venipuncture - butterfly, capillary and arterial puncture

Question 1

Butterfly Needle (Winged Infusion Set) is also called

Answer 1

scalp vein set

Question 2

what are the two varieties of the winged infusion set

Answer 2

1. Lower adapter/ connector at the end of the tubing to connect the barrel of the syringe.
2. Proper sheathed needle at the end of the tubing where you can attach the tube holder and can perform a closed system collection using your butterfly needle.

*Need to use small volume of evacuated tubes. Available but not in the Philippines. Why? Small evacuated tubes generate less vacuum pressure compared to larger tubes, reducing the likelihood of vein collapse.

Question 3

what are the equipment needed for butterfly needle extraction

Answer 3

butterfly needle/ winged infusion set
evacuated tube
alcohol pads
tourniquet
gauze pad, cotton and micropore

Question 4

wings of the butterfly needle

Answer 4

it has a rough and smooth side
smooth side must be facing you = bevel up
shld be feeling/ touching the rough side (fold it when holding it)

Question 5

what is the purpose of the luer cap/ connecter of the butterfly needle

Answer 5

Attach the barrel of the syringe

and for the proper sheathed needle at the end of the tubing, it can be pulled off at the the white (middle of the needle and the upper white portion)

Question 6

butterfly needle extraction procedure

Answer 6

transes

Question 7

how do you position the hand

Answer 7

A support or armrest may be needed. Use tackle box

Question 8

the site to puncture using butterfly needle

Answer 8

Should be the dorsal part (at the back) of the hand.

If you are going to consider an insertion of 10 degree or less, select a vein that is close to the skin or very prominent.
It is not advisable to use a butterfly needle if the vein is deep and needs to be more than 10 degrees.

Lightly clenched fist (Not too hard)

Question 9

Why do we need to anchor the veins?

Answer 9

As our veins are prone to rolling. So magaslaw.

Question 10

what is the ideal gauge for the needle

Answer 10

most of the hand veins are small

hence, ideal gauge is 23

Can also use 24 or 25 gauge. But expect that there will be a slow flow of blood during the collection.
DO NOT forcibly pull the plunger. If you do, you will hemolyze the specimen.

Question 11

how do you anchor the veins

Answer 11

Pull the skin down using thumb
Anchor the vein by pulling at the fingers area not the surface of the site. Kase it is abalaa.
Afterwards, can see the back flow of the blood.

Question 12

in step 13-14, what do you do if it is
ETS ended:
if syringe:

Answer 12

ETS ended:
Fill, remove and mix tubes.
Remove the needle, activate the safety device and apply pressure.

if syringe:
Fill barrel, remove needle, put a bandage, apply pressure, remove barrel from the connector & transfer blood to tubes.

Question 13

Butterfly Needle Extraction Procedural Errors

Answer 13

Proper selection of needle gauge:
a 25-gauge needle is not recommended unless it has thin-wall technology.
Again, the ideal would be 23 gauge.

Angle of insertion:
Ideal: 10 degrees or less when the veins are close to the skin.

Use of evacuated tubes:
Small volume evac. Tubes should be selected.
Large volume tubes can collapse veins or hemolyze the specimen.

Question 14

Butterfly Needle Extraction Order of Draw

Answer 14

same order of draw
HOWEVER,
When using a push button (“ETS-ended”) butterfly blood collection system for venipuncture and a coagulation tube is the first tube to be drawn, a discard tube should be drawn first.
The discard tube is used to fill the blood collection tubing dead space.
This assures maintenance of the proper anticoagulant/ blood ratio.
The discard tube can be another blue top tube or a plain, non clot activator vacutainer.

Question 15

Why does the discard tube be drawn first if our test requires us to use a coagulation tube first?

Answer 15

If not, a citrate tube will contain a dead space coming from the tubing. Hence, it will alter the anticoagulant blood ratio.
The citrate tube is very sensitive.
The discard tube can be any tube. For example, serum tube (SST), red plain tube.

Question 16

Butterfly Needle Extraction Disposal
barrel:
needle and tube:

Answer 16

Barrel - in infectious waste
Needle and tube - sharps container

Question 17

capillary puncture is also known as

Answer 17

skin puncture

Question 18

composition of Capillary Specimens

Answer 18

Mixture of arterial, venous & capillary blood
Interstitial & intracellular fluid (Aka tissue fluid)
More closely resembles arterial blood than venous

Question 19

what happens when you are selecting capillary blood/ puncture or when you failed venipuncture but you only need a small amount of blood. For example, CBC

Answer 19

you can perform capillary puncture. But must state in the test request indicating that the specimen came from a capillary puncture or the sample is a capillary blood.

Question 20

why do we have to state in the test request indicating that the specimen came from a capillary puncture or the sample is a capillary blood.

Answer 20

as the reference values are different from venous blood and capillary blood

Capillary reference values may differ from venous values
- Glucose concentrations are higher in capillary blood
- Total protein (TP), calcium (Ca2+) and potassium (K+) concentrations are lower in capillary blood.

Question 21

how can you explain to kids about the pain when puncturing

Answer 21

tell them that it’s like a bite from an ant or like a sting from a bee.

*there are ways to distract them

Question 22

Used for blood films for hematology determinations

Answer 22

microscope slides

[It’s commonly used in hematology to make blood films, which are thin layers of blood spread across the slide. These films allow lab professionals to study blood cells closely for abnormalities, counts, or diseases like anemia and infections.]

Question 23

what is used to warm the site and how does it help

Answer 23

warming devices
Warming the site increases blood flow as much as 7 times
Other alternatives: massaging, can use warm towel (not too hot as u might burn the area)
Warming the site can cause vasodilation = allowing free flow of blood.

Question 24

Sterile, disposable, sharp-pointed or bladed instrument

Answer 24

Lancet/ Incision Devices

Punctures or cuts skin to obtain capillary blood specimen
Designed for either finger or heel puncture

Question 25

why are earlobes are not recommended for capillary puncture

Answer 25

because of the inadequacy of the blood sample that can be obtained from that site *The earlobe was commonly used, but it is no longer recommended because reduced blood flow renders it unrepresentative of the circulating blood.

Question 26

Small plastic tubes used to collect tiny amounts of blood from capillary punctures

Answer 26

Microcollection Containers (different order of draw) *Some contain anticoagulant, clot activators, gel separators *Some come with narrow capillary tubes attached (“straw”) *Have color-coded bodies or stoppers & markings for min/max fill levels (When filling your microtubes, look at the indicator lines that will give u an idea on until where u can fill it up Can fill up to 500uL of blood)

Question 27

What are the anticoagulants that are available for microcollection?

Answer 27

EDTA Plain tube with clot activator Gold top that has gel and clot activator Gray Sodium heparin and lithium heparin Amber tubes for bilirubin testing - Usually perform capillary puncture in neonates/infants - Common test - Amber tubes: as bilirubin is photosensitive = protect sample

Question 28

Disposable, narrow-bore plastic or plastic glass tubes

Answer 28

Microhematocrit Tubes - Prone to break. Handle with care. - Fill by capillary action

Question 29

Used primarily for hematocrit determinations

Answer 29

Microhematocrit Tubes comes in 2 varieties: Red ring is heparinized Blue ring is plain glass

Question 30

how does the one end of the microhematocrit tube is sealed

Answer 30

with plastic or clay sealants

Question 31

what are the Capillary Blood Gas Equipment (CBG)

Answer 31

CBG collection tubes: narrow-bore plastic capillary tubes Stirrers: metal filings or bars inserted into tube to mix Magnet: used for mixing, in conjunction with stirrer Plastic caps: used to seal tubes

Question 32

what are the indications for Capillary Puncture in Adults & Older Children

Answer 32

Available veins are fragile or must be saved for other procedures Several unsuccessful venipunctures have performed Patient has clot-forming tendencies Patient is apprehensive or has an intense fear of needles There are no accessible veins (IVs in both arms, scars, burns) For POCT procedures such as glucose monitoring If a patient can't afford to have it drawn from the line.

Question 33

what are some reasons for capillary puncture in infants & very young children

Answer 33

Small blood volume & risk of anemia Risk of cardiac arrest when large quantities of blood are removed Venipuncture is difficult & may damage veins & surrounding tissues Puncturing deep veins can cause hemorrhage, venous thrombosis, infection & gangrene Risk of injury due to restraint needed for venipuncture Capillary Blood is preferred specimen for some tests

Question 34

how much blood is allowed to take from the infants/ newborns

Answer 34

Concerned about the infants/ newborns is the volume of the blood. Allowed to take 10% of the blood. This is being monitored as it might cause iatrogenic anemia.

Question 35

what is the order of draw for capillary specimen

Answer 35

1. Blood gas specimens (CBGs) 2. Slides 3. EDTA specimens 4. Other additive specimens -Heparin -Chloride -Oxalate 5. Serum specimens -this is the last as the first few drops are a free flow and we do not want clotting. *Coagulation tests are strictly not allowed. As citrate is not included in the order of draw.

Question 36

what happens if you overfill the tube (micro collection tube)

Answer 36

it may cause microclot Need to follow the indicator lines. Minimum volume is 250uL. Maximum volume is 500 uL

Question 37

when collecting capillary blood, why should we not scrape the skin

Answer 37

as it can cause hemolysis *Care must be observed during the collection because it may cause elevation of potassium.

Question 38

what is the procedure for capillary puncture

Answer 38

transes

Question 39

in step no. 5: how do you position the patient for capillary puncture Finger puncture: Young child: Infant heel puncture:

Answer 39

Finger puncture: are supported on firm surface, hand extended & palm down (gravity is your friend) Young child: held in lap of parent or guardian Infant heel puncture: supine position Swaddling of infants/ newborns may be helpful in the collection. and Expose one foot as you'll be collecting at the heel.

Question 40

how do you select the puncture, incision site for capillary puncture general criteria: adults & older children: infants:

Answer 40

General criteria: - Skin is warm, pink, normal color - No scars, cuts, bruises, rashes, cyanosis, edema or infection Adults & older children: - Palmar surface of distal or end segment of middle or ring finger of nondominant hand (as the patient may use their dominant hand to write, carry stuff. Hence it may cause pain.) - Central, fleshy portion of the finger (as the patient may use their dominant hand to write, carry stuff. Hence it may cause pain.) Central, fleshy portion of the finger Infants: - Medial or lateral plantar surface of the heel - Lateral is the primary area of choice (CANNOT puncture at heel bone as it may cause osteomyelitis) - Medial is where the posterior tibial artery is located (preterm) - No more than 2.0 mm deep (As deeper it might puncture the bone.)

Question 41

what happens when you puncture the bone

Answer 41

it may cause Osteomyelitis: Inflammation of the bone marrow and adjacent bone. Osteochondritis: Inflammation of bone and cartilage, as the result of infection Fracture in calcaneus: Heel bone

Question 42

where does the most significant capillary vessels are located

Answer 42

0.35 to 1.6 mm below the surface of the skin

Question 43

what is the distance of skin to bones and main nerves of infants

Answer 43

it is around 1.2 to 2.2 mm

Question 44

Recommended site & direction of finger puncture & infant heel puncture

Answer 44

○ 0.85 mm for preterm infants ○ 2 mm for full term infants

Question 45

why and how do we warm the site

Answer 45

○ Warming increases blood flow up to sevenfold ○ Wrap site for 3 to 5 min, with a warm, moist washcloth, towel or diaper or warming device temp not to exceed 42 degrees C (108F)

Question 46

how do you puncture these following sites: FINGER PUNCTURE HEEL PUNCTURE

Answer 46

FINGER PUNCTURE ■ Grasp patient’s finger between non dominant thumb and index finger ■ Place lancet device flat against skin in central, fleshy pad HEEL PUNCTURE ■ Grasp foot gently but firmly with nondominant hand ■ Encircle heel by wrapping your index finger around arch thumb around bottom & other fingers around top of foot ■ Place ancient flat against skin on medial or lateral plantar surface of heel

Question 47

why do we wipe away the first blood drop in capillary puncture

Answer 47

First drop is typically contaminated with excess tissue fluid

Question 48

in capillary puncture, why do we not we scoop/ scrape the blood

Answer 48

As it will cause hemolysis. Just bring the mouth of the container to assist the blood to shoot in the microcontainer.

Question 49

true or false: Capillary blood should be free-flowing and may contain tissue fluid.

Answer 49

true

Question 50

in capillary puncture, what happens if there is an excessive squeezing of site

Answer 50

Excessive squeezing of the site while collecting blood can also lead to alteration in the composition of the blood and inaccurate results. *Milking, scraping of microcontainers and excess pressure may cause hemolysis.

Question 51

what happens if an infant/ newborns is excessively crying

Answer 51

it will cause leukocytosis. allow a few min. of rest before collection (Hence. Let them rest for a few minutes before collecting. As we do not want a false increase in WBC. )

Question 52

how do we label the specimens for capillary puncture

Answer 52

Using a micropore