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http://evolve.elsevier.com/Warekois/phlebotomy CHAP TE R 9 Routine Venipuncture
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PROCEDURE 9-1—cont’d
Routine Venipuncture
18. Label the tubes.
Label each tube at the patient’s bedside, or in
the drawing room in the presence of an
outpatient. Do not leave the room without
rst labeling the tubes. Place one end of
the label close to the tube cap end. If you
are labeling by hand, use either a ballpoint
pen or a permanent marker—never a pencil or a nonpermanent marker. The label
must have the patient’s name and ID number, the date and time of collection, and
your initials or ID number. If you are using computer-generated labels, make sure
that the label has all the required information, and then add your initials or ID number and the date and time of collection.
Never label a tube before collection. This can
lead to serious errors if, for instance, another person makes the collection or tubes
for different patients are mixed before collection. If possible, compare the informa-
tion on the labeled tube to the patient’s ID
band, or ask the patient to conrm the
information on the label.
Specimens requiring special handling, such as
warming or exclusion from light, should
be placed in the proper container now.
143
19. Attend to the patient.
Check the puncture site to be sure bleeding
has stopped.
Raise the bed rail, if you lowered it.
Dispose of all contaminated materials in a
biohazard container.
Place all specimens in either bags or tube
holders, and then remove your gloves and
wash your hands.
FLASHBACK
See Procedures 4-1 and 4-3.
Thank the patient and smile.
In some inpatient situations, it is appropriate
to report to the nursing station that you are
nished with the patient. For instance, a
fasting patient may be able to eat after the
phlebotomist is nished, or a medication
that was withheld can now be administered.
Copyright 2016, 2011, 2007, 2002 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Continued
144
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CHAPTER 9 Routine Venipuncture http://evolve.elsevier.com/Warekois/phlebotomy
PROCEDURE 9-1—cont’d
Routine Venipuncture
20. Deliver the specimen.
Deliver the specimen to the laboratory.
Follow the laboratory’s policy about record-
ing your work in the computer, logbook,
or other tracking system.
Log in the specimen arrival time in the
logbook.
Complete all your paperwork.
AVOID THAT ERROR!
It has been a long day for phlebotomist Sylvia Karnower when
she enters the room of her last patient, Ana Campos. Ms. Campos is out of bed, and Sylvia asks her to lie down so she can take
a blood sample. Ms. Campos sits on the edge of the bed, arm
out. “I’ve been lying down all day, and I can’t stand another
minute of it,” she says. “Just stick me like this.” Sylvia figures it is
the patient’s choice, so she proceeds with the draw. Just as the
first tube begins to fill, Ms. Campos slumps over and falls back
on the bed. What was the error and what should Sylvia have
done differently? And what should she do now?
ROUTINE VENIPUNCTURE
WITH A SYRINGE
Procedure 9-2 describes the steps for a routine veni-
puncture with a syringe. Patients with fragile veins
may need to have blood drawn using a syringe because the stronger vacuum of the evacuated tube may
collapse the vein. A small needle is usually used for
the draw. After the blood is drawn, the needle safety
shield is activated. Blood is transferred to evacuated
tubes using a needleless blood transfer device.
REVIEW FOR CERTIFICATION
The steps of routine venipuncture are designed
to produce a blood sample quickly, accurately, and
BI BL IOG R AP H Y
Catalano K: Update on the National Patient Safety Goals—
Changes for 2005, AORN J 81:336–341, 2005.
College of American Pathologists: So you’re going to collect a
blood specimen: An introduction to phlebotomy, ed. 13, North-
eld, Ill., 2010, College of American Pathologists.
CLSI: Procedures for the collection of diagnostic blood speci-
mens by venipuncture; Approved standard—sixth edition. CSLI
document GP41-A6 (formerly H03-A6). Wayne, Pa., 2007,
Clinical and Laboratory Standards Institute.
Ernst DJ, Ernst C: Phlebotomy tools of the trade, part 2: Survey-
ing the antecubital area, Home Healthc Nurs 20:402–403, 2002.
efciently while ensuring the safety of both the
phlebotomist and the patient during the collection.
Positive patient ID is the most important step in the
procedure. A tourniquet is used to locate a vein, but
care must be taken to avoid applying it too tightly or
leaving it on too long. Once the site is cleaned, the
needle is inspected, the rst tube is prepared, and
the needle is inserted at an angle of 15 to 30 degrees
in a single smooth, quick motion. Tubes are held at
a slight downward angle while lling and are mixed
immediately after lling. They are labeled after lling, once the needle has been withdrawn and gauze
has been applied to the puncture site. Syringe collection is sometimes used for patients with fragile
veins. Blood is transferred to evacuated tubes after
drawing.
The Joint Commission: Accreditation program: Hospital na-
tional patient safety goals, Oakbrook Terrace, Ill., 2010, The
Joint Commission.
Lippi G, Salvagno GL, Montagnana M, et al: Phlebotomy issues
and quality improvement in results of laboratory testing, Clin
Lab 52:217–230, 2006.
United States Department of Health and Human Services: Advance
beneciary notice of noncoverage (ABN), ed. 4, 2013. Retrieved
from www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNProducts/downloads/abn_booklet_icn
006266.pdf.
Copyright 2016, 2011, 2007, 2002 by Saunders, an imprint of Elsevier Inc. All rights reserved.
http://evolve.elsevier.com/Warekois/phlebotomy CHAP TE R 9 Routine Venipuncture
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PROCEDURE 9-2
Venipuncture With a Syringe
1. Follow the beginning steps for a routine
venipuncture.
Perform steps 1 through 8 and 10 of Procedure
9-1, including removing and inspecting the
needle. The needle should be checked
immediately before insertion because its
small size makes it susceptible to damage
from improper handling during preparation.
Because you will not be collecting directly into
an evacuated tube, do not perform the
portions of step 7 that concern attaching the
needle to the adapter and inserting the tube
into the adapter.
2. Prepare the syringe and perform the
venipuncture.
Twist the needle onto the tip of the syringe.
Pull the plunger back to be sure it moves freely,
and then push it all the way back in to expel
any air.
Reapply the tourniquet and perform the veni-
puncture, as in steps 9 and 11 of Procedure
9-1. A ash of blood should appear in the
syringe hub, indicating that the vein has
been entered.
145
Copyright 2016, 2011, 2007, 2002 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Continued
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CHAPTER 9 Routine Venipuncture http://evolve.elsevier.com/Warekois/phlebotomy
PROCEDURE 9-2—cont’d
Venipuncture With a Syringe
3. Fill the syringe.
Unlike the evacuated tube, the syringe does not
automatically ll with blood. Pull back the
plunger evenly, gently, and slowly to with-
draw the blood. Be sure to rmly brace the
hand holding the barrel against the patient’s
arm so that only the plunger moves. Excess
pressure due to pulling back on the plunger
too quickly can cause hemolysis or the vein
to collapse.
4. Withdraw the needle, and transfer the blood
to evacuated tubes.
Withdraw the needle and stop the bleeding as in
step 16 of Procedure 9-1. Activate the safety
device.
Transferring the blood to evacuated tubes is
done in the same order as if the evacuated
tube system were used (blood culture, light
blue, and so on). Rubber stoppers should not
be removed.
Place the tubes in a tube holder.
Never transfer blood from a syringe with an
exposed needle. Instead, activate the safety
device on the needle, remove it from the
syringe, and dispose of it according to your
institution’s procedures. Then, attach a
needleless blood transfer device to the
syringe.
Copyright 2016, 2011, 2007, 2002 by Saunders, an imprint of Elsevier Inc. All rights reserved.
http://evolve.elsevier.com/Warekois/phlebotomy CHAP TE R 9 Routine Venipuncture
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PROCEDURE 9-2—cont’d
Venipuncture With a Syringe
Holding the syringe upright, push the rst tube
up into the transfer device. Angle the tube
slightly so blood ows slowly down the side
of the tube, rather than dropping straight
down, to prevent hemolysis. Allow the tube
to ll without applying any pressure to the
plunger. Pushing on the plunger causes hemolysis and increases the risk of causing an
aerosol spray when the needle is removed.
The evacuated tube will ll according to its
vacuum capacity. If you need to ll a second
tube, remove the rst and insert the second
tube just as you did the rst.
147
5. Dispose of the syringe and transfer device
together in the appropriate container.
Copyright 2016, 2011, 2007, 2002 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Continued
148
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CHAPTER 9 Routine Venipuncture http://evolve.elsevier.com/Warekois/phlebotomy
PROCEDURE 9-2—cont’d
Venipuncture With a Syringe
6. Complete the procedure.
Finish the procedure as in steps 18 to 20 of
Procedure 9-1.
AVOID THAT ERROR!
The waiting room at Consolidated Medical Services is filled, with
seven outpatients still waiting for draws and more patients likely
to arrive at any moment. Phlebotomist Tomas Sanchez knows
the efficient functioning of the laboratory depends on him, and
he is working quickly to clear the backlog. He seats his next patient, checks her ID against the requisition, prepares his tubes,
applies the tourniquet, and swabs the site with alcohol. Moments
later, he blows on the site to remove the last traces of liquid,
then inserts the needle. The samples obtained, he finishes with
the patient and labels the tubes. “Next!” What did he do wrong,
and what should he have done?
WHAT WO ULD YOU DO?
You must not draw blood from the patient. Drawing from the wrong patient can lead to incorrect diagnosis or treatment and may even lead to death of the patient. It can also get you red and subject you to
legal action. Although it seems likely the patient is the one you were expecting, there is a slight chance
he is not—it is possible that two patients with the same name and similar dates of birth are both patients
at the hospital and the ID numbers are in error. Find a nurse to determine where the error arose. You
must resolve the discrepancy before you draw.
AVOID THAT ERROR!
Ms. Campos has fainted, fortunately remaining on the bed
rather than falling to the floor and risking severe injury.
Sylvia should have insisted that the patient lie back in the
bed, with enough support to prevent movement should she
faint. Had Ms. Campos refused, Sylvia should have contacted the nurse. That is exactly what she must do now,
to make sure the patient is safe and has not been injured
during syncope.
AVOID THAT ERROR!
Tomas blew on the site, potentially contaminating it with bacteria
or viruses from his mouth. Despite the need for rapid turn-
around, he should have waited for the site to air-dry before
proceeding with the draw.
Copyright 2016, 2011, 2007, 2002 by Saunders, an imprint of Elsevier Inc. All rights reserved.
http://evolve.elsevier.com/Warekois/phlebotomy CHAP TE R 9 Routine Venipuncture
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STUDY QUESTIONS
See answers in Appendix F.
1. What is the most important aspect of any phlebotomy procedure?
2. Describe how to properly identify a patient.
3. What information is typically on a requisition form?
4. List the steps you should perform when requisitions are received.
5. Dene hemoconcentration.
6. Name three veins in the antecubital area suitable for venipuncture.
7. Explain why the median cubital vein is the rst choice for venipuncture.
8. Describe how veins, arteries, and tendons feel when palpating them.
9. What techniques can you use to help locate a vein?
10. Dene hematoma.
11. Describe the correct position of the patient’s arm after withdrawing the venipuncture needle.
12. Explain the correct procedure for labeling blood tubes.
13. List the information a phlebotomist must look for on a requisition slip.
14. Explain the reasoning behind preparing the patient before you wash your hands and put on gloves.
15. Describe the purpose of an ABN, and the phlebotomist’s role in their use.
149
CERTIFICATION EXAMINATION PREPARATION
See answers in Appendix F.
1. Which is a purpose of the requisition?
a. Identifying the patient
b. Determining the specimens to be
collected
c. Allowing the equipment necessary for
the collection to be gathered
d. All of the above
2. Which vein is often the only one that can be
palpated in an obese patient?
a. Median
b. Cephalic
c. Basilic
d. Iliac
3. Upon entering a patient’s room, you should rst
a. assemble your equipment.
b. put on your gloves.
c. introduce yourself.
d. identify the patient.
4. Which vein lies close to the brachial artery?
a. Cephalic
b. Median cubital
c. Basilic
d. Iliac
5. At what angle should a venipuncture needle
penetrate the skin?
a. 10 to 15 degrees
b. 15 to 30 degree
c. 30 to 40 degrees
d. 45 degrees
6. Which information must match on the patient’s
ID band and the requisition?
a. DOB
b. ID number
c. Patient’s name
d. All of the above
7. When should the tourniquet be removed from
the arm in a venipuncture procedure?
a. After the needle is withdrawn
b. As the needle is withdrawn
c. Before the needle is withdrawn
d. The tourniquet should not be removed
Copyright 2016, 2011, 2007, 2002 by Saunders, an imprint of Elsevier Inc. All rights reserved.
150
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CHAPTER 9 Routine Venipuncture http://evolve.elsevier.com/Warekois/phlebotomy
8. Tourniquets should be placed _____ inches
above the venipuncture site.
a. 1 to 2
b. 2 to 3
c. 3 to 4
d. 4 to 5
9. The following can occur if the tourniquet is
left on the patient too long:
a. nerve damage.
b. hemoconcentration.
c. occluded radial pulse.
d. hematoma.
10. Hematomas can be caused by
a. removing the tourniquet after removing
the needle.
b. withdrawing the needle before removing
the last tube.
c. withdrawing the needle too quickly.
d. removing the tourniquet before remov-
ing the needle.
11. An increase in the ratio of formed elements to
plasma is called
a. hemolysis.
b. petechiae.
c. hemoconcentration.
d. hematoma.
12. Small red spots on the skin are referred to as
a. hemolysis.
b. petechiae.
c. hemoconcentration.
d. hematoma.
13. If you are asked to perform a venipuncture on
an inpatient who is not wearing an ID band,
you should
a. identify the patient by asking his or her
name, and perform the venipuncture.
b. ask the patient’s nurse to attach a new
ID band before proceeding.
c. notify the physician.
d. refuse to perform the venipuncture.
14. Which vein is the rst choice for
venipuncture?
a. Basilic
b. Median cubital
c. Cephalic
d. Iliac
15. During the venipuncture procedure, the
tourniquet should stay on no longer than
a. 30 seconds.
b. 45 seconds.
c. 1 minute.
d. 2 minutes.
Copyright 2016, 2011, 2007, 2002 by Saunders, an imprint of Elsevier Inc. All rights reserved.
CHAPTER 10 Capillary Collection
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151
apillary collection, also called dermal puncture
C
or skin puncture, is the usual collection proce-
dure for infants. In adults, it is an alternative collec-
tion procedure when minute amounts of blood
are needed for testing, or for patients for whom
venipuncture is inadvisable or impossible. In addition, it is typically used when collecting blood from
OU TL I NE
Reasons for Performing Capil-
lary Collection
Differences between Venous
and Capillary Blood
Equipment for Capillary Collec-
tion
Skin Puncture Devices
Microsample Containers
Additional Supplies
Site Selection
General Considerations
Puncture Depth and Width
Capillary Collection Sites for
Adults and Older Children
Capillary Collection Sites for
Infants
Capillary Collection
Procedure10-1: Capillary Col-
lection
Other Uses of Capillary Punc-
OB J E CT IV E S
After completing this chapter, you should be able to:
1. List situations in which a capillary collection might
be preferred.
2. Explain why it is necessary to inform the physician
when capillary blood is collected.
3. Describe the common skin puncture devices.
4. Discuss containers that may be used to collect
capillary blood.
5. Explain how circulation may be increased at the
puncture site.
6. Discuss proper capillary collection site selection.
7. Explain why it is important to control the depth of
the puncture.
infants and point-of-care testing. The depth of
puncture must be carefully controlled to produce
adequate ow while avoiding contact with underlying bone. Skin puncture devices deliver a precise
incision, and microsample containers, sized to t
the desired sample, collect the blood from the
puncture site.
ture
Bleeding Time Test
Procedure 10-2: Bleeding
Time Test
Review for Certification
8. List, in order, the steps for capillary collection.
9. Describe how the cut should be made when
a finger is used as the puncture site.
10. Explain why the first drop of blood is discarded.
11. List precautions to be observed when collecting
capillary blood.
12. State the order of the draw in collecting capillary
blood.
13. List, in order, the steps for performing a bleeding
time (BT) test.
KE Y TE R M S
ancillary blood glucose test
bleeding time (BT) test
bilirubin, uric acid,
phosphorus, and
potassium (BURPP)
Copyright 2016, 2011, 2007, 2002 by Saunders, an imprint of Elsevier Inc. All rights reserved.
calcaneus
capillary tubes
Caraway or Natelson
pipets
iatrogenic anemia
microcollection containers
microcollection
tubes
microhematocrit
tubes
osteochondritis
osteomyelitis
venous thrombosis
151
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CHAPTER 10 Capillary Collection http://evolve.elsevier.com/Warekois/phlebotomy
AB BR E VI AT IO NS
ABG arterial blood gas
BT bleeding time
BURPP bilirubin, uric acid, phosphorus, and potassium
CBC complete blood count
CBG capillary blood gas
µL microliter
OSHA Occupational Safety and Health
Administration
PFA platelet function assay
WHAT WO ULD YOU DO?
You are working the morning shift at Bayview Walk-in Clinic. You call your next patient, Latisha
Williams, from the waiting room. She hands you a requisition from her physician at the clinic, indicating
she needs to have her serum glucose level checked. You ask her to sit down. As you collect your red-top
tube and multisample needle, you notice she is looking a little nervous, so you try to calm her by
chatting about the weather. As you begin to apply the tourniquet, she looks even more afraid. Suddenly
she says, “Stop! Don’t stick me with that needle! They never did that before!” What would you do?
REASONS FOR PERFORMING
CAPILLARY COLLECTION
Although venipuncture is the most common way
to obtain a blood sample, at times it is impossible or
inadvisable to do so. In these situations, capillary collection (also called skin puncture or dermal puncture)
offers a valuable alternative. Capillary collection is
the preferred method for obtaining blood from newborns and infants for neonatal bilirubin, newborn
screening, and point-of-care testing. Capillary collection is also used for ancillary blood glucose testing.
A requisition form generally does not state that a
capillary collection should be performed, and it is
up to the phlebotomist to choose the best collection
method for the tests ordered. For this reason, you
must be familiar with the advantages, limitations,
and appropriate uses of capillary collection. Knowing how and when to perform a capillary collection
is a vital skill for a phlebotomist.
Capillary collection is preferred in several situations and for several types of patients (Box 10-1).
Adult patients undergoing frequent glucose monitoring are excellent candidates for capillary collection, because the test requires only a small amount
of blood, which must be taken frequently. Access
to venipuncture sites may be difcult with obese
patients, whose veins are often hard to nd, and
with geriatric patients, who often have small or
fragile veins that can make obtaining venous blood
difcult. Venipuncture may be contraindicated for
patients with burns or scars over venipuncture
sites or for those at risk for venous thrombosis
(caused when clots form within the veins), because
BOX 10-1 Patients for Whom Capillary
Puncture May Be Considered
• Children,especiallyyoungerthanage2
• Geriatricpatients
• Obesepatients
• Patientsatriskforseriouscomplicationsassociatedwith
deepvenouspuncture
• Patientsatriskforvenousthrombosis
• Patientsforwhomonlyonebloodtesthasbeenordered
forwhichadermalpunctureisappropriate
• Patientsrequiringfrequentbloodtests
• Patientsundergoingfrequentglucosemonitoring
• Patientswithburnsorscarsovervenipuncturesites
venipuncture increases the risk of venous thrombosis. Other patients may be at risk for serious
complications associated with deep venipuncture,
including iatrogenic anemia, hemorrhage, infection, organ or tissue damage, arteriospasm, or
cardiac arrest. Iatrogenic anemia is anemia caused
by excessive blood draws.
Capillary collection is usually the preferred
method of collection for newborns, infants, and
children younger than 2 years. Young children’s
smaller veins and lower blood volume make venipuncture both difcult and potentially dangerous.
Reducing blood volume through venipuncture is a
concern for newborns and infants. It may lead to
anemia and even cardiac arrest and death.
In addition to serving as a substitute for veni-
puncture, capillary blood gas (CBG) determination
Copyright 2016, 2011, 2007, 2002 by Saunders, an imprint of Elsevier Inc. All rights reserved.
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