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 Becan-McBride
Garza
TENTH EDITION

PHLEBOTOMY

PHLEBOTOMY HANDBOOK
HANDBOOK
B LO O D S P E C I M E N C O L L E C T I O N F R O M B A S I C T O A DVA N C E D

Diana Garza
Kathleen Becan-McBride

FROM BASIC TO ADVANCED

BLOOD SPECIMEN COLLECTION

www.pearson.com

ISBN-13: 978-0-13-470932-1
ISBN-10: 0-13-470932-2
9 0 0 0 0

9 780134 709321

Garza_mech.indd 1 3/9/18 2:19 PM

 Contents vii

Other Factors Affecting the Patient 295 Procedure 10–3 Basics of Patient Identification 325
Complications Associated with Test Requests and Special Considerations 326
Identification 296 Identity Errors are Preventable 328
Identification Discrepancies 296 Equipment Selection and Preparation 329
Time of Collection 296 Supplies for Venipuncture 329
Requisitions 296 Venipuncture Site Selection 330
Complications Associated with the Specimen Collection Tools to Make Difficult Veins More Prominent 336
Procedure 296 Procedure 10–4 Use of a Tourniquet and Vein Palpation 337
Tourniquet Pressure and Fist Pumping 296 Procedure 10–5 Cleansing the Puncture Site 339
Failure to Draw Blood 297 Tourniquet Application 340
Backflow of Anticoagulant 298 Decontamination of the Puncture Site 340
Fainting (Syncope) 298 Venipuncture Methods 340
Hematomas 300 Evacuated Tube System and Winged Infusion System, or
Petechiae 300 Butterfly Method 340
Excessive Bleeding 300 Procedure 10–6 Performing a Venipuncture Using the
Nerve Complications 300 Evacuated Tube Method 341
Seizure during Blood Collection 300 Procedure 10–7 Hand Vein Venipuncture Using a
Hemoconcentration 300 Winged Infusion/Butterfly Set 347
Intravenous Therapy 301 Syringe Method 350
Hemolysis 301 Procedure 10–8 Syringe Method 351
Collapsed Veins 302 Failure to Collect Blood after a Puncture 353
Improper Collection Tube 302 Order of Draw for Blood Collection Tubes 354
Self Study Manufacturers of Blood Collection Tubes 357
Study Questions 304 Specimen Identification and Labeling 357
Case Study 305 Caring for the Puncture Site 358
Action in Practice 1 305 Disposal of Used Supplies and Equipment 359
Action in Practice 2 305 Patient Assessment at the End of the Venipuncture
Competency Assessment 306 Procedure 359
References 306 Other Issues Affecting Venipuncture Practices 360
Resources 307 Self Study
Study Questions 365
CHAPTER 10 Venipuncture Case Study 1 366
Procedures 308 Case Study 2 366
Action in Practice 366
Chapter Learning Objectives 308 Competency Assessment 367
Key Terms 308 References 369
NAACLS Entry-Level Phlebotomist Competencies 309 Resources 370
Blood Collection 310
Health Care Worker Preparation 310 CHAPTER 11 C
 apillary or Dermal Blood
Procedure 10–1 Preparing for the Patient Encounter 312
Specimens 371
Procedure 10–2 Hand Hygiene and Gloving
Technique 315 Chapter Learning Objectives 371
Precautions 317 Key Terms 371
Needlestick Prevention Strategies 317 NAACLS Entry-Level Phlebotomist Competencies 372
Approaching, Assessing, and Identifying the Patient 318 Indications for Skin Puncture 372
Initial Introduction and Patient Approach 318 Composition of Capillary Blood 373
Physical Disposition of the Patient 320 Basic Technique for Collecting Diagnostic Capillary
Positioning of the Patient and the Health Care Worker 322 Blood Specimens 374
Test Requisitions 324 Preparation for Skin Puncture 376
Patient Identification Process 324 Supplies for Skin Puncture 376
viii Contents

Skin Puncture Sites 378 Self Study

Improving Site Selection 379 Study Questions 419
Cleansing the Skin Puncture Site 380 Case Study 1 420
Skin Puncture Procedure 380 Case Study 2 420
Procedure 11–1 Acquiring a Capillary Case Study 3 420
Blood Specimen (Dermal or Skin Puncture) Action in Practice 420
Using a Retractable Safety Device 381 Competency Assessment 421
Order of Collection 385 References 422
Blood Films/Slides for Microscopic Analyses 386
Resources 422
Procedure 11–2 Blood Smears/Films/Slides for
Microscopic Analysis 387
PART IV P
 oint-of-Care Testing and
Other Considerations for Capillary Blood Samples 390
Test Results Notations Due to Differences in Type of
Special Procedures
Specimen 390
Microhematocrit and Other Hematology Specimens 390 CHAPTER 13 P
 ediatric and Geriatric
Blood pH and Blood Gas Determinations 390 Procedures 423
Completing the Interaction 390 Chapter Learning Objectives 423
Disposal 390 Key Terms 423
Labeling 390 NAACLS Entry-Level Phlebotomist Competencies 424
Completing the Patient Interaction 391 Pediatric Patients 424
Future Trends 391 Age-Specific Care Considerations 425
Self Study Preparing Child and Parent 425
Study Questions 392 Psychological Response to Needles and Pain 428
Case Study 1 393
Distraction Techniques 428
Case Study 2 393
Room Location 428
Case Study 3 393
Equipment Preparation for a Friendlier Environment 428
Action in Practice 1 393
Positions for Restraining a Child 429
Action in Practice 2 393
Combative Patients 430
References 395
Decreasing the Needlestick Pain 430
Resources 395
Oral Sucrose 431
Precautions to Protect the Child 431
CHAPTER 12 Specimen Handling,
Latex Allergy Alert 431
Transportation, and
Pediatric Phlebotomy Procedures 431
Processing 396 Microcapillary Skin Puncture 431
Chapter Learning Objectives 396 Skin Puncture Sites 432
Key Terms 396 Procedure 13–1 Heel Stick Procedure 433
NAACLS Entry-Level Phlebotomist Competencies 397 Capillary Blood Gases 436
Specimen Handling After the Venipuncture 397 Procedure 13–2 Collection for Capillary Blood Gas
Specimen Delivery Methods 404 Testing 437
Hand Delivery 405 Neonatal Screening 439
Pneumatic Tube Systems 405 Procedure 13–3 Collection of Capillary Blood for
Transportation by Automated Carrier 406 Neonatal Screening 440
Transportation by Drone 406 Fingerstick on Children 442
Processing the Specimen on Arrival at the Clinical Venipuncture on Children 442
Laboratory 406 Collecting Blood from IV Lines 446
Shipping Biohazardous Specimens 413 Procedure 13–4 Procedure for Heparin or Saline Lock
Reporting Laboratory Results 417 Blood Collection 447
Written Reports 417 Procedure 13–5 Procedure for Central Venous
Verbal Reports 417 Catheter Blood Collection 448
Computerized Reports 418 Geriatric Patients 450
 Contents ix

Considerations in Home Care Blood Collections 453 Procedure 15–3 Safety Butterfly Assembly Blood
Self Study Culture Collection 479
Study Questions 454 Procedure 15–4 Evacuated Tube System for Blood
Case Study 455 Culture Collection 481
Action in Practice 455 Procedure 15–5 After Blood Culture Collection by the
Previous Methods 482
Competency Assessment 455
Possible Interfering Factors 482
References 456
Glucose Tolerance Test (GTT) and HbA1c 483
Resources 457
Postprandial Glucose Test 487
Modified Oral Glucose Tolerance Test 487
CHAPTER 14 Point-of-Care Collections 458 Lactose Tolerance Test 487
Chapter Learning Objectives 458 Arterial Blood Gases 488
Key Terms 458 Radial Artery Puncture Site 488
NAACLS Entry-Level Phlebotomist Competencies 459 Brachial and Femoral Artery Puncture Sites 489
Types of POCT 460 Procedure 15–6 Radial ABG Procedure 491
Glucose Monitoring 460 Therapeutic Drug Monitoring (TDM) 494
Procedure 14–1 Obtaining Blood Specimen for Glucose Collection for Trace Metals (Elements) 495
Testing (Skin Puncture) 462 Genetic Molecular Tests 495
Point-of-Care Testing for HbA1c 464 Intravenous Line Collections 496
Quality in Point-of-Care Testing and Disinfecting POCT Collecting Blood through a Central Venous
Analyzers 464 Catheter 497
Blood Gas and Electrolyte Analysis 466 Procedure 15–7 Collecting Blood through a CVC 497
Point-of-Care Testing for Acute Heart Damage 467 Cannulas and Fistulas 499
White Blood Cell Count System 467 Donor Room Collections 499
Blood Coagulation Monitoring 467 Donor Interview and Selection 500
Hematocrit, Hemoglobin, and Other Hematology Collection of Donor’s Blood 501
Parameters 468 Autologous Transfusion 501
Cholesterol Screening 469 Therapeutic Phlebotomy 502
Other POCT Tests and Future Trends 469 Self Study
Self Study Study Questions 503
Study Questions 470 Case Study 1 504
Case Study 471 Case Study 2 504
Action in Practice 1 471 Action in Practice 504
Action in Practice 2 471 Competency Assessment 505
Competency Assessment 472 References 505
References 472 Resources 506
Resources 472

CHAPTER 16 U
 rinalysis, Body Fluids, and
CHAPTER 15 B
 lood Cultures, Arterial, Other Specimens 507
Intravenous (IV), and Special
Chapter Learning Objectives 507
Collection Procedures 473 Key Terms 507
Chapter Learning Objectives 473 NAACLS Entry-Level Phlebotomist Competencies 508
Key Terms 473 Urine Collection 509
NAACLS Entry-Level Phlebotomist Competencies 474 Single-Specimen Collection 511
Blood Cultures 474 Procedure 16–1 Clean-Catch Midstream Urine
Procedure 15–1 Site Preparation for Blood Culture Collection Instructions for Women 512
Collection 475 Procedure 16–2 Clean-Catch Midstream Urine
Procedure 15–2 Safety Syringe Blood Culture Collection Instructions for Men 513
Collection 477 Timed Urine Collections 514
x Contents

Procedure 16–3 Collecting a 24-Hour Urine Blood Alcohol and Breath Testing 549
Specimen 514 Future Trends 552
Cerebrospinal Fluid 516 Self Study
Fecal Specimens 517 Study Questions 553
Seminal Fluid 518 Case Study 1 554
Amniotic Fluid 518 Case Study 2 554
Synovial Fluid 519 Case Study 3 554
Other Body Fluids 519 Competency Assessment 555
Culture Specimens 519 References 555
Buccal Swabs 519 Resources 556
Sputum Collection 520
Nasopharyngeal Culture Collections 520 Appendix
Throat Swab Collections 520
Appendix 1  AACLS Entry-Level Phlebotomist
N
Procedure 16–4 Collecting a Sputum Specimen 521 Competencies and Chapter
Procedure 16–5 Collecting a Throat Swab for Coverage 558
Culture 522 Appendix 2 Competency Assessment Tracking
Skin Tests 524 Checklist 561
Gastric Analysis 524 Appendix 3 Finding a Job 569
Breath Analysis for Peptic Ulcers 525 Appendix 4 International Organizations 574
Sweat Chloride by Iontophoresis 525 Appendix 5 The Basics of Vital Signs 575
Self Study Procedure A5–1 Taking Oral Temperature 576
Study Questions 526 Procedure A5–2 Taking Aural Temperature 577
Case Study 526 Procedure A5–3 Taking Axillary Temperature 578
Action in Practice 1 527 Procedure A5–4 Assessing Peripheral Pulse
Rate 579
Action in Practice 2 527
Procedure A5–5 Taking Blood Pressure 581
Competency Assessment 527
Procedure A5–6 Assessing Respiration Rate 585
References 528 Appendix 6 Hand Hygiene in Health Care Settings:
Resources 528 Stay Up-to-Date with the Centers
for Disease Control and Prevention
(CDC) and the Food and Drug
CHAPTER 17 D
 rug Use, Forensic Toxicology, Administration (FDA) 586
Workplace Testing, Sports Appendix 7 Common Laboratory Assays,
Medicine, and Related Reference Intervals, and Critical
Limits 588
Areas 529
Appendix 8 Blood Collection and Allowable
Chapter Learning Objectives 529 Volumes from Pediatric and Neonatal
Key Terms 529 Patients 596
NAACLS Entry-Level Phlebotomist Competencies 530 Appendix 9 Cautious Use of Abbreviations,
Acronyms, and Symbols 598
Overview and Prevalence of Drug Use 530
Appendix 10 Formulas, Calculations, and Metric
Drug Analysis: Rationale, Methods, and Conversion 600
Interferences 535
Appendix 11 Military Time (24-Hour Clock) 603
Drug Testing in Neonates or Pregnant Women 538 Appendix 12 Basic Spanish for Specimen Collection
Forensic Toxicology Specimens 539 Procedures 605
Chain of Custody 541 Appendix 13 Answers to Study Questions,
Workplace Drug Testing 541 Case Studies, and Competency
Tampering with Specimens 547 Checklists 608
Drug Testing in the Private Sector 548
Drug Use in Sports 548 Glossary 626
Blood Doping and the Use of Erythropoietin
(EPO) 549 Index 638
About the Authors

Diana Garza received her Bachelor of Science degree in Biology from Vanderbilt
­University in Nashville, Tennessee, followed by an additional year to complete her
Medical Laboratory Science certification requirements at Vanderbilt University Medical
Center. Her interest in laboratory sciences and in teaching led her to earn a Masters in
Science Education at the Peabody School of Vanderbilt University. Dr. Garza worked at
Vanderbilt Medical Center in the Microbiology Department while a graduate student.
A move back to her home state of Texas led her to a collaborative graduate program with
Baylor College of Medicine at the University of Houston and resulted in her Doctorate
of Education in Allied Health Education and Administration, all while she worked in
the Microbiology Laboratory at the University of Texas M. D. Anderson Cancer Center
(MDACC). Dr. Garza’s laboratory and teaching experience continued at the University
of Texas Health Science Center at Houston and for many years at MDACC, where she
later became the Administrative Director of the Division of Laboratory Medicine. While
in Houston, Drs. Garza and Becan-McBride were involved in numerous national and
international courses for technologists, nurses, and physicians to teach phlebotomy tech-
niques. Together, they developed curriculum materials, and in 1984 published one of the
first comprehensive textbooks focused solely on phlebotomy practices. Their successful
coauthoring partnership has endured for over three decades. In 1990, Dr. Garza joined the
faculty of Texas Woman’s University–Houston Center, where she taught online quality
improvement courses, was tenured, and became editor of several journals and contin-
uing education publications. She has taught extensively; been a reviewer/inspector in
many regulatory processes; participated in accreditation procedures; and continues to
author, edit, and publish numerous manuscripts in the field of phlebotomy. Dr. Garza
has served on numerous health care advisory boards, as a board member for many non-
profit health care organizations, and on nationwide committees in the field of laboratory
medicine, including those for certification examinations, accrediting committees, and as
a consultant for companies and health care organizations. She continues her writing and
editorial pursuits primarily in the field of phlebotomy.

Kathleen Becan-McBride recently retired from the Directorship of Community and

­Educational Outreach at The University of Texas Health Science Center at Houston
(UTHealth) and tenured Medical School Professor in the Department of Family and
­Community Medicine at UTHealth. She received her Bachelor of Science degree in
­Biology from the University of Houston with completion of her medical laboratory sci-
ence education at St. Luke’s Episcopal Hospital in Houston, Texas, and national board
certification as a Medical Laboratory Scientist. While working at St. Luke’s ­Episcopal
Hospital Clinical Laboratory, she received a full scholarship to the University of
­Houston/Baylor College of Medicine’s collaborative Masters in Allied Health Education
and Administration Program. This inspired Dr. Becan-McBride to continue her stud-
ies, and she completed her Doctorate in Higher Education and Administration while
teaching in the Medical ­Laboratory Science program and Physician Assistant program at
­University of Texas Medical Branch Galveston and Medical Laboratory Technician pro-
gram at ­Houston Community College. She then became a faculty member and Chair of
the Clinical Laboratory Science Department at UTHealth. And in more recent years, she
has become the Director of Community and Educational Outreach, Director of Workforce
and Resource Development, and Professor in the Medical School Department of Family
and Community Medicine.
xi
xii About the Authors

Dr. Becan-McBride has published 24 books and more than 57 articles, and has been
on numerous national and international health care advisory boards and several editorial
boards for health care journals. She is continuing to serve on national and international
committees and commissions. She has had research projects related to the medical lab-
oratory sciences and also the community (i.e., UV/TB Prevention Research Project in
­Homeless Shelters in Houston). Most recently, she had received a National Institute
of Health (NIH) grant in research on new point-of-care (POC) technology as defined
through blood collection techniques. Dr. Becan-McBride is on educational advisory
boards for medical laboratory science educational programs and community outreach
programs. She has had invitational medical laboratory science presentations nationally
and internationally in Singapore, China, Russia, France, South America, New Zealand,
and, more recently, Croatia. She was the elected Chair of the ASCP Board of Certification
Board of Governors from 2008 to 2010, and received the ASCP Mastership Award in 2012;
the ASCP Board of Certification Distinguished Service Award in 2012; and the ASCP
Mentorship Award in 2016. Dr. Becan-McBride continues her Texas Higher Education
Consultants’ activities in writing, presenting, and editing, mainly in the expanding area
of blood collection.
During her years at UTHealth, Dr. Becan-McBride has been fortunate to have
the opportunity to receive several grants for phlebotomy training programs.
Drs. ­Becan-McBride and Garza became involved in developing curricular materials to
teach phlebotomy students, as well as nursing and other health professional students.

These two authors developed one of the first comprehensive textbooks devoted
strictly to phlebotomy and its importance in the clinical laboratory and in health care
settings. After several editions, it went on to become an award-winning, top-selling
international textbook that has been considered to be a “gold standard” in the field of
phlebotomy. Drs. Becan-McBride and Garza have been collaborators for over 33 years on
numerous phlebotomy textbooks (including e-books), videos, online teaching products
for instructors, and other curricular materials. They have also been invited presenters at
many national and international conferences. Their efforts, work, and passion in phle-
botomy have inspired many valuable improvements to the field.
Preface

Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced,

Tenth ­Edition, is designed for health care students and practitioners who are responsible
for blood and specimen collections (i.e., nurses, phlebotomists, medical laboratory tech-
nicians, medical laboratory scientists, respiratory therapists, and others). The primary
goals of this book are:

■■ to link the phlebotomist (blood collector) to the latest safety information, techniques,
skills, and equipment for the provision of safe and effective collection procedures,
■■ to improve diagnostic and therapeutic laboratory testing,
■■ to enhance customer satisfaction, and
■■ to promote better health outcomes for all patients.

This renowned and updated textbook provides the most up-to-date, comprehensive
compilation of information about phlebotomy available in the world.
This edition has reconfigured student learning objectives to be a more advanced
extension of the National Accrediting Committee for Clinical Laboratory Sciences’
(NAACLS) “entry-level” competencies. Both NAACLS and Student Learning Objectives
are listed at the beginning of each chapter. The chapter-specific Student Learning Objec-
tives cover a range of basic to more advanced techniques and concepts for phlebotomists.
The key features include:

■■ Communication, clinical, technical, and safety skills that any health care worker will
use in the practice of phlebotomy and other specimen collection procedures.
■■ A renewed focus highlights professionalism and ethical behavior in serving every
individual patient.
■■ The chapter featuring new equipment (Chapter 8) emphasizes the most updated and
comprehensive safety features of phlebotomy supplies and equipment, with new
images from key manufacturers in the industry.
■■ The latest information about current industry standards from the Clinical and
­Laboratory Standards Institute (CLSI), World Health Organization (WHO), the
Centers for Disease Control and Prevention (CDC), risk and error reduction, patient
and worker safety, needlestick prevention, and The Joint Commission National
Patient Safety Goals.
■■ Content stresses the importance of patient communication through topics such as
generational traits, age-specific considerations, cultural factors, patients with special
needs, and current health care issues related to gender identity. More advanced content
provides the latest techniques in vascular access for difficult blood collections from
pediatric and/or adult patients; and the latest information on diabetic testing using
procedures overlapping between the glucose testing and Hemoglobin A1c protocols.
■■ Provides extensive information and insights about quality issues to improve tech-
nical skills and patient outcomes and highlights the professional role that phleboto-
mists play as essential members of the health care team.
■■ An advanced focus on medical terminology, roles of other health care providers,
special considerations for specific and/or vulnerable groups of patients, and health
literacy.
xiii
xiv Preface

■■ Expanded content areas include drug testing, paternity testing, drug-resistant bac-
teria, viral infections, importance of timed tests, and special high risk situations in
patient identification.

The scope of work for the blood collector has expanded to encompass additional
patient care duties and clinical responsibilities, a more patient-sensitive role, and
improved interpersonal communication skills to deal effectively with every patient, treat
their families with respect, handle any special needs, and establish effective collabora-
tions with other members of the health care teams. These roles and responsibilities have
global applications.
As with previous editions, and based on input from various reviewers, the order
in which the material is presented generally follows the way in which a phlebotomist
approaches the patient (i.e., beginning with important communication skills, knowledge
of ethical behavior and legal implications, and a basic understanding of physiologic
aspects, then moving to safety and infection control considerations in preparation for the
phlebotomy procedure, preparation of supplies and equipment, actual venipuncture or
skin puncture, and potential complications). Specialized specimen collection procedures,
point-of-care testing, pediatric care, and considerations for the elderly are included.
Problem-solving cases, Action in Practice cases, and Check Yourself sections integrate
the information into real-life situations. The Competency Assessments provide a Check
Yourself feature, which can be used by instructors as a supplement for evaluation and by
students to self-monitor their skills and knowledge. And the Glossary has been updated
and expanded to include key words and other terms important to phlebotomists. The
appendices provide useful procedures (such as taking vital signs) and important terms,
phrases, and symbols. Updates include the lastest blood pressure categories from the
American College of Cardiology.
The content is divided into four major parts:

■■ PART I: Overview, Safety Procedures, and Medical Communication—provides

a knowledge base of the roles and functions of a phlebotomist in the health care
industry and presents information about quality, communication skills, legal issues,
safety, first aid, and infection control in the workplace. Special attention is focused
on compassionate communication with vulnerable patients.
■■ PART II: Anatomy and Physiology of the Human Body—provides the detailed
anatomy and physiology of body systems, with a more advanced emphasis on the
circulatory system. Relevant medical terminology is also covered thoroughly.
■■ PART III: Phlebotomy Equipment and Procedures—provides comprehensive,
advanced coverage on the latest equipment and supplies, and the most updated
information and comprehensive description of the actual techniques and proce-
dures used in phlebotomy. This section also includes updated documentation and
transportation procedures needed for safe handling of biohazardous specimens, and
sending specimens both nationally and internationally. Special emphasis is given to
minimizing adverse risks and preventing clinical and technical complications that
may occur during the preanalytical processes.
■■ PART IV: Point-of-Care Testing and Special Procedures—provides information
about pediatric phlebotomy procedures, the latest developments in vascular access
procedures, blood culture collections, arterial and IV collections, and special consid-
erations for the elderly, homebound, and long-term care patients. In addition, topics
such as testing for prediabetes and diabetes, neonatal testing, paternity testing, and
drug, alcohol, and forensic laboratory testing practices are reviewed.
 Preface xv

Key Features of the Tenth Edition

■■ Student Learning Objectives at the beginning of each chapter list the important
concepts discussed in the chapter. These objectives go beyond minimal or “entry-
level” expectations for phlebotomists.
■■ NAACLS Competencies for Entry-Level Phlebotomists provides selected N ­ AACLS
competencies covered in each chapter and indicates the level of coverage in that
chapter as “beginning or basic (B), intermediate (I), or advanced (A).” Naturally,
the earlier chapters are more basic, and some competencies are repeated later in the
textbook as they are covered at a more detailed, intermediate, or advanced level.
■■ Key Terms list the vocabulary introduced and clearly defined in the chapter. These
terms also appear in boldface type within the body of the chapter so that they are
easier to find.
■■ Clinical Alerts indicate procedures or concepts and safe practices that have vitally
important clinical consequences for the patient. Each Clinical Alert! indicates that
extra caution should be taken by the health care worker to comply with the proce-
dure, thereby avoiding adverse outcomes for the patient, phlebotomist, or the health
care organization.
■■ Procedures throughout the text provide illustrated, step-by-step instructions with
an “on-the-job” perspective.
■■ New colorful photographs and figures illustrate important concepts and show pro-
cedural steps and equipment. Updated artwork provides visual reinforcement of
key concepts.
■■ Study questions at the end each chapter help test your knowledge of the chapter
content.
■■ Case Studies help you develop problem-solving and troubleshooting skills.
■■ Action in Practice presents an additional case study with questions to test your
critical thinking skills.
■■ Check Yourself presents a brief description of a procedure to be performed along
with questions to test your knowledge of the requirements and steps to perform to
complete the procedure.
■■ Competency checklists provide a list of competencies you should master relevant
to the chapter content and the National Accrediting Agency for Clinical Laboratory
Sciences (NAACLS) competencies.
■■ References correlate to the endnotes in the chapter.
■■ Resources provide additional readings and/or websites related to the chapter
content.
■■ The Glossary has been updated to include more terms as a valuable reference.
■■ A full-color Tube Guide chart provides a list of the types of blood collection tubes
and shows the appropriate color codings with additives.
■■ The Appendices include a guide to NAACLS phlebotomy competencies covered in
specific chapters, essentials for finding a job, basic procedures for taking vital signs,
a hand hygiene update, laboratory tests with blood requirements, reference inter-
vals, and critical limits, cautious use of abbreviations and symbols, formulas and
calculations used in laboratories, use of military time, Spanish phrases for health
care personnel, current information about allowable volumes of blood withdrawn
from pediatric and neonatal patients, and more.
xvi Preface

Video Program
A video library is available for viewing on The Phlebotomy Handbook’s Student Resources
Page (www.pearsonhighered.com/healthprofessionsresources). The video series con-
tains segments demonstrating a wide array of blood specimen collection procedures and
patient interactions (including pediatrics and adults in both clinic and hospital settings).
The videos emphasize safety, infection control, effective communication, quality assess-
ment, and avoiding errors. The footage correlates with many of the procedures shown in
Phlebotomy ­Handbook, 10th edition, and was filmed in collaboration with the authors.
The video series is ideal for independent self-study or review for those aiming to enhance
their understanding and performance. It is also an excellent classroom teaching tool for
instructors who wish to supplement their teaching with dynamic footage of experts in
action. The series provides an additional teaching tool to support National Association
for Accreditation of Clinical Laboratory Sciences competencies for accredited programs
in Phlebotomy.

Additional Resources for Educators

This tenth edition has online/electronic companion resources that are cross-­referenced
to the text. The Instructor’s Resource Manual contains a wealth of material to help fac-
ulty plan and manage their course. It includes a detailed lecture outline, a complete
test bank, teaching tips, and more for each chapter. For instructors, log on to www
.­pearsonhighered.com to access the complete test bank and PowerPoint lectures that
contain discussion points with embedded color images from the book.

An Accompanying Guide for Examination

Review
Available for separate purchase is Pearson’s SUCCESS! in Phlebotomy: Q&A Review,
8th edition. This is an aid to students and health care workers preparing for a certifica-
tion examination. It has over 850 exam-type questions and an accompanying access to
www.myhealthprofessionskit.com, with multiple-choice questions, flashcards, and an
audio glossary.
In summary, the authors have created a book with several audio and visual learning
tools that health care professionals and students can use as a central authority on blood
collection practices. Instructors can also use this as the central text for teaching specimen
collection skills.
Acknowledgments

We are grateful to many generous individuals, product suppliers, manufacturing com-

panies, professional organizations, and health care organizations for their assistance in
preparing the previous editions of this text. The first edition was conceptualized in the
1980s, when phlebotomy was learned in an apprentice-type situation and teaching mate-
rials were nonexistent. As licensing, credentialing, manufacturing of new products, pro-
cedures, competencies, hazards, and safety regulations expanded, so did our text. Each
edition used previous editions as a framework for updating, redesigning, and improving
the next. In 2006, Phlebotomy Handbook, 7th edition, won a first-place Book Award from
the American Medical Writers Association in the Allied Health Category, and we are
proud to continue the tradition of excellence in this tenth edition with the participation
of so many talented people. Thus, we thank many phlebotomists, medical technicians
and technologists, artists, photographers, reviewers, and educators who have given us
countless editorial tips and practical advice over the years. We also thank health care
workers around our country and the world who have taken the time to read about new
and better ways of improving the practice of phlebotomy.
We are particularly grateful to BD Vacutainer Systems, Greiner Bio-One, Marketlab,
the American Society for Clinical Pathology, The University of Texas M. D. Anderson
Cancer Center (MDACC), Memorial Hermann Health Care System, and The ­University
of Texas Houston Health Science Center for their support throughout many stages of
our previous and current editions. We thank Donna Hermis and Matt Ostroff for their
assistance and expertise as contributing authors. We also thank the many students,
faculty, and staff of the Diagnostic Center at the University of Texas M. D. Anderson
Cancer Center who were models for the photographs and technical experts, especially
Dr. Brandy Greenhill, Program Director, Clinical Laboratory Science Program; Kimberly
Murray; and Peter McLaughlin, MD. Thanks also go to photographer Patrick Watson for
his patience, efficiency, and organizational skills.
We greatly appreciate our positive working relationships with editors and copyedi-
tors, past and present, who have encouraged us and improved our writing through eight
editions. Special thanks go to Jane Licht, Cheryl Mehalik, Lin Marshall, Mark Cohen,
Melissa Kerian Bashe, Cathy Wein, and Amy Peltier.
Last, and most important, we gratefully acknowledge our families, who have
proudly grown up with this text as part of their lives. They have continued to encour-
age us and have supportively tolerated the thousands of hours over many years that we
have spent writing the previous and current edition of this textbook. They will always
hold a special place in our hearts.
Diana Garza
Kathleen Becan-McBride

xvii
Reviewers
Thank you to the following reviewers for their valuable contributions:
Pamela Audette, MBA, MT, RMA
Program Chair, Medial Assistant
Program
Finlandia University
Hancock, Michigan
Jerry Barton, MLS (ASCP)
Phlebotomy Program Director
Cape Fear Community College
Wilmington, North Carolina
Doris Beran, MPH, MT (ASCP)
Allied Health Instructor
Coconino Community College
Flagstaff, Arizona
Jimmy Boyd, MLS (ASCP)
Program Director
Arkansas State University-Beebe
Beebe, Arkansas
Jennifer M. Elenbaas, MBA-HM
Instructor
Davenport University
Grand Rapids, Michigan
xviii
Penny Ewing, BS, CMA (AAMA)
Instructor
Gaston College
Dallas, North Carolina
Vickie Kirk, MBA, MT(ASCP),
PBT(ASCP)CM
Phlebotomy Director, Instructor of
Health Sciences
Edison State Community College
Piqua, Ohio
Michelle Mantooth, MSc, MLS
(ASCP)CM, CG(ASCP) CM
Instructor
Trident Technical College
North Charleston, South Carolina
Kimberly Meshell
Program Director, Instructor
Angelina College
Lufkin, Texas
Angela Norwood, BS, PBT(ASCP)
Phlebotomy Professor, Department
Chairperson
College of Lake County
Grayslake, Illinois
Margaret Oliver, MT (ASCP)
Instructor
Neosho County Community College
Ottawa, Kansas
Evelyn Paxton, MS, MT (ASCP)
Program Director
Rose State College
Midwest City, Oklahoma
Pam Tully, MHS, MT (ASCP), PBT
(ASCP)
Phlebotomy Program Director
Bossier Parish Community College
Bossier City, Louisiana
Chapter 1

Phlebotomy Practice and

Quality Assessment
KEY TERMS

Chapter Learning Objectives acute care

aliquot
Upon completion of Chapter 1, the learner is responsible for doing the ambulatory care
following: anatomic pathology
Centers for Medicare & Medicaid
1. Define phlebotomy and identify health professionals who perform phlebotomy
Services (CMS)
procedures.
clinical decisions
2. Identify the importance of phlebotomy procedures to the overall care of the patient. Clinical Laboratory Improvement
3. List professional competencies for phlebotomists, the role in delivering, collecting, Amendments
and/or transporting specimens to and from the laboratory, and key elements of a clinical pathology
performance assessment. competency statement
4. List members of a health care team who interact with phlebotomists. continuing education (CE)
continuous quality improvement (CQI)
5. Describe the roles and qualifications of clinical laboratory personnel and common
examination (analytical phase)
laboratory departments/sections.
Food and Drug Administration (FDA)
6. Describe the health care delivery system and settings in which phlebotomy services are inpatients
routinely performed.
International Organization for
7. Describe the clinical laboratory workflow pathway, or testing cycle, from beginning Standardization (ISO)
laboratory requests to reporting laboratory test results. long-term care
8. Explain components of professionalism and desired character traits for phlebotomists. nanotechnology
nosocomial infections
9. Describe coping skills that are used to reduce stress in the workplace.
personal protective equipment (PPE)
10. List the basic tools used in quality improvement activities and give examples of how a phlebotomist
phlebotomist can participate in quality improvement activities. phlebotomy
11. Define the difference between quality improvement and quality control procedures. point-of-care (POC)
postexamination (postanalytical
phase)
preexamination (preanalytical phase)
professionalism
quality
quality control (QC)
quality improvement
Six Sigma
stakeholders
standards of practice
2 Chapter 1 Phlebotomy Practice and Quality Assessment

NAACLS Entry-Level Phlebotomist Competencies

Addressed in This Chapter
(From NAACLS Revised 11-2017, accessed 1/18/2018. Copyright by National Association for
Accreditation of Clinical Laboratory Sciences (NAACLS).)
(Depth and Level of Coverage: B = basic/beginning; I = intermediate; A = advanced)
Please note that topics covered in one chapter may also be discussed in more detail in other chapters.
1.00 Demonstrate knowledge of the health care delivery system and medical terminology.
1.1 Identify the health care providers in hospitals and clinics and the phlebotomist’s role as
a member of this health care team. (B, I)
1.2 Describe the various hospital departments and their major functions in which the
­phlebotomist may interact in his/her role. (B)
1.3 Describe the organizational structure of the clinical laboratory department. (B)
1.4 Discuss the roles of the clinical laboratory personnel and their qualifications for these
professional positions. (B)
1.5 List the types of laboratory procedures performed in the various disciplines of the clinical
laboratory department. (B)
4.00 Demonstrate understanding of the importance of specimen collection and specimen
integrity in the delivery of patient care.
4.2 Describe the types of patient specimens that are analyzed in the clinical laboratory. (B)
4.3 Define the phlebotomist’s role in collecting and/or transporting these specimens to the
laboratory. (B)
7.00 Demonstrate understanding of requisitioning, specimen transport, and specimen processing.
7.1 Describe the process by which a request for a laboratory test is generated. (B)
7.5 Identify and report potential preanalytical errors that may occur during specimen
­collection, labeling, transporting, and processing. (I)
8.00 Demonstrate understanding of quality assurance and quality control in phlebotomy.
8.1 Describe quality assurance in the collection of blood specimens. (B, I)
8.2 Identify policies and procedures used in the clinical laboratory to assure quality in the
obtaining of blood specimens (B, I)
8.2.1 Perform quality control procedures. (B)
8.2.2 Record quality control results. (B)
8.2.3 Identify and report control results that do not meet predetermined criteria. (B)
9.00 Communicate (verbally and nonverbally) effectively and appropriately in the workplace.
9.3 Interact appropriately and professionally. (I)
9.6 Model professional appearance and appropriate behavior. (I)
9.7 Follow written and verbal instructions. (I)
9.9 List the causes of stress in the work environment and discuss the coping skills used to
deal with stress in the work environment. (I)

Phlebotomy Practice and Definition

Clinical decisions are based on medical standards of practice, diagnostic testing (e.g.,
laboratory tests and x-rays), a patient’s history, and observation of signs and symptoms.
Therefore, before physicians can make clinical decisions, they need laboratory test results
for the patient. The development of modern diagnostic techniques, clinical laboratory
automation/robotics, nanotechnology, computer technology, standardization, globaliza-
tion, and changes in the delivery of health care services have increased the variety and
number of laboratory test options available for clinical decisions. Since laboratory test
results play such an important role in the clinical management of patients, many health
care workers are taking greater roles in the specimen collection process. Among those
who perform phlebotomy tasks are clinical or medical laboratory personnel (including
certified phlebotomists), nurses and nurse aides, respiratory therapists, medical assistants
 Chapter 1 Phlebotomy Practice and Quality Assessment 3

(certified or registered, CMA or RMA), clinical assistants, home health personnel, and
others. Regardless of specific job backgrounds, common elements about the practice of
phlebotomy should be known by all who are responsible for blood specimen collections.
The term phlebotomy is derived from the Greek words, phlebo, which relates to
veins, and tomy, which relates to cutting. In ancient times, phlebotomy was practiced
to withdraw blood using various means, including knives, crude lancets, leeches, blood
cups or bowls, pumps, and glass syringes. In some cultures, phlebotomy was thought
to cleanse or purify the body and/or get rid of unwanted spirits. However, today, mod-
ern phlebotomy equipment and practices are very advanced. The current definition of
­phlebotomy can be summarized as the incision of a vein for collecting a blood sample
(a portion of blood that is small enough so as not to cause harm) for laboratory testing or
other therapeutic purposes (e.g., transfusion of blood components); synonymous words
are venesection or venisection. The phlebotomist, or blood collector, is the individual
who performs phlebotomy. The term phlebotomist will be used throughout this text even
though it is interchangeable with blood collector. Phlebotomists often assist in the collec-
tion and transportation of specimens other than venous blood (e.g., arterial blood, urine,
tissues, sputum) and may perform clinical, technical, or clerical functions. However, the
primary function of the phlebotomist is to assist the health care team in the accurate, safe,
and reliable collection and transportation of specimens for laboratory analyses.
In this text, numerous phlebotomy procedures and practices are covered, ranging
from the most basic to more advanced procedures. However, there are two commonly
used phlebotomy techniques that are the essence of all phlebotomy practices:
■■ Venipuncture—Withdrawing a venous blood sample (from a vein, not an artery)
using a needle attached to an evacuated tube system or other collection devices (cov-
ered in Chapters 8 and 10).
■■ Skin (dermal) or capillary puncture—Using a superficial skin puncture (typically
a finger) with a specially designed safety lancet to withdraw a smaller amount of
capillary blood (covered in Chapters 8, 11, and 13).
■■ Advanced and/or specialized procedures are covered in Chapters 13, 15, 16, and 17.
Patients’ blood specimens are discrete portions of blood taken for laboratory analysis
of one or more characteristics to determine the character of the whole body.1 Laboratory
analyses of a variety of specimens are used for three important clinical purposes:
■■ Diagnostic and screening tests—To figure out what is
wrong with the patient (e.g., tests that detect abnormal-
ities) or for screening to detect irregularities that require
follow-up testing. Specific laboratory procedures are cov-
ered in later chapters.
■■ Therapeutic assessments—To develop the appropriate
therapy or treatment of the medical condition (e.g., tests that
predict the most effective treatment or the drug of choice)
■■ Monitoring—To make sure the therapy or treatment is
working to alleviate the disease or illness (e.g., tests to
confirm that the abnormality has returned to normal or
that the drug is reaching its effective dosage)
Thus, the requirement for a high-quality specimen that is
correctly identified, collected, and transported is vital to the
overall care of a patient. Phlebotomists’ duties vary in scope and FIGURE 1–1
range, depending on the setting. They may have duties related Clinical Laboratory Procedures are Used to Monitor Astronauts’ Health
to all phases of laboratory analysis or may be assigned to only on the International Space Station (ISS)
specimen collection duties in one area of a hospital. Technol- Many venipuncture procedures during space flight are performed to
ogy has enabled laboratory testing to be performed closer to acquire blood samples for research after they are returned to earth.
the point-of-care (POC); for example, at the patient’s bedside, at Here, Astronaut Aki Hashide holds his blood samples and prepares the
ancillary or mobile clinic sites, at a pharmacy clinic, in the home, tubes in a centrifuge in the ISS’s Columbus module. Note that one end
in an ambulance, or in more remote places such as a war zone, a of the tourniquet is floating near his face.
field clinic, or even the International Space Station (FIGURE 1–1 NASA
4 Chapter 1 Phlebotomy Practice and Quality Assessment

BOX 1–1

Potential Job Sites for Phlebotomists

and Clinical and Medical Assistants
Hospital (Inpatient) Settings
Acute-care hospitals (urban or rural)
Specialty hospitals (cancer, psychiatric,
­long-term care, pediatric)
Ambulatory Care (Outpatient) Settings
Health department clinics
Community health centers (CHCs)
Rural health clinics
Community-based mental health centers
School-based clinics
Prison health clinics
Dialysis centers
Screening centers
Home health agencies
Home hospice agencies
Durable medical equipment suppliers
Emergency care centers
Hospital-based clinics
Hospital-based emergency centers
Health maintenance organizations (HMOs)
Insurance companies
Physician group practices
Individual or solo medical practices
Specialty practices
Rehabilitation centers
Mobile vans for blood donations
Mobile vans for primary care delivery
Mobile mammography units
Free-standing surgical centers
Reference laboratory collection sites
Drug screening sites
Field hospitals and clinics
Fertility clinics
Pharmacy clinics

and BOX 1–1). Phlebotomists’ duties have become more coordinated with other health
care processes. In some cases, health professionals—such as nurses, respiratory therapists,
patient care technicians, clinical assistants, medical assistants, and others—have been cross-
trained to assume phlebotomy duties; in other cases, traditional laboratory-based phle-
botomists have been cross-trained to assume expanded clerical tasks such as procedural
coding for billing purposes, or patient care duties such as performing electrocardiograms
and low-risk laboratory procedures. Whatever the case, phlebot-
omists work closely and professionally in a variety of settings and
with varied patients and health care professionals (BOX 1–2 and
FIGURE 1–2).

HEALTH CARE SETTINGS AND HEALTH CARE

TEAMS
Health care organizations in the United States vary widely but
most fit into two categories: inpatient or hospital care (Box 1–2)
and outpatient or ambulatory care. Traditional hospitals are
typically organized into departments according to medical/
surgical specialties and/or around organ systems, as shown in
TABLE 1–1. Sometimes, departments are organized by therapy
FIGURE 1–2 services or procedures offered to the patient. Phlebotomists
Phlebotomists are Members of the Health Care Team should become knowledgeable about these areas of the hospi-
Wavebreakmedia/Shutterstock tal and the personnel who work there because patients spend
 Chapter 1 Phlebotomy Practice and Quality Assessment 5

BOX 1–2

Hospitals in the United States

According to the American Hospital Association, there are over 5,500 registered hospitals in the
United States. They vary according to the following factors2:

■■ Mission (patient care, education, research)

■■ Total number of staffed beds (over 897,000 beds in the United States)2
■■ Total annual admissions (over 35 million per year)2
■■ Total annual expenses for all registered hospitals (over $936 billion)
■■ Ownership (public or nonprofit, governmental [federal, state, local, prison system, college
infirmaries, etc.], for profit [investor owned or proprietary])
■■ Length of stay (short term, e.g., less than 30 days; or long-term, e.g., greater than 30 days)
■■ Type of care (e.g., acute care, cancer center, psychiatric, long-term care, pediatric,
rehabilitation, etc.)
■■ Location (urban or rural)
■■ Relationship to other health facilities (e.g., hospital system-managed by a central organi-
zation or a network of providers that work together to coordinate care and may or may not
be affiliated with each other)

TABLE 1–1

Medical, Surgical, and Ancillary Service Departments in Large Health Care Facilities
Health care professionals make up one of the largest workforce segments in the United States. For every one physician, there are approx-
imately 16 health care workers who provide direct and support services to the patient and physician. The following list is only a partial
listing of common clinical departments and personnel. There are many levels of education, experience, credentialing processes, and
licensing requirements for the health care industry, and it is beyond the scope of this text to cover all the important individuals. There
are also a variety of specialties and subspecialties for physicians (medical doctors, MDs), scientists, biomedical engineers, nurses, phy-
sician assistants (PAs), social workers, pharmacists, therapists, technical individuals, and spiritual support personnel who are valuable
members of the health care team but too numerous to mention here.

Department Functions Personnel

Allergy Diagnosis and treatment of persons who have allergies or “reactions” to irritating Physicians, nurses, medical assistants
agents.
Anesthesiology Pain management before, during, and after surgery. Anesthesiologist, nurse anesthetist
Cardiology Medical diagnosis and treatment of conditions relating to the heart and Cardiologist (MD)
circulatory system.
Cardiovascular Surgical diagnosis and treatment of heart and blood circulation disorders. Cardiovascular surgeon (MD), surgical nurse
Dermatology Diagnosis and treatment of skin conditions. Dermatologist (MD), nurse, medical assistant
Diagnostic Imaging or Uses ionizing radiation for treating disease, fluoroscopic and radiographic x-ray Radiologist, radiologic technician/technologist
Radiology instrumentation and imaging methods for diagnosis, and radioisotopes for both
diagnosing and treating disease. Sometimes patients are injected with dye that
might interfere with some laboratory tests. The phlebotomist should document
the circumstances as appropriate. In addition, the phlebotomist should be
aware of applicable safety requirements.
Electrocardiography Uses the electrocardiograph (ECG or EKG) to record the electric currents Cardiologist, nurse, medical assistant, EKG
produced by contractions of the heart. This assists in the diagnosis of heart technician
disease.
Electroencephalography Uses the electroencephalograph (EEG) to record brain wave patterns. Neurologist (MD), nurse
Endocrinology Diagnosis and treatment of disorders in the organs and tissues that produce Endocrinologist (MD), nurse
hormones (e.g., estrogen, testosterone, cortisol).
Family Medicine/General Care of general medical problems of all family members. Family practice or primary care physician (MD)
Practice
Gastroenterology Diagnosis and treatment of conditions relating to the esophagus, stomach, and Gastroenterologist
intestines.
(continued)
6 Chapter 1 Phlebotomy Practice and Quality Assessment

TABLE 1–1

Medical, Surgical, and Ancillary Service Departments in Large Health Care Facilities (continued)
Department Functions Personnel

Geriatrics/Gerontology Diagnosis and treatment of the older adult population. Gerontologist

Hematology Diagnosis and treatment of conditions relating to the blood. Hematologist
Immunology Diagnosis and treatment of conditions relating to the immune system. Immunologist
Internal Medicine General diagnosis and treatment of patients for problems of one or more Internist (MD) or doctor of osteopathic medicine
internal organs. (DO), nurse, physician assistant (PA)
Laboratory Medicine/ Uses sophisticated instrumentation to analyze blood, body fluids, and tissues for Pathologist, pathology assistant, laboratory
Pathology pathological conditions. Laboratory results are used in diagnosis, treatment, and personnel (Table 1–2, Box 1–4)
monitoring of patients’ health status.
Neonatal/Perinatal Study, support, and treatment of newborn and prematurely born babies and Neonatologist
their mothers.
Nephrology Diagnosis and treatment of conditions relating to the kidneys. Urologist
Neurology Nervous system. Neurologist, neurosurgeon
Nuclear Medicine Uses radioactive isotopes or tracers in the diagnosis and treatment of patients and Radiotherapist (MD)
in the study of the disease process. The radioactive substance is injected into the
patient and emits rays that can be detected by sophisticated instrumentation.
Phlebotomists should be knowledgeable of special safety requirements for
entering this area. Also, the radioisotopes may interfere with laboratory testing,
so documentation of this therapy may be required.
Nutrition and Dietetics Perform nutritional assessments and patient education and design special diets Nutritionist, dietician
for patients who have eating-related disorders (e.g., diabetes, obesity, anorexia).
Obstetrics/Gynecology Diagnosis and treatment relating to the sexual reproductive system of females, Obstetrician, gynecologist (MD)
using both surgical and nonsurgical procedures.
Occupational Therapy Assists the patient in becoming functionally independent within the limitations Occupational therapist (OT)
of the patient’s disability or condition. Occupational therapists (OTs) collaborate
with the health care team to design therapeutic programs of rehabilitative
activities for the patient. The therapy is designed to improve functional abilities or
activities of daily living (ADLs).
Oncology Diagnosis and treatment of malignant (life-threatening) tumors Oncologist (MD)
(i.e., cancer).
Ophthalmology Diagnosis and treatment of the eyes and vision-related medical problems. Ophthalmologist (MD), optometrist (DO)
Orthopedics Care of medical concerns related to bones and joints. Orthopedic surgeon (MD), physical therapist
Otolaryngology Diagnosis and treatment of medical problems related to the ears, nose, and Otolaryngologist, speech pathologist, audiologist
throat (ENT).
Pathology See Laboratory Medicine/Pathology
Pediatrics General diagnosis and therapy for children. Pediatrician (MD)
Pharmacy Dispenses medications ordered by physicians. Pharmacists also collaborate Doctor of Pharmacy (Pharm. D), pharmacist
with the health care team on drug therapies. Phlebotomists may collect blood
specimens at timed intervals to monitor the level of the drug in the patient’s
bloodstream.
Physical Medicine Diagnosis and treatment of disorders of the neuromuscular system. Physical therapist (PT), occupational therapist (OT)
Physical Therapy Assists in restoring physical abilities that have been impaired by illness or injury. PT and OT
Rehabilitation programs often use heat/cold, water therapy, ultrasound or
electricity, and physical exercises designed to restore useful activity.
Plastic Surgery Cosmetic surgery or surgical correction of the deformity of tissues, including Plastic surgeon (MD)
skin.
Proctology Diagnosis and treatment of diseases of the anus and rectum. Proctologist (MD)
Psychiatry/Neurology Diagnosis and treatment for people of all ages with mental, emotional, and Psychiatrist/Neurologist (MD)
nervous system problems, using primarily nonsurgical procedures.
Pulmonary Diagnosis and treatment of conditions relating to the respiratory system. Pulmonologist (MD)
Radiotherapy Uses high-energy x-rays, such as from cobalt treatment, in the treatment Radiotherapist (MD), nuclear medicine technician
of disease, particularly cancer. Safety precautions are important to avoid
unnecessary irradiation.
Rheumatology Diagnosis and treatment of joint and tissue diseases, including arthritis. Rheumatologist (MD)
Social Work/Patient Case management, patient navigators, and assist in discharge planning and Social workers (MSW, LCSW, DSW)
Advocacy emotional, financial, and social needs.
Surgery Diagnosis and treatment in which the physician physically alters a part of the General surgeon, specialty surgeon (orthopedic,
patient’s body. cardiovascular, etc.) (MD)
Urology Diagnosis and treatment of medical conditions related to sexual/reproductive Urologist, nephrologist (MD)
system in men and renal system for men and women.
Another random document with
no related content on Scribd:
The Project Gutenberg eBook of Ida's
new shoes
This ebook is for the use of anyone anywhere in the United States
and most other parts of the world at no cost and with almost no
restrictions whatsoever. You may copy it, give it away or re-use it
under the terms of the Project Gutenberg License included with this
ebook or online at www.gutenberg.org. If you are not located in the
United States, you will have to check the laws of the country where
you are located before using this eBook.

Title: Ida's new shoes

Author: Madeline Leslie

Release date: March 20, 2024 [eBook #73213]

Language: English

Original publication: Boston: Henry A. Young & Co, 1867

*** START OF THE PROJECT GUTENBERG EBOOK IDA'S NEW

SHOES ***
 Transcriber's note: Unusual and inconsistent spelling is
as printed.

AUNT HATTIE'S LIBRARY

Ida's New Shoes.

BY

AUNT HATTIE

[MADELINE LESLIE]

AUTHOR OF THE "BROOKSIDE SERIES," ETC.

"He that ruleth his spirit, is better

than he that taketh a city."—SOLOMON

BOSTON:

HENRY A. YOUNG & CO.

24 CORNHILL.

1870.
 Entered, according to Act of Congress, in the year 1867, by

REV. A. R. BAKER,

In the Clerk's Office of the District Court for the District of

Massachusetts.

To

NELLIE, ROLAND COTTON, ANNIE, AND FULLER

APPLETON,

CHILDREN OF MY BELOVED NEPHEW,

THE REV. JOHN COTTON SMITH, D.D.,

THESE SMALL VOLUMES ARE AFFECTIONATELY INSCRIBED,

WITH THE EARNEST PRAYER

THAT THEIR LIVES MAY PROVE THEM TO BE LAMBS IN THE FOLD

OF THE GREAT AND GOOD

Shepherd of Israel.

CONTENTS.
 CHAPTER I. THE NEW SHOES

CHAPTER II. IDA'S SNARLED HAIR

CHAPTER III. THE ORANGES

CHAPTER IV. VISIT TO GRANDMA

CHAPTER V. THE DANDELIONS

CHAPTER VI. JOSEPH'S PASSION

CHAPTER VII. THE SICK BOY

CHAPTER VIII. THE COUSINS

IDA'S NEW SHOES.

CHAPTER I.

THE NEW SHOES.

"LOOK, aunty, see my pretty new shoes!"

Little Ida danced up and down, holding back the skirt of

her dress to display the present papa had brought her.
 "Very pretty," said Aunt Mary. "I hope my little niece will
never let them carry her into mischief."

"No, indeed, aunty! I'm going to be a real good girl

now. See how softly I can step in them."

And she went on tiptoe to the door of the bedroom,

where her mother was confined with an attack of nervous
headache.

Mrs. Kent's head was bandaged tightly with a wet towel,

the room being darkened, in the hope she would be able to
drop to sleep.

But Ida did not think of this.

 "WHAT ARE YOU DOING?"

She wanted her mamma to see how nicely her foot

looked in the new boot. She was so quick in her motions,
that before Aunt Mary knew what she was about, she had
pushed a cricket to the side of the bed, and jumped up,
boots and all.

"O Ida! What are you doing?" exclaimed the lady, with a
groan. "I was just falling asleep. Jump right off the bed,
dear; you jar my head dreadfully."

"See my shoes, first, mamma! Berty tied 'em up for

me."

"Ida Kent, come out of that room this minute!" said

Aunt Mary. "Your ma is very sick; and you'll make her worse
with your noise."

"No, I won't! I'll make her better. I'm going to comb

your hair, mamma. You said I might."

Mrs. Kent groaned again. "Do take her away, Mary. I

shall die with this dreadful pain. If I could be quiet one hour,
I think I should be better."

Aunt Mary took Ida firmly by the hand.

"I won't go! I won't!" screamed the naughty child, at

the top of her voice, clinging at the same time to the
bedpost.

"Go this minute, Ida," said her mother, holding her

throbbing head between her hands. "And Mary, take off
those new shoes. She mustn't wear them till she can
behave better."

The naughty girl gave a scream of passion, and was

carried out of the room by Aunt Mary, who was obliged to
hold her hands to keep her from scratching anywhere she
could reach.

Mamma tried to shut her ears, but no, she could hear
the loud, angry screams, until Aunt Mary closed the doors in
a distant chamber.

Even then, her head throbbed painfully, as she readily

imagined the naughty conduct of her little girl.

"What shall I do with her?" she kept saying to herself.

"How can I help her conquer her hasty temper? So
affectionate one moment, so passionate the next."

Toward night, Mrs. Kent's pain was relieved. She was

able to sit up in bed and take a cup of gruel. Nothing could
exceed Ida's fond attention. She ran softly to the entry for a
shawl, then upstairs for another pillow, and afterwards sat
in a chair, her curly head resting on the bed, her forefinger
in her mouth, looking as placid and happy as if no cries of
passion had ever distorted her features.

Mrs. Kent was greatly refreshed by the gruel. She sat

up in bed long enough for Aunt Mary to smooth her tangled
hair, and then lay down, saying—

"I feel as if I could sleep."

Presently she put her hand softly on Ida's cheek.

"You're a good girl now," she said. "You're mamma's
comfort."
 Ida caught her mother's hand and kissed it, then went
to sucking her finger again.

By and by papa came home, and rocked his little girl in

his arms until the tea-bell rang.

"The sky seems remarkably clear to-night," he said to

his sister Mary, after a glance at Ida.

"Yes," she said, smiling; "a storm generally clears the

sky; and there has been a terrible one to-day."

"Was that what made her mother's head ache so bad?"

"No, she had gone to bed before; but of course the

scream's made it worse."

"The thunder you mean. In what direction did the storm

arise?"

"In the direction of the s-h-o-e-s." Aunt Mary spelled

the word so that Ida need not understand.

"To look at her now, one would think there never could
be a storm."

The little girl sat in a high chair by the side of her

father, diligently engaged in eating her bread and milk.

"I know what kind of storms you mean," said Berty,

laughing.

"Yes, I suppose so," answered his father. "You are quite

a man, you know."

"There were never such storms in his day," remarked

Aunt Mary, glancing kindly in the face of her favorite
nephew.
 "Please, aunty, give Ida some cake!" asked the little
girl, holding out her plate.

"Yes, dear;" and then added, "I wish her mother could
see her now."

"We have a nice young lady at table this evening,"

remarked Mr. Kent. "I would to have her come here to tea
every night."

"I'm going to be good all the time now," said Ida,

smiling in her father's face.

CHAPTER II.

IDA'S SNARLED HAIR.

IDA KENT was a very handsome child. Her face was

round and fair, her eyes deep-blue, her mouth small and
rosy, and her hair rippled and curled all over her head. This
was a great affliction to Ida; for, as it hung in ringlets over
her neck, it took a long time in the morning to comb out the
snarls.

Mrs. Kent, too, used to dread the job; and was always
happy when it was completed without arousing Ida's
temper. Many a time she had threatened to cut off the
curls; but her husband would not consent. He felt very
proud of them, and could not be made to believe that the
child would be better without them.

Mamma used to get a bowl of water, a towel to pin

around Ida's neck, the comb and brush all ready before she
called the little girl; and then she tried to amuse her by
telling some funny stories.

A few mornings after Mrs. Kent's sickness, Ida sat in her

mother's lap, and all was going on beautifully, when an
unlucky snarl caught in the comb, giving it quite a pull.

As quick as thought, the child turned and struck her

mother in the face.

"If you do that again, I'll whip you, naughty mamma!"

she cried, her face growing very red and angry.

"Stop, Ida! You mustn't talk so; it's wicked," said Mrs.
Kent, holding the child's hands. "You know mamma didn't
mean to pull; but I shall have to punish you with a rod, if
you strike me, or talk so; it is very wicked."

"I won't have my hair done any more!" screamed the

naughty girl, kicking with all her might.

"Ida!" called out her father from the next room. "Stop
that! Do you know, child, whom you are talking to?"

Berty came in at this minute, and Mrs. Kent took

advantage of this opportunity while her attention was
engaged to finish the curls.

In a few moments she had forgotten all about her

trouble. She came up to kiss papa, her mouth looking as
sweet as a ripe cherry, and then went dancing about the
room as happy as happy could be.
 When her brother had led her to the parlor, Mrs. Kent
said with a sigh, "That is the way she acts more than half
the time while I am curling her hair. I have tried whipping,
and coaxing, and everything I can think of. Her passion
grows worse every day."

"I have always hoped she would outgrow it," answered

Mr. Kent; "but I see something must be done."

"If you'll tell me what, I'll thank you," murmured the

mother in a discouraged tone.

The next week a lady called to see Aunt Mary. Ida was
playing quietly with some blocks in the corner of the room,
when the visitor caught a glimpse of her.

"Oh, what a darling little girl!" she exclaimed. "Come

and see me, my dear."

Ida obeyed, walked slowly across the floor, and glanced

shyly in the lady's face from under her curls.

"You little beauty!" repeated the stranger, taking the

child in her lap.

"Don't touch the lady's bonnet," said Aunt Mary, seeing

that her friend began to look annoyed at having her flowers
pulled out of place.

"I will! I will!" And Ida gave a rose-bud a sudden jerk

which left it in her hand.

The lady put her upon the floor; and Aunt Mary was so
mortified that she caught her up and carried her screaming
from the room.
 "I am sorry, for your sake, I spoke to the child,"
apologized the visitor; "but she looked so smiling I never
thought of her having such a temper."

"I never saw such a passionate girl," murmured Aunt

Mary, looking as if she were going to cry, "I always feel as if
an avalanche were hanging over my head. Sometimes she's
as sweet and loving as a June rose; and, in a moment, her
temper is beyond control."

"Is she well governed?"

"It is difficult to know what to do with one of her

disposition. Both my brother and his wife are very solicitous
concerning her. I wonder often at my sister's patience. She
has tried whipping and shutting her in a room by herself;
but nothing seems to have any lasting effect. I really think
half the cause of Mrs. Kent's nervous headaches may be
from anxiety about Ida. Yesterday she tried a new plan—
she led the child into her bedroom, and, without taking the
least notice of her screams and struggles, began to pray for
herself and her little girl."

"And what effect did this have?"

"Very quieting. My brother feared it was only the

novelty, but sister was encouraged to try it again."

CHAPTER III.

THE ORANGES.
 "Do you know, my love, who made you?"

"Yes, mamma; God made me and Berty and all the

folks."

"And what did he make you for, Ida?"

"I don't know, mamma."

"He made you and all his creatures, to be good, and to

do good."

"I'm good now, mamma; I don't kick any." And Ida

looked the picture of self-complacence.

"Yes, dear, no one can be better than you, when you

try; but I am sorry to say you don't always try. Do you
know the good God in the sky looks down upon you then,
and is very much displeased?"

"Then, what do you pray to him for?"

Mrs. Kent sighed. "Because," she answered, "I am

afraid, if my little girl does not try to correct her naughty
temper, that God will punish her. I ask him to forgive you,
and help you do right; and then ask him to give me
strength to govern you according to his will."

"I won't never be naughty again, mamma; I'm going to

be your good little Ida all the time now."

"Dear child, if I could believe that, a heavy burden

would be lifted off my heart."

It was scarcely half an hour later that Berty came in

from school eating an orange which a companion had given
him.

"I want an orange, mamma," cried Ida, her face

flushing.

"Berty will give you a piece of his; dear."

"I would, mamma; but the juice is all sucked out. See
Ida, it's nothing but skin."

"I want an orange! I will have an orange!" began the

little girl, kicking and screaming with all her strength.

Mrs. Kent put her handkerchief to her face. The

disappointment was too bitter. Ida had seemed so penitent,
she had really hoped her heart was touched, and would not
show such temper again.

"What a naughty girl!" said Berty. "See, you've made

mamma cry!"

Ida stopped kicking; stood for a moment irresolute;

then she ran and laid her head in her mother's lap.

"I'm sorry, mamma; I don't want an orange now. Take

away your handkerchief. See, I'm a good girl."

Mrs. Kent gazed in the child's face. It was beaming with

the new delight of having conquered. She took Ida in her
arms; pressing her to her heart.

"You have made mamma very happy," she said, kissing

her again and again. "Now I know you do mean to try and
conquer those wicked passions. Berty, go to the store,
darling, and buy the largest orange you call find. Buy two
large ones. We must have them cut up for supper; and Ida
shall sprinkle sugar on them and help us all herself from the
glass dish. I want papa and Aunt Mary and nurse to know
that my dear little girl is determined to be good; that she
has begun already to conquer herself."

I wish you could have seen Ida. She danced about the
room, kissing mamma ever so many times, and kept
running to the window to see whether Berty was coming.

Mrs. Kent looked as happy as her little girl. "Oh, if this

will only last!" she said to herself. And then she lifted her
heart in prayer to her heavenly Father, beseeching him to
put good thoughts into Ida's mind.

When tea was on the table, mamma brought forward

the nice dish of orange, and put it before Ida's plate. Then
she took the bowl from the tray and said—

"There, love, you may sprinkle on the sugar now. You

have been very patient while I cut the oranges."

Ida took the sugar-spoon and began her work. She did
not smile. She looked very solemn as if she felt the
importance of the trust.

"Why, what is this?" asked papa, coming behind her on

tiptoe.

"O papa!" Ida was so excited she sprang almost out of

her chair. "I'm going to help the oranges to you and
everybody. I've began to be good, and mamma won't have
to pray for me any more."

"You have, indeed, arrived at a state of perfection, if

that is no longer necessary," replied Mr. Rent, with a smile;
"but I want to hear all the particulars of so important a
change."
 "Mamma will tell you about it. Oh, I'm so good!" and
her eyes sparkled with happiness.

"Papa would like best to hear it from his little girl," said
mamma, kissing her. "Then we will sit down to tea, and you
may help us to your oranges."

The child looked somewhat confused, not knowing

exactly where to begin.

"You know," said Berty, "you began to kick and scream

because you wanted my orange."

"Yes, papa; and I saw mamma crying behind her

handkerchief; and I didn't kick any more. I said right off I'd
be good; and then mamma hugged me awfully. Now may I
help to the orange?"

"Wait a minute, dear, till papa has thanked the good

God for helping his little girl do right."

Papa kissed her with a tear twinkling in his eye. After he

had asked God's blessing on the food, Ida began her
pleasant task, passing each a few pieces of the fruit and
laughing gayly as Aunt Mary, Berty, and papa said, "Thank
you, Miss Kent."

CHAPTER IV.

VISIT TO GRANDMA.