BLOOD COLLECTION Capillary blood collection

Cart and Tray 1. The site should be on the inside (medial) or outside
 Carts and trays are examples of devices used to (lateral) portion of the bottom (plantar surface) of
store/carry equipment. They should contain all the the foot.
equipment required to properly perform 2. An imaginary line may be drawn from the middle of
phlebotomy the large toe to the heel and a line from between the
fifth toes to the heel.
3. The area outside of these two lines is considered
acceptable as a phlebotomy site.
4. Either side of the bottom surface of the heel,
however, is the recommended and most commonly
used area.
5. At no time should the back or sides of the heel be
used.
6. The depth of the puncture must be no greater than
2.4 mm in order to avoid damage to the bone.
7. The third or fourth finger should be used when the
patient is older than 1 year. The middle finger is
most often used.
8. The puncture should be made perpendicular to the
fingerprint, on the palmar surface of the end portion
of the finger, slightly off-center, but not on the side
or tip of the finger.
9. The depth of the puncture must be no greater than
2.4 mm in order to avoid damage to the bone.
Capillary Blood Collection
10. The puncture should be no deeper than 3.1 mm
• Capillary blood (peripheral
because the distance between the skin surface and
blood/microblood samples)
bone will vary from 3.1 to 10.9 mm.
• Small quantities required
11. The distance to the bone is only 1.5 to 2.4 mm in
- Hgb quantitation infants 6 months old, so the finger is not used on
- WBC and RBC counts this age group of children unless special devices are
- Blood smear preparation used.
12. The puncture site should contain no swelling and
previous puncture site should not be re-punctured.
Preparation of the puncture site – Capillary Blood
Collection
1. Make certain the puncture site is warm. If it is
not, use a warm moist cloth (not to exceed 42
degree Celsius) and cover the site for 3 to 10
minutes.
2. Clean the site with 70% isopropanol and
Sites of puncture
thoroughly dry with a sterile gauze (any alcohol
left on the puncture site may cause the blood to
hemolyze).
3. Holding the finger (or foot), firmly puncture
the site. If a lancet is used, insert it through the
skin as far as it will go, but do not depress the
surface of the skin site because this will force
the lancet to penetrate to an unsafe depth. With
a good single puncture, 0.5 mL of blood may be
obtained.
4. Using sterile dry gauze, wipe away the first
drop of blood.
5. Apply moderate pressure, approx. 1 cm
behind the site of the puncture to obtain a drop
of blood.
6. Release this pressure immediately to allow
recirculation of the blood.
7. Hold the collection tube (or pipet) in a
horizontal to slightly downward position.
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 When the tube comes in contact with the drop
of blood, it should flow freely in the collection
tube. If multiple tubes are collected, EDTA tubes
should be filled first, followed by any other
anticoagulated tubes. Containers with no
additives should be filled last.
8. Repeat steps 5, 6 and 7 until enough blood has
been collected.
9. When blood collection is complete, the foot may
be elevated above the body (the finger may
be held in an upward position) and a sterile
gauze pad pressed against the puncture site
until bleeding stops. Application of an adhesive
bandage is questionable on children less than 2
years of age because of resultant skin irritation,
whereas slightly older children may remove the
adhesive bandage and chew or aspirate it.
Discussion – Capillary Blood collection
1. Rub the site vigorously with a gauze pad or
cotton moistened with 70% alcohol to remove
dirt and epithelial debris and to increase blood
circulation.
a. If the heel is to be punctured, it should
first be warmed by immersion in warm
water or applying a hot towel compress.
Otherwise, values significantly higher
than those in venous blood may be
obtained
2. After the skin has dried, make puncture 2-3mm
deep with a sterile lancet. A rapid and firm
puncture should be made with control of the
depth. A deep puncture is no more painful than a
superficial one and makes repeated puncture
unnecessary.
3. Blood from a skin puncture is a mixture of
venous, arterial and capillary blood. The
concentration of some constituents in the blood
will differ between skin puncture blood and an
arterial or venous specimen. Because of this test
reports should indicate if the blood sample was
obtained from a skin puncture.
4. The first drop of blood which contains tissue
juices should be wiped away. Excessive
massaging or squeezing of the finger or foot will
cause tissue juice to mix with and dilute the
blood. Rather, a freely flowing blood should be
taken or a moderate pressure some distance
above the puncture site is allowable.
5. Excess crying will affect some test results
(most notably, the WBC count may increase
considerably.) it is advisable to wait 30 minutes
to 1 hour following a crying-episode before
obtaining the blood specimen.
6. The thumb, big toe and ear lobe should not be
used as a skin puncture site for phlebotomy.
7. When collecting blood for hematology test, the
finger must be wiped dry after each test.
(platelets clump immediately in the blood at the
puncture site.)
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Because of platelet adhesiveness and
aggregation at the site of puncture, it is
advisable to collect the platelet count and blood
smears (if requested) first when samples for a
number of tests are to be obtained.
8. The technique used to obtained the blood
specimen is critical in order to maintain the
integrity. Even so, arterial and venous blood
differs in important respects.
9. Arterial blood is essentially uniform in
composition throughout the body. The
composition of blood that is venous blood
varies and is dependent on metabolic activity of
the preferred organ or tissue.
10. Site of collection can affect the venous
composition. Venous blood is oxygen deficient
relative to arterial blood, but also differs in pH,
CO2 concentration and PCV.
11. Increased pressure in the arterioles yields a
specimen enriched in arterial blood. Skin
puncture blood also contains interstitial and
intracellular fluids.
• Advantages of capillary blood
- It is obtained with ease
- It is the preferred specimen for making
peripheral blood films since no anticoagulant is
added that affect cell morphology
• Disadvantages of capillary blood
- Only small amounts of blood can be obtained
and repeated examinations require a new
specimen
- Platelet cannot be performed on capillary blood
since some platelets are unavoidably lost by
adherence onto the wound
- Precision is poorer in capillary than
venous blood because of variation in blood flow
and dilution with interstitial fluid
- Blood in microtubes frequently hemolyzes and
hemolysis interferes with most lab tests
Wash hands
 The most important means of preventing and
controlling the spread of infection is proper hand
washing:
1. Remove watch and rings
2. Without touching the sink, wet hands under
warm, running water. Apply soap and work up a
lather, rubbing hands together to create friction
for at least 15 seconds
3. Rinse hands in a downward motion from wrists
to fingertips
4. Repeat steps 2 and 3
5. Dry hands with a clean paper towel
6. Turn the faucet off with another clean paper
towel
Specimen collection by Venipuncture
- Patient identification
- Note isolation restrictions
- Note dietary restrictions
- Reassure patient
- Position the patient
 - Select venipuncture location
- Assemble supplies
- Apply the tourniquet
- Cleanse the site
- Inspect needle
- Perform venipuncture
- Release tourniquet
- Withdraw needle & apply pressure
- Post phlebotomy procedures
▪ Proper disposal
▪ Label specimen
▪ Check patient
Venous Blood Collection
- A venipuncture must be performed with
care.
- The veins of a patient are the main
source of blood for testing and the entry point
for medications, intravenous solutions and
blood transfusions.
- Because there are only limited number
of easily accessible veins in a patient, it is
important that everything be done to preserve
their good condition and availability. Part of this
responsibility lies with the medical technologist.
- A venous blood sample is used for most
tests that require anticoagulation or larger
quantities of blood, plasma or serum.
Position patient
- Patient should be either seated or lying down
while having blood drawn
- The patient’s arm should be firmly supported
and extended downward in a straight line from
the shoulder to the wrist
- Ensure patient’s hand is closed, which makes
the veins more prominent
- Do not ask the patient to pump his/her hand
Correct arm positioning
- Allows gravity to help veins enlarge
- Helps assure the specimen collection tubes fill
from the bottom up to prevent reflux and
additive carryover between sample tubes
A patient should never stand or sit on a high chair during
any process of blood collection. The technologist
must be ready for the occasional patient who faints
during this procedure.
However, this rarely occurs with hospital inpatients who
are lying flat in bed. There should be nothing in the
patient’s mouth at the time of phlebotomy
(thermometer or food).
Sites of puncture:
- The veins that are generally used are those in
the forearm, wrist or ankle
- The veins in the antecubital fossa of the
forearm are the preferred sites for
venipuncture. They are larger than those in the
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wrists or ankle regions and hence are easily
located and palpated in most people
- The three main veins in the forearm are the
median cubital, cephalic and the basilica veins
- In infants and children, venipuncture presents
special problems because of the small size of the
veins and difficulty controlling the patient
Select site
o Venipuncture is most commonly performed in
the antecubital fossa area of the arm where the
median cubital, cephalic and basilica veins lie
fairly close to the surface
o Use the tip of the index finger to palpate
(examine by feel) the vein. This helps determine
the size, depth, and direction of the vein
o Select the vein that is easily palpated, large
enough to support good blood flow, and well-
anchored or fixed by surrounding tissue
Site selection in arm
The highlighted area shows the antecubital fossa where
the major veins used for venipuncture are located
o Choose one that is bouncy and resilient,
large enough to support good blood flow
and well anchored by tissue
o Median cubital vein is the first choice
because it is large, well-anchored, least
painful and least likely to bruise
o Cephalic vein is the second choice. It is
large, but not as well anchored and is more
painful when punctured than the median
cubital.
o Basilic vein is the third choice. It is
generally easy to palpate, but not well
anchored. It lies near the brachial artery
and the median nerve, either of which could
accidentally be punctured
Avoiding the median nerve
o Avoid major nerves
o Hitting the patient’s nerve with a needle can
cause sharp and immediate pain
o The patient may also experience an involuntary
reflex action pulling the arm away from the
needle
o Arteries, which can be detected by a pulse,
should not be used for routine blood collection
o To avoid inadvertently puncturing an artery, do
not select that vein that overlies or is close to an
artery
o As seen in the diagram, both the median nerve
and the brachial nerve artery lie close to the
basilic vein
o Excessive or blind probing while performing a
venipuncture can lead to permanent injury of
the
nerve or artery
Assemble Equipment
• Prior to initiating venipuncture, gather all
equipment needed
• Place the necessary evacuated tubes in the proper Blood Collection: Open System
sequence for specimen collection
• A sharps container should be easily accessible for
immediate needle disposal following completion of
the venipuncture
Gauze
o Clean 2” x 2” gauze pads are used to place
pressure over the venipuncture site once
the needle is removed
o Do not use cotton. It tends to stick to the
wound site
o Do not remove gauze too soon. The clot that Blood collection: Closed System
is forming may be disturbed and bleeding
may restart
Bandages
o Use an adhesive bandage to cover the site
once bleeding has ceased
o Use paper, cloth or knitted tape over a
folded gauze square for patients who are
sensitive to adhesive bandages
o To prepare a gauze pad, fold the gauze in
half, and then in half again to form a
square. Place this over the puncture site
Venous Blood Collection
and secure in place with tape
1. Prepare the vacutainer assembly: insert the
Antiseptics
shorter end of the vacutainer needle into holder
o The venipuncture site must be thoroughly
(The end of the needle is generally covered by a
cleansed prior to puncture. Isopropyl
rubber like sleeve to prevent blood from leaking
alcohol (70%) is commonly used
from the needle when collecting more than one
o Alcohol wipes usually come in individually
tube of blood.)
wrapped prep pads
2. Insert the first tube into the vacutainer holder
o When opened, the pad should be fully
until the top is even with the line on the holder.
saturated with alcohol; if it is not, discard
Do not puncture the top of the tube with the
the pad and open another
inside needle. Each tube contains a vacuum that
o Isopropyl alcohol is not a disinfectant, e.g.,
draws the appropriate amount of blood into the
iodine. If tubes are being drawn for blood
tube. Puncturing the top causes loss of this
culture, cleansing of the site must be done
vacuum.
using a disinfectant. Follow the laboratory’s
3. When using a syringe to draw blood move the
standard operating procedure for blood
culture draws plunger up and down in the barrel once or twice
Tourniquet to make certain it does not stick. Expel all air
- A variety types are available and illustrated from syringe. Place the needle on the syringe
here. Each has advantages and disadvantages. (while keeping the cap on the shaft of needle)
- Latex is commonly used because it is and twist it to make certain it fits securely.
stretchable, does not support bacterial growth
and can be cleaned with disinfectant. *Check to make sure the needle is sharp, the syringe
- CAUTION: alternatives to latex must be used moves smoothly and there is no air left in the barrel.
when patient has developed an allergy to latex. *The gauge & the length of the needle used depend on
Anaphylactic shock occurs if a latex tourniquet the size and depth of the vein to be punctured. The
is used. gauge number varies inversely with the diameter of
the needle. The needle should not be too fine or too
long.
*19 or 21 gauge suitable for most adults. 23 gauge for
children. The smaller the gauge number the larger
the bore.

Apply Tourniquet
- Apply tourniquet to increase pressure in the
veins and aid in vein selection.

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 - When correctly placed on the patient’s arm it - Release tourniquet as soon as possible,
should be tight enough to slow venous flow depending upon blood flow. Ideally, do not
without affecting arterial flow, it should feel leave tourniquet on for more than one minute.
slightly tight to the patient, allowing more blood Insertion Angle
to flow into than out of the area.
- The veins enlarge, making them easier to
palpate and penetrate with a needle.
- Ideally, never leave a tourniquet on the patient
longer than one minute. Tourniquets left on
longer may alter test result.
- Do not apply a tourniquet over an open sore.
- Do not apply a tourniquet to the arm on the side
of a recent mastectomy
Tie Tourniquet
- 3-4 inches above the intended venipuncture
site
- Apply and maintain tension. Without rolling or
twisting the tourniquet, bring the two sides
together.
- Cross one side over the other and securely tuck
a portion of the upper side under the lower side
- The loop should be below the tourniquet band
and the free ends (flaps) of the tourniquet are
pointing away from the venipuncture site.
- The flaps should be positioned so they can
easily be grasped with one hand.
Cleanse Site
- Clean venipuncture site with antiseptic to help
prevent microbial contamination to the
specimen and patient. Remove Needle
- Start at the center of the site and move outward - Release tourniquet prior to removing needle.
in ever widening, concentric circles. Failure to Ensure patient’s hand is open.
follow this procedure may re-introduce dirt and - After the last tube is removed from holder, hold
bacteria. Use sufficient pressure to remove a clean gauze pad in position over the entry site.
surface dirt and debris. Gently and quickly remove needle from the arm.
- Repeat the process with a fresh alcohol prep - It is necessary to apply pressure to the site to
pad if the site’s is still dirty. prevent leakage of blood and possible
- Let the site air dry (30 – 60 seconds) prior to hematoma formation.
beginning the venipuncture. - As soon as needle is fully withdrawn, but not
- Do not wipe, blow on or fan the site, as these before, apply pressure firmly to the puncture
actions may re introduce contaminations. site using a gauze pad.
- For blood culture draws, refer to the - If the patient is alert, ask him/her to continue to
laboratory’s standard operating procedure for apply pressure until bleeding has stopped.
instructions. - Keep arm extended and preferably raised; arm
Insert Needle should not be bent as this increase the risk of
- Grasp patient’s arm with thumb on top and hematoma formation.
finger wrapped to the back. Fill Tube
- Pull skin taut below the intended venipuncture - Maintain tube in a downward position so that
site with thumb, anchoring vein to keep it from blood and any tube additive it contains does not
moving or rolling. touch the needle.
- Using a smooth motion, quickly insert the - Fill tube until vacuum is exhausted and blood
needle, bevel up. flow stops.
- Stop needle advancement when a slight - Remove tubes from holder by applying pressure
decrease in resistance is felt, signaling entry against flanges of tube holder with thumb and
into the vein. index finger while using a slight twist to remove
- Advance tube onto needle to the end of holder. the tube.
- Use thumb to push tube while index and middle - Hold needle steady as tubes are removed and
fingers grasp flanges of tube holder. Blood inserted.
should begin to flow into tube. - If tube contains an additive, invert it gently
several times after removal to mix the blood

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 and additive. Additional mixing can be
performed while other tubes are filling.
Disposals
- Discard contaminated needles in a designated
container referred to as a “sharp container”
- A variety of containers are manufactured. They
provide for safe removal of the needle from the
holder whether and evacuated tube system or
syringe is used
- They must be rigid, puncture-resistant, leak-
proof, disposable, and easily sealed when full.
They should have a locking lid which does not
permit entry to the container
- They are usually red, bright orange, or yellow
and must be labeled “BIOHAZARD”
Dispose Needle
- Discard contaminated needles in a container
referred to as a “sharp container”
- Never cut, bend, break or recap needles
- A variety of containers are manufactured. They
provide safe removal of the needle form holder
when using an evacuated tube system.
- Place needle in the proper slot in the lid and
turn it clockwise until it unscrews from the
holder.
- Do not attempt to remove needle with your
fingers. If needle does not separate from the
holder, throw the entire unit away in a sharps
container.
Label tube
o Always verify information on tube labels. All
identifiers on the labels must be accurate
o Label tubes after they are drawn, while the
patient is still present, to reduce the risk of
specimen misidentification
o If additional information must be added to the
label (e.g., fasting, time to draw), write with ink,
never pencil
o Never:
o Label tubes prior to venipuncture
o Leave an inpatient room before labeling the
tubes
o Dismiss an outpatient before labeling is
completed
Transport tube
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o When transporting tubes through public
hallways, place them in a secondary container to
minimize the risk of leakage and pillage
o The secondary container must be clearly
labeled
“BIOHAZARD”
o Once the tubes are in the container, seal it
before transport. Securely attach paper
requisitions to the secondary transport
container
DISCUSSION
1. If a syringe is employed the tubes to be filled
should be placed in a test tube rack. As soon as
the syringe is filled, the stopper(s) should be
punctured with the needle and the tube(s)
allowed to fill with blood until the blood flow
stops.
2. When the vacutainer system is being used to
obtain several tubes of blood, collect a non-
anticoagulated tube first. Coagulation
specimens should be collected next, followed by
tubes containing heparin, EDTA and oxalate,
fluoride (in the order listed.)
If a coagulation specimen is to be drawn first, a
“discard” tube should be filled with several mL
of blood first and then discarded. This prevents
contamination of the specimen with tissue fluid
from the venipuncture site. As soon as a tube
containing anticoagulant is filled, mix the tube
by inversion about 10 times while the next tube
is filling with blood.
3. In the event that you have been unable to
puncture the vein immediately, use your free
index finger to locate the vein. It may be that the
needle has not gone deeply enough, or perhaps
it is slightly to the left or right of the vein. Do
not attempt to puncture the vein from that
location.
This is painful to the patient and may cause
tissue damage. Withdraw the needle until the
point is almost to the surface of the skin and
then redirect the needle. The procedure is
acceptable if the needle is close to the vein, but
care should be taken that the patient is not
caused too much pain. Sometimes a second
venipuncture is necessary.
4. If the patient is receiving intravenous therapy in
both arms, it is advisable to puncture a vein
below the intravenous site if the therapy is
stopped for a minimum of 2 minutes or if a
different vein from the intravenous location is
used.
5. A technologist or student should not stick a
patient more than two times. If the blood
sample has not been obtained after the second
 attempt. It is usually advisable to call another
technologist. By this time, both you and the
patient have lost confidence.
6. It is important that pressure be applied to the
site of the venipuncture, failure to follow this
procedure leads to a hematoma (bleeding into
the tissue)
7. When performing a venipuncture in the lower
arm or hand, on small children or on a patient
with poor or small veins, a syringe or pediatric
(small) vacutainer assembly and tubes is
generally used. The use of standard sized
vacutainer tubes tends to collapse these veins.
8. If the area surrounding the puncture site begins
to swell while blood is being withdrawn, this
usually indicates that the needle has gone
through the vein or the bevel of the needle is
halfway out of the vein and blood is leaking into
the tissues. The tourniquet should be released
and the needle withdrawn immediately, with
pressure applied to the site.
9. In some instances, it is almost impossible to
locate a vein in the arm. In such cases, the veins
of the lower arm, wrist or hand may be used.
The student should gain a reasonable amount of
skill and confidence before attempting a
venipuncture in these areas. The technologist
should not perform a venipuncture on the veins
in the ankle or foot.
10. When a venipuncture must be carried out on a
small child, it is very important to release the
tourniquet when the blood starts to enter the
syringe, children’s veins are small and collapse
quickly because blood is removed from the vein
faster than it enters it.
11. At all times be careful not to stick yourself with
the needle. If this happens, report it to the
supervisor immediately.
Sites of puncture
- Puncture the external jugular vein in the neck
region and the femoral vein in the inguinal area
is the procedure of choice for obtaining blood
Advantages of Venipuncture
• Allows repetition of tests/follow up
• Avoids tissue juices
• Can be mailed
• Fastest method from a large number of patients
Disadvantages of Venipuncture
• More complications may arise
• Hard to do on some patients
Specimen processing
• Serum or plasma should be separated from cells
within 2 hours of collection (unless collected in a gel
separator tube)
• Allow red top tubes to clot sufficiently (20-30
minutes) before centrifugation to avoid fibrin
strands
• Centrifuge 10 to 5 minutes at 1000-1200g
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• Keep tubes capped during centrifugation to avoid
loss of CO2, change of pH, evaporation, or aerosol
formation
• Lipemic specimens can be ultra-centrifuged to
remove chylomicrons
Venipuncture (Phlebotomy)
• Venous blood is deoxygenated blood that contains
substances that come from metabolic activities of
different organs
• Venous blood is mostly used in analysis of blood
chemistry and immunologic studies
• Venous blood is more easily collected than arterial
blood
• May be obtained via one-movement or two-
movement techniques
• Sites of venipuncture include:
- Antecubital fossa veins (most preferred site) –
median cubital and cephalic veins
- Wrist, ankle and hand veins
Arterial puncture
- Arterial blood is oxygenated blood. It is uniform
in composition throughout the body.
- Used to measure oxygen tension, carbon
dioxide tension and blood pH.
- Blood gas analyses (BGA) are critical to
patients with pulmonary problems, oxygen
therapy, cardiovascular problems and those
undergoing major operations.
Sites of arterial puncture
- Radial arteries
- Brachial arteries
- Femoral arteries
- Radial and brachial arteries are the preferred
sites.
• Each site of arterial puncture used different gauge of
needles:
- Brachial artery – 18-20 gauge
- Radial artery – 23-25 gauge
• In collecting arterial blood, needle is positioned at
different angles in each site:
- Brachial artery – 45-60 degrees
- Femoral artery – 90 degrees
• Heparin is used as anticoagulant for arterial
puncture
• Capillary blood can be collected for analysis of blood
gas (site must be pre-warmed before collection).
• The best method of arterial blood collection in
newborn is the umbilical artery catheter.
• Skin puncture site must be warmed before
collection to increase the blood flow
(arterialization.)
- Thermal using dry heat or paper towel with
warm water (39-42 degree Celsius)
- Mechanical by flicking with index finger until
flushing is observed
- Chemical using Trafuril paste or Histamine
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