3. BUTTERFLY
The butterfly method of venipuncture also called the
winged infusion method.
The term butterfly is derived from the plastic “wings”
located between the needle and the tubing of the
winged infusion set.
3
4. BUTTERFLY
This method is used to collect blood
from patients who are difficult to stick
by conventional methods.
This method provides better control
when making the puncture and also
less pressure is exerted on the vein
wall from the evacuated tube.
4
5. BUTTERFLY
This method is recommended for
adults with small antecubital veins and
children, who typically have small
antecubital veins.
This method is also used when the
antecubital veins are unavailable, and
the veins in the forearm, wrist area, or
back of hand are used, as may occur
with elderly and obese patients.
5
6. BUTTERFLY
These alternative veins are usually
smaller and sometimes have a thin wall,
making them more likely to collapse
when using the vacuum tube method of
venipuncture.
With the vacuum tube method, the
“sucking action” exerted on the vein
when the pressure in the vacuum is
released causes the vein to collapse,
blocking the flow of blood into the
tube. 6
7. BUTTERFLY
This method results in less pressure on
the vein wall because the pressure
exerted by the evacuated tube must
travel through a length of tubing before
reaching the vein.
Because the pressure against the vein
wall is minimized, the vein is less likely
to collapse with the butterfly method.
7
9. GAUGE OF NEEDLE
The gauge of the winged infusion needle ranges from
21G to 25G, and the length of the needle ranges from
½ to ¾ inch.
The needle is short and sharp, making it easier to stick
difficult veins.
9
10. GAUGE OF NEEDLE
For extremely small veins, a 23G needle
should be used to prevent rupture of
the vein by a large needle.
In this case, it is preferable to use
smaller-volume tubes because large
evacuated tubes may put too much
vacuum pressure on the vein, causing it
to collapse.
10
11. WINGED INFUSION SETS
The winged infusion needle is attached to a 6- or 12-
inch length of tubing and a Luer adapter, attached to a
(posterior) needle with a rubber sleeve.
11
13. WINGED INFUSION SETS
A plastic holder is screwed onto the Luer adapter,
which allows to to be used with evacuated tubes.
Winged infusion sets are also available with a hub
adapter that allows them to be used with a syringe.
13
14. WINGED INFUSION SETS
Safety needles are available with shields that covers the
contaminated needle after it is withdrawn from the
patient’s vein.
14
15. GUIDELINES
Position the patient according to the site
selected for the venipuncture.
Antecubital, wrist, and forearm veins.
Position the patient in a straight line from the
shoulder to the wrist.
Hand veins.
Position the patient’s hand on the armrest, and
ask the patient to make a loose fist or to grasp a
rolled towel. This combination causes the hand
veins to stand out so that accurate selection of a
puncture site can be made. Locate a suitable
vein between the knuckles and the wrist bones.
Hand veins are usually visible and easy to locate.
15
17. GUIDELINES
Position the tourniquet according to the venipuncture
site as follows:
If the veins of the forearm are used, apply the tourniquet to the
forearm, approximately 2 inches above the puncture site.
For hand veins, position the tourniquet on the arm just above the
wrist bone.
17
18. GUIDELINES
Grasp the needle by compressing the
plastic wings together. Insert the needle
with the bevel facing up at a 15-degree
angle to the skin. When the vein has been
entered, decrease the angle to 5 degrees.
After decreasing the needle angle to 5
degrees, slowly thread the needle inside
the vein an additional ¼ inch. This
anchors or seats the needle in the center
of the vein and allows the medical
assistant to use both hands to change
tubes. (We will be holding the butterfly 18
19. GUIDELINES
To prevent venous reflux, keep the
evacuated tube and holder in a
downward position as in the vacuum
tube venipuncture procedure.
This technique ensures that the blood
fills from the bottom up and not near
the rubber stopper.
19
20. GUIDELINES
When multiple tubes are to be drawn,
follow the proper order of draw. The
order of draw for the butterfly method
is identical to that for the vacuum tube
method.
Following this order of draw prevents
contamination of nonadditive tubes and
cross-contamination of additive tubes.
20
21. PROBLEMS ENCOUNTERED WITH
VENIPUNCTURES
Sometimes the medical assistant encounters problems
when attempting to draw blood from a patient.
The appropriate response depends on the type of
problem.
21
23. NAUSEA AND VOMITING
When emesis occurs, reassure the patient and make
them comfortable.
Give the patient an emesis basin, and instruct them to
breathe slowly and deeply.
A wet washcloth for the head is often helpful.
23
24. FAINTING
Patient becomes dizzy and faint at the site
of blood or due to fasting.
ASK the patient if they have a tendency to
faint, If YES, have them lie down.
If during the procedure patient states they
are faint or appear faint REMOVE THE
NEEDLE immediately, have patient lower
the head and breathe slowly and deeply.
Signs that patient is about to faint include:
blood draining from their face, rapid
breathing, restless movement.
24
26. FAILURE TO OBTAIN BLOOD
Periodically, even individuals highly
skilled at performing venipuncture have
difficulty obtaining blood.
Although large and prominent veins
make it easier to collect the blood
specimen, conditions often exist that
make the procedure more difficult.
26
27. DEFECTIVE EVACUATED TUBES
Occasionally, blood will not flow into a tube because the
vacuum in the tube has been depleted.
This may occur from a manufacturing defect, use of an
expired tube, or a very fine crack (which may occur if the
tube is dropped).
If the tube has been pushed past the indicator line on the
holder before insertion in the vein, the vacuum has been
depleted.
Always have extra tubes incase of defects or errors.
27
28. WHAT NOT TO DO
28
http://www.youtube.com/watch?v=VHJG6hwt36c
1:31 minutes
29. FAILURE TO OBTAIN BLOOD
It is often difficult to draw blood from
obese patients who have small,
superficial veins and whose veins
suitable for venipuncture are buried in
adipose tissue.
Elderly patients with arteriosclerosis
may have veins that are thick and hard,
making them difficult to puncture.
29
30. FAILURE TO OBTAIN BLOOD
Other patients have veins that are small
or have a thin wall, making the veins
likely to collapse.
After two unsuccessful attempts at
venipuncture, the medical assistant
should seek assistance in obtaining the
blood specimen.
30
31. FAILURE TO OBTAIN BLOOD
Factors that result in a failure to obtain blood after the needle
has been inserted include not inserting the needle far enough,
preventing it from entering the vein.
Insertion of the needle too far, causing it to go through the
vein; and the bevel opening becoming lodged against the wall
of the vein.
31
33. FAILURE TO OBTAIN BLOOD
Probing is often uncomfortable for the
patient and can affect the integrity of the
blood specimen, leading to inaccurate test
results.
Occasionally, an evacuated tube loses its
vacuum because of a manufacturing defect
or through improper handling of the tube.
If suspected, this problem can be
corrected by removing the defective tube
and inserting another vacuum tube.
33
34. INAPPROPRIATE PUNCTURE
SITES
If a patient complains of pain or
soreness in a potential venipuncture
site, this area should be avoided.
In addition any skin areas that are
scarred, bruised, burned, or adjacent to
areas of infection should not be used.
A venipuncture should not be
performed on an arm with edema or an
arm on the same side as a mastectomy.
34
36. INAPPROPRIATE PUNCTURE
SITES
Edema makes it more difficult to locate a vein. Avoid
collection of blood from these sites, usually hands and
feet, but arms can be swollen, will contaminate
specimen with tissue fluid.
Other sites to avoid include an arm that has a cast
applied to it or an arm on the same side as a radical
mastectomy.
If double mastectomy confer with physician, may need
to perform finger stick or perform venipuncture on legs
or feet.
36
37. SCARRED AND SCLEROSED
VEINS
An individual who has had many
venipunctures over a period of years
often develops scar tissue in the wall of
the vein.
Elderly patients may have veins that
have become thickened from
arteriosclerosis.
In both cases, the veins feel stiff and
hard when palpated. 37
38. SCARRED AND SCLEROSED
VEINS
A scarred or sclerosed vein is difficult
to stick, and the blood return may be
poor owing to a narrowed lumen; it is
recommended that another vein be
used for the venipuncture.
If this is impossible, the needle should
be inserted with careful pressure to
avoid going completely through the
vein.
38
39. ROLLING VEINS
The median cubital vein, located in the center of the
antecubital space, is considered the best vein for a
venipuncture.
Sometimes it is impossible to use this vein, however,
such as when it lies deep in the tissues and cannot be
palpated or is scarred from repeated venipunctures.
39
40. ROLLING VEINS
The veins on either side of the median
cubital (cephalic or basilic) can be used,
but they tend to “roll,” or move away
from the needle, escaping puncture.
To prevent rolling, firm pressure should
be applied below then vein to stabilize
it as the needle is inserted.
40
41. COLLAPSING VEINS
Veins are most likely to collapse in
individuals who have small veins with
thin walls.
This is particularly true when the
vacuum tube method is being used.
The “sucking action” exerted on the
vein when the pressure in the vacuum
is released causes the vein to collapse,
blocking the flow of blood into the
tube. 41
42. COLLAPSING VEINS
The typical result observed is that a
small amount of blood enters the tube
and then stops.
Because better control and less
pressure on the vein is possible,the
butterfly method of venipuncture is
recommended to obtain the specimen
in patients with small veins.
42
43. PREMATURE NEEDLE
WITHDRAWAL
Patient movement or improper venipuncture technique
can cause the needle to come out of the vein
prematurely.
Because of the pressure exerted by the tourniquet,
blood may be forced out of the puncture site, and
immediate action is required to prevent a hematoma.
43
44. HEMATOMA
A hematoma is caused by blood leaking
from the puncture site of the vein and
into the surrounding tissues, resulting
in a bruise.
A hematoma is caused by a needle that
is inserted too far and that goes
through the vein, a bevel opening that
is partially in the vein and partially out
of the vein.
44
45. HEMATOMA
Hematomas occur when area around
puncture site begins to swell indicating
that blood is leaking into the tissues
which will result in a bruise.
Due to partial insertion into the vein or
insertion through the vein.
If this happens IMMEDIATELY remove
the needle, apply pressure for 2
minutes and recheck to ensure
bleeding has stopped.
Fill out an incident report
45
46. HEMATOMA
A hematoma is also caused by insufficient
pressure applied to the puncture site after
removing the needle.
The first sign of a hematoma is a sudden
swelling around the puncture site.
If this occurs when the needle is in the
patient’s vein, the tourniquet and needle
should be removed immediately, and
pressure should be applied to the
puncture site until the bleeding has stops.
46
47. PREMATURE NEEDLE
WITHDRAWAL
The tourniquet should be removed at once, a gauze
pad placed on the puncture site, and pressure applied
until the bleeding has stopped.
47
48. HEMOLYSIS
When RBCs are ruptured hemoglobin is released
and serum appears pink to red.
If grossly hemolyzed will appear dark red.
May be due to conditions such as: burns or
some diseases.
Usually caused by improper technique:
Needle too small
Pulling to hard on plunger of syringe
Expelling blood vigorously into a tube
Shaking/mixing specimen in tube too vigorously
Not allowing alcohol to dry before drawing blood
May cause false increase in: potassium, magnesium, iron,
LDH, phosporous, ammonia and total protein.
48
50. HEMOLYSIS
The blood specimen should be handled
carefully at all times. Blood cells are
fragile, and rough handling may cause
hemolysis, or breakdown of the blood
cells.
Hemolyzed blood specimens produce
inaccurate test results. To prevent
hemolysis, these guidelines should be
followed:
50
51. HEMOLYSIS
Store the vacuum tubes at room
temperature because chilled tubes can
result in hemolysis.
Use an appropriate-gauge needle to
collect the specimen; a needle with a
gauge between 20G and 22G should be
used.
Using a small-gauge needle (e.g. 25G) can
cause the blood cells to rupture as they
pass through the lumen of the needle. 51
52. PETECHIAE
Prior to blood collection examine potential
site. Small red spots on the patients skin
may indicate rupture of minute veins
below the skin.
May be due to coagulation problems or
abnormalities
Phlebotomist must be aware of the fact
that the patient may bleed excessively
after blood collection.
Make sure bleeding stops prior to leaving
the patient. Notify physician if excessive
bleeding occurs.
52
54. TOURNIQUET APPLIED TOO
TIGHTLY
If there is no arterial pulse or the patient complains of
pinching or numbing of the arm, the tourniquet is too
tight.
Loosen it slightly before proceeding.
54
55. EXCESSIVE BLEEDING
Patient on anticoagulants, on aspirin containing
medications or has decreased number of platelets.
Do not leave patient until bleeding has stopped.
55
56. NEUROLOGIC
Patient may feel sharp, electric tingling if nerve is hit.
Immediately discontinue the venipuncture
Fill out incident report and submit
Patient may need physical therapy.
56
57. NEUROLOGIC
Seizures are rare complication, immediately stop the
venipuncture
Call for help
Do not place anything in the patient’s mouth
Fill out incident report
57
58. IV THERAPY
Never draw above an IV site, consider the
following:”
Try opposite arm
When there is no other option always draw
site 5 inches below IV site
If IV in both hands confer with the
physician if blood can be drawn from the
IV line.
Proper protocol must be followed which
involves having IV turned off waiting
appropriate time limit, discard first tube
drawn. 58
59. HEMOCONCENTRATION An increase in concentration of large molecules
and formed elements in the blood.
Some causes are:
Prolonged tourniquet application
Massaging, squeezing or probing a site
Long term IV therapy
Sclerosed or occluded veins
Dehydration
Certain diseases
Hemoconcentration may cause false increase in:
potassium, magnesium, LDH, phosphorous,
ammonia, and total protein.
59
60. THROMBOSIS
Thrombi are solid masses derived from blood
constituents in the vessels, ie, a clot.
Thrombus may partially or fully occlude a vein or artery
making venipuncture difficult.
60
62. BASAL STATE
The basal state refers to the patient’s physical
condition in the early morning hours
approximately 12 hours after the last meal.
Many factors can affect the basal state.
Results of lab tests are more reliable because
normal values are most often determined from
specimens collected during this time.
It is recommended that specimens collected for
determination of concentrations of the following
analytes be collected during this time.
Glucose Triglycerides
Electrolytes Cholesterol
Proteins
62
63. DIET
To ensure a basal state, overnight fasting is
necessary as blood composition is
significantly altered after a meal.
Fasting refers to abstinence from food and
beverage except water.
Fasting time will vary according to test
ordered and it is critical to ask a patient when
they last ate.
If a patient has eaten and the doctor still
wants the test drawn write “non fasting” on
the lab requisition. 63
64. LIPEMIA
Serum is normally clear, light yellow or
straw colored, turbid specimens appear
cloudy and milky and may be due to
the following:
Lipema, excess fats in the blood due to
lipids present after eating fatty
substances such as meat, butter, cream
or cheese.
Lipemic specimens may indicate the 64
65. DIURNAL RHYTHMS AND
POSTURE
Body fluids fluctuate during the day
Certain hormone levels are reduced in the
afternoon, while eosinophils and serum
iron are increased.
Posture changes are well known to alter
lab results.
Changing from supine to sitting or
standing causes water to shift from
intravascular or interstitial compartments.
Enzymes, proteins, lipids, iron and calcium
significantly increase with positions
changes. 65
66. TOURNIQUET INTERFERENCE AND
FIST PUMPING
May cause false increase or decrease in
certain analytes in the blood.
Some analytes leak from blood into the
tissues causing false increase in:
Plasma cholesterol, iron, lipid, protein and
potassium.
Certain enzymes may be falsely increased or
decreased.
Tourniquets interference can occur within 3
minutes.
66
68. PEDIATRIC PHLEBOTOMY
Performed only by personnel trained in techniques for
pediatric phlebotomy
Must gain the child’s and parent’s confidence
Ask the parent about the child’s previous experiences
and how the child may react
If the parent cannot help with necessary restraint, refer
to office policy
68
70. SPECIAL CONSIDERATIONS FOR PERFORMING PEDIATRIC
BLOOD DRAWS
Communication is a Must
Positive Body Language..(Releaxed/Cheerful)
Soft Voice Tone
Eye to Eye Contact
Good Listener
Sensitive to Child’s Wishes
Get the Child Involved
Be Hones
70
71. CHALLENGES DEALING WITH
PEDIATRIC PATIENTS
Psychological
Fear of Strangers
Separation Anxiety
Limited Language Use
Fear of Pain
Patient Allergies
Lower Blood Volume
Choking Hazard with Adhesive Bandages
71
73. AGE AND PROCEDURE
0-6 months
Heel Sticks
6 months – 2 years
Finger sticks
Hand Sticks & Venipunctures
(Doctor’s orders only)
2 years & older
Venipuncture
73
74. DERMAL PUNCTURE
0-6 Months old Heel Stick
A dermal puncture can be
performed on these areas
of the foot
74
75. NEVER
Puncture Deeper than 2.4 – 2.5 mm
Puncture through a Previous Site
Puncture on the Posterior Curvature of
the Heel or Arch
Puncture Through a Bruised or Swollen
Site
Puncture the Heel More than Twice for
any One collection
Use the Lancet More than Once
75
76. HEEL STICK
1.Positively identify patient.
2.Wash hands & put on gloves.
3.Puncture the lateral medial part of the heel.
NEVER puncture posterior curvature of heel!
NEVER puncture the arch!
4.Make sure to inspect heel. Avoid areas with
previous scarring or damage.
5.Warm the area for at least 3 minutes Warm
tap water (39 –42c) in towel or commercial
heel warmer
6.Disinfect the area with a 70% alcohol prep
pad. Scrub well. 76
77. HEEL STICK
7.Do NOT use betadine.
8.Dry the area with a sterile gauze. Do NOT use
cotton balls –can interfere with blood flow.
9.Make sure the area is dry –Any alcohol left on
the skin will cause the specimen to hemolyze.
10.Hold the foot with a firm grip. Grasp the
foot so that the heel is exposed between thumb
& index finger.
11.Puncture the site at a 90° angle, parallel to
the bone. Stick across the heel prints.
12.Apply pressure to heel and activate the
lancet. 77
78. HEEL STICK13.Make sure the blade retracts.
14.NEVER puncture deeper than 1.2 ‐2.2 mm‐can
cause osteomyelitisor sepsis –could injure bone,
blood vessels, tendons, nerves, or cartilage.
15.Wipe off the first drop of blood, due to tissue
fluid. Ease thumb pressure to the site and then
apply intermittent pressure to obtain a good blood
flow. 16.DO NOT MILK, SQUEEZE, OR MASSAGE THE
AREA!It could cause the specimen to hemolyze and
have excessive tissue fluid.
17.Collect the specimens in the proper tubes and
correct order of draw. DO NOT SCOOP.
78
80. VENIPUNCTURE ON
CHILDREN UNDER 2
If the procedure must be performed on Children under 2
years old:
Use a 23-25 gauge butterfly needle with a syringe
(allows you to control the amount of vacuum applied)
Use pediatric tubes for the transfer of the blood from the
syringe method
–Use superficial veins on the back of the hand for all
newborns and infants under 2
Remember never to use an area with edema, infection, or
an IV
80
81. NEONATAL BILIRUBIN
COLLECTION
High levels of Bilirubin cause:
–Jaundice (yellow skin coloring)
•Infants are placed under special UV lamps to lower
Bilirubinlevels
–Brain Damage
–Death
–Transfusion may be needed
81
82. NEONATAL BILIRUBIN
COLLECTIONProper collection procedure is CRUCIAL…
Turn off UV lights to prevent breakdown of specimen
Perform heel stick quickly to minimize exposure from light (must be
protected during transportation & testing)
Amber‐Colored Collection Tube
Aluminum Foil to Cover Collection Tube
Be sure to collect specimen carefully to avoid hemolysis, which could
falsely decrease Bilirubin results
82
83. THE ADOLESCENT WANTS TO KNOW
THE “5 W’S”
1.Who is going to be doing the procedure?
2.What is going to be done?
3. When are you going to be doing it and when
will it be over?
4.Where are you going to stick me?
5.Why are you doing this to me?
83
84. FIVE STEPS IN PHLEBOTOMY
PROCEDURES MAKING PEDIATRIC
DRAWS EASIER
#1. Have a Special Room/Cubicle
A. Quiet and away from large groups & noise
B. Decorate
C. Display Awards
84
85. FIVE STEPS IN PHLEBOTOMY
PROCEDURES MAKING PEDIATRIC
DRAWS EASIER
#2. Build Trust
A. Reassure the patient that it is okay to be frightened
B. Allow the patient to scream or make faces, but instruct
them NOT TO MOVE
C. Explain the procedure to the child, using words that
can be understood
85
86. FIVE STEPS IN PHLEBOTOMY
PROCEDURES MAKING PEDIATRIC
DRAWS EASIER
#2. Build Trust
D. Maintain eye contact
E. Answer questions the child/parent
might have
F. Find out the child’s favorite song
G. Keep voice calm, but authoritative,
yet friendly
86
87. FIVE STEPS IN PHLEBOTOMY
PROCEDURES MAKING PEDIATRIC
DRAWS EASIER
#3. Have Assistant Hold Child
Holding Procedure as Follows:
The assistant places one hand palm up,
under the child’s elbow, and other hand
palm down, on the child’s wrist. The
assistant’s fingers are placed in such a
manner as to allow the child to squeeze
the fingers.
87
88. FIVE STEPS IN PHLEBOTOMY
PROCEDURES MAKING PEDIATRIC
DRAWS EASIER
#3. Have Assistant Hold Child Holding
Procedure as Follows:
For a Toddler: Lay him on an
examination table on his back. From
opposite side of the table, the assistant
bends at waist, placing trunk gently, but
firmly on that of the patient, placing
hands as previously described.
88
89. FIVE STEPS IN PHLEBOTOMY
PROCEDURES MAKING PEDIATRIC
DRAWS EASIER
#4. Do a “Quick Draw”
A. Have equipment close & check for
problems
B. Know the type of vein & the device
you will be using
C. Draw quickly & calmly, keeping the
patient calm
89
90. FIVE STEPS IN PHLEBOTOMY
PROCEDURES MAKING PEDIATRIC
DRAWS EASIER
#5. Finish with Finesse
A. Give promised rewards
B. Encourage school age children to share their
experiences with classmates
C. Draw quickly & calmly, keeping patient calm
D. PRAISE! PRAISE! PRAISE!
90
92. ELDERLY BLOOD DRAWS
Collection from elderly patients can present both
physical and psychological challenges.
The skin becomes less elastic, and the layers of skin
become thinner.
Bruising is more likely, and it takes longer to replace
cells, so that longer healing times are needed.
92
93. ELDERLY BLOOD DRAWS
Blood vessels may narrow due to atherosclerosis. Loss of
supporting connective tissue leads to “loose skin,” and
loss of muscle tissue may allow veins to move from their
usual location.
Arteries are close to the surface in the elderly. Do not
mistake an artery for a vein.
93
How should one handle questions asked by parents? (Parents often ask the phlebotomist to explain the tests being done and why. You should be very careful when divulging information; never tell the parents what disease or condition a specific blood test detects. Refer questions to the child’s physician.)
Refer students to Table 46-7, Childhood Behavior and Parental Involvement during Phlebotomy.
Table 46-8 shows general guidelines for pediatric venipuncture.
Discuss the weight and corresponding single draw limits for pediatric venipuncture.
