WINGED COLLECTION

A. Observance of Proper Etiquette and Application of Pre-phlebotomy Procedures

Step 1. Wash hands and apply gloves
Guideline: Wash your hands properly and within 20 seconds; do not allow your clothes to touch the sink
while washing; the gloves are pulled over the protective clothing
Rationale: Proper hygiene; to prevent bacterial contamination to the patient
Step 2. Observe patient courtesy
Guideline: Knock first (inpatient) and or greet the patient properly (inpatient and outpatient)
Rationale: To leave a good impression to the patient
Step 3. Introduction of the phlebotomist, identification of the phlebotomist’s identity, patient
identification and explanation of the phlebotomy procedure
Guideline: Make sure to state your name and all the patient’s information; be detailed in the procedure
Rationale: To confirm identification; assure the patient; prevent treatment errors
Step 4. Patient preparation: Positioning the Patient
Guideline: Support the hand on the bed or drawing chair armrest; have the patient make a fist; ask the
patient if he or she is allergic to latex
Rationale: To fill the tubes from the bottom up; to prevent difficult vein palpation; to prevent allergic
reaction
Step 5. Equipment preparation
Guideline: All necessary supplies like syringe, correct tubes, winged blood collection set, blood transfer
device etc. should be collected beforehand
Rationale: To be ready for any possible use during the procedure
Step 6. Tourniquet application (3-4 inches above wrist bone or insertion site in the antecubital
fossa)
Guideline: Tourniquet should be placed on the arm 3 to 4 inches above the wrist bone; the ends should
be pointing away from the venipuncture site
Rationale: A tourniquet applied too close to the venipuncture site may cause the vein to collapse; to
make the veins more visible; not to cause distraction in the procedure and harm to the patient
Step 7. Site selection
Guideline: Palpate the top of the hand or wrist; select a vein that is large and straight
Rationale: So that it can be easily anchored
Step 8. Removal of tourniquet
Guideline: Pull the end of the loop to release the tourniquet with one-hand; it should only be on for 1min
Rationale: To prevent hemolysis
Step 9. Cleansing the site
Guideline: It must be done with 70% isopropyl alcohol; circular motion; 2-3 inches wide; wait to dry
Rationale: To prevent bacterial contamination and stinging sensation
Step 10. Selection and assembly of puncture equipment
Guideline: Assemble the equipment as the alcohol is drying; attach the winged blood collection set to
the evacuated tube holder or the syringe; stretched out the coiled tubing; place supplies on the same side
as your free hand during blood collection; if using syringe, pull the plunger back; to remove any air in
the syringe
Rationale: In order not to waste time; to be easily prepared for the procedure; to be sure of the
continuous blood flow to the syringe or tube; to avoid reaching across the patient and causing
 unnecessary movement of the needle in the patient’s vein; to ensure that the syringe moves freely; to
remove any air in the syringe
Step 11 Reapply the tourniquet
Guideline: Must be done tightly enough and properly positioned; do not touch with an unclean finger;
instruct the patient to make a fist
Rationale: To achieve adequate pressure; to prevent bacterial contamination; to produce larger amount
of blood for collection

B. Performance of the Venipuncture Collection Procedure

Step 12. Examine the needle
Guideline: The plastic cap of the needle is removed and the point of the needle is visually examined
Rationale: To see if there are any defects such as a non-pointed or rough (barbed) end
Step 13. Anchor the vein (8 o’clock position relative to intended puncture site so that thumb does
not interfere with needle insertion).
Guideline: Place the thumb of the nondominant hand below the knuckles and pull the skin taut
Rationale: It will keep the skin tight, which will help prevent the vein from slipping to the side (rolled)
when the needle enters
Step 14. Insert the assembled winged needle set and adapter/ syringe using your dominant hand
Guideline: Grasp the needle between the thumb and index finger by holding the back of the needle or by
folding the wings together; smoothly insert the needle into a vein at a shallow 10-15-degree angle with
bevel up; thread the needle into the lumen of the vein until the bevel is firmly “seated” in the vein
Rationale: In order for the patient to feel the stick in a brief moment; if too slow it is more painful and
may cause a spurt of blood to appear at the puncture site
Step 15. Once a flash of blood appears on the line, using the non-dominant hand, gently pull the
syringe plunger
Guideline: Pull back the syringe plunger slowly and smoothly with the nondominant hand to collect
blood; when using evacuated tube holder, use the thumb to advance the tube onto the evacuated tube
needle, while the index and middle fingers grasp the flared ends of the holder; insert tubes in the correct
order of draw; use a discard tube when collecting anticoagulated tubes then invert it immediately
Rationale: To provide stability; to collect appropriate amount of blood; can cause blood to begin to clot;
to prime the tubing and maintain the correct blood-to-anticoagulant ratio; acceptable sample
Step 16. Untie the tourniquet when blood flows into the tube; ask the patient to open the fist.
Guideline: Pull the end of the loop to release the tourniquet with one-hand; tourniquet should only be on
for 1 minute; tell the patient to relax his or her hand
Rationale: To have stability and blood flow; to prevent hematoma
Note: If it is felt by the phlebotomist that this procedure would cause vein collapse, then there
is no need for early release of tourniquet, but tourniquet must not be tied for more than 2 minutes
Step 17. Cover the puncture site with clean gauze and remove the assembled butterfly set
smoothly. “fish-out” needle cap using one-hand scoop technique.
Guideline: Place folded gauze over the puncture site and withdraw the assembled butterfly set in a
smooth swift motion and cover the needle with its cap with one hand only; the syringe is detached; hold
the syringe vertically with the blood transferred device at the bottom; do not push the plunger
Rationale: To prevent blood from leaking; to ensure safety in sharps; tubes will be filled by the vacuum
in the tube; to ensure that the tubes fill from the bottom up; to avoid cross contamination; to prevent any
chance of blood refluxing back into the needle
 Step 18. Apply pressure to puncture site and bandage
Guideline: Still in the same position; pressure must be applied until the bleeding has stopped and usually
about 2 to 3 minutes; adhesive bandage or tape is applied over the folded gauze square
Rationale: To prevent blood from leaking into the surrounding tissue and producing a hematoma; for
additional pressure and safety
C. Post collection Procedures
Step 19. Label the tubes
Guideline: It must be labeled with the confirmed identity of the patient after the sample has been
collected; mislabeled samples are like misidentified patients
Rationale: To prevent confusion of the samples when additional tubes are needed because of lost
vacuum or re-stick; can result in serious patient harm
Step 20. Properly dispose used supplies
Guideline: Butterfly device with tubing is discarded in the puncture-proof container (usually red) with
the needle end first while holding the plastic wing; if attached to an ETS, the entire butterfly device with
tubing and holder is discarded in the puncture-proof container (usually red); dispose all other
contaminated supplies in biohazard container (yellow)
Rationale: To prevent bacterial contamination and to ensure safety in sharps
Step 21. Assess and properly dismiss the patient
Guideline: Return the bed, bed rails and used chairs to the original position (inpatient); they can be
excused when the arm is bandaged and the tubes are labeled and instructed to eat if the patient has been
fasting and doesn’t have any scheduled procedures (outpatient) both: patients should be thanked for their
cooperation
Rationale: It cause harm/injury to the inpatient; for the outpatient to be reminded; to show respect and to
leave a good impression

CAPILLARY COLLECTION

A. Observance of Proper Etiquette and Application of Pre-phlebotomy Procedures

Step 1. Wash hands and apply gloves
Guideline: Wash your hands properly and within 20 seconds; do not allow your clothes to touch the sink
while washing; the gloves are pulled over the protective clothing
Rationale: Proper hygiene; to prevent bacterial contamination to the patient
Step 2. Observe patient courtesy
Guideline: Knock first (inpatient) and or greet the patient properly (inpatient and outpatient)
Rationale: To leave a good impression to the patient
Step 3. Introduction of the phlebotomist, identification of the phlebotomist’s identity, patient
identification and explanation of the phlebotomy procedure
Guideline: Make sure to state your name and all the patient’s information; in the nursery, an
identification band must be present on the infant and not just on the bassinet; verbal identification of
pediatric outpatients may have to be obtained from the patients; in pediatric patients, you must be
friendly, confident appearance while explaining the procedure to the child and parent/s; do not say that
the procedure will hurt, and explain why the necessity of remaining very still; parents should be given
the choice of staying with the child or leaving the room
Rationale: To confirm identification; assure the patient; prevent treatment errors; to confirm the infant’s
identification; so that the child will be comfortable with you; explaining the procedure in a simpler way
will make the child confident with you; saying it will hurt will make the child cry affecting the
 concentration of WBC and capillary blood gases; if the parent/s choose to stay, they may be asked to
assist in holding and comforting the child for they provide emotional support and help enlist the child’s
cooperation but if they are very agitated, their legs and free hand may have to be restrained
Step 4. Patient preparation: Positioning the Patient
Guideline: The patient must be seated or lying down with the hand supported on a firm surface, palm up,
and fingers pointed downward for fingersticks; for heelsticks, infants should be lying on the back with
the heel in a downward position
Rationale: In order to get the appropriate amount of blood; continuous blood flow; to make sure that the
infant won’t get hurt during the procedure
Step 5. Equipment preparation
Guideline: Because of the variety of puncture devices and collection containers available for dermal
puncture, phlebotomists should carefully examine the information on the requisition form; in the
nursery, only carry the necessary equipment to the patient area
Rationale: to ensure that they have the appropriate equipment to collect all required samples as well as
the skin puncture device that corresponds to the age of the patient; to keep the infant from harm
Step 6. Site selection
Guideline: The selection of puncture sites must have the sufficient distance between the skin and bone; it
is also based on the age and size of the patient
Rationale: To prevent contact with the bone, followed by infection or inflammation (osteomyelitis or
osteochondritis); in order to know what kind of dermal puncture should be done
Step 7. Selection and assembly of puncture equipment
Guideline: Select equipment according to the age of patient, the type of test ordered, and the amount of
blood to be collected
Rationale: In order to perform the suitable procedure in the right way

B. Performance of the Capillary Blood Collection Procedure (Finger Puncture)

Step 8. Select the middle or ring finger, ideally of the non-dominant hand. The patient must not
wear a ring on the finger as this may obstruct the blood circulation
Guideline: Select the puncture site in the fleshy areas located off the center of the third or fourth fingers
on the palmar side of the nondominant hand; do not use the side or tip of the finger.
Rationale: The distance between the skin and bone is sufficient in those fingers; you may not get the
amount of blood that you needed if you didn’t not puncture in the center
Step 9. Ensure the patient’s hand is warm and relaxed and ensure the patient is comfortably
seated.
Guideline: Warm the puncture site if necessary; gently massage the finger towards the tip
Rationale: Warming dilates the blood vessels and increases arterial blood flow; to increase blood flow
Step 10. Disinfect and thoroughly dry the puncture site. Scrub the patient's middle finger or ring
finger with an alcohol swab.
Guideline: It must be done with 70% isopropyl alcohol; circular motion; wait to dry
Rationale: To prevent bacterial contamination, stinging sensation, hemolyze RBCs
Step 11. Make the incision on the upward-facing side of the fingertip. Apply only light pressure
towards the fingertip until a blood drop appears. The puncture should be made slightly off center
from the fleshy portion, near to the side of the fingertip. Don’t press too much or milk the finger!
It may take a few seconds after the puncture until the blood flow starts.
 Guideline: Prepare the lancet by removing the lancet locking device and open the cap to the micro
collection container; hold the finger between the nondominant thumb and index finger, with the palmar
surface facing up and the finger pointing downward; place the lancet firmly on the fleshy area of the
finger perpendicular to the fingerprint and depress the lancet trigger.
Rationale: In order for the blood to come out easily
Step 12. Blot the first drop of blood on a gauze pad and discard pad in appropriate container.
Guideline: Gently squeeze the finger and wipe away the first drop of blood that may contain alcohol
residue and tissue fluid
Rationale: Prevents formation of rounded blood drop because blood will mix with alcohol and run down
the finger
Step 13. Keep the finger in a downward position and gently massage it to maintain blood flow.
Hold the Microtainer at an angle of 30 degrees below the collection site and use the scoop on
the Microtainer
Guideline: Collect rounded drops into micro collection containers in the correct order of draw without
scraping the skin; do not milk the site; collect the sample within 2 minutes
Rationale: To fill it to the specified mark/level; may cause the specimen to hemolyze; to prevent clotting
Step 14. Put a bandage on the puncture site, making sure that blood flow has stopped; and
instruct the patient when to remove it.
Guideline: Place gauze on the site and ask the parent or patient to put pressure to the puncture site until
it stops bleeding
Rationale: To prevent blood from leaking into the surrounding tissue
Step 15. Cap the Microtainer and gently invert it 10 times.
Guideline: Cap the micro collection container when the correct amount of blood has been collected; mix
tubes 5 to 10 times by gentle inversion as recommended by the manufacturer; they may have to be
gently tapped throughout the procedure
Rationale: To prevent the sample from contamination; to prevent clots from forming; to mix the blood
with the anticoagulant

C. Performance of the Capillary Blood Collection Procedure (Toe Puncture)

Step 8. Select the third or fourth toe for adults; and big toe for babies.
Guideline: For adults: Select the puncture site in the fleshy areas located off the center of the third or
fourth toes on the plantar side of the foot; For babies; it contains more tissue than the other toes; do not
use the side or tip of the toes
Rationale: The distance between the skin and bone is sufficient in those toes and it not that callused from
walking; you may not get the amount of blood that you needed if you didn’t not puncture in the center
Step 9. Ensure the patient’s foot is warm and relaxed and ensure the patient is comfortably seated
or lying.
Guideline: Warm the puncture site if necessary; gently massage the toes toward the tip
Rationale: Warming dilates the blood vessels and increases arterial blood flow; to increase blood flow
Step 10. Disinfect and thoroughly dry the puncture site. Scrub the patient's toe with an alcohol
swab.
Guideline: It must be done with 70% isopropyl alcohol; circular motion; wait to dry
Rationale: To prevent bacterial contamination, stinging sensation, hemolyze RBCs
Step 11. Make the incision on the upward-facing side of the toe. Apply only light pressure towards
the toe until a blood drop appears. The puncture should be made slightly off center from the
 fleshy portion, near to the side of the toe. Don’t press too much or milk the toe! It may take a few
seconds after the puncture until the blood flow starts.
Guideline: Prepare the lancet by removing the lancet locking device and open the cap to the micro
collection container; hold the toe between the nondominant thumb and index toes, with the plantar
surface facing up and the toe pointing downward; place the lancet firmly on the fleshy area of the finger
perpendicular to the toeprint and depress the lancet trigger
Rationale: In order for the blood to come out easily
Step 12. Blot the first drop of blood on a gauze pad and discard pad in appropriate container.
Guideline: Gently squeeze the toe and wipe away the first drop of blood that may contain alcohol
residue and tissue fluid
Rationale: Prevents formation of rounded blood drop because blood will mix with alcohol and run down
the finger
Guideline: Collect rounded drops into micro collection containers in the correct order of draw without
scraping the skin; do not milk the site; collect the sample within 2 minutes
Rationale: To fill it to the specified mark/level; may cause the specimen to hemolyze; to prevent clotting
Step 14. Put a bandage on the puncture site, making sure that blood flow has stopped; and
instruct the patient when to remove it.
Guideline: Place gauze on the site and ask the parent or patient to put pressure to the puncture site until
it stops bleeding
Rationale: To prevent blood from leaking into the surrounding tissue
Step 15. Cap the Microtainer and gently invert it 10 times.
Guideline: Cap the micro collection container when the correct amount of blood has been collected; mix
tubes 5 to 10 times by gentle inversion as recommended by the manufacturer; they may have to be
gently tapped throughout the procedure
Rationale: To prevent the sample from contamination; to prevent clots from forming; to mix the blood
with the anticoagulant

D. Performance of the Capillary Blood Collection Procedure (Heel Puncture)

Step 8. Select an area for puncture on the foot on the lateral plantar surface.
Guideline: Acceptable areas for heel puncture are the medial and lateral areas of the plantar (bottom)
surface of the heel. These areas can be determined by drawing imaginary lines extending back from the
middle of the large toe to the heel and from between the fourth and fifth toes to the heel. Do not use
other areas particularly the arch or back of the heel.
Rationale: It is in these areas that the distance between the skin and the calcaneus (heel bone) is greatest;
they may cause damage to nerves, tendons, and cartilage.
Step 9. Ensure the patient’s foot is warm and relaxed and ensure the patient is comfortably seated
or lying.
Guideline: Moistening a towel with warm water (42°C) or activating a commercial heel warmer and
covering the site for 3 to 5 minutes effectively warms the site; gently massage the foot
Rationale: Warming dilates the blood vessels and increases arterial blood flow; to increase blood flow
Step 10. Disinfect and thoroughly dry the puncture site. Scrub the site with an alcohol swab.
Guideline: It must be done with 70% isopropyl alcohol; circular motion; wait to dry
Rationale: To prevent bacterial contamination, stinging sensation, hemolyze RBCs
Step 11. Make the incision on the upward-facing side of the foot. Apply only light pressure until a
blood drop appears. The puncture should be made slightly off center from the fleshy portion, near
 to the side of the foot. Don’t press too much or milk the toe! It may take a few seconds after the
puncture until the blood flow starts.
Guideline: Prepare the lancet by removing the lancet locking device and open the cap to the micro
collection container; hold the heel firmly by wrapping the heel with the nondominant hand; place the
lancet perpendicular to the heel print and depress the lancet trigger.
Rationale: In order for the blood to come out easily
Step 12. Blot the first drop of blood on a gauze pad and discard pad in appropriate container.
Guideline: Wipe away the first drop of blood that may contain alcohol residue and tissue fluid
Rationale: Prevents formation of rounded blood drop because blood will mix with alcohol and run down
the finger
Step 13. Gently massage it to maintain blood flow. Hold the Microtainer at an angle of 30 degrees
below the collection site and use the scoop on the Microtainer to fill it to the specified mark.
Guideline: Collect rounded drops into micro collection containers in the correct order of draw without
scraping the skin; do not milk the site; collect the sample within 2 minutes
Rationale: To fill it to the specified mark/level; may cause the specimen to hemolyze; to prevent clotting
Step 14. Put a bandage on the puncture site, making sure that blood flow has stopped
Guidelines: Place gauze on the site and ask the parent or guardian to put pressure to the puncture site
until it stops bleeding
Rationale: To prevent blood from leaking into the surrounding tissue
Step 15. Cap the Microtainer and gently invert it 10 times.
Guideline: Cap the micro collection container when the correct amount of blood has been collected; mix
tubes 5 to 10 times by gentle inversion as recommended by the manufacturer; they may have to be
gently tapped throughout the procedure
Rationale: To prevent the sample from contamination; to prevent clots from forming; to mix the blood
with the anticoagulant
E. Post collection Procedures
Step 16. Label the microtubes
Guideline: It must be labeled with the confirmed identity of the patient after the sample has been
collected; mislabeled samples are like misidentified patients
Rationale: To prevent confusion of the samples when additional tubes are needed because of lost
vacuum or re-stick; can result in serious patient harm
Step 17. Properly dispose used supplies
Guideline: Dispose the lancet in the puncture-proof container (usually red); dispose all other
contaminated supplies in biohazard container (yellow)
Rationale: To prevent bacterial contamination and to ensure safety in sharps
Step 18. Assess the newborn and return to parents or guardian
Guideline: Examine the site for stoppage of bleeding; do not place a bandage on an infant younger than
2 years; return the newborn to its bassinet in the nursery; thank the patient and parents/guardian
Rationale: To know whether the newborn is already clear in the procedure; to assure the newborn’s
safety; to show respect to the newborn and the parents as well
***
Guideline: Return the bed, bed rails and used chairs to the original position (inpatient); they can be
excused when the arm is bandaged and the tubes are labeled and instructed to eat if the patient has been
fasting and doesn’t have any scheduled procedures (outpatient) both: patients should be thanked for their
cooperation
 Rationale: It cause harm/injury to the inpatient; for the outpatient to be reminded; to show respect and to
leave a good impression

References:

The Phlebotomy Textbook by Susan King Strasinger, Marjorie Schaub Di Lorenzo. -- 3rd Edition., 2011
Laboratory Activity No. 8a: Venipuncture Procedure: Winged Infusion Set/Butterfly Collection System Method
by jtbuya/rjlpadaoan, 2020
Laboratory Activity No. 9a: Special Blood Collection Procedures: Capillary Collection
by jtbuya/rjlpadaoan, 2020