MODULE 5.
VENIPUNCTURE PROCEDURE The test requisition could be manual, computerized, or bar-
-Introduction-
The term venipuncture refers to the process of collecting or
"drawing" blood from a vein of the patient for laboratory
testing purposes. Phlebotomists should possess the
necessary knowledge and skills to perform venipuncture
since they will perform this procedure frequently as part of
their duties and responsibilities in the healthcare institution.
-objectives-
Upon completion of this module, you should be able to:
1. describe the test request process, types of
requisitions used, and requisition information;
2. discuss test status designations, status priorities,
and the procedure to follow for each status
designation;
3. explain proper "bedside manner" and demonstrate
how to handle special situations associated with
patient contact;
4. justify the importance of proper patient identification;
5. explain how to prepare patients for testing· and
answer inquiries and what to do if a patient objects
to a test;
6. describe how to verify fasting and other diet
requirements;
7. cite each step in the different venipuncture
procedures;
8. list necessary information found on specimen tube
labels and state acceptable reasons for inability to
collect specimen;
9. perform the different venipuncture procedures and
the proper way to-safely dispense blood into tubes
following a syringe collection; and
10. state the unique requirements associated with
drawing blood from special populations including
pediatric, geriatric, and long-term care patients.
Definition of terms
Term Definition (Meriam Webster Dictionary)
Venipuncture - surgical puncture of a vein especially
for the withdrawal of blood or for
intravenous medication
Procedure - a series of steps followed in a regular
definite order
-discussion-
. helps improve the documentation, handling, and reporting
PART 1. TEST REQUEST PROCESS,
TYPES OF REQUISITIONS USED,
AND REQUISITION INFORMATION
The first step of the pre-examination phase is the test
request that comes from a physician. The request form
includes information on the type of test ordered and any
special instructions or conditions that should be considered
during the pre-examination and examination phase. This
form will be part of the patient's medical record and can be
referred to, should issues regarding the test arise.
coded. Manual requisition forms usually have parts for
request, report, and billing. With the advances in
technology, the use of the manual method has declined.
However, these forms still serve as back-up when the
computerized system fails.
The computerized requisition form includes patient
information, test status, and other details that are useful for
the test. A computer-generated label for the collection tube
is made available, with which the phlebotomist must note
the time of collection and confirm the information by affixing
his/her initials. The required pieces of information in the
requisition form are as follows:
• Name of the physician who ordered the test
• Patient's full name including the middle initial .
• The medical record number for inpatients
• Birthday and age of the patient
• Room number and bed number if inpatient
• Type of test ordered
• Date when the test is to be performed
• Billing information (if required)
• Test status
• Special precaution
The manual or computerized request may contain a
barcode, which is scanned into a computer using a special
device with a lase. The information in the code is then
interpreted and processed. The use of these codes greatly
help in minimizing clerical error.
PART 2. VENIPUNCTURE STEPS
Step 1: Review and Accession the Test Request
The test requisition to avoid duplication of request, to
ensure proper collection timing, and to identify special
instructions or equipment required for the test. In reviewing
the request, the phlebotomist must (1) check the
completeness of the required information, (2) verify the
tests to be collected including information such as the time
and date of collection, (3) take note of any dietary
restrictions or special conditions that should be followed
before the actual collection, and (4) determine the test
status or priority of collection.
The test request is then accessioned, which means that the
specimen to be collected is assigned a special number that
will serve as the reference number, for all associated
processes and paperwork. Accessioning the test request
of test results.
Status Designations, Status Priorities and Procedure
for Each Status Designation
See Table 5.1 Common Test Status Designations on next page

Step 2: Approach, Identify, and Prepare the Patient
Proper “Bedside Manner” and Handling Special
Situations Associated with Patient Contact
Phlebotomist should organize the test request according to
priority and prepare all the necessary equipment and
supplies needed to complete their collection round.
They should check for phlebotomy-related signs and
warnings regarding the condition of the patient such as "No
taking of blood pressure (BP) or venipuncture on the right
arm.” These signs are usually posted on the door or wall
next to the patient's room.
"Bedside manner" refers to the behavior of a healthcare
worker as perceived by the patient which is applicable to
both in- and out-patient settings. Proper approach, conduct,
and demeanor which help the phlebotomists gain the trust
and confidence of the patient are part of the professional
bedside manner. The following practices of phlebotomists
show proper bedside manner:
• Knock on the door gently before entering the room.
• Make a good impression by greeting the patient
warmly.
• Stay organized and have all the supplies available
and approach the patient in a professional manner
that goes well with having a neat appearance.
• Maintain a calm expression as most patients are
afraid of blood collection.
• Introduce yourself and explain the procedure.
Obtain the verbal or expressed consent of the
patient before proceeding with the test.
• Remain compassionate and professional during
the procedure.
• Thank the patient for his/her cooperation before
leaving.
If there is a physician or clergy in the room, the
phlebotomists may interrupt only if the ordered test is stat
or timed. They have to excuse and ask permission to
proceed with the test. Family members or visitors can stay
in the room, but it would be better if they could step out of
the room until the process is finished. If the patient to be
tested is not available and the phlebotomists are unable to
obtain the specimen, it should be indicated in the form that
no collection has been made. The form should be submitted
to the nurses' station.
Importance of Proper Patient Identification
Positively confirming the identity of the patient is an
important part of specimen collection. Obtaining a
specimen from the wrong person can have serious
consequences and can even be fatal in cases that involve
blood transfusion. Misidentifying patients can be a reason
or cause for a phlebotomist's dismissal or lawsuit against
him/her on the grounds of malpractice.
When identifying patients, confirm the name and date of
birth of the patient. The patient's response should match the
information on the test request form. Otherwise, the
difference or error should be resolved and rectified before
collection. The identification bracelets should also match,
and the phlebotomist should inform the nurse on duty if
there are any discrepancies or missing IDs.
If the patient is fast asleep, the phlebotomfst should wake
up the patient gently for proper identification. A patient in
the emergency room or intensive care unit may be
unconscious during the time of the collection. Ask for the
help of a relative, nurse, or physician in identifying the
patient. Make sure to note the name of the person who
confirmed the identity of the patient.
If the patient is young, mentally-incapacitated, or there is a
language barrier, the phlebotomist should ask a relative, an
attendant, or the nurse to identify the patient. The
information provide should match those on record and the
pieces of details indicated in the ID bracelet.
The ID bands for inpatient newborns or babies-under 2
jears old are placed in the lower leg. The nurse, guardian,
or relative must confirm the identity of the child. The identity
of the person confirmed the identity must be noted on the
request form.
Patient Preparation for Testing
The phlebotomist should explain the test procedure to the
patient and confirm that the patient understood what has
been discussed. As part of the informed consent advocacy,
a verbal or expressed consent should be obtained before
proceeding with the collection.
It is best to direct a patient's inquiries on the purpose or
result of the test to the patient's nurse or physician to avoid
any miscommunication. If the patient objects to the
collection, respect the right of the patient to refuse testing.
The refusal should be noted in the test request and the
authorized personnel should be informed about the refusal.
MODULE 5 –VENIPUNCTURE PROCEDURE 2
A patient must be treated with care under all circumstances,
and the phlebotomist must remain calm and professional
even jf the patient is being difficult or is exhibiting needle-
phobia. Special attention should be given to minimize the
trauma.
Step 3: Verify the Patient’s Diet Restrictions and Latex
Sensitivity
Verifying Fasting and Other Diet Requirements
Phlebotomists should verify if there are special instructions
on the diet of the patient that need to be followed such as
fasting for about 8 to 10 hours. During fasting, the patient
may he allowed to drink water to avoid dehydration. It is
best to advise the doctor if the patient has not been able to
follow; the fasting requirement so a decision could be made
if the collection will proceed as scheduled.
A patient with allergic reaction to. latex can have life-
threatening reactions upon exposure, so it is important. to
check if all pieces of equipment used on the patient are
latex-free and there are no latex items in the room.
Step 4: Sanitize Hands
Proper hand hygiene should be observed to prevent the
spread of infection.
Step 5: Position the Patient, Apply the Tourniquet,
and Ask Patient to Make a Fist
During the venipuncture procedure, an, inpatient is usually
lying down in bed, while an outpatient is seated b n a blood
drawing chair, except when the patient is prone to fainting
in which case, he/ she is placed in a reclining chair, sofa, or
bed. Be sure that the hand or arm for venipuncture
procedure is well supported.
The phlebotomist can then proceed to the tourniquet
application and fist clenching. The tourniquet should be
placed 3 to 4 inches from the intended site. Apply over a
gauze if the patient has sensitive skin, and never apply a
tourniquet over an open sore, When the tourniquet is in
place, ask the patient to clench his/her fist.
Step 6: Select Vein, Release Tourniquet, and Ask
Patient to Open Fist
The antecubital area of the arm is the preferred
venipuncture site. When the phlebotomist has found a vein,
he/she should roll his finger from one side to the other to
gauge its size. Using the fingers, the phlebotomist should
trace the path to determine a possible entry point. The
depth and patency are checked by pressing on the site a
couple of times. If the vein is not suitable, the phlebotomist
should look for an alternative site, or a capillary puncture
could be an option.
Tourniquet Application:
1. Place the tourniquet 3 to 4 inthes or about 4 to 5 finger
widths from the intended puncture site.
2. Hold one side of the tourniquet in each hand. It should
be a few inches from the end.
3. Apply a little tension so that it will be snug when tied.
4. Bring the two sides together. Hold both ends between
the thumb and forefinger of the right hand.
5. Reach over the right hand and grasp the right side of
the tourniquet between the thumb and forefinger of the
left hand and release it from the grip of the right hand.
6. Near the left index finger, cross the left end over the
right. Hold both sides together between the thumb and
forefinger of the left hand, close to the patient’s arm.
7. While securely holding both sides, use either the left
middle finger or the right index finger to tuck a portion
of the left side under the right side and pull into a loop.
8. Tie the tourniquet properly with its ends pointing
towardthe shoulder.
If the tourniquet is applied, release it and the patient should
be asked to open his fist.
Step 7: Clean and Air-Dry the Site
The venipuncture site· should be cleaned using an
antiseptic, such as 70% isopropyl alcohol, to prevent
infection or contamination. The area should cover about 2
to 3 inches diameter using a circular motion, and moving
outward in concentric circular motion. Allow the area to dry
for about a minute, but do not use unsterilized gauze, and
never fan or blow the site. Avoid touching the site after
cleaning.
Step 8: Prepare the Equipment and Put on Gloves
The age of the patient, volume of blood for collection, and
the size and location of the vein are factors to be considered
when choosing the system, needle size, and volume-of the
tube that will be used. Make sure that you are wearing a
clean pair of gloves.
Steps in Equipment Preparation for Different
Venipuncture Procedures
A. Evacuated Tube System
1. Select the rappropriate tube for ETS and tap to
dislodge any additives in the stopper.
2. Select and inspect the needle for defects.
3. Twist needle to expose the back of the needle.
4. Screw this end to the threaded hub of the tube holder.
5. Place the first tube in the holder.
6. Position the tube in the holder.
B. Winged Infusion Set (Butterfly)
1. Use a 23-gauge butterfly gauge with a safety feature.
2. Inspect the package before aseptically opening and
removing the butterfly.
3. Attach the butterfly to an ETS holder or syringe.
4. Select the appropriate small-volume tube for the test.
,
C. Syringe System
1. Select the appropriate syringe and needle.
2. Test the plunger before opening the sterile package.
3. Open the package aseptically.
4. Securely attach the needle to the syringe.
Step 9: Reapply the Tourniquet, Uncap, and Inspect the
Needle
MODULE 5 –VENIPUNCTURE PROCEDURE 3
Reapply the tourniquet without touching the cleaned area.
Get the collection equipment using your dominant hand.
Remove the needle cover and inspect the needle. The
needle should not come into contact with anything prior to
venipuncture. If this happens, remove, and replace it with a
new one.
Step 10: Ask the Patient to Remake a Fist, Anchor to
Vein, Insert Needle
Ask the patient to make a fist. Anchor the antecubital vein
by holding the patient's arm with your free hand. The fingers
should support the back of the arm just below the elbow.
Place the thumb at least 1 to 2 inches below, but slightly on
the side of the site of venipuncture, Pulling the skin toward
the wrist.
When inserting the needle, the phlebotomist should hold
the collection device or butterfly needle with his/her
dominant hand. He/She should position the needle above
the insertion site with the bevel facing up, then insert it using
a smooth forward motion in a 30-degree angle.
Step 11: Establish the Blood Flow, Release the
Tourniquet, and Ask the Patient to Open Fist
Press on the collection tube into the tube holder. Make su~e
that the needle has completely penetrated the stopper.
Push the tube with the thumb while the middle and index
fingers straddle and grasp the flanges of the tube holder
slightly pulling it back. Let the blood flow into the tube.
Release the tourniquet and ask the patient to release
his/her fist.
Step 12: Fill, Remove, and Mix the Tubes in Order of
Draw or Fill the Syringe
The phlebotomist should make sure that the required
volume has been collected. Tubws that contain additives
must be inverted gently several times to mix the content.
The tourniquet must be released before removing the
needle.
Step 13: Place Gauze, Remove the Needle, Activate the
Safety Feature, and Apply Pressure
Fold a gauze square into fourths and place it lightly over the
site where the needle is inserted: Do not apply pressure.
Remove the needle and activate the safety feature (if
applicable) while simultaneously applyig pressure with your
free hand. The arms should be extended or raised.
Step 14: Discard the Collection Unit, Syringe Needle, or
Transfer Device
Step 15: Label the Tubes
Necessary Information in the Specimen Tube Labelling
a. Patient's complete name (first and last names)
b. Date of birth
c. ID number (if applicable)
d. Date and time of collection
e. Initials of the phlebotomist
f. Additional information such as “fasting”
Step 16: Observe Specimen Handling Instructions
Step 17: Check Patient's Arm and Apply Bandage
Step 18: Dispose of Contaminated Materials
Step 19; Thank the Patient, Remove Gloves and
Sanitize Hands
Step 20: Transport the Specimens to the Lab
PART 3. REQUIREMENTS FOR DRAWING BLOOD
FROM SPECIAL POPULATION
I. Pediatric Puncture
Special attention is necessary when performing pediatric
venipuncture involving children below two years old. To
minimize pain and trauma of the patients, this procedure
should be limited to superficial veins only.
The challenges faced when dealing with pediatric patients
include veins that are usually small and underdeveloped
making it difficult to draw blood. A considerable risk of
damage could be permanent if proper procedure is not
followed. There is also the risk of anemia since the volume
of blood in the body is smaller.
In addition, dealing with the parents or guardians could also
be a challenge. The phlebotomist should exhibit a warm
and caring approach and it would be good to ask the
parents or guardians about the child's past blood collection
experience. They should be allowed to stay in the room with
the child if they want to.
The phlebotomist should take a slow approach and
determine the level of anxiety of the patient to gain. the
latter’s trust. The procedure should be explained clearly
using terms that the child could easily understand,
emphasizing that the young patient should keep still during
the the procedure. It is also useful to offer some form of
reward for the patient's cooperation.
Eutectic mixture of local anesthetics (EMLA) is used for
pain interventions. This comes in cream and oral forms and
takes about an hour to take effect and anesthetize the area.
During the procedure, there are several ways to restrain the
movement of the patient: an infant is wrapped in the
blanket; a toddler is usually seated on his/her parent's lap;
and for children, a second person commonly leans over the
child who is in a lying position.
II. Geriatric Venipuncture
Geriatric or elderly patients need special attention because
they may have special conditions such as arthritis,
diabetes, Parkinson's disease, stroke, atherosclerosis, and,
dementia, which make blood drawing a challenge. Another
problem is their hearing, visual, or mental impairment. The
elderly also have thinner skin and smaller muscles which
cause the veins to roll easily. Note that as a personage,
MODULE 5 –VENIPUNCTURE PROCEDURE 4
his/her veins lose their elasticity, making them prone to
collapse during this kind of procedure.
-SUMMARY-
The healthcare institution also has to consider safety issues
like the space requirement for walkers and wheelchairs, The venipuncture procedure is complex and requires both
and maintenance of nonslip clutter-free floors for the knowledge and skill. When drawing a blood specimen, the
elderly. The wheels of a patient's wheelchair must be locked trained phlebotomist must follow the necessary steps
during the procedure. required to successfully perform the venipuncture process.
Phlebotomy is a proficiency that all medical technologists
The following procedure should be followed when doing should learn all throughout their career. Honing such skill
venipuncture on an elderly patient: requires countless practice and loads of time. Such skill can
a. Identify the patient properly and confirm the patient never be acquired overnight.
information. Ask the attendant or relative if
necessary.
b. Carefully select which needle to use (short. draw or -reference-
butterfly needle.
c. Apply the tourniquet carefully to make sure that the • Learning Guide for Principles of Medical
skin will not be damaged. Laboratory Sciences 2
d. Make sure that the present site is not the site from Copyright 2020 by C&E Publishing Inc.,
a previous venipuncture. Bernard U. Ebuen, Nini F. Lim, Edliberto P.
e. Avoid rubbing the site vigorously during cleaning. Manahan, Jose Jurel M. Nuevo, Maria Luisa R.
f. Present the vein from rolling by anchoring it firmly Olano, and Aileen C. Patron
during the venipuncture.
g. Hold the pressure. over the site and take note that
the bleeding the elderly patients can take a longer Prepared by:
time to stop than in younger patients.
Ruth Abigail S. Contante, RMT, LPT
III. Long-term Care Patients Instructor
Dialysis Patients
Use the dorsum of the hand of patients undergoing
hemodialysis to preserve the veins of the arms for
hemodialysis access. The phlebotomist should comply and
select another site other than the arm used with an
arteriovenous (AV) fistula.

Long-Term Care Patients

Long-term care services are provided to patients who
cannot perform regular daily activities due to their health
condition. These can be assisted-living with the help of
relatives or friends, which could be in their private homes or
in community-based rehabilitation facilities such as an adult
day-care center.

Home-care Patients
Home health services are for patients who need medical
attention and assistance from health professionals from
time to time. Home care phlebotomists are independent,
flexible, with exceptional interpersonal and organizational
skills, and can carry all the necessary equipment with them
during house calls.

Hospice Patients
Hospice care is for patients who need end-of-life care, and
mostly have a prognosis of six months or less. The
phlebotomist should work with extra care with these
patients, treating them kindly and with respect, giving these
dying patients comfort and dignity.
Student assessment question 1:
Following the steps of venipuncture, re-enact the
following steps (but DO NOT INSERT THE NEEDLE)
and then take a picture of each step and paste it on the
answer sheet. Make sure to label each picture with the
appropriate step. (50 pts)
MODULE 5 –VENIPUNCTURE PROCEDURE 5