohol wipe using vigorous friction; scrub on the top and in the
grooves for 15 seconds (30 seconds for a blood culture).
12. Flush with 10 mL of normal saline (use 20 mL when TPN or when heparin was infusing).
13. Using the same syringe, withdraw 5 mL of blood. Remove the syringe, and discard it in the biohazard
container.
14. Wait 10 to 15 seconds to draw the specimen.
15. Use a sterile syringe to collect the specimen.
16. Attach the syringe and blood collection tubes to the blood transfer device, and fill the tubes in the
correct order.
17. Mix tubes immediately for the correct number of gentle inversions.
18. Label all tubes in front of the patient, and confirm with the patient or identification band that the
information is correct.
19. Scrub the hub for 15 seconds with alcohol to remove blood.
20. Attach a prefilled, nonsterile 10-mL saline syringe and flush. Use two syringes for a total of 20 mL.
21. Resume previous fluids if applicable.
22. Prepare the specimen and requisition form for transport to the laboratory.
23. Dispose of used supplies in a biohazard container.
24. Remove your gloves, sanitize your hands, and thank the patient.
Summary for the Procedure for Blood Collection From an Implanted Port
1. Obtain and examine the requisition form.
2. Greet the patient, explain the procedure to be performed, and obtain informed consent.
3. Identify the patient following normal protocol.
4. Sanitize your hands and put on gloves.
5. Palpate the shoulder area to locate and identify the septum of the access port.
6. Prep the area with a vigorous scrub using a chlorhexidine gluconate applicator.
7. Allow antiseptic to dry 30 seconds.
8. Connect the noncoring needle tubing on the end of one 10-mL saline flush syringe, and prime the
needle with saline until it is expelled.
9. Locate the septum of the port.
10. Holding the noncoring needle with the dominant hand, puncture the skin and insert the needle at a
90-degree angle into the septum.
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291 292 SECTION 3 ✦ Phlebotomy Techniques
11. Advance the needle until resistance is met.
12. Inject 1 to 2 mL of saline; observe for swelling and ease of flow.
13. Aspirate for blood return. If observed, continue to flush with saline.
14. Using the same syringe, aspirate 10 mL of blood and discard it. Discard 20 mL for coagulation tests.
15. Attach the syringe or the evacuated tube holder to the needle tubing and collect the minimum amount
of blood necessary.
16. If a syringe is used, dispense the blood into the appropriate blood collection tubes in the correct order
of fill using a blood transfer device.
17. Mix the blood by gentle inversion three to eight times.
18. Flush the needle and port with 20 mL of saline.
19. Change syringes and flush with 3 mL of heparinized saline or according to facility policy.
20. Remove the needle and apply a sterile dressing over the site.
21. Label the specimens and confirm the label with patient or identification band.
22. Prepare the specimen and requisition form for transport to the laboratory.
23. Dispose of used supplies in appropriate biohazard containers.
24. Remove your gloves, sanitize your hands, and thank the patient.
Summary of the Procedure for a Dorsal Hand Vein Blood Collection
1. Obtain and examine the requisition form.
2. Greet the parent, explain the procedure to be performed, and obtain informed consent.
3. Identify the patient following normal protocol.
4. Sanitize your hands and put on gloves.
5. Immobilize the infant/child.
6. Select the vein by encircling the wrist and gently bending it downward. Do not use a tourniquet.
7. Clean the site with 70 percent isopropyl alcohol, and allow it to air-dry.
8. Select a 23- to 25-gauge hypodermic needle with a clear hub and appropriate microcollection tubes.
9. Encircle the vein with the thumb underneath and the index and middle fingers on top of the wrist, and
apply pressure with the index finger.
10. Insert the needle into the vein at a 15-degree angle to the skin with the bevel up.
11. Fill microcollection tubes directly from the blood that drips from the hub of the needle.
12. Release the finger pressure intermittently to allow the blood to continue to flow.
13. After collection of the specimens, place gauze over the needle but do not press down.
14. Remove the needle and apply pressure for 2 to 3 minutes or until the bleeding stops.
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CHAPTER 10 ✦ Special Blood Collection 293

15. Label the tubes.

16. Perform appropriate specimen handling.
17. Dispose of used supplies in biohazard containers.
18. Remove your gloves and sanitize your hands.
19. Enter the collection volume in the infant’s/child’s chart or logbook.
20. Deliver the specimens promptly to the laboratory.
6842_Ch11_295-332 17/01/19 11:49 AM Page 295 6842_Ch11_295-332 17/01/19 11:49 AM Page 296

11
296 SECTION 3 ✦ Phlebotomy Techniques

It may not be possible to obtain a satisfactory

INTRODUCTION
CHAPTER Although venipuncture is the phlebotomy procedure
that is performed most frequently, it is not appropriate
in all circumstances. Advances in laboratory instru-
specimen by dermal puncture from patients who are
severely dehydrated or who have poor peripheral
circulation or swollen fingers. You may not be able to
use dermal puncture for certain tests because of the
larger amount of blood required, such as some coag-

Dermal Puncture
Learning Outcomes
Upon completion of this chapter, the reader will be able to:
11.1 State the complications associated with puncture of the deep veins
in infants.
11.2 List the reasons for performing dermal punctures on infants,
children, and adults, and explain why certain tests cannot be
performed on capillary specimens.
11.3 Describe the composition of capillary blood, and name four test
results that may differ when obtained with capillary versus venous
blood.
11.4 Describe the types of equipment needed for collection of a dermal
specimen.
11.5 Identify acceptable and unacceptable sites for performing heel and
finger punctures and the times when each is performed.
11.6 Discuss the purpose and method for warming the puncture site.
11.7 State the complications resulting from the presence of alcohol at the
puncture site.
11.8 State the correct positioning of the lancet for dermal puncture.
11.9 Name the major causes of contamination of capillary specimens.
11.10 State the order of collection for capillary specimens.
11.11 Describe the correct labeling of capillary specimens.
11.12 Correctly perform dermal punctures on the heel and the finger.
11.13 Discuss the necessary precautions for collecting high-quality
specimens for newborn bilirubin tests.
11.14 Discuss why and how newborn filter paper screening tests are
collected.
11.15 Describe the collection of capillary blood gases (CBGs), including
sources of technical error.
11.16 Explain the reason for thick and thin blood smears and describe
how they are made.
For additional resources please visit
http://davisplus.fadavis.com
mentation and point-of-care testing (POCT) make it ulation studies that require plasma, erythrocyte sedi-
possible to perform many laboratory tests on capillary mentation rate (ESR), and blood cultures.
specimens obtained by dermal puncture.
Dermal (capillary or skin) puncture is the method
of choice for collecting blood from infants and chil-
dren younger than 2 years for the following reasons:
IMPORTANCE OF CORRECT
COLLECTION
Key Terms ● Locating superficial veins that are large enough
to accept even a small-gauge needle is difficult
Correct collection techniques for dermal puncture
Arterialize in these patients, and available veins may need
are critical because of the small amount of blood
Blood smear to be reserved for IV therapy.
that is collected and the high possibility of specimen
Calcaneus ● Use of deep veins, such as the femoral vein, can
contamination, microclots, and hemolysis. Hemolysis
Congenital hypothyroidism be dangerous and may cause complications,
is seen more frequently in specimens collected by
Cyanotic including cardiac arrest, venous thrombosis,
dermal puncture than in those collected by venipunc-
Cystic fibrosis hemorrhage, damage to surrounding tissue and
ture. Hemolysis may not be detected in specimens
Dermal organs, infection, and reflex arteriospasm (which
containing bilirubin; however, it can interfere with
Differential can result in gangrene).
various laboratory test results, including the newborn
Ecchymosis ● Drawing excessive amounts of blood from pre-
bilirubin determination.
Edematous mature and small infants can rapidly cause iatro-
Hemolysis may occur during dermal puncture for
Feathered edge genic anemia (i.e., a 2-pound infant may have a
the following reasons:
Galactosemia total blood volume of only 150 mL). For pedi-
atric patients, blood collection should be limited Excessive squeezing of the puncture site
Iatrogenic ●
to 1 to 5 percent of total blood volume within a (“milking”)
Interstitial fluid
24-hour period and to 10 percent of total blood Increased numbers of red blood cells (RBCs)
Intracellular fluid ●
volume over an 8-week period. You can estimate and increased RBC fragility in newborns
Jaundiced
an infant’s blood volume by dividing his or her Residual alcohol at the site
Osteochondritis ●
weight in pounds by 2 to obtain kilograms and Vigorous mixing of the microcollection tubes
Osteomyelitis ●
then multiplying the kilograms by 100 (approx- after collection
Palmar
imate total blood volume).
Phenylalanine
Certain tests require capillary blood, such as
Phenylketonuria (PKU) ●
newborn screening tests and CBGs.
Plantar COMPOSITION OF CAPILLARY
● Injury may occur by restraining a child.
BLOOD
Dermal puncture may be required in many adult
patients, including those who are:
Blood collected by dermal puncture comes from the
● Burned or scarred capillaries, arterioles, and venules. Therefore, it is
● Receiving chemotherapy and require frequent a mixture of capillary, arterial, and venous blood
tests and whose veins must be reserved for and may contain small amounts of interstitial fluid
therapy (tissue fluid from the spaces between the cells) and
● Likely to be thrombotic intracellular fluid (fluid within the cells). Because of
● Geriatric or have very fragile veins arterial pressure, the composition of capillary blood
● Likely to have inaccessible veins more closely resembles arterial blood than venous
● Obese blood. Warming the site before specimen collection
● Apprehensive increases blood flow as much as sevenfold, thereby
● Receiving home glucose monitoring and POCT producing a specimen that is very close to the com-
(see Chapter 13) position of arterial blood.
295
6842_Ch11_295-332 17/01/19 11:49 AM Page 297
Except for arterial blood gases (ABGs), very few
chemical differences exist between arterial and
venous blood. However, because of the composition
of capillary blood, there are a few analytes where the
reference value may differ between venous and capil-
lary blood. For example, the concentration of glucose
is higher in capillary blood than in venous blood, and
the concentrations of potassium, total protein, and
calcium are lower. Therefore, you should make a note
on the requisition form when dermal punctures are
performed for these specimens. In addition, you
should not alternate between dermal puncture and
venipuncture when the results for these analytes will
be compared.
Technical Tip 11-1. When you document that a
specimen was collected by dermal puncture, you
allow the health-care provider to consider the
collection technique when interpreting the results.
DERMAL PUNCTURE EQUIPMENT
Dermal puncture supplies include automatic retrac-
table safety skin puncture devices, microcollection
containers, 70 percent isopropyl alcohol pads, gauze
pads, bandages, an approved sharps container, glass
slides, and a heel warmer. With the exception of
puncture devices, collection containers, heel warm-
ers, and glass slides, the same equipment is used for
venipuncture.
Dermal Puncture Devices
As shown in Figure 11-1, a variety of skin puncture de-
vices of varying lengths and depths are commercially
available. All models must have Occupational Safety
and Health Administration (OSHA) required safety
devices that retract and lock after use to prevent reuse
and accidental puncture. Many studies have com-
pared the various devices with respect to efficiency of
collection, specimen hemolysis, and the formation of
ecchymosis (bruising) at the collection site. No single
method appears to be superior, so it is up to you as
the phlebotomist to choose the best device to ensure
the best outcome for the patient.
To prevent contact with bone, the depth of the
puncture is critical. The Clinical and Laboratory Stan-
dards Institute (CLSI) recommends that the incision
depth should not exceed 2 mm in a device used to
perform heel punctures. There is concern that even
6842_Ch11_295-332 17/01/19 11:49 AM Page 298
CHAPTER 11 ✦ Dermal Puncture 297
FIGURE 111 Dermal puncture devices.
this measurement is too deep in certain infants, parti-
cularly premature infants. With automatic devices,
the length of the lancet and the spring release mech-
anism control the puncture depth. Manufacturers
provide separate devices designed for heel punctures
on premature infants, newborns, and babies; finger
punctures on toddlers and older children; and finger
punctures on adults.
Phlebotomist Alert Dermal punctures should
never be performed using an uncontrolled surgical
blade. OSHA requires a lancet safety device with a
retractable blade or needle.
To produce adequate blood flow, the depth of the
puncture is actually much less important than the
width of the incision. This is because the major vascular
area of the skin is located at the dermal-subcutaneous
junction, which in a newborn is only 0.35 to 1.6 mm
below the skin but can range to 3 mm in a large adult
(Fig. 11-2). Designated puncture devices can easily
reach that area. Therefore, the number of severed
capillaries depends on the incision width. Incision
widths vary from needle stabs to 2.5 mm. Sufficient
blood flow should be obtained from incision widths
no larger than 2.5 mm. Longer incisions should be
avoided because they will produce unnecessary dam-
age to the heel or finger.
As illustrated in the following examples, several
color-coded lancets of varying depths and widths are
available from manufacturers to accommodate low,
medium, and high blood flow requirements. The type
298 SECTION 3 ✦ Phlebotomy Techniques
Epidermis
Dermis
(nerve endings)
Capillary bed
Subcutaneous
tissue
FIGURE 112 Vascular area of the skin at the juncture
between the dermis and the subcutaneous tissue.
FIGURE 114 QuikHeel® lancet. (Courtesy of Becton, Dickinson,
and Company, Franklin Lakes, NJ.)
of device selected depends on the age of the patient,
the amount of blood specimen required, the collec-
tion site, and the puncture depth. BD Microtainer®
Tenderfoot devices are available for a range of patients,
Contact-Activated Lancets (Becton, Dickinson, and
from micro-preemies (blue), to preemies (white), to
Company, Franklin Lakes, NJ) are available in a full
newborns (pink/blue) and toddlers (pink) (Fig. 11-5).
range of blades for collecting specimens using micro-
The Tenderlett for fingers is available for toddlers,
hematocrit tubes, as well as Microtainer blood collec-
juniors, and adults (Fig. 11-6).
tion tubes and needles to collect blood for single-drop
Unistik® 3 (Owen Mumford Ltd, Marietta, GA)
glucose testing. The BD Microtainer Contact-Activated
safety lancets are available in five versions with varying
Lancet (Fig. 11-3) is designed to activate only when
needle gauges and penetration depths. The lancet
the blade or needle is positioned and pressed against
used depends on the type of skin and amount of
the skin. BD QuikHeel Lancets® are color-coded heel
blood required for testing:
puncture lancets made specifically for premature
Unistik 3 Gentle for pediatric patients (30 gauge)
infants, newborns, and babies (Fig. 11-4). ●
International Technidyne Corporation (Edison, ● Unistik 3 Comfort for delicate skin (28 gauge)
NJ) provides a range of color-coded, fully automated, ● Unistik 3 Normal for normal skin/general use
single-use, retractable, disposable devices of varying (23 gauge)
depths. Tenderfoot® and Tenderlett® devices are ● Unistik 3 Extra for tougher skin/larger speci-
designed for heel and finger punctures, respectively. mens (21 gauge)
FIGURE 113 BD Microtainer® Contact-Activated Lancets.
Blue, high flow (1.5-mm blade, 2-mm depth); purple, low FIGURE 115 Tenderfoot® toddler (pink), newborn (pink/blue),
flow (30-gauge needle, 1.5-mm depth); and pink, medium preemie (white), and micro-preemie (blue) heel incision
flow (21-gauge needle, 1.8-mm depth). devices (International Technidyne Corporation, Edison, NJ).
6842_Ch11_295-332 17/01/19 11:49 AM Page 299
FIGURE 116 Tenderlett® toddler, junior, and adult lancets
(International Technidyne Corporation, Edison, NJ).
● Unistik 3 Dual for low-flow heel stick and high-
flow finger stick (18 gauge; Fig. 11-7)
The Unistik® Tiny Touch™ device is available for
heel punctures on newborns (Fig. 11-8).
Greiner Bio-One (Monroe, NC) Lancelino Safety
Lancets are color-coded, retractable lancets with an
ergonomically rounded design for a comfortable
grip, a rounded base for pinpoint precision, and
simple activation by applying pressure on the punc-
ture site. Safety Lancet needle depths range from 1.2
to 2.4 mm. The Lancelino Safety Lancet with blade
is 0.8 mm wide with a depth penetration of 2 mm
(Fig. 11-9).
The latest device designed to make blood collec-
tion fast and painless is Seventh Sense Biosystem’s
Touch Activated Phlebotomy (TAP™). The device,
which is about the size of a stethoscope head, is
secured on the skin of the patient’s upper arm by an
FIGURE 117 Unistik® 3 Capillary blood sampling devices.
© Owen Mumford Ltd.
CHAPTER 11 ✦ Dermal Puncture
FIGURE 118 Unistik® Tiny Touch™. © Owen Mumford Ltd.
FIGURE 119 Greiner Bio-One Lancelino Safety Lancets.
(Courtesy of Greiner Bio-One. Printed with permission.)
adhesive hydrogel. When you push a button, 30 tiny
needles (each the size of a human hair) penetrate the
outer layers of the skin. The device uses vacuum
pressure to pull 100 µL of blood from the capillaries
into an interior reservoir containing either heparin
or ethylenediaminetetraacetic acid (EDTA). After
2 minutes, an indicator tells you the collection is com-
plete, and you can remove the device. The device is
sent to the laboratory for testing, or the specimen can
be analyzed immediately in a point-of-care device.
When you are ready to test the specimen, you extract
the blood using a pipette that is inserted on the un-
derside of the TAP device and transfer the specimen
either to the POCT device or a laboratory instrument
(Fig. 11-10).
Technical Tip 11-2. Select the puncture device
that will safely provide the appropriate volume of
blood to perform the required tests.
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299 300 SECTION 3 ✦ Phlebotomy Techniques
FIGURE 1110 Touch Activated Phlebotomy (TAP™).
Microcollection Containers
Figure 11-11 illustrates some of the common specimen
containers available for collection of capillary blood.
Microcollection tubes (microtubes) have largely
replaced the large-bore glass Caraway and Natelson
micropipettes. Some containers are designated for a
specific test, and others serve multiple purposes. Usu-
ally, the type of container chosen is related to labora-
tory preference because advantages and disadvantages
can be associated with each system.
Capillary Tubes
Capillary tubes, which are frequently referred to as
microhematocrit tubes, are small tubes used to collect
approximately 50 to 75 µL of blood for the primary
purpose of performing a microhematocrit test. The
tubes are designed to fit into a hematocrit centrifuge
and its corresponding hematocrit reader. Tubes are
FIGURE 1111 Microcollection tubes.
available plain or coated with ammonium heparin;
they are also color coded, with a red band for he-
parinized tubes and a blue band for plain tubes.
Heparinized tubes should be used for hematocrit tests
collected by dermal puncture, and plain tubes are
used when the hematocrit test is being performed on
blood from a lavender stopper EDTA tube. When you
have collected a sufficient amount of blood, you close
the end of the capillary tube that has not been used
to collect the specimen with clay sealant or a plastic
plug. You should use extreme care to prevent break-
age when collecting specimens and sealing the tubes.
Microhematocrit tubes protected by plastic sleeves
and self-sealing tubes are available to prevent break-
age when collecting specimens and sealing the end
(Fig. 11-12).
Safety Tip 11-1. Use of glass capillary tubes is not
recommended because they can easily break when
sealed.
Microcollection Tubes
Plastic collection tubes, such as the Microtainer, pro-
vide a larger collection volume than the microhema-
tocrit tube and present no danger from broken glass.
A variety of anticoagulants and additives, including
FIGURE 1112 Microhematocrit capillary tubes and a
micropipette for capillary blood gases with metal filing called
a “flea.”
6842_Ch11_295-332 17/01/19 11:49 AM Page 301
separator gel, are available, and the tubes are color
coded in the same way as evacuated tubes. Separation
of serum or plasma is achieved by centrifugation in
specifically designed centrifuges.
BD Microtainer tubes with BD Microgard™ clo-
sures are designed to reduce the risk of blood splatter
and blood leakage. The Microgard closure is removed
by twisting and lifting. Tubes have a wide diameter,
textured interior, and integrated blood collection
scoop to enhance blood flow into the tube and elim-
inate the need to assemble the equipment. After com-
pletion of the blood collection, you place the cap on
the container and gently invert the anticoagulated
tubes five to 10 times to ensure complete mixing. The
BD Microtainer MAP microtube has a pierceable cap
that is compatible with most automated hematology
instruments (Fig. 11-13).
Microtainer tubes have markings to indicate mini-
mum and maximum collection amounts in micro-
liters to prevent underfilling or overfilling, which can
cause erroneous results. Tube extenders are available
for this system to facilitate labeling and handling.
Each tube contains printed lot numbers and the
expiration date.
Other capillary blood collection devices have plas-
tic capillary tubes inserted into the collection con-
tainer (SAFE-T-FILL® Capillary Blood Collection
System, RAM Scientific Co., Needham, MA). After
you have collected the blood, you remove the capil-
lary tube and use the appropriate color-coded cap to
close the tube.
Figure 11-14 shows various manufacturers’ micro-
collection tubes.
Technical Tip 11-3. Microcollection tubes are
color coded to match evacuated tube colors and
include amber containers for light-sensitive analyte
testing.
FIGURE 1113 BD Microtainer® MAP.
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CHAPTER 11 ✦ Dermal Puncture 301 302 SECTION 3 ✦ Phlebotomy Techniques
Additional Dermal Puncture Supplies
Alcohol pads, gauze, and sharps containers are re-
quired for dermal puncture just as they are for
venipuncture. Blood smears for white blood cell dif-
ferential and the examination of RBC morphology
may be made during the dermal puncture procedure
and require a supply of glass slides.
As discussed previously, warming the puncture site
increases blood flow to the area sevenfold. This can
be accomplished by using warm washcloths or towels
or a commercial heel warmer. A heel warmer is a
packet containing sodium thiosulfate and glycerin
that produces heat when the chemicals are mixed
together by gently squeezing the packet (Fig. 11-15).
DERMAL PUNCTURE PROCEDURE
Many of the procedures associated with venipuncture
also apply to the dermal puncture. Therefore, major A B
emphasis in this chapter is placed on the techniques
and complications that are unique to dermal punctures.
Phlebotomist Preparation
Before performing a dermal puncture, you must have
a requisition form containing the same information
required for the venipuncture. When you collect a
specimen by dermal puncture, you must note this on
the requisition form because, as discussed previously,
the concentration of some analytes differs between
venous and capillary blood.
Because of the variety of puncture devices and col-
lection containers available for dermal puncture, you
should carefully examine the information on the req-
uisition form to ensure that you have the appropriate
equipment to collect all required specimens as well
as the skin puncture device that corresponds to the
C D
age of the patient.
Frequently, you will perform dermal punctures in FIGURE 1114 Several types of microcollection tubes. A, Microtainers® with Microgard Closure (Becton,
the nursery and must observe its specified protective Dickinson, and Company, Franklin Lakes, NJ). B, MiniCollect® Capillary Blood Collection Tubes (Greiner Bio-One,
isolation procedures, such as the wearing of gowns Kremsmunster, Austria). C, Microvette®/Multivette® Capillary Blood Collection System (Sarstedt, Newton, NC).
and gloves, extensive hand sanitizing, and carrying D, Safe-T-Fill® Capillary Blood Collection Device (Ram Scientific, Inc., Needham, MA).
only the necessary equipment into the patient area.
Keep equipment out of the reach of the patient at all
times.
(requisition form, verbal identification, and identifi- Approaching pediatric patients can be difficult, and
cation [ID] band). In the nursery, an ID band must you must present a friendly, confident appearance
Patient Identification and Preparation be present on the infant and not just on the bassinet. while explaining the procedure to the child and the
For dermal puncture, patients must be identified Verbal identification of pediatric outpatients may parents. Do not say the procedure will not hurt, and
using the same procedures as used for venipuncture have to be obtained from the parent or guardian. be sure to explain the necessity of remaining very still.
6842_Ch11_295-332 17/01/19 11:49 AM Page 303
FIGURE 1115 Commercial heel warmer.
Give parents the choice of staying with the child or
leaving the room. If they choose to stay, you may ask
them to assist in holding and comforting the child.
Very agitated children may need to have their legs and
free hand restrained, as discussed in Chapter 10.
This restraint can be accomplished by a parent or
coworker, or you can confine the child in a blanket
or commercially available papoose-style wrap. You
must obtain and document parental consent in the
child’s medical record when you use a restraint.
Technical Tip 11-4. Having the parents present
during a dermal puncture can provide emotional
support and help enlist the child’s cooperation.
Preexamination Consideration 11-1.
Excessive crying may affect the concentration of
white blood cells and CBGs. Note excessive crying
on the requisition form.
Patient Position
The patient must be seated or lying down with his or
her nondominant hand supported on a firm surface,
palm up and fingers pointed downward for finger
punctures. For heel punctures, an infant should be
lying on his or her back with the heel lower than the
torso in a downward position.
Site Selection
Choose the puncture site on the basis of the age and
size of the patient. As mentioned in the discussion
of skin puncture devices, a primary danger in dermal
6842_Ch11_295-332 17/01/19 11:49 AM Page 304
CHAPTER 11 ✦ Dermal Puncture 303
puncture is accidental contact with the bone fol-
lowed by infection or inflammation (osteomyelitis or
osteochondritis, respectively). This problem can be
avoided by selecting puncture sites that provide
sufficient distance between the skin and the bone.
The primary dermal puncture sites are the heel and
the distal segments of the third and fourth fingers.
Performing dermal punctures on earlobes is not
recommended.
Areas selected for dermal puncture should not be
callused, scarred, bruised, edematous (swollen), cold
or cyanotic (blue in color), or infected. Never make
a puncture through a previous puncture site because
this practice can easily introduce microorganisms
into the puncture and allow them to reach the bone.
Do not collect blood from the fingers on the same
side as a mastectomy without a health-care provider’s
order.
Heel Puncture Sites
The heel is used for dermal punctures in infants
younger than 1 year because it contains more tissue
than the fingers and has not yet become callused
from walking.
The medial and lateral areas of the plantar (bot-
tom) surface of the heel are acceptable areas for
heel puncture, as shown in Figure 11-16. Determine
these areas by drawing imaginary lines extending
back from the middle of the large toe to the heel and
from between the fourth and fifth toes to the heel. It
is in these areas that the distance between the skin
and the calcaneus (heel bone) is greatest. Notice the
short distance between the back (posterior curvature)
of the heel and the calcaneus (see Fig. 11-16). This is
the reason why this area is never acceptable for heel
puncture.
Do not perform punctures in other areas of the
foot, particularly not in the toe or arch, where they
may cause damage to nerves, tendons, and cartilage.
Finger Puncture Sites
Finger punctures are performed on adults and chil-
dren older than 1 year. Fingers of infants younger
than 1 year may not contain enough tissue to prevent
contact with the bone.
The fleshy areas located near the center of the
third and fourth fingers on the palmar side of the
nondominant hand are the sites of choice for finger
puncture (Fig. 11-17). Because the tip and sides of the
finger contain only about half the tissue mass of the
central area, the possibility of bone injury is increased
304 SECTION 3 ✦ Phlebotomy Techniques
Heel Puncture Sites the blood specimen. Patients who routinely perform
home glucose monitoring may request a specific finger,
and you should accommodate their wishes whenever
possible. Box 11-1 summarizes dermal puncture selec-
tion sites.
Warming the Site
For optimal blood flow, you may warm the finger or
heel from which you are planning to take the speci-
men. This is required primarily for patients with very
cold or cyanotic fingers, for heel punctures to collect
multiple specimens, and for the collection of CBGs.
Warming dilates the blood vessels and increases arte-
rial blood flow. Moistening a towel with warm water
(42°C) or activating a commercial heel warmer and
covering the site for 3 to 5 minutes effectively warms
the site. Be sure to wrap the packet in a towel and
hold it away from your face and the patient’s face dur-
ing initial activation.
Do not warm the site for longer than 10 minutes,
Calcaneus
(heel bone) or test results may be altered.
Phlebotomist Alert Use caution in moistening
Puncture zone the towel to ensure that the water temperature is
FIGURE 1116 Acceptable sites for heel puncture. not greater than 42°C to avoid burning the patient,
especially when warming the skin of an infant for a
puncture.
Yes No
No Cleansing the Site
(light area)
Clean the site with 70 percent isopropyl alcohol.
Allow the alcohol to dry on the skin for maximum
BOX 111 Summary of Dermal Puncture Site
Selection
• Use the medial and lateral areas of the plantar
surface of the heel.
• Use the central fleshy area of the third or fourth
FIGURE 1117 Acceptable sites for finger puncture and
finger.
correct angle for puncture.
• Do not use the back of the heel.
• Do not use the arch of the foot.
in these areas. Problems associated with use of the • Do not puncture through old sites.
other fingers include: • Do not use areas with visible damage.
• Do not use fingers on newborns or children younger
● Possible calluses on the thumb
than 1 year.
● Increased nerve endings in the index finger
• Do not use swollen sites.
● Decreased tissue in the fifth finger
• Do not use earlobes.
A swollen or previously punctured site is unaccept- • Do not use fingers on the side of a mastectomy.
able because the increased tissue fluid will contaminate
6842_Ch11_295-332 17/01/19 11:49 AM Page 305
antiseptic action, and then remove the residue with
gauze to prevent interference with certain tests. Failure
to allow the alcohol to dry
1. Causes a stinging sensation for the patient
2. Contaminates the specimen
3. Hemolyzes RBCs
4. Prevents formation of a rounded blood drop
because blood will mix with the alcohol and run
down the patient’s finger
Phlebotomist Alert Do not use povidone-iodine
for dermal punctures because specimen
contamination may elevate some test results,
including bilirubin, phosphorus, uric acid, and
potassium levels.
Preexamination Consideration 11-2.
Residual alcohol causes rapid hemolysis that can
alter test results for certain analytes.
Performing the Puncture
While you perform the puncture, be sure the patient’s
heel or finger is well supported and held firmly,
without squeezing the puncture area. Apply gentle
pressure to the area before the puncture in order to
increase blood flow to the area.
Heel Puncture
Hold the patient’s heel between the thumb and index
finger of your nondominant hand, with your index
finger around the arch and your thumb below the
bottom of the heel. Wrap your other fingers around
the top of the foot (Fig. 11-18).
Finger Puncture
Hold the patient’s finger between the thumb and
index finger of your nondominant hand, with the pal-
mar surface facing up and the patient’s finger point-
ing downward to increase blood flow (Fig. 11-19).
Technical Tip 11-5. For patients with small fingers,
you may find it easier to hold three or four fingers
for better control.
Puncture Device Position
Choose a puncture device that corresponds to the size
of the patient. Remove the trigger lock if necessary.
Place the puncture device firmly on the puncture
CHAPTER 11 ✦ Dermal Puncture
FIGURE 1118 Correct position for heel puncture.
FIGURE 1119 Holding a child’s fingers for a capillary
puncture.
site; do not indent the patient’s skin when placing
the lancet on the puncture site. Align the blade of
the puncture device to cut across (perpendicular
to) the grooves of the fingerprint or heel print. This
aids in the formation of a rounded drop because
the blood will not have a tendency to run into the
grooves.
Depress the lancet release mechanism to puncture
the patient’s skin, hold for a moment, and then release.
Be sure to maintain pressure because the elasticity of
the skin naturally inhibits penetration of the blade.
Removing the lancet before the puncture is complete
will yield a low blood flow.
Technical Tip 11-6. Failure to place puncture
devices firmly on the skin is the primary cause of
insufficient blood flow. One firm puncture is less
painful for the patient than two “mini” punctures.
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305 306 SECTION 3 ✦ Phlebotomy Techniques
Puncture Device Disposal
Discard the puncture device in an approved sharps
container immediately after completing the punc-
ture. You must use a new puncture device when an
additional puncture is required.
Specimen Collection
Wipe away the first drop of blood with a clean gauze
before beginning the blood collection, (unless testing
the first drop of blood is required by the manufac-
turer of a point-of-care instrument). This prevents
contamination of the specimen with residual alcohol
and tissue fluid released during the puncture. When
collecting capillary specimens, even a minute amount
of contamination can severely affect specimen quality.
Therefore, blood should be flowing freely from the
puncture site as a result of firm pressure and should
not be obtained by milking of the surrounding tissue,
which will release tissue fluid. Alternately applying
pressure to and releasing pressure from the area will
produce the most satisfactory blood flow. Tightly
squeezing the area with no relaxation cuts off blood
flow to the puncture site.
Technical Tip 11-7. Applying pressure about
⁄2 in. away from the puncture site frequently
1
produces better blood flow than applying pressure
very close to the site.
Be sure the collection device does not touch the
puncture site, and do not scrape it over the skin be-
cause this will produce specimen contamination and
hemolysis. As stated previously, position the patient’s
fingers slightly downward with the palmar surface
facing up during the collection procedure to allow
gravity to fill the capillaries.
Technical Tip 11-8. While you are collecting the
specimen, the patient’s hand does not have to be
turned over completely. Rotating the hand 90 degrees
will allow you to clearly see the blood drops
without placing yourself in an awkward position;
this rotation will produce adequate blood flow.
Technical Tip 11-9. Do not use a scooping motion
to collect the blood. Scraping the scoop of the
collection tube across the skin can hemolyze the
specimen.
Capillary Tubes and Micropipettes
Because capillary tubes and micropipettes fill by cap-
illary action, you can touch the collection tip lightly
to the drop of blood, which will draw the blood into
the tube. To prevent the introduction of air bubbles,
hold capillary tubes and micropipettes horizontally
while they are filling. Place the end of the tube into
the drop of blood and maintain the tube in a hori-
zontal position to fill by capillary action during the
entire collection. Removing the microhematocrit
tube from the drop of blood causes air bubbles in the
specimen. The presence of air bubbles limits the
amount of blood that can be collected per tube and
interferes with blood gas determinations. When the
tubes are filled, seal them with sealant clay or desig-
nated plastic caps. Recommended tubes are plastic
or coated with a puncture-resistant film. When using
a sealant tray, place the end that has not been con-
taminated with blood into the clay, taking care to not
break the tube. Remove the tube with a slight twisting
action to firmly plug the microhematocrit tube.
Microcollection Tubes
Microcollection tubes are slanted down during the
collection, which allows blood to run through the cap-
illary collection scoop and down the side of the tube.
Place the tip of the collection tube beneath the puncture
site so that it touches the underside of the drop. The
first three drops of blood provide the channel to allow
blood to flow freely into the tube. Gently tapping the
bottom of the tube may be necessary to force blood to
the bottom. When a tube is filled, attach the color-coded
top. Invert tubes with anticoagulants five to 10 times
or per manufacturer’s instructions. When blood flow
is slow, it may be necessary to mix the tube while the
collection is in progress. It is important to work quickly
because blood that takes more than 2 minutes to collect
may form microclots in an anticoagulated microcollec-
tion tube. Collect the correct amount of blood indi-
cated by the minimum and maximum marks on the
tube. An overfilled tube may clot, whereas an under-
filled tube can cause morphological changes in cells.
Technical Tip 11-10. Fast collection and mixing
ensure accurate test results.
Technical Tip 11-11. Clotting is triggered
immediately on skin puncture and represents the
greatest obstacle to collecting quality specimens.
6842_Ch11_295-332 17/01/19 11:49 AM Page 307
Order of Collection
The order of draw for collecting multiple specimens
from a dermal puncture is important because of the
tendency of platelets to accumulate at the site of a
wound. Therefore, you should first collect blood for
tests to evaluate platelets, such as the blood smear,
platelet count, and complete blood count (CBC). Make
the blood smear first, and then collect the lavender
EDTA tube. The order of collection (Fig. 11-20) for
multiple tubes is:
● CBGs
● Blood smear
● Lavender EDTA tubes
● Green, light green, amber lithium heparin tubes
● Gray EDTA tubes
● Gold, amber, red serum tubes
Bandaging the Patient
When you have collected a sufficient amount of
blood, apply pressure to the puncture site with gauze.
Elevate the patient’s finger or heel, and apply pres-
sure until the bleeding stops. Confirm that bleeding
has stopped before removing the pressure and apply-
ing the bandage. Instruct patients to leave the band-
age on for at least 15 minutes.
Do not use bandages for children younger than
2 years because a child may remove the bandages, place
them in his or her mouth, and possibly aspirate the
bandages. Also, adhesive may cause irritation to or tear
sensitive skin, particularly the fragile skin of a new-
born or older adult patient.
Labeling the Specimen
Label the microcollection tubes with the same infor-
mation required for venipuncture specimens. Labels
can be wrapped around microcollection tubes or
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CHAPTER 11 ✦ Dermal Puncture 307 308 SECTION 3 ✦ Phlebotomy Techniques
groups of capillary pipettes. Then, for transport, place
the capillary pipettes in a large tube because the
outside of the capillary pipettes may be contami-
nated with blood. This procedure also helps to pre-
vent breakage. Label specimens before leaving the
patient area.
BD Microtainer tubes have extenders that can be
attached to the container. This allows the computer
label to be applied vertically.
Completion of the Procedure
The dermal puncture procedure is completed in
the same manner as the venipuncture by disposing
of all used materials in appropriate containers,
removing your gloves, sanitizing your hands, and
thanking the patient and/or the parents for their
cooperation.
All special handling procedures associated with
venipuncture specimens also apply to capillary speci-
mens. Observe test collection priorities.
To prevent excessive removal of blood from small
infants, be sure to make an entry on the log sheet
documenting the amount of blood collected each
time a procedure is performed on the patient.
As with venipuncture, it is recommended that you
attempt only two punctures to collect blood. When
you must make a second puncture to collect a suffi-
cient amount of blood, do not add that blood to the
tube collected previously. This can cause erroneous
results as a result of microclots and hemolysis. Also,
be sure to perform the second puncture at a different
site using a new puncture device.
Procedure 11-1 shows the technique unique to the
finger puncture, and Procedure 11-2 shows the heel
puncture technique.
Go back to DavisPlus for Video 11-1 (Dermal
Puncture).
Text continued on page 313
FIGURE 1120 Order of draw using BD Microtainer® tubes. (Courtesy of Becton, Dickinson, and Company, Franklin
Lakes, NJ.)
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CHAPTER 11 ✦ Dermal Puncture 309 310 SECTION 3 ✦ Phlebotomy Techniques

PROCEDURE 111 ✦ COLLECTION OF CAPILLARY BLOOD FROM A FINGER PROCEDURE 111 ✦ COLLECTION OF CAPILLARY BLOOD FROM A FINGER
PUNCTURE PUNCTURE (Continued)
EQUIPMENT: Step 6. Select equipment according to the age of the Step 12. Hold the patient’s finger between your nondomi- Step 16. Collect rounded drops into microcollection tubes
Requisition form patient, the type of test ordered, and the nant thumb and index finger, with the palmar in the correct order of draw, without scraping the
Latex-free gloves amount of blood to be collected. surface facing up and the finger pointing patient’s skin. Do not milk the puncture site.
70 percent isopropyl alcohol pad downward. Collect the specimen within 2 minutes to prevent
Finger puncture safety device Step 13. Place the lancet firmly on the fleshy area of the clotting.
Microcollection tubes patient’s finger perpendicular to the fingerprint
Gauze pads and depress the lancet trigger.
Warming device
Sharps container
Indelible pen
Bandage

PROCEDURE:
Step 1. Obtain and examine the requisition form.
Step 2. Greet the patient, explain the procedure to be
performed, and obtain consent.
Step 3. Identify the patient verbally by having him or her
state both the first and last names and date of Step 17. Cap the microcollection tubes when you have
Step 7. Sanitize your hand and put on gloves.
birth and spell the last name. Compare the collected the correct amount of blood.
information on the patient’s ID band with the Step 8. Select the puncture site in the fleshy areas located
requisition form. A parent or guardian may do this off the center of the third or fourth fingers on the Step 14. Discard the lancet into the approved sharps
for a child. Ask for a photo identification for palmar side of the patient’s nondominant hand. container.
outpatients without an ID band. Do not use the side or tip of the patient’s finger. Step 15. Lower and gently squeeze the patient’s finger to
Step 4. Prepare the patient and/or parents and verify diet Step 9. Warm the puncture site if necessary. form a drop of blood. Wipe away the first drop of
restrictions, as appropriate, allergies to latex, or Step 10. Cleanse and dry the puncture site with 70 percent blood, which may contain alcohol residue and
previous problems with blood collection. isopropyl alcohol, and allow it to air-dry. tissue fluid.
Step 5. Position the patient’s nondominant arm on a
firm surface with his or her hand palm up. A
child may have to be held in either a vertical
or horizontal restraint or be held by the parent
(see Chapter 10).

Step 11. Prepare the lancet by removing the lancet

locking device, and then open the cap to the
microcollection tube.

Continued
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PROCEDURE 111 ✦ COLLECTION OF CAPILLARY BLOOD FROM A FINGER
PUNCTURE (Continued)
Step 18. Mix the tubes five to 10 times by gentle inversion
as recommended by the manufacturer. You may
have to tap the tubes gently throughout the
procedure to mix the blood with the anticoagulant.
Step 19. Place gauze on the site and ask the patient or
parent to elevate the finger and apply pressure
until the bleeding stops.
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CHAPTER 11 ✦ Dermal Puncture 311
Step 20. Label the tubes before leaving the patient and
verify identification with the patient ID band or
verbally with an outpatient. Observe any special
handling procedures.
Step 21. Examine the site for stoppage of bleeding and
apply a bandage if the patient is older than
2 years. Instruct the patient or parent to remove
the bandage after 15 minutes.
Step 22. Dispose of used supplies in biohazard containers.
Step 23. Thank the patient.
Step 24. Remove your gloves and sanitize your hands.
Step 25. Complete the paperwork.
Step 26. Immediately transport the specimen to the
laboratory.
312 SECTION 3 ✦ Phlebotomy Techniques
PROCEDURE 112 ✦ COLLECTION OF BLOOD BY HEEL PUNCTURE
EQUIPMENT: Step 7. Warm the baby’s heel for 3 to 5 minutes by
Requisition form wrapping the heel with a warm washcloth or
Latex-free gloves using a commercial heel-warming device.
70 percent isopropyl alcohol pad
Heel puncture safety device
Microcollection tubes
Gauze pads
Warming device
Sharps container
Indelible pen
PROCEDURE:
Step 1. Obtain and examine the requisition form.
Step 2. Place the collection tray in a designated area.
Step 3. Check the requisition and select the necessary
equipment.
Step 8. Select the puncture site on the medial or lateral
Step 4. Sanitize your hands and apply gloves. Put on a
plantar surface of the baby’s heel. Do not use the
gown if it is a nursery requirement.
arch or back of the heel.
Step 5. Identify the patient by comparing the ID band that
Step 9. Cleanse the puncture site with 70 percent
is attached to the baby with the requisition form.
isopropyl alcohol and allow it to air-dry.
Step 6. Position the baby lying on his or her back with the
Step 10. Prepare the lancet by removing the lancet locking
foot lower than the body.
device and open the caps to the microcollection
tubes.
Step 11. Hold the baby’s heel firmly by wrapping the heel
with your nondominant hand.
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CHAPTER 11 ✦ Dermal Puncture 313 314 SECTION 3 ✦ Phlebotomy Techniques

light during and after the collection. Bilirubin is a

PROCEDURE 112 ✦ COLLECTION OF BLOOD BY HEEL PUNCTURE (Continued)
Step 12. Place the lancet perpendicular to the baby’s heel
print and depress the lancet trigger.
Step 13. Discard the lancet in an approved sharps
container.
Step 14. Lower the baby’s heel, and gently squeeze it to
form a drop of blood. Wipe away the first drop of
blood.
Step 15. Collect rounded drops of blood into the
microcollection tubes without scraping the
baby’s skin. Do not milk the puncture site.
Step 16. Collect the proper amount of blood in the
correct order of draw. Cap the microcollection
tubes and/or seal the microhematocrit tubes.
Step 17. Mix the tubes five to 10 times by gentle
inversion as recommended by the
manufacturer. You may have to tap the tubes
gently throughout the procedure to mix the
blood with the anticoagulant.
Step 18. Place gauze on the puncture site and apply
pressure until the bleeding stops.
Step 19. Label the tubes and observe any special
handling procedures.
Step 20. Check the site for bleeding. Do not place a
bandage on an infant younger than 2 years.
Step 21. Dispose of used supplies and remove all
collection equipment from the area.
Step 22. Remove your gloves (and gown if you are
wearing one) and sanitize your hands.
Step 23. Thank the parent if present.
Step 24. Complete the patient log sheet.
Step 25. Immediately transport the specimens to the
laboratory.
very light-sensitive chemical and is destroyed rapidly
when exposed to light. Infants who appear jaundiced
(yellow skin color) frequently are placed under an
ultraviolet (UV) light to lower the level of circulating
bilirubin. This light must be turned off during speci-
men collection. Amber-colored microcollection tubes
are available for collecting bilirubin (Fig. 11-21); if
you are using microcollection tubes of another color,
then you should shield the filled tubes from light.
Be sure also to avoid hemolysis; it will falsely lower
bilirubin results in some procedures and must be
corrected for in others. Also, you must collect the
specimens at the specified time so that the rate of
bilirubin increase can be determined. Noninvasive
transcutaneous bilirubin measurements in neonates
are discussed in Chapter 13.
FIGURE 1121 Amber-colored Microtainer® tube for the
collection of neonatal bilirubin.
Technical Tip 11-12. Be sure to turn off the
UV light when collecting specimens for newborn
bilirubin tests, unless the device is strapped directly
to the infant, to avoid breaking down the bilirubin
in the specimen.
Preexamination Consideration 11-3.
Bilirubin levels may decrease as much as
50 percent in a blood specimen that has been
exposed to light for 2 hours.
Newborn Screening
Newborn screening is the testing of newborn babies
for genetic, metabolic, hormonal, and functional
disorders that can cause physical disabilities, mental
retardation, or even death if not detected and treated
early. Screening of newborns for 50 inherited meta-
bolic disorders currently can be performed from
blood collected by heel puncture and placed on
specially designed filter paper. Each state has its
own laws requiring specific test screening of new-
borns; however, all states screen newborns for the
presence of the most prevalent disorders. Many of
these disorders can be prevented by early changes in
the newborn’s diet or early administration of a miss-
ing hormone. All states screen for phenylketonuria
(PKU), congenital hypothyroidism, galactosemia, and
cystic fibrosis (Box 11-2).

BOX 112 Newborn Screening Disorders

SPECIAL DERMAL PUNCTURE
Collection of Newborn Bilirubin
One of the tests performed most frequently on new-
borns measures bilirubin levels, and specimens for
this determination often are collected at timed inter-
vals over several days.
Increased serum bilirubin levels (hyperbilirubine-
mia) in newborns may be caused by the presence of
hemolytic disease of the newborn, or it may occur
simply because the liver of newborns (particularly
premature infants) is not developed enough to process
the bilirubin produced from the normal breakdown of
RBCs. Bilirubin test results are critical to infant survival
and mental health because the blood-brain barrier is
not fully developed in neonates, a condition that allows
bilirubin to accumulate in the brain and cause perma-
nent or lethal damage. The decision to perform an
exchange transfusion is based on bilirubin levels and
the newborn’s age and condition.
Phlebotomy technique is critical for the determi-
nation of accurate bilirubin results, and specimens
must be collected quickly and protected from excess
Phenylketonuria
Phenylketonuria (PKU) is caused by the lack of the enzyme that metabolizes the amino acid phenylalanine to tyrosine,
which accumulates and causes problems with brain development as well as delays in physical, mental, and social skills. Early
detection is crucial because the damage is irreversible but can be treated with a diet low in phenylalanine and high in tyrosine.
Congenital Hypothyroidism
Congenital hypothyroidism is a thyroid hormone deficiency present at birth. Delays in growth and brain development
that produce physical and developmental abnormalities can be avoided by the use of oral doses of thyroid hormone
within the first few weeks after birth.
Galactosemia
Galactosemia is a genetic metabolic disorder caused by the lack of the liver enzyme that converts galactose (sugar in
milk) into glucose. Galactose accumulates in the blood and can cause an enlarged liver, renal failure, cataracts,
blindness, and brain damage. Treatment is the lifelong elimination of all milk and dairy products by the infant.
Cystic Fibrosis (CF)
CF is an inherited disorder caused by a genetic mutation that affects the transport of chloride across cell membranes.
Secretions of thick mucus that are produced from this mutated gene build up in the lungs and organs of the digestive
system, causing breathing disorders, infections, and malnutrition. Treatment includes mucus-thinner medicine,
bronchodilators, and antibiotics for infection.
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CHAPTER 11 ✦ Dermal Puncture 315 316 SECTION 3 ✦ Phlebotomy Techniques

Blood Collection or after the drying process. After the specimen has
Except for the hearing test, newborn screening tests dried for at least 3 hours, place the specimen in
are performed on blood collected by dermal punc- a special envelope and send it to the appropriate
ture. Blood is collected between 24 and 48 hours after laboratory for testing. Procedure 11-3 describes the
birth, before the baby is released from the hospital. technique for collecting blood for newborn screen-
Correct collection of the blood specimen is critical ing tests.
Acceptable Uneven Circle not
for accurate test results. When additional blood tests specimen application completely
are requested, CLSI standards recommend that new- of blood filled Technical Tip 11-14. Be sure that all required
born screening specimens be collected separately, FIGURE 1123 Correct and incorrect blood collection with patient information is filled out on the newborn
after prewarming and puncturing a second site. filter paper. screening test form.
Specimen collection devices (cards) are used, consist- FIGURE 1122 Newborn screening specimen form.
ing of a patient information form attached to specifically new circle and a larger drop of blood. Allow the col-
designed filter paper that has been preprinted with lected specimen to air dry in a suspended horizon-
Technical Tip 11-15. Specific state mandates for
an appropriate number of circles as part of the requi- newborn screening can be found at the U.S.
tal position, at room temperature and away from
sition form (Fig. 11-22). You must be careful not to Perform the heel puncture in the routine man- direct sunlight. To prevent cross-contamination, do
National Newborn Screening and Global Resource
touch or contaminate the area inside the circles or to ner and wipe away the first drop of blood. Then not hang specimens to dry or stack specimens during
Center website: genes-r-us.uthscsa.edu/.
touch the dried blood spots. Take care also to avoid apply a large drop of blood directly onto a filter
contaminating the specimen with water, formula, paper circle. Do not touch the filter paper to the
alcohol, urine, lotions, or powder. Causes for invalid baby’s heel. To obtain an even layer of blood, use
newborn screening specimens are listed in Table 11-1. only one large free-falling drop to fill a circle. Apply PROCEDURE 113 ✦ NEWBORN SCREENING BLOOD COLLECTION
the blood to only one side of the filter paper and be
sure there is enough to soak through the paper and EQUIPMENT: Step 3. Evenly fill the circle on one side of the filter paper,
Technical Tip 11-13. Always check the expiration
be visible on the other side. Each circle must be allowing the blood to soak through the paper and
date of the newborn specimen collection card Newborn screening filter paper form
filled for testing. As shown in Figure 11-23, if a circle Latex-free gloves be visible on the other side.
before performing the capillary puncture.
is not evenly or completely filled, you should use a 70 percent isopropyl alcohol pad
Heel puncture safety device
TABLE 111 ● Reasons for Invalid Newborn Screening Specimens Gauze pads
Warming device
INVALID SPECIMEN POSSIBLE CAUSES
Sharps container
Quantity insufficient for testing Filter paper was removed before blood completely filled the circle or Indelible pen
before blood soaked through to the other side
PROCEDURE:
Filter paper touched gloves, powder, or lotion
Appears scratched Blood applied with capillary pipette Step 1. Perform Steps 1 to 14 of Procedure 11-2:
Collection of Blood by Heel Puncture.
Not dry before mailing Specimen mailed before drying a minimum of 3 hours
Step 2. Touch the filter paper to a large drop of blood.
Appears oversaturated Excessive blood applied to filter paper using an alternative device
Blood applied to both sides of the filter paper
Appears diluted, discolored, or “Milking” of the area surrounding the puncture site Step 4. Fill all required circles correctly.
contaminated
Filter paper contaminated with powder, alcohol, formula, water, or lotion
Blood spots exposed to direct heat
Exhibits serum rings Alcohol not dry before puncture
Filter paper contaminated with powder, alcohol, formula, water, or lotion
“Milking” of the puncture site
Specimen dried improperly
Use of a capillary pipette to fill the spots
Appears clotted or layered Several drops of blood used to fill the circle
Blood applied to both sides of the filter paper
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PROCEDURE 113 ✦ NEWBORN SCREENING BLOOD COLLECTION (Continued)
Step 5. Place gauze on the site and apply pressure until
the bleeding stops.
Step 6. Place the filter paper in a suspended horizontal
position to dry for 3 hours. Do not stack multiple
filter papers.
Step 7. Label the specimen and place it in the special
envelope when dry.
Step 8. Check the site for bleeding. Do not place a
bandage on an infant.
Phlebotomist Alert Do not press or touch the
filter paper against the puncture site on the heel.
Technical Tip 11-16. Uneven or incomplete
saturation of filter paper circles because of layering
from multidrop application will yield an
unacceptable specimen for testing.
Technical Tip 11-17. Blood spots must be
thoroughly dry before you close the attached
fold-over flap over the spots.
Capillary Blood Gases
Arterial blood is the preferred specimen for blood gases
(oxygen and carbon dioxide content) as well as (poten-
tial hydrogen)pH levels in adults (see Chapter 12).
However, performing deep arterial punctures in new-
borns and young children is usually not recommended;
therefore, unless blood can be obtained from umbilical
or scalp arteries, blood gases are performed on capil-
lary blood. Blood is collected from the plantar area of
the heel and the palmar area of the fingers.
As discussed in Chapter 6, capillary blood is
actually a mixture of venous and arterial blood, with a
higher concentration of arterial blood. The concen-
tration of arterial blood is also increased when the
collection site is warmed. Therefore, when collecting
CBGs, it is essential to warm the collection site to arte-
rialize the specimen using a commercial heel warmer
or warm, moist washcloth.
Technical Tip 11-18. Do not forget to wipe away
the first drop of blood before collecting a CBG
specimen.
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CHAPTER 11 ✦ Dermal Puncture 317 318 SECTION 3 ✦ Phlebotomy Techniques
PROCEDURE 114 ✦ CBG COLLECTION BY HEEL PUNCTURE
Step 9. Dispose of used supplies and remove all EQUIPMENT: Step 4. Completely fill the capillary tube without any
collection equipment from the area. Requisition form air spaces. Place the magnetic “flea” in the
Step 10. Remove your gloves (and gown if you are Latex-free gloves capillary tube.
wearing one) and sanitize your hands. 70 percent isopropyl alcohol pad
Step 11. Complete the patient log sheet. Heel puncture safety device
Heparinized capillary tubes with seals (caps)
Step 12. Thank the parents if present.
Metal stirrer “flea”
Step 13. Deliver the specimen to the laboratory for Round magnet
mailing to the reference testing agency. Warming device
Gauze pads
Sharps container
Indelible pen
Ice slurry, if needed
Collect the specimens in heparinized capillary
tubes that correspond with the volume and sampling PROCEDURE:
requirements of the blood gas analyzer being used.
Plugs or clay sealants are needed for both ends of Step 1. Perform Steps 1 to 14 of Procedure 11-2:
the tubes, and a magnetic stirrer “flea” and circular Collection of Blood by Heel Puncture. Step 5. Immediately seal both ends of the capillary tube.
magnet are used to mix the specimen with heparin to Step 2. Select the necessary equipment.
prevent clotting.
After warming the site to 40°C to 42°C for 3 to
5 minutes to increase the flow of arterial blood,
collect blood using a routine dermal puncture. Make
sure the capillary tube is filled completely and does
not contain air bubbles. The capillary tube should
fill in less than 30 seconds. When the capillary tube
is full, immediately seal both ends to prevent expo-
sure to room air that could affect the blood gas
composition. Slip the round magnet over the capil-
lary tube. Then mix the blood by moving the mag-
net up and down the capillary tube several times.
Label the capillary tube and place it horizontally
in an ice slurry to slow the metabolism of white Step 6. Mix the specimen with the heparin by moving the
blood cells as well as changes in the pH and concen- Step 3. Hold the capillary tube horizontal to the drop magnet up and down the capillary tube several
trations of blood gases when the specimen will not of blood and fill the capillary tube in less than times.
be tested within 15 minutes. Procedure 11-4 illus- 30 seconds to avoid exposure to air in the blood.
trates the technique for collecting CBGs by heel
puncture.
Technical Tip 11-19. To avoid air bubbles in the
capillary tube, hold it in a horizontal position and be
sure that blood flows easily from the puncture site.
Preexamination Consideration 11-4.
Air bubbles or empty spaces in the capillary tube
cause inaccurate CBG results.
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PROCEDURE 114 ✦ CBG COLLECTION BY HEEL PUNCTURE (Continued)
Step 7. Place gauze on the site and apply pressure until
the bleeding stops.
Step 8. If the specimen will be transported to the
laboratory after more than 15 minutes, label the
capillary tube and place it in an ice/water slurry.
Step 9. Check the site for bleeding. Do not place a
bandage on an infant younger than 2 years.
Step 10. Dispose of used supplies and remove all
collection equipment from the area.
Preparation of Blood Smears
Blood smears are needed for microscopic examination
of blood cells for a differential blood cell count, for
special staining procedures, and for nonautomated
reticulocyte counts. You may make smears when one
of these tests is ordered and a dermal puncture is per-
formed. You should collect blood for the blood smear
before other specimens to avoid platelet clumping.
When you collect specimens by venipuncture,
usually you make the smear in the laboratory from
the EDTA tube. You should make blood smears within
1 hour of collection to avoid cell distortion caused by
the EDTA anticoagulant. You must mix the EDTA
tube for 2 minutes. Then use a plain capillary tube
or a device called DIFF-SAFE to dispense a drop of
blood onto the slide (Fig. 11-24). You can make blood
smears manually (Fig. 11-25) or by using an automated
instrument (Fig. 11-26).
Sometimes, you have to make a blood smear at the
bedside after a venipuncture to be sure there is no
anticoagulant interference. This practice can be dan-
gerous, however, because you must force blood from
the needle onto the slide, and you cannot dispose of
the needle until you have made the smear. Carrying
numerous smears in a crowded collection tray can cause
contamination of equipment and ungloved hands.
Phlebotomist Alert Always wear gloves when
handling blood smears because they are infectious
until they have been fixed with alcohol in the
laboratory.
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CHAPTER 11 ✦ Dermal Puncture 319 320 SECTION 3 ✦ Phlebotomy Techniques
Step 11. Remove your gloves (and gown if you are
wearing one) and sanitize your hands.
Step 12. Complete the patient log sheet.
Step 13. Thank the parents if present.
Step 14. Immediately transport the specimen to the
laboratory.
A
FIGURE 1125 Blood smear made manually.
Learning to prepare an acceptable blood smear
requires considerable practice and can be a source
of frustration for beginning phlebotomists. Once
you master the technique, however, you will sel-
dom fail to achieve an acceptable smear on the first
attempt.
A blood smear that is prepared properly has a
smooth film of blood that covers approximately one-
half to two-thirds of the slide, does not contain ridges B
or holes, and has a lightly feathered edge without
streaks. Perform the microscopic examination in the
A
area of the feathered edge because the cells there
have been spread into a single layer. An uneven smear
indicates that the cells are not evenly distributed;
therefore, test results will not be truly representative
of the patient’s blood. Errors in technique that result
in an unacceptable specimen are summarized in
Table 11-2. The technique for preparing a blood
smear is described in Procedure 11-5.
Blood Smears for Malaria
C
The parasites that cause malaria (Plasmodium
species) invade the RBCs, and their presence is de- FIGURE 1124 A, Inserting the DIFF-SAFE device.
tected by microscopic examination of thick and B, Applying the blood drop to the slide. C, Blood drop B
thin blood smears. Patients with malaria exhibit pe- on a slide.
riodic episodes of fever and chills related to the FIGURE 1126 A, Placing a drop of blood on an automated
multiplication of the parasites within the RBCs. instrument. B, Blood smear.
Therefore, specimen collection is frequently re-
quested on a timed basis similar to that of STAT Thin smears (two or three) are prepared in the circle about the size of a dime. Allow the smear to dry
blood cultures. Smears may be prepared from manner described previously. Make thick smears by for at least 2 hours before staining. Thick smears con-
EDTA anticoagulated blood unless a dermal punc- placing a large drop of blood in the center of a glass centrate the specimen for detection of the parasites,
ture is requested. slide and then using a wooden applicator stick or the and then thin smears are examined for parasitic mor-
corner of another slide to spread the blood into a phology and identification.
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CHAPTER 11 ✦ Dermal Puncture 321 322 SECTION 3 ✦ Phlebotomy Techniques

TABLE 112 ● Effects of Technical Errors on Blood Smears

DISCREPANCY POSSIBLE CAUSES PROCEDURE 115 ✦ PREPARING A BLOOD SMEAR FROM A DERMAL
Uneven distribution of blood (ridges) Increased pressure on the spreader slide PUNCTURE (Continued)
Movement of the spreader slide not continuous Step 6. Place a second slide (spreader slide) with a Step 8. When the blood is evenly distributed across the
Delay in making the slide after drop was placed on the slide clean, smooth edge in front of the drop at a spreader slide, lightly push the spreader slide
Holes in the smear Dirty slide 30- to 40-degree angle inclined over the blood. forward with a continuous movement all the way
past the end of the smear slide. Be sure to maintain
Contamination with glove powder
the 30- to 40-degree angle, and do not apply
No feathered edge Spreader slide not pushed the entire length of the smear slide pressure to the spreader slide.
Streaks in the feathered edge Chipped or dirty spreader slide
Spreader slide not placed flush against the smear slide
Pulling the spreader slide into the drop of blood so that the blood
was pushed instead of pulled
Drop of blood started to dry out because of a delay in making the
smear
Smear too thick and short Drop of blood was too big
Angle of the spreader slide was greater than 40 degrees
Smear too thin and long Drop of blood was too small
Angle of spreader slide was less than 30 degrees Step 7. Draw the spreader slide back to the edge of the
Spreader slide was pushed too slowly drop of blood, allowing the blood to spread across
the end. Choose the slide position that works best
for you. Step 9. Place the slide in an area where it can dry
undisturbed and repeat the procedure for the
second smear.
PROCEDURE 115 ✦ PREPARING A BLOOD SMEAR FROM A DERMAL
PUNCTURE
EQUIPMENT: Step 5. Place the second drop of blood in the center of
Latex-free gloves a glass slide approximately 1/2 to 1 in. from
70 percent isopropyl alcohol pad the end or just below the frosted end by lightly
Finger or heel puncture safety device touching the drop with the slide. The drop should
Three plain or frosted glass slides be 1 to 2 mm in diameter.
Gauze pads
Warming device A
Sharps container
Pencil
Bandage

PROCEDURE:
Step 1. Perform Steps 1 to 14 of Procedure 11-1:
Collection of Capillary Blood From a Finger
Puncture.
Step 2. Perform a dermal puncture on a finger or heel.
Step 3. Obtain three clean glass slides.
Step 4. Wipe away the first drop of blood.

Continued B
6842_Ch11_295-332 17/01/19 11:50 AM Page 323
PROCEDURE 115 ✦ PREPARING A BLOOD SMEAR FROM A DERMAL
PUNCTURE (Continued)
Step 10. Place gauze on the puncture site and apply
pressure until bleeding stops.
Step 11. Smears collected on slides with frosted ends are
labeled by writing the patient’s information on
the frosted area with a pencil. Smears collected
on slides that do not have frosted ends have a
label with the appropriate information attached
to the thick end of the slide.
POINTOFCARE TESTING
The development of portable handheld instruments
capable of performing a variety of routine labora-
tory procedures has increased the efficiency of
patient testing. You can collect specimens by dermal
puncture and test them in the patient area. Test re-
sults are available quickly, and you can avoid trans-
portation of specimens to the laboratory. Dermal
punctures are performed following routine dermal
puncture procedures, unless modifications are
recommended by the instrument manufacturers.
Follow all manufacturer recommendations when
performing POCT. The POCT performed most rou-
tinely is discussed in Chapter 13.
BIBLIOGRAPHY
Center for Phlebotomy Education. Phlebotomy Today Stat!
Painless Skin Punctures: Is a Revolution Coming? March
2017. https://www.phlebotomy.com/pt-stat/stat0317.html.
Accessed August 7, 2018.
6842_Ch11_295-332 17/01/19 11:50 AM Page 324
CHAPTER 11 ✦ Dermal Puncture 323
Step 12. Place the slides in a transport container. Place
the contaminated spreader slides in the sharps
container.
Step 13. Remove your gloves and sanitize your hands.
Step 14. Transport the slides to the laboratory.
CLSI: Blood Collection on Filter Paper for Newborn
Screening Programs. Approved Standard, ed. 6. CLSI
document NBS01-A6. Clinical and Laboratory Standards
Institute, Wayne, PA, 2013.
CLSI: Procedures and Devices for the Collection of Diag-
nostic Capillary Blood Specimens. Approved Standard,
ed. 6. CLSI document GP42-A6. Clinical and Laboratory
Standards Institute, Wayne, PA, 2008.
CLSI: Procedures for the Collection of Arterial Blood
Specimens. Approved Standard, ed. 4. CLSI document
GP43—A4. Clinical and Laboratory Standards Institute,
Wayne, PA, 2004.
Jones, PM: Newborn screening: what’s new? Lab Medicine
39(12);737-741, 2008.
National Newborn Screening and Global Resource Center.
Newborn Screening Information. genes-r-us.uthscsa.edu/.
324 SECTION 3 ✦ Phlebotomy Techniques
Key Points
✦ Dermal puncture is the method of choice for
blood collection on children younger than
2 years to avoid causing iatrogenic anemia
because smaller amounts of blood can be
collected. Deep vein puncture in children is
dangerous and may cause complications.
✦ Dermal puncture is advantageous for adult
patients who are burned or scarred, are
receiving chemotherapy, have thrombotic
tendencies, are geriatric with fragile veins, are
obese, are apprehensive, have inaccessible veins,
or are diabetic.
✦ Capillary blood is a mixture of arterial and
venous blood and may contain small amounts of
interstitial and intracellular fluids. Potassium,
total protein, and calcium have lower
concentrations in capillary blood, and glucose
has a higher value. Record on the requisition
form when the capillary blood was collected.
✦ A variety of automated, retractable safety
puncture devices are available. The type
of device that you select depends on the
age of the patient, the amount of blood
specimen required, the collection site, and the
puncture depth. When using a heel puncture
device, make sure the incision depth does not
exceed 2 mm.
✦ Specimen collection containers include
microhematocrit tubes and microcollection
tubes that are color coded to match the
evacuated tube system, indicating the type
of additive in the tube.
✦ Recommended sites for dermal puncture
include the medial and lateral plantar surfaces
of the heel and the fleshy areas near the center
of the palmar surface of the third and fourth
fingers.
✦ Unacceptable areas for puncture include the
back or the arch of the foot, the tips or sides
of the finger, previous puncture sites, areas
with visible damage, and fingers on the side
of a mastectomy.
✦ Warming a site increases the blood flow sevenfold.
You can warm the site with a commercial heel
warmer or by covering the site with a warm towel
at a temperature no higher than 42°C for 3 to
5 minutes.
✦ Failure to allow alcohol to dry after cleansing the
site will cause a stinging sensation for the patient,
contaminate the specimen, hemolyze the RBCs,
and prevent the formation of a rounded blood
drop because the blood will mix with the alcohol
and run down the patient’s finger.
✦ Be sure to align the blade of the puncture
device to cut across (perpendicular to) the
grooves of the patient’s finger or heel print.
✦ The order of collection for multiple tubes is
CBGs, lavender EDTA tubes (blood smear first
if required), green and amber lithium heparin
tubes, grey EDTA tube, and gold, amber, and
red serum tubes.
✦ You must collect specimens for newborn
bilirubin levels at the correct time and protect
them from light during and after collection to
prevent the bilirubin from breaking down in
the test tube. Hemolysis must be avoided.
✦ Mandatory newborn screening tests are
performed by dermal puncture on the heel for
genetic, metabolic, hormonal, and functional
disorders that may cause physical and mental
disorders when not detected or treated at birth.
You will collect blood on filter paper and send it
to a reference laboratory for testing.
✦ Collect CBG specimens in infants and small
children from the heel or finger. You must
collect these specimens quickly and without air
spaces in the capillary tube that will expose the
specimen to room air, causing inaccurate
results. Use a magnetic stirring “flea” and round
magnet, which are moved up and down the
tube, to mix heparinized capillary tubes.
✦ Blood smears are needed for the microscopic
examination of blood cells for a differential blood
cell count, special staining procedures, and
nonautomated reticulocyte counts. A properly
prepared blood smear covers approximately one-
half to two-thirds of the slide, does not contain
ridges or holes, and has a lightly feathered edge
without streaks.
✦ Thick and thin smears are made to diagnose the
presence of malaria. Thick smears concentrate
the specimen for detection of the parasites, and
thin smears are examined for parasitic
morphology and identification.
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CHAPTER 11 ✦ Dermal Puncture 325 326 SECTION 3 ✦ Phlebotomy Techniques

15. The blood specimen for this test must be 19. Inaccurate CBG results are caused by
Study Questions protected from light: a. mixing the specimen.
a. CBGs b. warming the site.
1. Dermal punctures are often performed on 8. The maximum length of a puncture device used b. CBC c. air bubbles in the collection tube.
a. patients receiving chemotherapy. on the heel is c. PKU d. transporting on ice.
b. geriatric patients. a. 1 mm. d. Bilirubin
20. When a blood smear is prepared, the proper
c. diabetic patients. b. 1.5 mm.
16. A test included in a newborn screen that angle of the spreader slide is
d. All of the above c. 2 mm.
requires placement of blood in circles on filter a. 15 degrees.
d. 2.5 mm.
2. Drawing excess amounts of blood from a paper is b. 25 degrees.
premature infant can cause 9. Selection of an improper heel puncture site can a. PKU. c. 30 degrees.
a. iatrogenic anemia. result in b. electrolytes. d. 45 degrees.
b. arteriospasm. a. puncture of the calcaneus. c. bilirubin.
21. A thick blood smear is required for
c. infection. b. specimen hemolysis. d. CBC.
a. a differential blood count.
d. All of the above c. the need for vigorous massaging.
17. Before mailing a newborn screening test to b. special stains.
d. additional patient discomfort.
3. Which of the following tests must be collected the reference laboratory, the blood spots must c. malaria.
by capillary blood? 10. Failure to puncture across the fingerprint will dry for d. a nonautomated reticulocyte test.
a. Newborn screening tests cause a. 15 minutes.
b. Coagulation tests a. blood to run down the finger. b. 1 hour.
c. ESRs b. hemolysis. c. 2 hours.
d. Blood cultures c. contamination of the specimen. d. 3 hours.
d. additional patient discomfort.
4. The concentration of this analyte is higher in 18. An arterialized specimen must be collected for
blood collected by dermal puncture than by 11. Why should a dermal puncture collection site which of the following tests?
venipuncture: be warmed? a. Bilirubin
a. Glucose a. To prevent hemolysis b. Newborn screening tests
b. Potassium b. To increase blood flow c. Blood gases
c. Total protein c. To prevent clotting d. Malaria blood smear
d. Calcium d. To cause hemoconcentration
5. When a dermal puncture device is selected, the 12. Wiping away the first drop of blood
most critical consideration is the a. increases blood flow. Clinical Situations
a. width of the incision. b. prevents specimen contamination.
b. amount of blood needed.
c. depth of the incision.
c. causes air bubbles to enter the tube.
d. stimulates platelets and faster clotting.
1 Shar, the hematology supervisor, notices that many of the blood specimens collected by
dermal puncture are hemolyzed. Shar schedules a continuing education in-service session
d. tests requested. for the phlebotomy team.
13. Failure to allow alcohol to dry on the puncture
6. The equipment required for a dermal puncture site may cause a. Why should preparation of the collection site be stressed?
excludes a. inability to form a round drop. b. Why is it important for the phlebotomists to obtain rounded drops of blood to prevent
a. a safety lancet. b. specimen contamination. hemolysis?
b. a microcollection tube. c. RBC hemolysis.
c. a tourniquet. d. all of the above.
c. Should the in-service session include the procedure to follow when a second puncture
must be performed to obtain a full tube of blood? Why or why not?
d. alcohol pads.
14. The order of draw for a bilirubin, blood smear,
7. On newborns, dermal punctures are performed
on the
and CBC by dermal puncture is
a. CBC, blood smear, and bilirubin. 2 Alisa delivers a lavender-top Microtainer to hematology and two red-top Microtainers to
the chemistry laboratory collected by dermal puncture from a newborn’s heel. Shar, the
a. index finger. b. blood smear, CBC, and bilirubin.
hematology supervisor, is concerned because the platelet count is much lower than the
b. medial or lateral plantar areas of the heel. c. bilirubin, blood smear, and CBC.
previous day’s count, whereas all the other CBC parameters match the previous values. The
c. back of the heel. d. blood smear, bilirubin, and CBC.
serum in the red-top tubes appears to be hemolyzed.
d. earlobe.
a. Could the phlebotomy technique have caused this?
b. Why or why not?
c. What could have caused hemolysis in the tubes?
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CHAPTER 11 ✦ Dermal Puncture 327 328 SECTION 3 ✦ Phlebotomy Techniques

3 Josef collects a specimen for a serum bilirubin in a red Microtainer, labels the specimen, Summary of the Procedure for Collection of Blood by Heel Puncture
and leaves the tube on the counter in chemistry while everyone is at lunch. Jake, the
chemistry supervisor, rejects the specimen. 1. Place the collection tray in the designated area.
a. Why is this specimen unacceptable? 2. Examine the requisition form and select the necessary equipment.
b. How could this have been avoided?
3. Sanitize your hands and put on a gown (if required) and gloves.
c. State a sample characteristic that made the specimen unacceptable.
4. Assemble the equipment.
5. Identify the patient using the identification (ID) band.
6. Warm the heel.
Summary of the Procedure for Collection of Capillary Blood From a Finger Puncture 7. Select an appropriate puncture site.
8. Cleanse the puncture site with 70 percent alcohol and allow it to air-dry.
1. Examine the requisition form.
9. Remove the safety lancet locking feature if present. Do not contaminate the puncture safety device.
2. Greet the patient, explain the procedure, and obtain consent.
10. Place the puncture safety device perpendicular to the heel print, flat against the skin.
3. Ask the patient to state his or her first and last names and date of birth and spell the last name.
11. Perform the puncture smoothly across the heel print.
4. Compare requisition form information with the patient’s statement.
12. Dispose of the puncture device in the sharps container.
5. Compare requisition form information with the identification (ID) band.
13. Lower the heel, and gently apply pressure.
6. Sanitize your hands and put on gloves.
14. Wipe away the first drop of blood.
7. Organize and assemble the equipment.
15. Collect rounded drops into the microcollection tubes in the correct order without scraping.
8. Select the appropriate finger.
16. Do not milk the site.
9. Warm the finger if necessary.
17. Collect an adequate amount of blood.
10. Cleanse the site with 70 percent alcohol and allow it to air-dry.
18. Mix the microcollection tubes five to 10 times.
11. Remove the safety lancet locking feature if present. Do not contaminate the puncture safety device.
19. Apply pressure until the bleeding stops.
12. Place the puncture safety device perpendicular to the finger, flat against the skin.
20. Remove all collection equipment from the area.
13. Smoothly perform the puncture across the fingerprint.
21. Dispose of the used supplies.
14. Dispose of the puncture safety device in the sharps container.
22. Label the tubes and verify the identification.
15. Point the finger down and apply gentle pressure.
23. Remove and dispose of your gloves and gown.
16. Wipe away the first drop of blood.
24. Sanitize your hands.
17. Collect the microcollection tubes in the correct order without scraping.
25. Thank the parents if present.
18. Apply gauze to the site and ask the patient to apply pressure.
26. Complete the patient blood collection log sheet.
19. Label the tubes and confirm the information with the ID band or the patient.
27. Immediately deliver the specimens to the laboratory.
20. Examine the site for stoppage of bleeding and apply a bandage.
21. Dispose of used supplies.
22. Remove your gloves.
23. Sanitize your hands.
24. Thank the patient.
25. Immediately transport the specimens to the laboratory.
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CHAPTER 11 ✦ Dermal Puncture 329 330 SECTION 3 ✦ Phlebotomy Techniques

Summary of the Procedure for Newborn Screening Blood Collection Summary of the Procedure for Capillary Blood Gas Collection by Heel Puncture
1. Examine the requisition form. 1. Examine the requisition form.
2. Sanitize your hands and put on gloves. 2. Identify the patient using the identification (ID) band.
3. Identify the patient using the identification (ID) band. 3. Sanitize your hands and put on gloves.
4. Organize and assemble the equipment. 4. Begin the 3- to 5-minute heel warming.
5. Select an appropriate heel site. 5. Organize and assemble the equipment.
6. Warm the heel. 6. Select an appropriate heel site.
7. Cleanse the site with 70 percent alcohol and allow it to air-dry. 7. Cleanse the site with 70 percent alcohol and allow it to air-dry.
8. Remove the safety lancet locking feature if present. Do not contaminate the puncture safety device. 8. Remove the safety lancet locking feature if present. Do not contaminate the puncture safety device.
9. Place the puncture safety device perpendicular to the heel print, flat against the skin. 9. Place the puncture safety device perpendicular to the heel print, flat against the skin.
10. Perform the puncture smoothly across the heel print. 10. Perform the puncture smoothly across the heel print.
11. Dispose of the puncture device in the sharps container. 11. Dispose of the puncture device in the sharps container.
12. Lower the heel and apply gentle pressure. 12. Lower the heel and apply gentle pressure.
13. Wipe away the first blood drop. 13. Wipe away the first drop of blood.
14. Evenly fill a circle. 14. Fill the capillary tube without bubbles.
15. Fill all required circles correctly. 15. Add the magnetic flea to the heparinized capillary tube.
16. Do not touch the inside of the circles or blood spots. 16. Seal both ends of the capillary tube.
17. Place the filter paper in an appropriate transport position. 17. Mix the specimen with the magnet.
18. Apply pressure until the bleeding stops. 18. Apply gauze and pressure to the site until the bleeding stops.
19. Dispose of the equipment and supplies. 19. Label the pipette.
20. Correctly complete all required paperwork. 20. Place the tube in an ice-water slurry if the specimen will not be delivered to the laboratory within
15 minutes.
21. Remove your gloves.
21. Dispose of the equipment and used supplies.
22. Sanitize your hands.
22. Remove your gloves.
23. Thank the parents if present.
23. Sanitize your hands.
24. Immediately deliver the specimen to the laboratory.
24. Thank the patient or parents if present.
25. Immediately transport the specimen to the laboratory.
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CHAPTER 11 ✦ Dermal Puncture 331

Summary of the Procedure for Preparing a Blood Smear From a Dermal Puncture
1. Examine the requisition form.
2. Obtain three clean glass slides.
3. Ask the patient to state his or her first and last names and date of birth and spell the last name.
4. Compare the requisition form information with the patient’s statement.
5. Compare the requisition form information with the identification (ID) band.
6. Sanitize your hands and put on gloves.
7. Select and cleanse an appropriate site with 70 percent alcohol, and allow it to air-dry.
8. Remove the safety lancet locking feature if present. Do not contaminate the puncture safety device.
9. Place the puncture safety device perpendicular to the finger or heel, flat against the skin.
10. Smoothly perform the puncture across the fingerprint or heel print.
11. Dispose of the puncture safety device in the sharps container.
12. Point the finger or heel down, and gently apply pressure.
13. Wipe away the first drop of blood.
14. Put the correct size drop on the appropriate area of the slide.
15. Position the slide.
16. Place the spreader slide at a 30- to 40-degree angle.
17. Pull the spreader slide back to the blood drop.
18. Allow the blood to spread across the spreader slide.
19. Push the spreader slide evenly forward.
20. Place the smear to dry, thick side down.
21. Collect the second smear using the correct technique.
22. Label the slides.
23. Smears should have a feathered edge with no streaks.
24. Confirm that the blood is evenly distributed.
25. Confirm that the smear does not have holes.
26. Confirm that the smear is not too long or too thin.
27. Confirm that the smear is not too short or too thick.
28. Dispose of the equipment and used supplies.
29. Remove your gloves and sanitize your hands.
30. Thank the patient.
31. Immediately transport the slides to the laboratory.
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CHAPTER
Arterial Blood Collection
Learning Outcomes
Upon completion of this chapter, the reader will be able to:
12.1 State the recommended requirements for personnel performing
arterial punctures.
12.2 Define arterial blood gases (ABGs), and describe their diagnostic
function.
12.3 List the equipment and materials needed to perform arterial
punctures.
12.4 Define “steady state,” and list additional patient information that
must be recorded when performing blood gas determinations.
12.5 State four factors that should be considered when selecting a site for
arterial puncture, and name the preferred site.
12.6 State the purpose of and steps for performing the modified Allen test.
12.7 Describe the steps in the performance of an arterial puncture.
12.8 State five technical errors associated with arterial puncture and the
effect of each error on the specimen.
12.9 Discuss six complications of arterial puncture, including their effects
on the patient and the precautions taken to avoid them.
12.10 List reasons for a specimen to be rejected.
For additional resources please visit
http://davisplus.fadavis.com
6842_Ch12_333-352 17/01/19 3:12 PM Page 334
12
334 SECTION 3 ✦ Phlebotomy Techniques
INTRODUCTION Technical Tip 12-1. You should not perform
arterial punctures until you complete specialized
The composition of arterial blood is uniform through-
training in your place of employment.
out the body, whereas the composition of venous
blood varies because it receives waste products from
ARTERIAL BLOOD GASES
different parts of the body. Nevertheless, because
arterial blood collection is more uncomfortable and
dangerous for the patient and is more difficult to Testing of ABGs measures the ability of the lungs to
perform, the normal reference values for most lab- provide O2 to the blood and to remove CO2 from the
oratory tests are based on venous blood. Arterial blood and exhale it.
blood is requested primarily for the evaluation of Conditions requiring the measurement of blood
arterial blood gases (ABGs) (oxygen [O2] and car- gases may be of respiratory or metabolic origin and in-
Key Terms bon dioxide [CO2]) to diagnose respiratory condi- clude chronic obstructive pulmonary disease (COPD),
tions and may be requested for the measurement cardiac and respiratory failures, severe shock, lung
Allen test of lactic acid and ammonia in certain metabolic cancer, diabetic coma, open heart surgery, and respi-
Arteriospasm conditions. ratory distress syndrome (RDS) in premature infants.
Brachial artery Performing arterial punctures is not a routine
Collateral circulation duty for phlebotomists. The Clinical Laboratory and
Technical Tip 12-2. Patients who require blood
Femoral artery Standards Institute (CLSI) recommends that all per-
gas determinations are often critically ill.
Local anesthetic sonnel complete specialized training before perform-
Luer tip ing arterial punctures. This training should include
Partial pressure ABGs are tested using specialized instruments that
instruction on:
Radial artery measure the acidity (pH), the partial pressure of O2
1. Complications associated with arterial punctures
Respiration rate (PO2), and the partial pressure of CO2 (PCO2) of the
2. Precautions taken to ensure a safe procedure
Steady state blood. These measurements allow for the determination
3. Specimen-handling procedures to prevent alter-
Thrombolytic therapy of bicarbonate (HCO3) level, oxygen content (ctO2),
ation of test results
Thrombosis and oxygen saturation (O2Sat). See Table 12-1 for ex-
4. Correct puncture technique
Ulnar artery planations and normal values for the tests performed.
5. Supervised puncture performance
Vasovagal reaction
Ventilation device Personnel trained to perform arterial punctures
Technical Tip 12-3. Instruments are available to
include physicians, nurses, medical laboratory sci- perform ABG testing in addition to metabolic tests,
entists, respiratory therapists, emergency medical such as glucose, electrolytes, and hemoglobin,
personnel, and qualified phlebotomists. In some from the same specimen.
facilities, collecting and testing of ABGs have become
the responsibility of the respiratory therapy depart-
ment. In facilities where the laboratory performs ARTERIAL PUNCTURE
the testing, you may be required to perform the punc-
ture or to assist the person performing the puncture
EQUIPMENT
and then deliver the specimen to the laboratory
following special procedures. Arterial blood is collected and transported in specially
You must have a thorough understanding of arte- prepared syringes. Specimens are introduced directly
rial punctures, whether or not you perform them. into blood gas analyzers from the collection syringe,
This chapter covers ABG analytes, equipment, patient as shown in Figure 12-1. This is necessary to protect
preparation, arterial puncture sites, puncture tech- the specimen from contact with room air.
nique, procedural errors, specimen handling, com-
plications of the procedure, and reasons for specimen Arterial Blood Collection Kit
rejection. Collection of capillary blood gases (CBGs), An arterial blood collection kit contains a heparinized
a procedure routinely performed by phlebotomists, syringe with a hypodermic needle with a safety shield.
is covered in Chapter 11. The syringe has a tightly fitting cap to cover the Luer
333
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CHAPTER 12 ✦ Arterial Blood Collection 335 336 SECTION 3 ✦ Phlebotomy Techniques

TABLE 121 ● Arterial Blood Tests

ARTERIAL BLOOD TEST
Partial pressure of oxygen (PO2)
Partial pressure of carbon
dioxide (PCO2)
pH
Bicarbonate (HCO3)
Oxygen content (ctO2)
Oxygen saturation (O2Sat)
DESCRIPTION/FUNCTION
Measures the pressure of oxygen (O2)
dissolved in the blood; tells how well O2
moves from the lungs into the blood
Measures the pressure of carbon dioxide
(CO2) dissolved in the blood; tells how
well CO2 moves out of the lungs
Measures the acidity or alkalinity of the
blood; indicates acidosis or alkalosis
Buffers the blood to prevent acidosis or
alkalosis
Measures the amount of O2 in the blood
Measures how much of the hemoglobin
in the red blood cells is carrying O2
Glass syringes must be available for use when spec-
imens cannot be tested within 30 minutes. They must
NORMAL VALUES be lubricated and heparinized before use. Liquid he-
75-100 mm mercury (Hg) parin can be used to prepare a glass syringe just before
use. The procedure for lubrication and heparinizing
a glass syringe is shown in Procedure 12-1.
35-45 mm Hg You must have a tightly fitting cap available to place
on the Luer tip of the collection syringe after you have
removed the needle. To prevent air from entering the
specimen, replace the cap immediately after you have
7.35-7.45
removed the safety needle from the syringe. Notice the
device included with the collection kit in Figure 12-2.
20-29 mEq/L Capping devices are available that remove air bubbles
already present in the syringe in addition to prevent-
15-22 mL/100 mL of blood ing the entry of air into the specimen.
95-100 percent If you use needles without a safety device, you can
remove the needle by inserting the needle into the
JELCO® Point-Lok® Needle Protection Device (Smiths
Medical North America) before you remove the needle
from the syringe.
Additional Supplies
When the specimen cannot be tested within 30 min-
utes, a container of crushed ice or ice and water is
required for maintaining specimen integrity. The
container must be large enough to cover the entire
blood specimen with the ice and water. Materials used
for specimen labeling must be waterproof when a
specimen is placed in an ice bath.
Materials for care of the puncture site include
alcohol pads for cleansing the site, gauze pads to apply
pressure to the site, and bandages. You can use self-
adhesive pressure dressing bandages, such as Coban,
for additional pressure. You must have a puncture-
resistant sharps container present.
Some facilities administer a local anesthetic before
performing arterial punctures. This requires a 1-mL
hypodermic syringe with a 25- or 26-gauge needle
containing 0.5 mL of an anesthetic such as lidocaine.
ARTERIAL PUNCTURE PROCEDURE
As discussed previously for venipuncture, when you
perform an arterial puncture, you must have a requi-
sition form containing the appropriate information.
You must identify the patient, explain the procedure,
obtain consent, and label the specimens with the
required information.

FIGURE 121 Technologist performing arterial blood gas
determination.
tip of the syringe after the needle has been removed
(Fig. 12-2).
Syringes and Needles
For arterial punctures, the CLSI recommends the use
of plastic syringes with freely moving plungers and a he-
parin anticoagulant. Depending on the requirements
of the testing instrument and the number of tests
requested, syringes may range in size from 1 to 5 mL.
They should be no larger than the volume of the spec-
imen required.
FIGURE 122 Arterial blood collection kit.
Needle sizes range from 20 to 25 gauge and are ⁄8 to
5
11⁄2 in. long. The size and the depth of the artery deter-
mine the needle used. Ideally, the syringe should self-
fill from the arterial pressure. When using 25-gauge
needles, you may have to slowly pull the plunger.
Phlebotomist Alert Excessive pulling on the
syringe plunger can cause air or capillary blood to
enter the specimen.
Heparin is the anticoagulant of choice for ABGs and
must be present in the syringe when the specimen is col-
lected. The type of heparin used must not interfere with
any additional tests being performed on the specimen.
Technical Tip 12-4. Lithium heparin, not sodium
heparin, is used as the anticoagulant when
electrolytes are ordered with the ABGs.
PROCEDURE 121 ✦ HEPARIN PREPARATION OF A LUBRICATED
AND HEPARINIZED SYRINGE
EQUIPMENT: Step 5. Cleanse the top of the heparin vial with alcohol.
Gloves Step 6. Draw 0.5 mL of heparin into the syringe.
1-, 3-, or 5-mL glass syringe
Step 7. Pull the plunger back to expose the area of the
Sterile mineral oil
syringe that will be in contact with the blood, and
Sterile cotton swab rotate the syringe so that the entire surface has
Heparin vial (1,000 IU/mL concentration) been heparinized.
20-gauge needle
Step 8. Remove the 20-gauge needle, and replace it with
20- to 25-gauge needle ( 5⁄8 to 11⁄2 in. long)
the needle to be used for performing the puncture.
Alcohol pads
Step 9. Hold the syringe with the needle pointing up and
PROCEDURE: expel the air; then point the needle down, expel
the excess heparin, carefully remove the needle,
Step 1. Coat the plunger of the syringe with sterile
and attach a new sterile needle. (When the
mineral oil using a sterile cotton swab.
heparin is expelled with the needle pointing
Step 2. Insert the plunger into the syringe with a circular downward, the space in the needle that would
motion to coat the inside of the syringe. normally contain air contains heparin so that air
Step 3. Obtain a vial of heparin with a concentration of cannot be introduced into the specimen. It is
1,000 IU/mL. important to expel the excess heparin from the
Step 4. Attach a 20-gauge needle to the collection syringe. syringe barrel because it will lower the pH value.)
6842_Ch12_333-352 17/01/19 3:12 PM Page 337
Phlebotomist Preparation
After carefully examining the requisition form, you
must collect all the required equipment and if neces-
sary heparinize the collection syringe and prepare a
syringe to administer the local anesthetic. All equip-
ment must be conveniently accessible when you are
performing the puncture.
Assessing the Patient
You should document on either the requisition form
or a designated ABG form the additional patient
information listed below:
1. Time of collection
2. Patient’s temperature
3. Patient’s respiration rate
4. Method of ventilation (room or mechanical
air, including the type of ventilation device
in use)
5. The amount of O2 the patient is receiving, re-
ported as either the fraction of inspired oxygen
(FIO2) or the rate of flow per minute shown on
the O2 monitor in liters per minute (L/M).
6. Patient status, such as comatose, agitated, or
anesthetized
7. Collection site and method (arterial puncture
or cannula, capillary puncture)
Technical Tip 12-5. Patient assessment
information may be included on the requisition
form, but it should be rechecked at this time.
Steady State
You should ensure the patient has been receiving
the specified amount of O2 and has refrained from
exercise for at least 20 to 30 minutes, as well as
noting any suctioning or respirator changes, before
you obtain the specimen. This is referred to as a
steady state.
Often, patients are apprehensive about arterial
punctures. That means you must take considerable
time and care to reassure them because an agitated
patient will not be in a steady state. Agitated patients
often have changed breathing patterns, such as hyper-
ventilation, that will affect their partial pressure
readings (i.e., it will lower the PCO2 and increase the
pH values). Telling an apprehensive patient that a
local anesthetic will be administered after the site has
been selected may aid in relaxing him or her.
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CHAPTER 12 ✦ Arterial Blood Collection 337 338 SECTION 3 ✦ Phlebotomy Techniques
Technical Tip 12-6. Keeping the patient calm B Abdominal aorta
is extremely important for patient safety and
Common iliac artery
specimen integrity. Do not perform specimen
collection hurriedly, but do so in an organized, Internal iliac artery
businesslike fashion.
External iliac artery
Selecting the Site
Arterial punctures can be hazardous, a situation that
limits the number of acceptable sites. To be accept-
able as a puncture site, an artery must be: Right subclavian
A artery
Femoral artery
1. Large enough to accept at least a 25-gauge Right common
needle carotid artery
2. Located near the skin surface so that deep Brachiocephalic
puncture is not required artery Popliteal artery
3. Located in an area where injury to surrounding Axillary artery
tissues will not be critical
4. Located in an area where other arteries are
present to supply blood (collateral circulation) in
case the punctured artery is damaged
Anterior tibial artery
Radial Artery
Brachial Posterior tibial artery
The radial artery, located on the thumb side of the artery
wrist, is the artery that you will use most often for
arterial puncture (see Fig. 12-3A). Although it is smaller Fibular artery
than the brachial artery, the radial artery is the artery Radial
artery
of choice for arterial puncture because: Ulnar artery
1. It lies close to the surface of the wrist and is easy Dorsalis pedis artery
to palpate. Deep palmar arch
2. There is less chance of a hematoma because it Superficial palmar arch
can be easily compressed against the wrist liga- Digital arteries
ments and bones; thus, pressure can be applied
more effectively on the puncture site after
removal of the needle. FIGURE 123 A, Arteries in the arm. B, Arteries in the leg.
3. The ulnar artery can provide collateral circula-
tion to the hand.
Femoral Artery authorized to insert and collect specimens from arte-
Brachial Artery rial cannulas. However, you may be asked to assist in
The femoral artery is a large artery located in the
In spite of its large size, the brachial artery is not the collection of specimens from cannulas.
groin. Physicians and specially trained personnel col-
routinely used for arterial puncture because:
lect specimens from this artery. It is used only when
1. It is much deeper and more difficult to puncture. no other site is available because of its poor collateral Modified Allen Test
2. It is located near the basilic vein, and you could circulation, risk of infection, and increased chance of Before performing a radial artery puncture, you
obtain venous blood. a hematoma or hemorrhage. should perform the modified Allen test to determine
3. It is located near the median nerve, which, if ac- whether the ulnar artery can provide collateral circu-
cidentally punctured, could cause nerve damage. Other Sites lation to the hand. Lack of available circulation could
4. There is no collateral circulation when the artery Other sites used for the collection of arterial blood result in loss of the hand or its function. Therefore if
is damaged. specimens include the umbilical and scalp veins as the modified Allen test result is negative, you may not
5. It lies in soft tissue that does not provide ade- well as the foot artery (dorsalis pedis) (Fig. 12-3B). perform the arterial puncture on that arm and should
quate support for postpuncture pressure, which Physicians and specially trained personnel collect choose another site.
could result in a hematoma. from these sites. They are also the only personnel The modified Allen test is shown in Procedure 12-2.
6842_Ch12_333-352 17/01/19 3:12 PM Page 339
PROCEDURE 122 ✦ THE MODIFIED ALLEN TEST
EQUIPMENT:
NONE
PROCEDURE:
Step 1. Identify the patient, explain the procedure, and
obtain consent.
Step 2. Extend the patient’s wrist over a rolled towel, and
ask the patient to form a tight fist.
Step 3. Locate the pulses of the radial and ulnar arteries
on the palmar surface of the wrist by palpating
with your second and third fingers; do not use
your thumb because it has a pulse.
Step 4. Compress both arteries.
Step 5. While you maintain pressure, have the patient
open his or her fist. You should observe that the
patient’s palm has become pale (blanched).
CHAPTER 12 ✦ Arterial Blood Collection
Step 6. Release pressure on the ulnar artery only, and
watch to see that color returns to the patient’s
palm. This should occur within 15 seconds if the
ulnar artery is functioning (positive modified Allen
test result).
Step 7. If color does not appear in the patient’s palm
within 15 seconds (negative modified Allen test
result), you must not use the radial artery.
Step 8. When the modified Allen test result is positive,
proceed by palpating the radial artery to
determine its depth, direction, and size.
Step 9. Record the results.
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339 340 SECTION 3 ✦ Phlebotomy Techniques
Preparing the Site
The risk of infection is higher in arterial punctures
than in venipunctures. Therefore, cleanliness of the
site is extremely important. Clean the area with alco-
hol and allow it to air-dry. Clean your gloved palpating
fingers in the same manner.
With a physician’s order, you may administer a
local anesthetic now. This is done by injecting a
small amount of anesthetic just under the patient’s
skin or into the surrounding tissue if the artery is
deep. Before injecting the anesthetic, gently pull
back on the plunger and check for the appearance
of blood, which indicates that you have inserted the
syringe into a blood vessel—rather than tissue.
Should this happen, you must prepare a new anes-
thetic syringe and choose a slightly different injec-
tion site. Allow 2 to 3 minutes for the anesthetic to
take effect; if the patient is apprehensive, allow him
or her to relax for 5 minutes (Procedure 12-3).
PROCEDURE 123 ✦ PREPARING AND ADMINISTERING A LOCAL
ANESTHETIC
EQUIPMENT:
Gloves
1-mL syringe
25- or 26-gauge needle
1 percent epinephrine-free lidocaine
Alcohol pads
Sharps container
PROCEDURE:
Step 1. Obtain the requisition form, and check it for
completeness.
Step 2. Greet and identify the patient.
Step 3. Explain the procedure, reassure the patient, and
obtain consent.
Step 4. Verify whether the patient has allergies to
anesthetics.
Step 5. Sanitize your hands, and put on gloves.
Step 6. Cleanse the anesthetic vial top with alcohol.
Step 7. Attach the needle to the syringe.
Step 8. Insert the needle into the vial, and withdraw
0.5 mL of anesthetic (lidocaine).
Safety Tip 12-1. Be sure to document on the
requisition form that the patient does not have an
allergy to local anesthesia.
Technical Tip 12-7. The anesthesia begins to wear
off in 15 to 20 minutes.
Performing the Puncture
Just before performing the puncture, relocate the
artery with the cleansed finger of your nondominant
hand. Place your finger directly over the area where
the needle should enter the artery—not where the
needle enters the skin.
Hold the heparinized syringe like a dart in your
dominant hand, and insert the needle about 5 to
10 mm below your palpating finger at an angle of 30 to
45 degrees with the bevel up. Slowly advance the needle
Step 9. Recap the needle, and place it horizontally on
the table.
Step 10. Locate and cleanse the puncture site with
alcohol. Allow the site to air-dry.
Step 11. Using your nondominant hand, raise the
intradermal layer of the patient’s skin slightly
above the artery, and insert the needle at a
10-degree angle.
Step 12. Pull back slightly on the syringe plunger to be
sure that blood does not appear because that
indicates puncture of a blood vessel.
Step 13. Slowly inject the anesthetic (lidocaine), forming a
wheal.
Step 14. Remove the needle.
Step 15. Wait 2 to 3 minutes for the anesthetic to take
effect.
Step 16. Proceed with the arterial puncture procedure
when the patient has relaxed.
Step 17. Document the application of anesthetic on the
requisition form.
6842_Ch12_333-352 17/01/19 3:12 PM Page 341
into the artery until blood appears in the needle hub.
Arterial pressure should cause blood to pump into the
syringe. When you use a plastic syringe and a small nee-
dle, you may have to pull the plunger back very care-
fully. If blood does not appear, you may redirect the
needle slightly, but it must remain under the skin.
Technical Tip 12-8. Blood that does not pulse into
the syringe and appears dark rather than bright red
may be venous blood and should not be used.
Removing the Needle
When enough blood has been collected, remove the
needle, and apply firm pressure to the site with a gauze
pad. Often, arterial punctures are performed on pa-
tients receiving anticoagulant therapy (Coumadin or
heparin) or thrombolytic therapy (tissue plasminogen
activator [tPA], streptokinase, or urokinase). There-
fore, you may need to apply pressure for longer than
5 minutes for these patients.
Technical Tip 12-9. You, not the patient, must apply
firm pressure over the puncture site for a minimum
of 3 to 5 minutes or until the site stops bleeding.
Expelling the Air, Capping the
Syringe, and Mixing the Specimen
With the hand holding the syringe, immediately expel
any air that has entered the specimen. Activate the nee-
dle protection shield, remove and discard the needle,
and apply the Luer cap or insert the needle into a Point-
Lok device. When a Point-Lok device is used, apply the
Luer cap to the syringe hub when both hands are free.
Immediately rotate the syringe to mix the anticoagulant
with the entire specimen. This can be done by rolling
the syringe on a firm surface with the hand that has
been holding the syringe or by gentle inversion.
Phlebotomist Alert Do not allow the patient to
apply pressure or apply a pressure bandage before
the bleeding has stopped.
Checking the Site
After 3 to 5 minutes, check the puncture site, and if
bleeding has stopped, discontinue the pressure. If
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CHAPTER 12 ✦ Arterial Blood Collection 341 342 SECTION 3 ✦ Phlebotomy Techniques
bleeding has not stopped, reapply pressure for an
additional 2 minutes. Repeat this procedure until the
bleeding has stopped. Notify patient care personnel PROCEDURE 124 ✦ RADIAL ARTERY PUNCTURE
if the bleeding does not stop.
EQUIPMENT: Step 8. Support and hyperextend the patient’s wrist.
Requisition form
Completing the Procedure Gloves
Alcohol pads
Label the specimen, and if you are using a glass syringe,
Heparinized blood gas syringe
place it in an ice-water bath.
Needle with safety device
After you have removed pressure from the site for
Luer cap
2 minutes, recheck the patient’s arm to be sure that a
Gauze pads
hematoma is not forming, in which case additional
Self-adhesive pressure bandage
pressure is required.
Ice slurry if necessary
Check the radial artery for a pulse below the punc-
Indelible pen
ture site, and notify the nurse if a pulse cannot be
Sharps container
located. This indicates a possible arteriospasm.
Biohazard bag
Apply a pressure bandage if no complications are
discovered. PROCEDURE:
In the same manner as discussed with previous Step 9. Perform the modified Allen test to assess
Step 1. Obtain a requisition form, and check it for
phlebotomy procedures, before leaving the room, collateral circulation.
completeness.
dispose of used materials in appropriate contain- Step 10. Locate and palpate the radial artery.
ers, remove your gloves, sanitize your hands, and Step 2. Greet the patient, and have the patient state his or
thank the patient. Procedure 12-4 describes the her first and last names, spell the last name, and
steps involved in performing the radial artery state the date of birth.
puncture. Step 3. Explain the procedure, reassure the patient, and
obtain consent.
Step 4. Obtain O2 therapy information, and ensure that
SPECIMEN INTEGRITY the patient is in a steady state.
Step 5. Sanitize your hands, and put on gloves.
ABG test results can be noticeably affected by im- Step 6. Organize your equipment.
proper collection and handling of a specimen. Of pri-
mary importance is maintaining the specimen under
strict anaerobic conditions. Specimen integrity also is
compromised by improper amount of anticoagulant,
failure to analyze the specimen in a timely manner, Step 11. Cleanse the site and the palpating finger.
and collection of venous rather than arterial blood Step 12. Administer anesthetic if necessary.
(Table 12-2). Step 13. Place a clean, gloved finger over the arterial
puncture site.
PROCEDURAL ERRORS
Procedural errors during arterial puncture include:
1. Introduction of air into the specimen as a result
of failure to seat the plunger firmly into the
syringe, failure to immediately expel any bubbles
from the syringe, or failure to seal the syringe Step 7. Heparinize a glass syringe, and prepare a local
or needle after collection anesthesia syringe if necessary.
6842_Ch12_333-352 17/01/19 3:12 PM Page 343
PROCEDURE 124 ✦ RADIAL ARTERY PUNCTURE (Continued)
Step 18. Activate the safety shield, maintaining pressure.
Step 14. Uncap and inspect the needle.
Step 15. Insert the needle, bevel up, at an angle of 30 to
Step 19. Remove the syringe needle while retaining
45 degrees, 10 to 15 mm below the palpating
finger. Stop when you see blood.
Step 20. Expel air bubbles, apply the Luer device cap, and
Step 16. Allow the syringe to fill to the designated level.
Step 17. Place gauze over the needle, remove the needle,
and apply pressure.
CHAPTER 12 ✦ Arterial Blood Collection
pressure.
mix the syringe while retaining pressure.
Continued
6842_Ch12_333-352 17/01/19 3:12 PM Page 344
343 344 SECTION 3 ✦ Phlebotomy Techniques
PROCEDURE 124 ✦ RADIAL ARTERY PUNCTURE (Continued)
Step 21. Check the puncture site for bleeding after 3 to Step 25. Apply a pressure bandage.
5 minutes. Maintain pressure if bleeding has not Step 26. Remove your gloves, and sanitize your hands.
stopped.
Step 27. Thank the patient.
Step 22. Label the specimen after bleeding has stopped.
Step 28. Immediately deliver the specimen to the
Step 23. Reexamine the puncture site. laboratory.
Step 24. Check for a radial pulse.
TABLE 122 ● Effect of Technical Errors on Arterial Blood Gas Results
TECHNICAL ERROR EFFECT
Air bubbles present Atmospheric oxygen enters the specimen, and carbon dioxide from the
specimen enters the air bubbles
Too much heparin pH is lowered
Too little heparin/inadequate mixing The presence of clots will interfere with the analyzer
Delayed analysis White blood cells and platelets in the specimen continue their metabolism,
utilizing oxygen and producing carbon dioxide
Venous rather than arterial specimen Falsely decreased partial pressure of oxygen (PO2) and increased partial
pressure of carbon dioxide (PCO2)
2. Excessive pulling of the syringe plunger, 30 minutes are still collected in glass syringes and
resulting in increased suction, which may placed in ice and water.
cause the aspiration of capillary blood into the
specimen
3. Not expelling excess heparin from a heparinized
Technical Tip 12-10. Specimens that will also
have electrolyte testing performed cannot be
syringe; the presence of excess heparin in the
placed on ice.
syringe falsely lowers the blood pH
4. An inadequate amount of heparin, resulting in
a clotted specimen Technical Tip 12-11. Take every precaution to
Current CLSI recommendations state that speci- avoid recollecting an arterial specimen because of
mens that will be analyzed within 30 minutes should improper handling.
be collected in plastic syringes and not placed in
an ice bath. The exception to this is when lactate
(lactic acid) tests have been ordered with the ABG
test; these specimens are iced immediately or ac-
ARTERIAL PUNCTURE
cording to facility protocol. Earlier recommenda- COMPLICATIONS
tions that all specimens be placed immediately in
ice to prevent use of O2 by leukocytes and platelets As mentioned previously, an arterial puncture is more
in the specimen have been amended because stud- dangerous for the patient than the venipuncture. Pos-
ies have shown that specimens collected in plastic sible complications include arteriospasm, hematoma
syringes and analyzed within 30 minutes are not formation, nerve damage, hemorrhage, infection,
affected. Specimens that cannot be analyzed within vasovagal reaction, and thrombosis (Table 12-3).
6842_Ch12_333-352 17/01/19 3:12 PM Page 345
TABLE 123 ● Arterial Puncture Complications
COMPLICATION CAUSE
Tissue destruction/ Arteriospasm
gangrene
Hematoma Arterial blood entering the tissue
Nerve damage Deep punctures
Hemorrhage Coagulation disorders and
thrombolytic therapy
Infection Failure to adequately cleanse the site
Vasovagal reaction Apprehension/pain
Arteriospasm
An arteriospasm is a spontaneous, usually temporary,
constriction of an artery in response to a sensation
such as pain. Closure of the artery prohibits collection
of the specimen and prevents O2 from reaching the
tissues, resulting in tissue destruction and possible
gangrene. This is why it is essential to determine the
presence of collateral circulation when performing
arterial punctures.
Hematoma Formation
Hematomas are more common after arterial punc-
ture than after venipuncture because the increased
pressure forces blood into the surrounding tissue.
Frequent causes of hematomas include failing to
maintain pressure for at least 3 to 5 minutes and
checking the site for bleeding; use of arteries located
in soft tissues, where pressure is difficult to apply; and
decreased elasticity in the arteries of older patients.
Nerve Damage
The possibility of nerve damage is greater with arterial
puncture than with venipuncture because of the need
to puncture more deeply into the tissue to reach the
artery, thereby increasing the possibility of encoun-
tering a nerve. Remember, the brachial artery is
located very near the median nerve.
Considering these possible complications, it is
easy to understand why you should perform arterial
punctures only after receiving specialized training
and when the requisition form indicates an arterial
puncture.
6842_Ch12_333-352 17/01/19 3:12 PM Page 346
CHAPTER 12 ✦ Arterial Blood Collection 345 346 SECTION 3 ✦ Phlebotomy Techniques
the thrombus continues to grow. This is caused most
frequently by irritation from the continued presence SPECIMEN REJECTION
PREVENTION of a cannula. Collateral circulation again becomes
Evaluating collateral circulation important. A specimen may be rejected for analysis when it is im-
properly collected, labeled, transported, or stored.
Phlebotomist applies pressure until Major reasons for specimen rejection are:
Phlebotomist Alert You should never perform an
bleeding stops arterial puncture just because you were unsuccessful ● Unlabeled or mislabeled specimen
Avoiding deep sites or additional training with the venipuncture. You must have a health-care ● Inadequate volume
for deep sites provider’s documented request. ● Wrong type of syringe used
Increased pressure, smaller-gauge needles ● Air bubbles in the specimen
● Clotted specimen
Accidental Arterial Puncture ● Hemolyzed specimen
Proper cleansing, sterile technique
Considering that the brachial artery is located near ● Improper handling during transport (temperature)
Calming the patient, offering local anesthetic the basilic vein, it is possible for you to puncture this ● Delay in delivery to the laboratory
artery accidentally. You should be alert for the appear-
ance of bright red blood that pulsates into the syringe,
BIBLIOGRAPHY
indicating that you have accidentally punctured the
Hemorrhage brachial artery. If you suspect an arterial puncture has CLSI. Procedures for the Collection of Arterial Blood
occurred, apply pressure in the manner previously Specimens. Approved Standard GP43-A4, ed. 4. Clin-
Patients who have coagulation disorders or are receiv- ical and Laboratory Standards Institute, Wayne, PA,
ing anticoagulant or thrombolytic therapy have an in- described for arterial punctures. Submit the specimen
2004.
creased risk of bleeding after arterial puncture. to the laboratory, and be sure to document the collec-
Puncture of a large artery, such as the femoral artery, by tion of arterial blood on the requisition form.
a large-gauge needle can produce considerable hemor-
rhaging in these patients. When the bleeding does not Technical Tip 12-12. Never hesitate to report
stop, you should summon medical assistance right away. anything unusual that you observe while
Do not leave the patient if the bleeding has not stopped. performing an arterial puncture.
Infection
Failure to cleanse the arterial puncture site adequately,
resulting in the introduction of microorganisms into the
arterial circulation, is more likely to cause infection than
the introduction of microorganisms into the venous cir-
culation. In the arterial circulation, the organisms are
easily carried into many areas of the body without com-
ing in contact with the protective lymphatic system,
which runs in close proximity to the venous circulation.
Vasovagal Reaction
Apprehensive patients may experience a vasovagal
reaction, resulting in a sudden loss of consciousness.
Stimulation of the vagus nerve as a result of sudden
stress or pain produces vascular dilation and a rapid
drop in blood pressure (hypotension). If this occurs,
you should summon medical assistance right away.
Thrombus Formation
Formation of a clot (thrombus) on the inside wall
of an artery or vein in response to a puncture hole
can produce occlusion of the vessel, particularly when
6842_Ch12_333-352 17/01/19 3:12 PM Page 347
Key Points
✦ Personnel performing arterial punctures must
complete specialized training that includes
recognition of complications, safety
precautions, specimen handling, puncture
technique, and supervised puncture
performance.
✦ ABGs measure the partial pressure of O2 and
CO2 to determine the ability of the patient’s
lungs to supply O2 to the blood and to exhale
CO2 removed from the blood. Additional tests
include pH, HCO3, O2 content, and O2
saturation. Refer to Table 12-1.
✦ Specialized equipment needed for arterial
puncture includes heparinized 1- to 5-mL
plastic syringes, 20- to 25-gauge 5⁄8 - to 11⁄2-inch
needles with safety shields, and Luer syringe
caps. Glass syringes are used when the specimen
cannot be tested within 30 minutes. The
procedure for heparinizing a glass syringe is
shown in Procedure 12-1.
✦ To be in a steady state, the patient must have
been receiving the same amount of ventilated
O2 and not have exercised for 20 to 30 minutes.
A steady state is important for accurate ABG
results.
✦ Additional information required on a
requisition form for ABGs includes the time of
collection, the patient’s temperature and
respiration rate, the method of ventilation and
the amount of O2 the patient is receiving (in
L/M), patient activity, and the collection site.
Study Questions
1. To perform arterial punctures, a health-care
worker must be
a. certified in his/her field.
b. licensed in his/her field.
c. trained in arterial punctures.
d. trained to insert IVs.
2. The ABG test that measures the patient’s ability
to exhale is the
a. PO2.
b. PCO2.
c. HCO3.
d. pH.
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CHAPTER 12 ✦ Arterial Blood Collection 347
✦ The preferred site for arterial puncture is the
radial artery. Reasons for selection of an arterial
puncture site include the size of the artery, the
location of the artery in an area where injury to
surrounding tissue will not be critical, the
proximity to the surface, and the presence of
collateral circulation.
✦ The purpose for performing the modified Allen
test before puncturing the radial artery is to
ensure the presence of collateral circulation
from the ulnar artery. Refer to Procedure 12-2.
✦ Radial artery puncture is made by holding the
syringe like a dart and entering the artery at an
angle of 35 to 45 degrees 3 to 10 mm below the
palpating finger that is placed over the arterial
puncture site. You must hold pressure on the
puncture site for at least 3 to 5 minutes after
needle removal. Refer to Procedure 12-4.
✦ Technical errors that affect ABG specimen
quality include the presence of air bubbles,
excessive heparin, not enough heparin,
inadequate mixing, delayed analysis, and
collection of venous rather than arterial blood.
Refer to Table 12-2.
✦ Complications from arterial puncture include
arteriospasm, hematomas, nerve damage,
hemorrhage, infection, vasovagal reactions, and
tissue destruction. Refer to Table 12-3.
✦ A specimen may be rejected for analysis if it is
improperly labeled, transported, or stored.
3. The primary anticoagulant used for ABGs is
a. lithium heparin.
b. sodium citrate.
c. potassium oxalate.
d. ammonium citrate.
4. ABG specimens that cannot be tested within
30 minutes
a. are collected in glass syringes.
b. are collected in heparinized plastic syringes.
c. are stored at room temperature after
collection.
d. both a and c.
348 SECTION 3 ✦ Phlebotomy Techniques
5. Which patient information may be excluded on 10. When performing an arterial puncture
an ABG requisition form? a. the artery is entered below the palpating
a. Collection site finger.
b. Pulse rate b. the artery is entered above the palpating
c. Respiration rate finger.
d. Method of ventilation c. a pressure bandage is immediately applied
after puncture.
6. Before an arterial blood collection, a patient
d. the needle is held at an angle of 10 to
must be in a steady state, which requires that he
25 degrees.
or she refrain from exercise for:
a. 30 minutes. 11. Which of the following is a technical error that
b. 60 minutes. can affect the quality of an ABG specimen?
c. 12 hours. a. Using heparin as an anticoagulant
d. 24 hours. b. Testing the specimen within 30 minutes
c. Removing air bubbles from the syringe
7. Factors to consider when choosing an artery for
d. Obtaining dark red blood
puncture include all of the following except
a. large enough to accommodate a 25-gauge 12. A complication of arterial puncture that can
needle. lead to tissue destruction is
b. located near the skin surface. a. an arteriospasm.
c. located near the brachial nerve. b. hemorrhage.
d. in the presence of other arteries are present. c. a vasovagal reaction.
d. both a and c.
8. The preferred site for arterial puncture is the
a. brachial artery. 13. Which of the following will cause laboratory
b. ulnar artery. personnel to reject an ABG specimen?
c. femoral artery. a. Air bubbles in the specimen
d. radial artery. b. Collected in a heparinized syringe
c. Delivered to the laboratory within 15 minutes
9. A negative modified Allen test result indicates
d. Nonclotted specimen
a. the ulnar artery can be punctured.
b. the radial artery can be punctured.
c. the radial artery cannot be punctured.
d. the radial artery does not supply collateral
circulation.
Clinical Situations
1 When entering a patient’s room to collect an ABG specimen, Nicole learns that the patient
has just returned from physical therapy. The patient has been disconnected from a
portable O2 device and was just reconnected to the bedside O2 system.
a. When should Nicole collect the specimen? Why?
b. What additional information related to the patient’s status should Nicole obtain?
2 When performing an arterial puncture, Lane notices that the blood is not pulsating into
the syringe.
a. What other observation should Lane make?
b. Should Lane be concerned? Why or why not?
c. Which ABG test result could be falsely decreased? Increased?
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CHAPTER 12 ✦ Arterial Blood Collection 349 350 SECTION 3 ✦ Phlebotomy Techniques

8. When the modified Allen test result is positive, proceed by palpating the radial artery to determine its
3 When performing a venipuncture in the antecubital area of a patient who is obese, Carter
notices that blood is pulsating into the evacuated tube.
depth, direction, and size.
9. Record the results.
a. What other observation should Carter make?
b. What blood vessel may have been punctured?
c. What additional precautions should Carter take to protect the patient?
d. What is the most probable complication for this patient? Summary of the Procedure for Preparing and Administering a Local Anesthetic
1. Obtain a requisition form, and check it for completeness.
2. Greet and identify the patient.
Summary of the Procedure for Heparin Preparation of a Lubricated 3. Explain the procedure, reassure the patient, and obtain consent.
and Heparinized Syringe 4. Verify whether the patient has allergies to anesthetic.
1. Coat the plunger of the syringe with sterile mineral oil using a sterile cotton swab. 5. Sanitize your hands, and put on gloves.
2. Insert the plunger into the syringe with a circular motion to coat the inside of the syringe. 6. Cleanse the anesthetic vial top with alcohol.
3. Obtain a vial of heparin with a concentration of 1,000 IU/mL. 7. Attach the needle to the syringe.
4. Attach a 20-gauge needle to the collection syringe. 8. Insert the needle into the vial, and withdraw 0.5 mL of anesthetic (lidocaine).
5. Cleanse the top of the heparin vial with alcohol. 9. Recap the needle, and place it horizontally on the table.
6. Draw 0.5 mL of heparin into the syringe. 10. Locate and cleanse the puncture site with alcohol. Allow the site to air-dry.
7. Pull the plunger back to expose the area of the syringe that will be in contact with the blood, and rotate 11. Using your nondominant hand, raise the intradermal layer of the patient’s skin slightly above the artery,
the syringe so that the entire surface has been heparinized. and insert the needle at a 10-degree angle.
8. Remove the 20-gauge needle, and replace it with the needle to be used for performing the puncture. 12. Slightly pull back on the syringe plunger to be sure that blood does not appear because that indicates
puncture of a blood vessel.
9. Hold the syringe with the needle pointing up and expel the air; then point the needle down, expel the
excess heparin, carefully remove the needle, and attach a new sterile needle. 13. Slowly inject the anesthetic (lidocaine), forming a wheal.
14. Remove the needle.
15. Wait 2 to 3 minutes for the anesthetic to take effect.

Summary of the Procedure for the Modified Allen Test 16. Proceed with the arterial puncture procedure when the patient has relaxed.
17. Document the anesthetic application on the requisition form.
1. Identify the patient, explain the procedure, and obtain consent.
2. Extend the patient’s wrist over a rolled towel, and ask the patient to form a tight fist.
3. Locate the pulses of the radial and ulnar arteries on the palmar surface of the wrist by palpating
with your second and third fingers; do not use your thumb because it has a pulse.
Summary of the Procedure for a Radial Artery Puncture
4. Compress both arteries. 1. Obtain a requisition form, and check it for completeness.
5. While maintaining pressure, have the patient open his or her fist. Observe that the patient’s palm has 2. Greet and identify the patient.
become pale (blanched).
3. Explain the procedure, reassure the patient, and obtain consent.
6. Release pressure on the ulnar artery only, and watch to see that color returns to the patient’s palm. This
4. Obtain oxygen therapy information, and ensure that the patient is in a steady state.
should occur within 15 seconds if the ulnar artery is functioning (positive modified Allen test result).
5. Sanitize your hands, and put on gloves.
7. If color does not appear in the patient’s palm within 15 seconds (negative modified Allen test result), do
not use the radial artery. 6. Organize the equipment.
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CHAPTER 12 ✦ Arterial Blood Collection 351

7. Heparinize a glass syringe, and prepare the local anesthetic syringe if necessary.
8. Support and hyperextend the patient’s wrist.
9. Perform the modified Allen test to assess collateral circulation.
10. Locate and palpate the radial artery.
11. Cleanse the site and the palpating finger.
12. Administer anesthetic if necessary.
13. Place a clean, gloved finger over the arterial puncture site.
14. Uncap and inspect the needle.
15. Insert the needle, bevel up, at an angle of 30 to 45 degrees, 10 to 15 mm below the palpating finger.
Stop when you see blood.
16. Allow the syringe to fill to the designated level.
17. Place gauze over the needle, remove the needle, and apply pressure.
18. Activate the safety shield, maintaining pressure.
19. Remove the syringe needle while retaining pressure.
20. Expel air bubbles, apply the Luer device cap, and mix the syringe while retaining pressure.
21. Check the puncture site for bleeding after 3 to 5 minutes. Maintain pressure if bleeding has not
stopped.
22. Label the specimen after the bleeding has stopped.
23. Reexamine the puncture site.
24. Check for radial pulse.
25. Apply a pressure bandage.
26. Remove your gloves, and sanitize your hands.
27. Thank the patient.
28. Immediately deliver the specimen to the laboratory.