Venipuncture Course 02 10 S

FOR FUTURE MEDICAL PROFESSIONALS
Venipuncture
Course &
Training Kit
A BASIC COURSE IN PHLEBOTOMY AND IV TECHNIQUES
A product developed and marketed by

THE APPRENTICE CORPORATION
Author: Dr. Anton Scheepers
Copyright The Apprentice Corporation 2013
All rights reserved.
THE APPRENTICE CORPORATION: COPYRIGHT INFORMATION

All material contained in this The Apprentice Doctor Venipuncture Course is protected by international copyright
laws. Copyright of the contents of The Apprentice Doctor CD-ROMs, DVD-ROMs and website content (including but not
limited to text, pictures, sketches, logos, animations, photographic material, video material, sound samples, and graphic
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No part of The Apprentice Doctor CD-ROMs, DVD-ROMs, websites, books, or e-books may be reproduced or transmitted
in any form or by any means without the express written consent of The Apprentice Corporation. Contact information
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The Apprentice Corporation
275 Woodward Avenue
Kenmore, NY 14217 U.S.A.
Or per email: enquiries@TheApprenticeDoctor.com
We appreciate your integrity in this regard.
First edition - October 2013
Venipuncture Course and Kit |
PREFACE
A basic understanding of general human (or veterinary)
anatomy and physiology, especially the cardiovascular
system, is required in order to understand and safely apply
the techniques that the student will learn.
Every simple venipuncture procedure is in essence a
minor surgical procedure governed by the basic principles
of surgery:
Have a comprehensive understanding of basic
medical sciences, especially anatomy and physiology
of the relevant areas and systems.
Follow the basic principles of sterility and asepsis,
including the use of barrier techniques.
Take a medical history and interpret this information
to modify your treatment plan.
Use good lighting.
Respect life and bodily tissues.
Perform the procedure in a humane and professional
manner.
Anticipate the possibility of complications and deal
them promptly and effectively.
The Apprentice Doctor Venipuncture Skills Course
and Kit are not intended to be used as a substitute for
clinical training. Instead, The Apprentice Doctor offers
a firm foundation so students can successfully master
the initial learning curve in a non-clinical setting before
confidently entering the clinical situation.
The Apprentice Doctor Venipuncture Course and Kit
consist of:
1. The Apprentice Doctor Venipuncture Course on
DVD-ROM
2. The Apprentice Doctor Venipuncture Kit with a
Venipuncture Trainer, as well as a variety of medical
items to complete all the practical projects.
IMPORTANT NOTES:
The information offered in The Apprentice Doctor
Venipuncture Course material is based on recent
guidelines set by the World Health Organization (WHO),
and the Centers for Disease Control and Prevention (CDC).
The References section gives more information with links
to help you keep track of the latest information.
Keep in mind that specifics may differ from the information
or protocol of your local hospital or training institution.
In a clinical field, there are often a number of acceptable
protocols, knowledge of more than one offers students
a fuller picture. Protocols and standards may vary in
different regions and countries, as well as in different
hospitals and training institutions. The basic principles

and essential steps, however, should remain very similar.
Workable protocols and standards in a mission hospital in
rural Tanzania in Africa will be quite different from what
is acceptable in a top level training hospital in New York.
Medical professionals should always use the highest
standards and never compromise patient or personal
safety.
Despite thorough research, the author and contributing
professionals arent necessarily perfect. Should you
notice any mistakes in either the theory or the practical
demonstrations on DVD-ROM, kindly report this to the
author in writing or email. Your suggestions will be
appreciated for future versions.
The www.TheApprenticeDoctor.com website and
community complement our products by offering future
medical professionals a chance to join like-minded
students and by providing a platform for learning from
practicing healthcare professionals. You will find a suitable
community in your area, and youll receive lots of free
advice and support.
Dr. Anton Scheepers, The Apprentice Corporation staff,
and The Apprentice Doctor community leaders would
like to wish you a successful future and look forward to
being of assistance towards fulfilling your dreams!
The Apprentice Doctor Venipuncture Course and
Kit is recommended training material for all healthcare
professionals whether prospective, in training, or qualified:
Medical students
Pre-medical students
Paramedics and EMT students
Nursing students
Phlebotomy students
Dental students
Veterinary students
Surgery interns/registrars
Advanced first aid practitioners
Military medics
High school students interested in a career in medicine
(guidance required)
Practicing healthcare professionals who would like to
improve their venipuncture skills
The Apprentice Doctor Venipuncture Course is
intended as supportive training material for formally
registered and accredited medical, dental and veterinary
courses. In itself, this course does not qualify one as a
phlebotomist or any other type of medical professional.
FOREWORD
In any practical endeavorfrom writing a book, to
painting a picture, to performing a surgical operationa
solid foundation in the basic skills of the discipline is an
essential prerequisite.
The days when clinical skills were simply taught from senior
to junior, from one year to the next are long gone. Clinical
skills require an in-depth knowledge of the procedure
as well as the opportunity to practice in a simulation
environment, with definite guidelines to follow, and
parameters to evaluate the students progress. Students
need to train in a non-clinical setting until they have the
proficiency, knowledge, and confidence to be successful in

the clinical situation. Simulation training is not an optional
extra, but an essential step in training clinicians who are
able to practice medicine safely while avoiding or at least
minimize clinical errors.
An affordable venipuncture course and kit has been
long overdue. The authors, developers, and the various
contributors should be commended on a task well done!
Dr John Lemmer Emeritus professor Oral Medicine and
Periodontics, University of the Witwatersrand
WARNINGS
Before starting the course, please read these warnings
carefully:
Kit is an Educational product. All items in this kit are
intended exclusively for non-clinical purposes. Do not
use any of these items on actual human or animal
patients, even in an emergency.
This kit and its components are intended exclusively
for training/educational purposes. They are not
intended for use in any clinical setting, or in the cure,
mitigation, treatment, or prevention of disease in man
or other animals.
Kit contains sharp instruments. Please be cautious!
Keep out of reach of children of 14 years and younger,
especially toddlers and babies.
Adult supervision is required for students 15-17 years
of age. It is essential that students 18 years and older
take extreme care while doing the practical projects.
Some items may contain latex rubber, not suitable for
persons with latex allergies.
Always use clean items. Wash used items with liquid
soap and water after each session then leave in an
antiseptic solution (e.g., Savlon) for 60 minutes. Rinse
thoroughly with clean water and dry before replacing
in the kit.
Re-use items only in a non-clinical practice

situation. In a clinical setting, the re-use of items is
not recommended (such as tourniquets) or strictly
prohibited (used items such as needles, IV fluids, etc.).
Refer to your local hospitals policies and protocols.
For any cut or needle prick injuriessqueeze the
wound for 15-30 seconds to bleed out impurities,
wash profusely with soap and water, apply pressure
to stop the bleeding, and then apply an adhesive
bandage strip. Seek professional medical assistance.
Discard all sharp instruments in the Used Sharps
Biohazard Container provided. On completion of
The Apprentice Doctor Venipuncture Course
(including all the practical projects), close the sharps
waste container and take the container to a hospital,
a healthcare facility or any medical professional
for proper sharps biohazard waste disposal. NEVER
dispose any sharps (used or unused) into a regular
waste bag or bin! Alternatively contact us per email
and we will mail a self-addressed box. Return with
your sharps container for safe disposal.
Keep sharp instruments away from the eyes. Protective
glasses or visors are recommended.
Important! Familiarize yourself with the warnings on
the package and the disclaimer on the leaflets inside the
package and on the DVD-ROM before proceeding.
KEYS TO SYMBOLS USED IN THE PRACTICAL PROJECTS
VIDEO
Sharps will be used!

Sharp or potentially sharp medical items or objects (e.g., glass medicine vials) will be used.
Perform the procedures in these projects with great caution and care.
Discard sharp and potentially sharp items ONLY in the sharps waste container.
Study the section ASPECTS OF SAFETY before doing these projects.
A definite possibility of blood contamination exists when performing these procedures in a

real clinical setting.
Ensure that all relevant aspects of sterility and asepsis are in place, and use appropriate
barrier techniques (gloves, masks, visors, protective glasses, etc.).
Blood hazard
SIMULATION PROCEDURE

Venipuncture Trainer is required see PROJECT 10 to set up the Venipuncture Trainer.

Practice as much as you wish, within the limits of the safety guidelines and the restrictions
regarding age.
It is essential that all students take great care with handling sharps while doing these practical
projects.
CLINICAL PROCEDURE: RESTRICTED
Procedure may only be performed on real patients in a proper medical setting by either
qualified medical professionals or students under proper supervision in a formal training
facility with all relevant legalities and medical indemnities in place.
CLINICAL PROCEDURE: VOLUNTEERS ALLOWED
These procedures can be practiced on a suitable fellow student or other adult volunteer.
DISCLAIMER
The producer or supplier of this application does not:
Offer any warranty regarding the accuracy or
correctness of any information contained in this
application.
Assume any responsibility for any damage or
consequential damage related in any way to the
information, instrumentation, or items contained in
this product/application or as a result of their use.
The user takes full and exclusive responsibility for the safe
application of any information contained in this application.
The user also takes full and exclusive responsibility for
all safety aspects related in any way to the use of any
instrument, or item supplied with this application. This
exclusive responsibility applies equally to the user or to
any person being supervised by the user.
No warranties are offered on the functional status or fitness
for the specific application of any information, instrument
or item supplied in this application.
The supplier accepts no responsibility for the malfunction
of any instrument or item. (The buyer will be entitled to
the replacement of such defective items within the time
limits of the Basic Terms and Conditions).
The supplier disclaims all liability for any direct or indirect

damagesspecific or consequentialrelated in any way
to the information and instrumentation or to any items
contained in this application.
All practical exercises are performed exclusively at the
users risk. The producer or supplier of this application
disclaims any responsibility for any medical emergencies,
medical problems, or any other problems whatsoever that
may arise while using any instrument or item or applying
any information supplied with this application.
Regarding correctness of information and potential
problems arising from any misinformation:
Keep in mind that there are differing points of view in
medicine and medical knowledge changes quickly. If
you think that any information is incorrect, contact us at
enquiries@theapprenticedoctor.com.
It is solely and exclusively the responsibility of the
users of this application to ensure that the information
offered in this course is correct, current and in line with
their hospital or institutions guidelines and protocols.
The Apprentice Corporation, its employees,

any associates, as well as the distributors of the
product completely absolve themselves of any
liability or potential liability for any misadventure or
complications that may result from using this kit or
the information contained in the course material. We
take no responsibility whatsoever for any adverse
outcome, problems, or complications of any nature
that might occur as a direct or indirect consequence
of using the kit or applying the information from the

course material. Using this Kitthe instruments,
items, and information supplied on the CDROMis conditional upon your acceptance of this
disclaimer and commitment to honor copyrights.
For further information on copyright see Copyright
Information.
REIMBURSEMENT POLICY
The Apprentice Corporation is confident that you will
be satisfied with this product in each and every way, as
supported by our extremely low return statistics.
If for any reason, you are dissatisfied with your choice,
The Apprentice Corporation will be happy to reimburse
you (less postage and shipping charges) should you
wish to return the complete medical kit, as well as the
DVD-ROM in an undamaged state within 8 weeks of
purchase.
Please be ethical. It is simply unfair to order and open
the kit, as well as some of the items then copy the course
material on your computer or other electronic device
and then expect a refund on returning the product.
Before returning, delete ALL copies of the course
material in your possession then repackage the kit with

ALL the items and devices in their original condition,
before returning. Shipping is your responsibility and
expense. Reimbursement will follow automatically
once the kit has been received in our warehouse and
has been inspected for completeness and damage.
KINDLY INFORM US REGARDING YOUR INTENTION
TO RETURN THE KIT VIA EMAIL. THE ORDER
NUMBER AND THE DATE OF THE TRANSACTION
SHOULD ACCOMPANY YOUR REQUEST FOR
REIMBURSEMENT.
Email: enquiries@TheApprenticeDoctor.com
For more information see the Basic Terms and Conditions
available on our website: www.TheApprenticeDoctor.com
RECOMMENDATIONS ON
HOW TO USE THE APPRENTICE DOCTOR VENIPUNCTURE KIT
VIDEO
To gain maximum benefit from The Apprentice
Doctor Venipuncture Course and Kit, the following
guidelines should be followed:
Read the WARNINGS and DISCLAIMER sections
attentively. They are available on The Apprentice
Doctor Venipuncture DVD.
Work systematically through course material. Be
sure that you understand each section and can
perform the practical projects skillfully before
proceeding to the next section. Do not skip a
section because you think it is unimportant or too
simple. Although basic principles often appear to
be simple, you must understand and practice these
simple building blocks in order to succeed later
with more complicated applications. Perform the
practical skills projects only when you understand
the theory involved in that specific section.
Start with the Introduction section. You will learn
about the items contained in The Apprentice
Doctor Venipuncture Kit. Section 2 contains
vital information about taking a medical history,
sterility and asepsis and offers the opportunity to
practice relevant basic skills.
Systematically study The Apprentice Doctor
Venipuncture Course Sections 3, 4 and 5 in
order and perform all of the practical projects using
your Venipuncture Trainer where applicable.
Do not omit Section 5 on complications it is
of utmost importance that one has a thorough
knowledge of related complications and how to

avoid, minimize and manage them.
Study all of the medical terms in the Venipuncture
Glossary. Play the various Venipuncture games
and have fun while learning!
Check out the hyperlinks, particularly the latest
information on the WHO and CDC websites.
Visit The Apprentice Doctor Web site (www.
TheApprenticeDoctor.com)
for
information
on other educational medical kits like The
Apprentice Doctor Suturing Course and Kit
and the Examine Patients Course and Kit as well
as information about events like The Apprentice
Doctor Camps and Clubs.
Please direct all technical enquiries regarding
orders and products via the Contact us facility on
the website. Use the Ask Dr. Anton link on the
website for enquiries related to The Apprentice
Doctor regarding course material or careers in
medicine.
Start with the Introduction section. You will learn
about the items contained in The Apprentice
Doctor Venipuncture Kit. Section 2 contains
vital information about taking a medical history,
sterility and asepsis and offers the opportunity to
practice relevant basic skills.
For business and reseller information email us at
enquiries@theapprenticedoctor.com.
OBJECTIVES OF THE COURSE

This course helps you master venipuncture and intravenous
(IV) techniques used by medical professionals.
On completion of this course, students should have

gained the following skills:
The course explains the art and science of phlebotomy,

setting up an IV-line, and related skills. Most importantly,
the Venipuncture Trainer and Kit give students the
opportunity to practice these skills before entering a
clinical setting.
An illustrated hands-on course is available online
and on DVD-ROM. Download an APP for your mobile
device.
The kit includes real medical items you will need to
practice more than 30 step-by-step practical projects.
A simple but effective Venipuncture Trainer is
included. Professional simulation arms are available
for group training.
Take the IV kit with you wherever you go its
lightweight and mobile.
Kit is the perfect resource for all venipuncture and IV
skills training and workshops.
The objectives of the course are to assist students in

mastering basic injection, phlebotomy and IV skills. The
course offers information on the theory and practice
of phlebotomy, setting up an IV line and associated
techniques. The course covers topics such as collecting
various samples for the laboratory, donating blood,
injecting local anesthetics, and much more.
On completion of this course, students should have a
good understanding of:

The importance of taking a medical history before

performing any invasive procedures
The importance of adhering to basic principles of
sterility and asepsis
The items used to perform a venipuncture procedure
and putting up an IV line
The basic principles of venipuncture
Various techniques of drawing venous, arterial and
capillary blood
Various types of injections (e.g., local and regional
anesthetic injections)
The basic principles of putting up an IV line
10
Collecting capillary blood

Drawing venous blood (various techniques)
Drawing arterial blood
Giving a subcutaneous injection
Giving an intra-muscular injection
The student will receive basic information regarding
other specimens (excluding blood) received by the
medical technology lab (e.g., urine, sputum and pus)
The student will understand how to recognize
and how to deal with common and less common
complications of venipuncture
INDEX
PREFACE
FOREWORD
WARNINGS
KEYS TO SYMBOLS
DISCLAIMER
REIMBURSEMENT POLICY
HOW TO USE THE APPRENTICE DOCTOR VENIPUNCTURE KIT
OBJECTIVES OF THE COURSE
10
INDEX
11
SECTION 1: INTRODUCTION
15
Case study 1: An Avoidable Accidentan Unnecessary Death
16
Types of intravenous fluids
18
PROJECT 1A FAMILIARIZE YOURSELF WITH YOUR VENIPUNCTURE KIT
19
SAFETY PROTOCOL AND SAFETY ITEMS
22
PROPER SHARPS DISPOSAL AND ILLEGAL INJECTION DRUG USERS
24
PROJECT 1B HOW TO USE A SAFETY NEEDLE/DEVICE
25
BASIC ANATOMY OF THE CIRCULATORY SYSTEM
28
Main Blood VesselsFull Body
28
Veins and arteries of the head and neck
29
Arteries of the arm
30
Veins of the arm
31
Veins of the arm (close-up)
32
Veins of the hand
33
Arteries of the leg
34
Veins of the leg
35
Anomalous superficial arteries in the arm
36
Blood
36
Blood plasma
36
Whole blood
37
Blood cells
37
Packed red blood
37
Hemoglobin
37
Hematology
37
SECTION 2 : PREPARATION
39
Case study 2: Contracting One of the Most Feared Diseases in the World Today
40
SHORT NOTES ON MEDICAL HISTORY
41
Patient information
42
PROJECT 2 TAKE A MEDICAL HISTORY
42
SHORT NOTES ON STERILITY AND ASEPSIS
43
PROJECTS 3A 3I
43
PROJECT 3A A TECHNIQUE FOR PROPER HANDWASHING
43
PROJECT 3B CLEANING HANDS WITH AN ANTISEPTIC RUB
46
PROJECT 3C HOW TO DON (PUT ON) CLEAN GLOVES
46
PROJECT 3D HOW TO SAFELY REMOVE USED GLOVES
47
11
*PROJECT 3E HOW TO CHANGE INTO THEATER ATTIRE
47
*PROJECT 3F HOW TO SCRUB FOR A STERILE PROCEDURE
47
*PROJECT 3G HOW TO GOWN FOR A STERILE PROCEDURE
47
PROJECT 3H HOW TO DON STERILE GLOVES
48
*PROJECT 3I HOW TO REMOVE CONTAMINATED GLOVES
48
PATIENT POSITIONING
49
TOURNIQUETS
51
PROJECT 4A HOW TO APPLY A TOURNIQUET (DISPOSABLE)
51
PROJECT 4B HOW TO APPLY A TOURNIQUET (TOURNISTRIP)
53
PROJECT 4C HOW TO APPLY A TOURNIQUET (REUSABLE)
54
PROJECT 4D HOW TO APPLY A TOURNIQUET (BLOOD PRESSURE CUFF)
54
PROJECT 5A IDENTIFY THE VEINS OF THE UPPER EXTREMITY
55
PROJECT 5B IDENTIFY THE VEINS OF THE LOWER EXTREMITY
57
PROJECT 5C OTHER IMPORTANT VEINS (FACE, NECK AND CHEST)
59
PROJECT 5D MAP THE VALVES IN VEINS
61
PROJECT 6A PREPARE TO GIVE AN INJECTION
63
PROJECT 6B HOW TO PREPARE THE PUNCTURE SITE ASEPTICALLY (ROUTINE VENIPUNCTURE)
69
PROJECT 6C HOW TO PREPARE THE PUNCTURE SITE ASEPTICALLY (COLLECTING BLOOD FOR BLOOD CULTURE)
71
PROJECT 6D HOW TO PREPARE THE PUNCTURE SITE ASEPTICALLY (COLLECTING BLOOD FROM BLOOD DONOR)
73
SECTION 3: VENIPUNCTURE SKILLS
75
Case study 3: My Life Changed Drastically in a Split Second
76
CAPILLARY BLOOD COLLECTION USING A LANCET
77
PROJECT 7A DRAW CAPILLARY BLOOD (ADULT)
77
PROJECT 7B DRAW CAPILLARY BLOOD (BABY)
79
PROJECT 8 HOW TO GIVE A SUBCUTANEOUS INJECTION
81
Intradermal injections
84
PROJECT 9 HOW TO GIVE AN INTRAMUSCULAR INJECTION
85
PROJECT 10A SET UP THE VENIPUNCTURE TRAINER PHLEBOTOMY
88
PROJECT 10B SET UP THE VENIPUNCTURE TRAINER FOR IV PROJECTS
89
PROJECT 10C SET UP THE VENIPUNCTURE TRAINER FOR ARTERIAL BLOOD
90
Taking care of the Venipuncture Trainer
90
Refilling the IV fluid bag
90
THERAPEUTIC PHLEBOTOMY (LETTING BLOOD)
90
MAXIMUM ALLOWABLE TOTAL BLOOD DRAW VOLUMES
90
PROJECT 11A DRAW VENOUS BLOOD USING A VACUUM TUBE
91
PROJECT 11B DRAW VENOUS BLOOD USING A SYRINGE
96
PROJECT 11C DRAW BLOOD USING A BUTTERFLY NEEDLE
99
PROJECT 11D HOW TO SETUP AND START AN IV LINE
102
PROJECT 11E HOW TO REMOVE THE IV LINE
106
SPECIAL GROUPS OF PATIENTS
107
The neonate patient
107
The pediatric patient
107
VETERINARY VENIPUNCTURE
108
The animal patient
108
AIDS TO ASSIST THE CLINICIAN
109
VeinViewer
109
AccuVein
109
Breastlight
109
Ultrasound
109
12
Radiography
109
PROJECT 12A IDENTIFY THE BODYS PULSE POINTS
110
PROJECT 12B PERFORM A MODIFIED ALLENS TEST
112
PROJECT 12C DRAW ARTERIAL BLOOD
114
BLOOD TRANSFUSIONS
117
Blood types (Blood Groups)
117
Agglutination
118
Blood donations
119
PROJECT 13 DONATING BLOOD FOR THE BLOOD BANK
120
SECTION 4: RELATED TOPICS OF INTEREST
123
Case study 4: Despite All the Training and the Necessary Care, Accidents Do Happen
124
CENTRAL VENOUS LINE
125
ARTERIAL CATHETERIZATION
126
CORONARY ARTERIOGRAPHY
127
INTERVENTIONAL RADIOLOGY
127
KIDNEY DIALYSIS
128
KIDNEY DIALYSIS
129
PORTS
129
TOTAL PARENTERAL NUTRITION (TPN)
130
ANESTHESIA
130
Topical Anesthetic
130
Local Anesthesia
130
Infiltration Local Anesthesia
130
PROJECT 14 INFILTRATING A WOUND WITH LOCAL ANESTHETIC BEFORE SUTURING
131
Local Anesthetic Block
134
Regional Anesthesia
134
General Anesthesia
135
Infusion Pumps
135
NEW DEVELOPMENTS
135
Microprobes for continuous monitoring
135
Needleless Injections
135
SHORT NOTES ON OTHER BODILY SECRETIONS
136
Saliva
136
Sputum
136
Breast milk
136
Semen
136
Sweat
137
SHORT NOTES ON OTHER BODILY EXCRETIONS
137
Urine
137
Urinalysis
137
Feces
137
SHORT NOTES ON OTHER BODILY FLUIDS
138
Cerebrospinal fluid (CSF)
138
Ascites
138
Effusion
138
Pleural
138
Joint effusion
139
Exudates and transudates
139
Pus
139
13
SECTION 5: COMPLICATIONS
141
Case study 5: A Routine Venipuncture Case
142
Vasovagal response and vasovagal syncope
143
Allergic responses
144
Contact dermatitis
144
Skin rash/Urticaria
144
Anaphylaxis (Anaphylactic Shock)
144
Needle penetration through the vein
145
Hematoma
145
Ecchymosis
146
Needle/cannula in the tissue
146
Tissue infiltration (extravasation)
146
Cannula/catheter blocked (occluded)
147
Catheter-related infections
147
Intra-arterial position of needle/cannula
148
Inadvertent intra-arterial injection of medication
148
Differentiation between arteries and veins
149
Superficial phlebitis
149
Septic thrombus
150
Deep vein thrombosis (DVT)
150
Embolism
151
Air embolism
151
Local tissue damage
153
Nerve damage
153
Arterial cannulation
153
Needle prick injuries
153
153
SECTION 6: CONCLUSION
155
ASSESSMENT MODULE
156
EPILOGUE
156
REFERENCES
156
CREDITS
157
GLOSSARY
160
14
Venipuncture Course and Kit | INTRODUCTION
CASE STUDY 1:
AN AVOIDABLE ACCIDENTAN UNNECESSARY DEATH
16
A 32-year-old nurse with an infectious smile cheerfully

reported for duty, but she had no idea that this would be
her final, ill-fated day.
Helosini Pillay was a vibrant young woman who had just
completed her degree and started a new job at Lancet
Laboratories in Morningside Clinic. Helosini sat down to
perform a routine blood draw on a patient. She accidentally
bumped the trolley where she had placed the needle and
syringe. The needle and syringe fell and pierce her right
calf. She reported it to her senior who ordered an HIV test
on this patient. Results showed that the patient was HIVnegative. However, a previous blood test indicated that he
had malaria.
Helosini asked if she might contract malaria from her
needle stick injury but was assured that she could only
contract malaria from a mosquito or if she lived in an area
that was at risk for malaria. She went home thinking that
everything would be fine.
That evening, Helosini complained to her sister that her leg

was turning blue and that she had flu-like symptoms. Nine
days later, she was worse. She decided to go to her doctor,
but changed her mind and went to a pharmacy instead
and purchased flu medication.
On Christmas Eve, Helosini was so sick that she went to
her doctor who diagnosed her with bronchitis. A few days
later, Helosinis sister, Yogeshini, found her unconscious
on the bathroom floor. Yogeshini rushed her sister to the
hospital where it was confirmed that she had contracted
malaria. In addition, she had developed a complication
called Adult Respiratory Distress Syndrome (ARDS). Family
members were called as she was in a critical condition and
gasping for breath.
She never regained consciousness and two weeks later
she died.
And so an expensive lesson is learnt. Routine use of safety
needles would have prevented this tragedy.
The Venipuncture Trainer in this kit has been designed with effectiveness and affordability in mind. Students of phlebotomy
will be able to use this versatile Venipuncture Trainer to practice basic skills over and over while experiencing a realistic feel
similar to the real clinical situation. As an optional extra, The Apprentice Corporation has artificial arms available for sale.
Keep in mind that no training system can replace the clinical phase of your training. Practice, gain confidence, then face
real clinical situations under supervision and always learn from both your successes and your failures.
PHLEBOTOMY
Phlebotomy is the procedure of removing (drawing)
blood from the vascular system by puncturing a vein
or sometimes an artery with a needle or by making an
incision (rarely) to obtain a blood sample for:
Diagnostic purposes
To be analyzed by a medical laboratory
Therapeutic purposes
-- To treat polycythemia vera, a condition that causes
an elevated red blood cell volume (hematocrit).
Phlebotomy is also prescribed for hepatitis B and
C and for patients with disorders that increase the
amount of iron in their blood to dangerous levels,
such as hemochromatosis. Phlebotomy may be
performed on patients with pulmonary edema to
decrease their total blood volume.
-- Collecting blood from blood donors, commonly
one unit of blood (500 mL) in a session.
Venipuncture is the act of puncturing a vein with a needle

or cannula (needle carrying a flexible plastic catheter) for
drawing blood, for administering a therapeutic substance
for intravenous feeding, or for therapeutic purposes.
Although venipuncture is often performed for medical
purposes or to administer a general anesthetic, it is in
essence a minor surgical procedure and thus the basic
principles of surgery apply.
Intravenous therapy (IV infusion) is the method
by which therapeutic fluid/solution or medication is
administered intravenously through an infusion set. The IV
set includes: a plastic or glass bottle containing a solution,
and tubing to connect the bottle to a catheter or a needle
in the patients vein.
17
TYPE
Isotonic
Isotonic
SOLUTION
(EXAMPLE)
USES
SPECIAL
CONSIDERATIONS
Dextrose 5% in water
Fluid loss
Use cautiously in renal and cardiac
(D5W)
Dehydration
patients
Hypernatremia
Can cause fluid overload
Shock
Can lead to overload
Hyponatremia
Use with caution in patients with
Blood transfusions
heart failure or edema
0.9% Sodium Chloride
Resuscitation
Fluid challenges
DKA (diabetic ketoacidosis)
Isotonic
Ringers Lactate/Lactated
Dehydration
Hypovolemia due to third spacing
Ringers (LR)
Burns
Contains potassium, dont use with
Lower GI fluid loss
renal failure patients
Acute blood loss
Dont use with liver disease (cant

metabolize lactate)
Hypotonic
0.45% Sodium Chloride (1/2
Water replacement
Use with caution
normal saline)
DKA
May cause cardiovascular collapse
Gastric fluid loss from NG or vomiting
or increased intracranial pressure

Dont use with liver disease, trauma,
or burns
Hypertonic
Dextrose 5% in
Later in DKA treatment
normal saline
Hypertonic
Dextrose 5% in normal saline
Use only when blood sugar falls

below 14 mmol/l (250 mg/dL)
Temporary treatment
Dont use in cardiac or renal patients
for shock if plasma expanders arent

available
Addisons crisis
Hypertonic
Dextrose 10% in water
Hypertonic water replacement

Conditions where some nutrition
with glucose is required
Table 1: Intravenous Fluid Comparison by Type
18
Monitor blood sugar levels
PROJECT 1A
FAMILIARIZE YOURSELF WITH YOUR VENIPUNCTURE KIT
Use the Content List and follow these steps to ensure that your Apprentice Doctor Venipuncture Kit and Trainer is
complete. Learn the names and functions of each item as you go.
VIDEO
WARNING
This kit contains sharp items that can be potentially
hazardous if they are not used correctly and safely. Keep
the kit and contents away from babies and children under
the age of 15. Adult supervision is required for students 1517. It is essential that all students take extreme care while
doing the practical projects.
Prepare yourself for the clinical situation and imagine
working on an HIV+ patient while practicing on the trainer.

Some items in the kit may contain LATEX and are not
suitable for persons with latex allergies.
Before proceeding, familiarize yourself with the warnings
on the package and DVD-ROM and with the disclaimer on
the leaflets inside the package.
19
REQUIREMENTS
Venipuncture Kit and Trainer and a clean, uncluttered work surface. Follow these steps:
STEP 1
[CLICK TO PRINT KIT CONTENT PAGE]
Do not unwrap or open any items at this point in time!

Unpack all of the items on your uncluttered working surface. Identify all the components of your
Venipuncture Kit and Trainer using the Content List. Learn the names and functions of all items as you
check them against the list.
CHECK LIST OF MEDICAL ITEMS INCLUDED IN THE KIT
20
The Apprentice Doctor

Venipuncture Course
DVD-ROM
IV Catheter
Venipuncture Trainer
Lancets Safety and

Regular
Connectors /
Lumen stoppers
Disposable Tourniquet
Syringe for SQ Injections
Butterfly Needles
Regular Syringes
IV Fluid Bag
Regular Needles
IV Lines
Safety Needles
Glass Vial
Plastic Vial
Alcohol Prep Swabs
10
Safety Vacuum
Container Device
Gauze Squares
10
Vacuum Container Hub

and Needles
Work Surface Cover
pairs
Blood Vacuum Tubes
Gloves
pairs
pairs
Cotton Wool
Roll of Strapping
Reusable Tourniquet
Sharps Waste Container
More information [CLICK HERE]
* PLEASE NOTE:

Tournistrip

Transparent Dressing
Ruler and Pen
Contents may vary slightly from the list depending on

availability.
Kits are double checked for quality and completeness
by our factory. In the unlikely event of problems,
please contact customer support personnel at
Enquiries@TheApprenticeDoctor.com
Regarding the use of safety needles:
The Apprentice Doctor Venipuncture Kit contains
safety needles. For the sake of keeping the kit
affordable, we have included regular needles, since
there is nearly no risk of acquiring a bloodborne disease
when using the kit according to the instructions. Safety
and regular needles can be used for the projects while
working on the Venipuncture Trainer. However, in the
clinical environment, safety needles should be used
exclusively.
21
STEP 2
Open the Venipuncture Trainer and compare it with the
illustration below.
STEP 4
Replace all the items in your Kit and proceed with the
Venipuncture Course, or close the kit and place it in a safe
location out of the reach of children.
POINTS OF INTEREST

The trainer is simple, effective, and functional.
The Apprentice Doctor offers realistic trainer simulation

arms for group training. [ORDER ONLINE].
STEP 3
Buy red food colorant available from grocery stores and
add to the kit.
Approximately 80% of hospitalized patients receive IV

therapy.
A large percentage of medications are administered
by intravenous infusion.
IV Therapy is becoming more widely used in extended
care facilities and in home care situations.
Central venous access has resulted in the widespread
use of long-term IV therapy.
Warm IV fluids are often used in restoring the body
temperature of hypothermic patients. IV fluids should
be warmed to approximately 43C or (109.4 F) prior
to administration. As most hypothermic patients are
also dehydrated, warm intravenous fluids serve a dual
purpose.
Contaminated IV fluids have at times resulted in the
death of a patient or even multiple deaths. Ensure that
you follow an acceptable antiseptic protocol when
administering IV fluids. If in doubt about the sterility of
the fluid (unusual color, change in transparency, etc.),
do not use the fluid and report this to your hospitals
infection control official for further investigation.
BEFORE STARTING, YOU MUST FIRST READ THE FOLLOWING:

ASPECTS OF SAFETY
What is the most serious complication that may follow a
simple venipuncture procedure? Is it a large hematoma? Is
it permanent nerve damage that causes the loss of normal
sensation over the forearm and hand? Or is it a motor nerve
injury with partial paralysis of muscles in the arm or hand?
The truth is much graver the ultimate complication is
death (see case studies in the various sections.)
A great number of serious or even fatal accidents and
complications are avoidable, so do not skip this section or
rush through it. This information is vitally important! Study
this section thoroughly before proceeding you and your
patients lives depend on your carefully application of this
information.
22
Sharps injuries are through the skin wounds caused by

sharp medical items like needles, scalpels, or other sharp
objects such as glass medicine vials. Sharps injuries are
occupational hazards frequently encountered by medical
professionals who handle needles. These injuries pose the
risk of transmitting bloodborne pathogens such as the
hepatitis B virus (HBV), the hepatitis C virus (HCV), as well
as the human immunodeficiency virus (HIV). Needlestick
injuries are common events in the healthcare environment;
Mario Saia et al in 2010 reported an estimated 384,000
cases in the USA alone.
Hollow needle injuries are especially dangerous and carry
a very high risk of transmitting bloodborne diseases.
Infected material coming into contact with a mucus
membrane (e.g. blood splashing into the eye) also carries a
risk of transmitting disease.
Centers for Disease Control and Prevention (CDC)

guidelines and recommendations regarding the use of
needles, cannulas, and intravenous delivery systems:

Use aseptic techniques to avoid contamination of

sterile injection equipment.
Do not administer medications from the same syringe
to more than one patient, even if the needle or
cannula on the syringe has been changed. Needles,
cannulas, and syringes are sterile, single-use items;
they should neither be reused for another patient nor
to access a medication or solution that might be used
for a subsequent patient.
Use fluid infusion and administration sets (i.e.,
intravenous bags, tubing, and connectors) for one
patient only and then dispose of them appropriately.
Once a syringe or needle/cannula has been used to
enter or connect a patients intravenous infusion bag
or administration set, consider it contaminated.Use
single-dose vials for parenteral medications whenever
possible.
Do not administer medications from single-dose vials
or ampules to multiple patients or combine leftover
contents.
If multi-dose vials must be used, both the needle or
cannula and syringe used to access the multi-dose
vial must be sterile.
Do not keep multi-dose vials in the immediate patient
treatment area and store in accordance with the
manufacturers recommendations; discard if sterility is
compromised or questionable.
Do not use bags or bottles of intravenous solution as a
common supply source for several patients.
Download CDC Posters on preventing injuries with

sharps:
[POSTER 1 HYPERLINK]
[STUDY CDC GUIDELINES FOR HANDLING
SHARPS]
Look at the WHO Publication on sharps injuries:
Assessing the burden of disease from sharps injuries
to health care workers at national and local levels.
All students, especially those in USA, should acquaint

themselves with the relevant legalities in the OSHA
Occupational Safety & Health Administrations
documents:

Read OSHAs Workers page,
Bloodborne Pathogens and Needlestick Preventions

and http://www.osha.gov/needlesticks/needlefaq.html
In the USA, the Needlestick Safety and Prevention

Act of 2000 makes the use of engineered sharps injury
protection mandatory in the workplace. In practice,
it means that safety needles and safety devices are
compulsory in the USA and in a number of other countries.
In order to reduce or eliminate the hazards of occupational
exposure to bloodborne pathogens, an employer must
implement an exposure control plan for the worksite
with details on employee protection measures. The plan
must describe how the employer will use a combination
of engineering and work practice controls. Among other
provisions, the employer must ensure the use of personal
protective clothing and equipment and provide training,
medical surveillance, hepatitis B vaccinations, as well as
signs and labels. Engineering controls are the primary
means of eliminating or minimizing employee exposure
and include the use of safer medical devices, such as
needleless devices, shielded needle devices, and plastic
capillary tubes.
[SEE ACT HERE: USA NEEDLESTICK SAFETY AND
PREVENTION ACT OF 2000]
IMPORTANT!
If you are injured or pricked by a needle or other sharp
object or get blood or other potentially infectious
materials in your eyes, nose, mouth or on broken skin,
immediately flood the exposed area with water and clean
any wound with soap and water or a skin disinfectant if
available. Immediately report this to your employer and
seek immediate medical attention.
Credit: U.S. Department of Labor
23
PROPER SHARPS DISPOSAL

AND ILLEGAL INJECTION
DRUG USERS
into a regular waste bin or bag. Hand a full sharps waste

container to a medical professional at a hospital, a medical
clinic, or to your family doctor for proper sharps waste
disposal.
Globally, around 16 million people inject drugs and 3

million of them are living with HIV according to 2012
WHO statistics.
Alternatively contact us per email and we will mail a selfaddressed box. Return with your sharps container for safe
disposal.
Email to enquiries@theapprenticedoctor.com
According to the most recent CDC data (2008):

Injection drug users represent 12% of annual new HIV
infections in the United States.
Injection drug users represent 19% of those living
with HIV in the United States.
Injection drug users often acquire infections like HIV
and Hepatitis B as a result of needle sharing and the use
of contaminated needles, often as a result of improper
biohazard sharps waste management or the erroneous
placement of needles in a regular waste bin or bag.
Kindly play your part in minimizing the morbidity of
this problem by NEVER discarding any used or unused
needles or any other sharp or blood contaminated items
24
PROJECT 1B
HOW TO USE A SAFETY NEEDLE/DEVICE
It is all about safetyfor your patients AND YOU!
VIDEO
WARNINGS:
INFORMATION
The Apprentice Doctor has done a fair amount of

research to identify the best safety needle system for our
Venipuncture Kits. Based on research of The Health Care
Product Evaluation Center at the University of Virginia,
the Autosafe-Reflex safety needles showed excellent
results and came out on top. Therefore we include
Autosafe-Reflex Safety Needles in The Apprentice
Doctor Venipuncture Kits.
In this project you will work with sharp items. Take

great care to avoid injury to yourself and others.
You will use safety needles in this project. The
Autosafe-Reflex needles safety features will make
a needle injury unlikely but in the final analysis there
is no substitute for caution.
Follow the instructions accurately!
You will need:

A comfortable work area
The unassembled Venipuncture Trainer
A 5 ml syringe
An Autosafe-Reflex safety needle
These needles are VERY easy to use however, in order for
them to be effective, one needs to use them correctly.
25
FOLLOW THESE
INSTRUCTIONS EXACTLY:
STEP 1
Look at the diagram of the needle with its various parts
STEP 7
Withdraw the plunger of the syringe to fill the syringe with
3-5 ml of air, just for practicing purposes.
STEP 8
Pull the safety mechanism back and hold gently, just on
the one side, in the activated position with your middle or
index finger.
STEP 9
Remove the protective sleeve of the needle.
STEP 10
Figure 2: Cross section of the Autosafe-Reflex safety needle
Perform a simulation IMI (intramuscular injection) by

injecting the Venipuncture Trainer. Penetrate the skin
at 90 and insert the needle up to the level of the safety
device. See PROJECT 9 How to Give an Intramuscular
Injection for more information.
STEP 2
STEP 11
Open a clean work surface cover. On it, place the

unassembled Venipuncture Trainer, an opened 5ml
syringe, and an unopened safety needle.
STEP 3
Wash your hands. Start now to develop this simple
but effective habit. If you like, don clean gloves (gloves
optional).
STEP 4
Orientation is important when opening the AutosafeReflex safety needle. Hold the needle with the paper
cover facing up. The needle is packed with its bevel facing
up, towards the paper cover. Kept in this orientation, the
needle will be positioned correctly for performing clinical
procedures like venipuncture.
STEP 5
Lift the edge of the paper cover and peel it backwards.
Pinch the package at the fold (at the base of the package)
and fold the base down.
STEP 6
Fit the needle to the syringe, and withdraw the safety
needle from the package while maintaining the needles
orientation.
26
Inject the air into the Venipuncture Trainer.

Warning note: Normally one would carefully eliminate all
air bubbles from the syringe and needle before injecting.
NEVER inject air into a patient neither by SCI, IMI, nor IVI.
STEP 12
Remove your index finger from the safety mechanism.
STEP 13
Withdraw the needle; you will notice the reflex mechanism
activates spontaneously and passively. The sharp needle
tip will be covered by the safety cap, in a somewhat offcenter position.
STEP 14
Remove the needle by disconnecting it from the hub
of the syringe. Discard the used needle into the sharps
waste container. Never try to recap a regular needle or
reassemble a safety needle. In a clinical setting, you will
discard the complete unit (syringe and needle).
NOTE:

In rare instances, after activating the AutosafeReflex needles safety device, you may need to
expose the needle again for example when
withdrawing medication from a vial using the safety
needle. See this demonstration on how to safely
expose the needle again: [VIDEO-CLIP]
Look at the Autosafe-Reflex Vacutainer
Phlebotomy Device it is equipped with an
Autosafe-Reflex needle. Do not open the device at
this stage this device will be used in PROJECT 11 A
DRAW VENOUS BLOOD USING A VACUUM TUBE.
POINTS OF INTEREST

According to the Centers for Disease Control and

Prevention (CDC), about 385,000 sharps injuries occur
annually to hospital employees and WHO resources
estimate the frequency of needlestick injuries at
about 3.5 million cases worldwide. [CLICK HERE] for
more information.
As a consequence of sharps injuries, there are an
estimated 66,000 infections with HBV, 16,000 with
HCV, and more than 1,000 with HIV worldwide.
CDC guidelines for PEP (post-exposure
prophylaxis) when a needle stick injury happens
when treating a patient with one of these diseases
(or passive carriers of these diseases):
Hepatitis B: Administer hepatitis B immune
globulin and/or hepatitis B vaccine.
Hepatitis C: There is no current active PEP for
HCV.
HIV: Administer three or more antiviral drugs
when the donor is HIV positive.
The prevalence of illegal drug injections in the USA
is simply mind-boggling! It is estimated that between
920 million and 1.7 billion illegal injections take place
each year in the United States. The illegal drug users
often use and share contaminated needles and
syringes.
Read the following WHO information on safe syringes
for injection safety: [CLICK HERE]
To order AUTOSAFE-REFLEX SAFETY NEEDLES AND

ASSOCIATED DEVICES [CLICK HERE]!
27
BASIC ANATOMY OF THE CIRCULATORY SYSTEM

Note: Student should already have a fair understanding of the basic anatomy and physiology of the cardiovascular system.
Study the following illustrations before proceeding with the course:
THE MAIN BLOOD VESSELS OF THE BODY
[DOWNLOAD PDF]
28
VEINS AND ARTERIES OF THE HEAD AND NECK
[DOWNLOAD PDF]
29
ARTERIES OF THE ARM
[DOWNLOAD PDF]
30
VEINS OF THE ARM
[DOWNLOAD PDF]
31
VEINS OF THE ARM (CLOSE-UP)
[DOWNLOAD PDF]
32
VEINS OF THE HAND
[DOWNLOAD PDF]
33
ARTERIES OF THE LEG
[DOWNLOAD PDF]
34
VEINS OF THE LEG
[DOWNLOAD PDF]
35
ANOMALOUS SUPERFICIAL ARTERIES IN THE ARM

The word anomaly is used when something is normal, but only occurs in a minority of the general population.
The arteries of the extremities normally run a deeper course compared to the equivalent veins. Both the radial artery and
the ulnar artery occasionally run an anomalous superficial course and may be mistaken for a vein by the well-intended
clinician. The superficial ulnar artery (SUA) is present in almost 4% and the superficial radial artery (SRA) in about 0.2% of the
population. An inadvertent arterial-puncture instead of a venipuncture could have catastrophic results.
See the Complications Section on handling this type of situation in more detail.
For more information [CLICK HERE]
BLOOD
Blood is classified as a specialized connective tissue from
an embryological point of view. Blood is the fluid that
circulates through the heart, arteries, capillaries, and veins
and is the chief means of transport within the body. It
transports oxygen from the lungs to the body tissues, and
carbon dioxide from the tissues to the lungs. It transports
nutritive substances and metabolites to the tissues and
removes waste products to the kidneys and other organs
of excretion. It has an essential role in maintaining fluid
balance. The total blood volume of an adult varies between

5-6 liters for males and 4-5 liters for females.
Whole blood is blood drawn from the body from which
no constituent, such as plasma or platelets, has been
removed.
Blood fractionation is the process of fractionating whole
blood, or separating it into its component parts. This is
typically done with a centrifuge.
Figure 3a: A typical hematology lab centrifuge apparatus
Figure 3b: Centrifuged blood in tube
Blood can be separated into 3 layers by a process of centrifugation (fast spinning of blood filled tubes in a laboratory
apparatus called a centrifuge).
1. The upper yellowish layer is blood plasma.
2. The thin, middle, buffy layer is white blood cells, as well as blood platelets.
3. The bottom layer is packed erythrocytes, or red blood cells. Blood serum is blood plasma without fibrinogen
or the other clotting factors.
BLOOD PLASMA
The liquid phase of the blood, obtained by sedimentation
or centrifugation of blood treated with an anticoagulant
(anti-clotting agent).
Plasma is mostly fluid, consisting mainly of water, as well
as three specific types of proteins (albumin, globulins,
36
and fibrinogen), dissolved salts (ions), food nutrients,

waste products, hormones, vitamins, and dissolved gasses
(oxygen and carbon dioxide).
Albumins main function is to prevent water from leaving
the capillaries thus albumin holds water inside the
intravascular space.
Globulins are mainly the immune systems antibodies.

Fibrinogen plays a major role in blood clotting.
Blood serum is blood plasma without fibrinogen or the
other clotting factors.
BLOOD CELLS
If a drop of human blood is thinly smeared across a
microscopy slide, you can see various different blood cells.
The pink roundish structures with white centers are the
erythrocytes (red blood cells).
of hemoglobin molecules. This maximizes the cells

oxygen-carrying ability. The biconcave shape increases
its surface area to ensure optimal gas exchange.
HEMOGLOBIN
Hemoglobin has four protein chains, and each protein chain is called a
globin. Hemoglobin consists of four contorted protein globin chains, two
Apha and two Beta.
Figure 4: A normal blood smear
Figure 4: A graphic illustration of hemoglobin
Blood cells include red blood cells, a variety of white blood

cells (lymphocytes, neutrophils, basophils, eosinophils,
and monocytes), and blood platelets.
Leukocytes include the following white blood cells:
lymphocytes, neutrophils, eosinophils, and monocytes.
Blood platelets are small cell fragments that play an
essential role in the blood clotting process. The buffy layer
between the plasma and red blood cells contains all the
white blood cells, as well as the blood platelets.
A heme is ring shaped molecule with an iron ion (Fe+2).

Oxygen has a high affinity to the heme ion. Each
hemoglobin molecule has four hemes; each heme
provides a place to carry an oxygen molecule. So each
hemoglobin molecule can carry four oxygen molecules.
Every single red blood cell is packed with 280 million
hemoglobin molecules. It follows that one red blood cell
could carry about one billion oxygen molecules!
Packed red blood cells are red blood cells that have
been separated from whole blood for transfusions. Packed
red blood cells (RBCs) essentially contain the same amount
of hemoglobin as whole blood, but most of the plasma
has been removed.
Hematology: Hematology is the study concerned with

the diagnosis, treatment, and prevention of diseases of the
blood and bone marrow, as well as of the immunologic,
hemostatic (blood clotting) and vascular systems. Because
of the nature of blood, the science of hematology
profoundly affects the understanding of many diseases.
Erythrocytes (red blood cells/RBCs)

Erythrocytes are biconcave in shape for two good reasons:
Flexibility. Its a very flexible cell that can fold or bend
to go through small capillaries.
Large surface area. RBCs are designed for one main
purpose: to carry O2 from the lungs to the tissue
cells and CO2 from tissue to the lungs. RBCs perform
this dedicated function for 120 days and then the
spleen and liver removes them from the bloodstream.
A mature RBC has neither a nucleus nor any other
organelles. Its packed mostly with large numbers
37
Venipuncture Course and Kit | PREPARATION
CASE STUDY 2:
CONTRACTING ONE OF THE MOST FEARED DISEASES IN THE WORLD TODAY
40
Imagine being extremely ill with a high fever, a splitting

headache, diarrhea, and vomiting. You are also bleeding
from the nose, the mouth, and all bodily orifices! The
healthcare workers treating you are wearing clothes
that look like space suits. In one week, your chance of
survival is a slim 20%.
Sounds exaggerated? This is realthe hemorrhagic fever
of the highly contagious Ebola virus! In the past 20
years, more than 1000 confirmed cases of Ebola had a
mortality rate of 80% to 90%. There is no known drug or
cure for Ebola.
Marilyn Lahana of Parkmore, South Africa is believed
to have been the first diagnosed victim to contract the
deadly Ebola virus. For three weeks, she bravely fought
for her life in isolation at Johannesburg Hospital, while
medical officials desperately scrambled to find the source
of the virus. Marilyn Lahana was a nurse working at a
private clinic in Johannesburg. Officials believe that she
contracted the virus from a man from Zaire who died at
this clinic undiagnosed three weeks earlier. People who

had been in contact with Marilyn were checked twice daily
for symptoms, but fortunately none of her family members
or friends contracted this vicious disease.
SHORT NOTES ON MEDICAL

HISTORY
WARNING!
The taking of a comprehensive medical history by a

qualified medical professional is essential for diagnosing,
managing, and treating any patient. A full comprehensive
medical history preceding each and every venipuncture
procedure is not only unnecessary but also impractical;
however a short list of relevant questions will go a long way
to avoiding complications and medico-legal problems.
Routinely ask about:
Bleeding tendencies and anticlotting therapy.
Previous complications following phlebotomy/
venipuncture (e.g., phlebitis, thrombosis, DVT, difficult
venous access, and accidental intra-arterial injections).
Infectious diseases (e.g., hepatitis, HIV).
Allergies specifically regarding cleaning agents (e.g.,
Iodine, strapping, plasters, and drugs or medications
to be administered via the IV route). Specifically
ask about latex allergy if you use latex gloves or a
disposable latex tourniquet.
Ebola is spread through tainted blood and the only sure

cure is by prevention. Patients with Ebola are kept under
strict quarantine.

All healthcare workers need to have a thorough

knowledge of sterility, asepsis, barrier techniques,
as well as well as, the various skills associated with
aseptic technique.
Saving lives are not necessarily intricate cardio or
neurosurgical procedures in most cases medical
professionals save lives by performing simple routines
like washing hands and donning clean gloves.
Your and your patients lives depend on you to strictly

follow procedures for sterility and asepsis do not slip up!
Some syringes and medication vials contain a tiny amount

of latex. Ensure that all items are factory marked: latex-free
if you treat a patient who is allergic to latex. A patients
severe latex allergy may become life threatening in a
matter of minutes!
41
PROJECT 2
TAKE A MEDICAL HISTORY
Gather the relevant information and prevent avoidable mishaps!
See The Apprentice Doctor Foundation Course for information on how to take a comprehensive medical history[CLICK
HERE]
PATIENT INFORMATION
When a physician orders a laboratory blood test, a lab requisition form needs to be filled out accurately and signed by
the physician. It is important to have a double-check system on requisition forms and sample labeling to ensure that the
correct blood samples are taken from the correct patient and that the correct results are allocated to the correct patient.
SAMPLE REQUISITION FORM

An accurately completed requisition form must accompany
each sample submitted to the laboratory. This information
is essential to process the specimen correctly. The patients
information is required:
Full names
Identification number
Date of birth
Gender
Full name of the requesting physician
Date and time of collection
Source of specimen (this information must be given
when requesting histology, microbiology, cytology,
fluid analysis, or other testing where analysis and
reporting is site specific.)
Phlebotomists name
Indicate the test(s) requested
An example of a simple requisition form with the
essential elements is shown below:
[PRINT A FORM]
A number of forms are available in the kit.
LABELING THE SAMPLE

A properly labeled sample is essential so that the results of
the test match the patient. NOTE: The information MUST
match the information on the requisition form. It should
show:
The patients full name
The patients identification number
Date, time and name (or initials) of the phlebotomist
must be on the label of each tube
Automated systems may include labels with bar codes.
Examples of labeled collection tubes are shown below:
42
Figure 5: Examples of labeled collection tubes
SHORT NOTES
ON ASEPTIC TECHNIQUE
Study this section carefully as it can make the difference between frequent and occasional complications and
possibly the difference between life and death!
Follow an acceptable hands-hygiene protocol:
Handwashing techniques
Wash your hands with an acceptable
method before and after every
venipuncture procedure.
Alcohol rub
Hygienically preparing your hands
with an alcohol-based hand sanitizer
before and after procedures is
a permissible way to prepare
uncontaminated hands aseptically.
Contamination
may
be
any
environmental dirt, bodily fluids
(e.g., blood) secretions (e.g., saliva) or
excretions (e.g., feces.)
Don clean gloves
Figure 6: A surgeon scrubbing before surgery
PROJECTS 3A 3I
PROJECT 3A
A TECHNIQUE FOR PROPER HANDWASHING
Learn to wash your hands prepare them hygienically before examining a patient
VIDEO
43
INFORMATION
It is recommended that students study the WHO

Guidelines on Hand Hygiene before starting this section
of the course.
The simple act of handwashing is probably the single
most important way to reduce the transfer of harmful
microorganisms from one person to another.
For handwashing to be effective, you must adherence
to proper technique.
Handwashing is also important for reasons of personal
hygiene, e.g., washing hands after using the bathroom
and before meals.
Staff working in the food and restaurant industries
require a high level of hygiene including a
protocol regarding handwashing in order to avoid
contaminating food with dangerous microorganisms.
SETTING:
The bathroom or any room with a suitable faucet and sink
for washing hands.
REQUIREMENTS

A nail clipper or nail care set.

Soap (antiseptic or regular). Liquid soap is preferable,
but a bar of soap will do.
Clean single-use towels, e.g., disposable paper towels.
NOTE:
1. Handwashing can be subdivided into the following
seven important steps.
Open faucet
Wet
Soap
Wash
Rinse
Dry
Close faucet
2. Hands should be washed for at least 40-60 seconds
to be effective.
3. A healthcare workers nails should ALWAYS be kept
neat, short, and hygienically clean!
PROCEDURE:
STEP 1
Turn on the faucet and adjust to a moderate stream of
water. Wet both hands up to the wrists.
44
STEP 2
Apply enough soap to the hands until you have a rich
foamy lather. Completely lather the surface of both hands
and up the wrist.
STEP 3
Repeat the following actions at least five times:
3.1 Rub hands palm to palm.
3.2 Right palm over the back of the left hand with

fingers interlaced and vice versa.
3.3 Palm to palm with fingers interlaced.
3.4 Backs of fingers to opposing palms with

fingers interlocked.
3.5 Rotational rubbing of left thumb clasped in

right palm and vice versa.
3.6 Rotational rubbing, backwards and forwards

with clasped fingers of right hand and vice
versa.
3.7 Rotational rubbing of wrist by opposing palm

and vice versa.
STEP 4
Rinse the hands well. Allow running water to flow over
the hands. If possible let the water run from the fingertips
to the palms and then towards the wrists. Rinse soap off
completely.
STEP 5
Dry hands thoroughly with a single-use disposable paper
towel. Start at the fingers, work to the palms and back of
the hands, and lastly dry the wrist areas. Use the same
towel to turn off the faucet. Alternatively use your elbow
to close the faucet. Do not use your clean hands.
STEP 6
Your hands are now hygienically prepared. If you intend to
perform a clinical examination, don clean gloves.
(See PROJECT 3C)
HINTS:

Use disposable paper towels. Cloth towels are not

suitable in a healthcare setting as they harbor and
retain bacteria and become more contaminated
with use.
Frequent handwashing will remove the skins
natural surface oils, causing scabby and rough
skin. To reduce this effect, wash hands in lukewarm
rather than hot water.
Use a moisturizing hand lotion containing lanolin to
help keep your hands feeling smooth and comfortable
POINTS OF INTEREST

An infection acquired in a hospital by a patient or a

staff member is called a nosocomial infection.
In the United States, nearly 2 million infections occur
among hospital patients (about one infection in 20
patients), and 99 000 of these patients die each year.
Hospital-acquired infection can be life threatening
and hard to treat due to multi-resistant bacterial
strains. Hand hygiene is one of the most important
ways to prevent the spread of infection.
In the United Kingdom, hospital-acquired infections
result in approximately 10,000 deaths each year.
Waterless alcohol-based hand sanitizers are effective
alternatives for routine sanitization of uncontaminated
(without blood, bodily fluids and dirt) hands
(see PROJECT 3B).
Surgeons and operating room staff use a special

technique called surgical scrubbing before an
operation (see PROJECT 3F). This technique is similar
to the above described handwashing technique with
the following main differences:
-- Surgical scrubbing requires meticulous scrubbing
with a sterile brush.
-- It requires more time (from 2 to 5 minutes).
-- The wash area extends from the nails up to just
above the elbows.
45
PROJECT 3B
CLEANING HANDS WITH AN ANTISEPTIC RUB
Print out the World Health Organizations (WHO) guideline diagram and follow the steps
VIDEO
PROJECT 3C
HOW TO DON (PUT ON) CLEAN GLOVES
46
Touching only the cuff, take the first glove out of the
original box.
Try to touch only the wrist area of the glove, i.e., the
top end of the cuff.
Don the first glove by sliding it over the fingers, palm,
and wrist.
With the bare hand, take a second glove from the box
again, only touching the gloves cuff or wrist.
Don the second glove touch only the external

surface of the second glove with the already gloved
hand.
Your gloved hands should not touch anything else
that is not indicated for glove use.
PROJECT 3D
HOW TO SAFELY REMOVE USED GLOVES

Pinch one glove at the wrist level to remove it, without

touching the skin of the forearm, and peel away from
the hand, thus allowing the glove to turn inside out
Hold the removed glove in the gloved hand and slide
the fingers of the ungloved hand inside between the
glove and the wrist. Remove the second glove by
rolling it down the hand and fold into the first glove
Discard the removed gloves in a suitable biological
waste container
Perform hand hygiene
PROJECT 3E *
HOW TO CHANGE INTO THEATER ATTIRE
*See The Apprentice Doctor Foundation Course for further information on how to perform these procedures. [CLICK HERE]
PROJECT 3F *
HOW TO SCRUB FOR A STERILE PROCEDURE
PROJECT 3G *
HOW TO GOWN FOR A STERILE PROCEDURE
47
PROJECT 3H
HOW TO DON STERILE GLOVES
PROJECT 3I*
HOW TO REMOVE CONTAMINATED GLOVES
48
PATIENT
POSITIONING
PERFORMING VENIPUNCTUREON A VEIN OF THE UPPER
EXTREMITY
Position the patient comfortably with their arm at heart
level or just below. Outpatients should be placed in the
sitting position and hospital patients lying in bed, in the
semi-Fowlers or supine position.
Inspection and palpation are essential components
for selecting a suitable vein; therefore the intended
venipuncture site must be exposed. Good lighting is
required. If needed, position the light at an angle to
enhance inspection of the veins.
Place a clean linen-saver below the arm to protect bed
sheets.
Ensure that all the venipuncture equipment and items that
you need are within easy reach.
Figure 8a: Patient in Semi-Fowlers position
Figure 7: Patient in sitting position
Figure 8b: Patient in supine position
49
The supine position is best when performing venipuncture

on a vein of the lower extremity or neck. To distend the
veins, you may position the bed in a slight Trendelenburg
position for the external jugular vein and in a slight reverse
Trendelenburg position for the veins of the lower extremity
Figure 9a: Trendelenburg
PATIENT POSITIONING FOR

ARTERIAL BLOOD SAMPLING
FROM THE RADIAL ARTERY
The patient should be seated comfortably (patients in bed
in the semi-Fowlers position) and the arm comfortably
extended towards you, wrist up, and extended with the
skin over the radial artery taut. Let the forearm rest on a
small pillow. Use a rolled towel under the back of the hand
to facilitate the extended wrist position.
PATIENT POSITIONING FOR

ARTERIAL BLOOD SAMPLING
FROM THE FEMORAL
ARTERY
The femoral artery is generally not recommended for ABG
sampling.
Place the patient in the supine position, with the groin and
leg extended and slightly abducted.
Figure 9b: Reverse Trendelenburg position
50
TOURNIQUETS - PROJECTS 4A 4D
PROJECT 4A
HOW TO APPLY A TOURNIQUET (DISPOSABLE)
A simple technique to facilitate easier venipuncture
INFORMATION
A tourniquet is a constricting or compressing device used
to control (stop or reduce) venous or arterial circulation to
an extremity for a period of time.
IMPORTANT NOTE
REGARDING ARTERIAL
TOURNIQUETS:
A surgeon may use an arterial tourniquet under controlled
conditions within specific time limits to stop the arterial
blood flow to a limb. However, in the following discussion
we will exclusively focus on the use of tourniquets to reduce
or stop the venous return of blood to the heart for a period
of time.
A venous tourniquet is usually applied 7-10 cm (3-4 inches)
above the intended venipuncture point on either the upper
or lower extremity. The idea behind applying a tourniquet
is to minimize the flow of venous blood back to the heart

while allowing the arterial blood to flow undisturbed to
the extremity. Blood will thus fill and distend the veins due
to their fairly thin and collapsible walls. Then the veins are
easier to see and feel, thus making venipuncture easier
to perform without complications. Pressure exerted by
the tourniquet must be high enough to stop or impede
the venous return to the heart, but low enough to allow
free arterial blood-flow, about 45-65 mmHg (millimeters
Mercury).
From a hygienic point of view, a disposable tourniquet is
the best option, as each one is discarded after a single-use.
Disadvantages may include cost and secondly you must be
careful of latex allergies, as these tourniquets are often made
of latex. Affordable latex-free disposable tourniquets (like
the one in your kit) are available and recommended.
Reusable tourniquets should be properly laundered at
regular intervals and after any suspected contamination.
Enquire about this at your hospitals infection control section.
51
REQUIREMENTS
You will need:
A volunteer test patient
One disposable (latex-free) tourniquet
A re-usable tourniquet
A blood pressure cuff (if you have one available)
FOLLOW THESE STEPS FOR

DRAWING BLOOD FROM THE
CUBITAL FOSSA AREA:
STEP 1
Take a short medical history, especially regarding allergies
(latex, Iodine and IV drugs, etc.).
The tourniquet and gloves in this kit are latex-free
STEP 2
Remove clothing from the arm up to the middle of the
upper arm. Place the tourniquet about 7-10 cm (3-4
inches) above the elbow.
STEP 3
Place the tourniquet under the patients arm with an end
in each hand. Ensure that it lies flat on the skin surface
STEP 4
Swap the two tourniquet ends to opposite hands so
that the end on the right is closer to you. Pull the ends
upwards to form an X.
52
STEP 5
Fold the end on the right side over on itself. Pull both
ends upwards, with the end on the right side being
somewhat tighter.
STEP 6
Tuck the double-folded end halfway under the other left
end, leaving the free end, approximately 5 cm (2 inches)
long, pointing away from you. Ask your volunteer patient
to clench a fist to help distend the veins. Inspect and
palpate the veins.
STEP 7
When you are finished with the venipuncture procedure,
simply pull the free end to release the tourniquet.
POINTS OF INTEREST
If a tourniquet is used for preliminary vein selection, do not
leave the tourniquet on for more than one minute. If you
need more time, release it for two minutes then reapply.
Recommended maximum tourniquet time for phlebotomy
procedures is one minute. WHO guidelines give the
maximum time as two minutes.
The following guidelines ONLY apply to practicing:
When practicing you may leave the tourniquet on for
longer as long as one does not make it so tight as to
stop the arterial flow as well which is unlikely. For safety
reasons when practicing do not leave the tourniquet on for
longer than 5 minutes. Take a break for at least 5 minutes
before reapplying.
PROJECT 4B
HOW TO APPLY A TOURNIQUET (TOURNISTRIP)
The Tournistrip is an easy-to-use disposable tourniquet that complies with single-use tourniquet protocol.
INSTRUCTIONS
STEP 1
Remove Tournistrip from box.
STEP 2
Expose the adhesive panel on
Tournistrip (see peel here)
STEP 3
Place Tournistrip around arm with
the printed side facing outward.
STEP 4
Hold the tab end between thumb
and forefinger and pull the slim end
to tighten.
STEP 5
Release Tournistrip.
Pull a Tournistrip from the roll and tear along the perforated
line. You can use the tabs on the box to help further reduce
cross infection.
Peel the removable section before wrapping the tourniquet

around arm.
Slip the slim end through the slot in the wider tab end.
When tension is sufficient, stick the slim end down on the

exposed adhesive strip
If necessary, lift Tournistrip away from the adhesive and
reapply.
To remove, pull slim end up and away from adhesive section.
Order Tournistrips [Click Here]
53
PROJECT 4C
HOW TO APPLY A TOURNIQUET (REUSABLE)
The main concern with reusable tourniquets is the
possibility of transferring harmful microbes to a patient,
especially if the cleaning recommendations are not
followed to maintain the highest levels of hygiene possible.
Reusable tourniquets if you follow the hygienic handling
recommendations see TOURNIQUETS CLEANING
GUIDE for more information.
A good reusable tourniquet should have an easy

application lock, as well as a quick release mechanism.
A simple design with VELCRO (like the one supplied in this
kit will do the job equally well).
[SEE VIDEO CLIP ON HOW TO APPLY THESE
TOURNIQUETS]
The BOA IV constricting band is an innovative reusable tourniquet that is simple to use and makes applying a tourniquet
both effective and simple visit www.NARescue.com for more information.
PROJECT 4D
HOW TO APPLY A TOURNIQUET (BLOOD PRESSURE CUFF)
Apply a blood pressure cuff 7-10 cm (3-4 inches) above the
intended venipuncture site.
Inflate the cuff to about 60 mmHg.
Proceed with the venipuncture procedure.
Deflate as soon as the task is completed (1 minuteno
more than 2 minutes if drawing blood for the lab).
54
PROJECTS 5A 5D
PROJECT 5A
IDENTIFY THE VEINS OF THE UPPER EXTREMITY
INFORMATION
REQUIREMENTS
Veins, by definition, are blood vessels that carry blood

towards the heart.
The veins of the arms are anatomically divided into two
groups: superficial and deep. The two groups communicate
(anastomose) frequently with each other. The superficial
veins are placed immediately beneath the integument
between the two layers of superficial fascia. The deep
veins often accompany the arteries. For the purpose of this
project we will focus in on the superficial veins.
You will need:

Alcohol hand rub
A pair of clean gloves
A tourniquet
A skin marker pen
A volunteer (A person with a low BMI, male, athletic,
middle-aged, or older with fair skin will show the veins
more clearly.)
If no volunteer is available, use your own arm
Good lighting
55
FOLLOW THESE STEPS
STEP 3
Study the detailed illustration of the veins of the upper

extremity (arm). [CLICK HERE]
Ask the volunteer to lie down and let the arm hang down
below the rest of the body to allow passive gravitation to
fill the veins with blood. Apply the tourniquet about 5-7
cm (2-3 inches) above the elbow joint
STEP 2
STEP 4
STEP 1
Have a look at the simplified diagrams:
Prepare your hands hygienically and don clean gloves.

(Gloving is optional for this project.)
See PROJECTS 3A, 3B and 3C
STEP 5
Use the simplified diagram to identify the veins of the
ventral (front) side of your arm by inspection and by
palpation. Use the tips of your middle three fingers.
STEP 6
Use the skin marker pen to draw the veins on the arm.
STEP 7
Figure 10a: The ventral arm veins
Identify the veins of the dorsum of the hand (upper

side), as per the simplified diagram, by inspection and by
palpation. Use the tips of your middle three fingers.
STEP 8
Use the skin marker pen to draw the veins on the hand.
Feel free to take a photograph of the venous pattern of
your volunteers arm. You may also want to label the veins
using the diagrams in Step 2.
POINTS OF INTEREST
Figure 10b: The dorsal hand veins
Figure 10c: The cubital fossa veins
56
The anatomical patterns of veins vary more than those of

the arteries of the body.
Look at this excellent anatomical study and publication:
Cubital Fossa Venipuncture Sites Based on Anatomical
Variations and Relationships of Cutaneous Veins and
Nerves by Kouji Yamada and coworkers. [Click Here]
The flow of blood in the venous system is complex for
several reasons:
The relatively low pressure within the veins.
The flow rate varies and is somewhat dependent on
the contraction of muscles.
Gravity affects the flow rate and intravenous pressure.
The collapsible nature of the relatively thin venous
walls.
Valves are present within the lumens of most veins.
Veins carry a large volume of blood: about 64% of the
blood volume!
PROJECT 5B
IDENTIFY THE VEINS OF THE LOWER EXTREMITY
INFORMATION
REQUIREMENTS
You will need:
Alcohol hand rub
A tourniquet
A skin marker pen
A suitable volunteer (A person with a low BMI, male,
athletic, middle-aged, or older with a fair skin will
show the veins more clearly.)
If no volunteer is available, use your own leg
Good lighting
STEP 3
Ask the volunteer to expose the leg area up to some
distance above the knee. The person should be standing,
sitting, or lying down with the leg lower than the rest of
the body to allow passive gravitation to fill the veins with
blood. Apply the tourniquet somewhere at least 10-15 cm
(4-6 inches) above the knee joint.
FOLLOW THESE STEPS

STEP 1
Study the detailed illustration of the veins of the lower
extremity (leg).
STEP 2
Have a look at the simplified diagram:
Figure 12: Examining the veins of the leg
STEP 4
(Gloving is optional but strongly recommended.)
Figure 11: The anterior leg veins
57
STEP 5
Identify the veins, using the simplified diagram, by
inspection and by palpation. Use the tips of your middle
three fingers.
the superficial veins into the deep venous system through

small perforator veins. Superficial, deep, and perforator
veins have one-way valves that allow blood to flow only
towards the heart.
A blood clot (thrombus) in one of the deep veins of the
leg can become life threatening when a part of the blood
clot breaks off (now called an embolus). The embolus may
travel through the heart and into one of the pulmonary
arteries where it will lodge in a blood vessel inside the lung.
A clot (thrombus) in the superficial veins might cause
discomfort and pain, but it is usually not a cause for
pulmonary embolism.
IMPORTANT WARNINGS
Figure 13: Identifying the greater saphenous vein
STEP 6
Use the skin marker pen to draw the veins on the leg. Feel
free to take a photograph of the venous pattern of your
volunteers leg (of course, with permission). You may also
label the veins using the diagram in Step 2.
POINTS OF INTEREST
There are two types of veins in the legs: superficial veins
and deep veins. Superficial veins lie just below the skin
and are usually visible on the surface. Deep veins are
located much deeper, next to the muscles and arteries
of the leg close to the femur and tibia. Blood flows from
58
As a general rule, always use the veins of the upper

extremities as your first choice for routine venipuncture.
Venipuncture on the lower extremities, in particular the
feet, is contraindicated in most situations because of the
increased bacteria flora on the feet and the risks of possible
infection and thrombosis.
Venipuncture on the lower extremities shall not be
performed on:
Patients who are diabetic or who suffer from
thrombophlebitis, venous thrombosis, or edema.
Legs or feet with any type of symptom (burning,
itchiness, pain, swelling, etc.).
Legs or feet showing the following clinical signs:
tenderness, ulceration, swelling, tumors, or any
change in color or temperature.
Legs or feet when injuries, areas of bruising, previous
burns, or scar tissue are visible.
Phlebotomists and nursing staff are required to get
permission from the attending physician before
using a vein of the lower extremity for venipuncture/
phlebotomy.
PROJECT 5C
OTHER IMPORTANT VEINS (FACE, NECK AND CHEST)
INFORMATION
The external jugular vein has two pairs of valves: the lower pair is located at its entrance into the subclavian vein and
the upper in most cases is about 4 cm above the clavicle. If you position a patient in the Trendelenburg position (body
tilted about 15 with the head lower than the feet) you may notice the external jugular vein pulsating. This is caused by
retrograde pressure from atrial systole (keep in mind that the entrances of the atriums are valveless and the venous valves
are flimsy [SEE VIDEO CLIP].
REQUIREMENTS
You will need:
Alcohol hand rub
A skin marker pen
A suitable same-gender volunteer (A person with a low
BMI and a fair skin will show the veins more clearly.)
If no volunteer available, use your own neck in the
mirror
Good lighting
59
FOLLOW THESE STEPS
POINTS OF INTEREST
STEP 1
Study the detailed illustration of the veins of the neck

[CLICK HERE].
STEP 2
Have a look at the simplified diagram:
Figure 14: The head and neck veins
STEP 3
Ask the volunteer to expose the neck area. Place the person
in the Trendelenburg position (head and neck about 15
down), tilt the head slightly to the opposite side, and
apply light pressure just above the clavicle. You can also
ask your volunteer to forcefully exhaling against resistance
(closed lips) so you can see the veins more clearly. This will
increase the intra-thoracic pressure and help to engorge
the external jugular veins. Keep in mind that the course
of the neck veins may vary to some extent; some patients
have double external jugular veins.
STEP 4
(Gloving is optional but strongly recommended.)
STEP 5
Identify the external jugular vein on both sides by inspection
and palpation as it crosses the sternocleidomastoid
muscle as shown in the diagram. Identify the anterior and
posterior jugular veins if possible.
STEP 6
Use the skin marker pen to indicate the course of the vein.
With permission, take a photograph of the venous pattern
of your volunteers neck. You may also label the veins using
the diagrams in Step 2.
60
External jugular vein cannulation is a skill that

every medical student should master. It is a useful
alternative in certain situations for:
-- Repeated blood sampling.
-- Administering intravenous fluid, medication,
chemotherapy, radiological contrast, as well as
blood and blood products.
-- The external jugular vein may be the site of
preference for venipuncture with burn patients
involving all the extremities. It is also useful in an
emergency situation.
-- The internal jugular veins course runs under the
sternocleidomastoid muscle, so it is not visible
under the skin as the external jugular vein is. It is
commonly used to place central venous catheters/
lines.
PROJECT 5D
MAP THE VALVES IN VEINS
INFORMATION
There are valves in most veins; exceptions include the portal, the hepatic, and the internal jugular veins. Venous
valves are bicuspid (two) flap-like structures made of elastic tissue. The valves function to keep blood moving in
one direction only. Once the blood has passed from the arteries through the capillaries, it flows at a slower rate
because little pressure remains to move the blood along towards the heart. In the veins below the heart, blood flow
is facilitated by muscular contraction. When the muscles contract, blood within the veins is squeezed forward in the
vein and the valves open. When the muscle is at rest, the valves close, which helps prevent the backward flow of
blood. This is called the muscle pump.
The direction of venous return in the extremities is from finger and toe tips towards the body
REQUIREMENT
You will need:
Alcohol hand rub
A skin marker pen
A volunteer (Look for a person with a low BMI,male,
physically fit, middle-aged or older, or with fair skin
to show the veins more clearly.)
If no volunteer is available, use your own arm
Good lighting
METHOD 1
FOLLOW THESE STEPS
STEP 1
Prepare your hands hygienically and don clean gloves
(gloving optional but strongly recommended).
STEP 3
Occlude the vein distally (on the fingers side) by
applying firm pressure with an index finger. Press your
second index finger next to your first index finger.
Move the second index finger towards the elbow while
exerting mild pressure. This empties the blood from the
lumen as you move your finger along the vein.
STEP 4
Stop at the proximal side of the section identified and
then release the second index finger. The vein will
immediately refill up to the point where a venous valve
is situated. Notice that the previously distended vein
remains flat up to the valve inside the vein. Lift the first
index finger and note the flat section of vein filling up
with venous blood.
STEP 5
Mark the position of the valves with the skin marker pen
and photograph the valve-mapped arm.
STEP 2
Identify a suitable volunteer: someone with clear and
prominent superficial veins on their arms. Ask this
person to make a fist and extend the arm, with the palm
up and slightly below elbow level. Locate a prominent
section of vein of about 10 cm (4 inches) on the inside
of the forearm.
61
METHOD 2
FOLLOW THESE STEPS
STEP 1
(Gloving optional but strongly recommended.)
STEP 2
Have a volunteer make a fist and extend the arm, with
the palm up and slightly below elbow level. Locate a
prominent vein on the inside of the forearm.
STEP 3
Starting near the elbow, run your finger along the vein
going towards the wrist. Exert mild pressure to empty

the blood from the lumen of the vein.
STEP 4
Blood will immediately refill the vein up to the point
where a venous valve is encountered and then you will
notice the distended vein remaining flat up to the point
of the valve inside the vein. Lift your finger and notice
how the flat section of vein fills up with venous blood.
STEP 5
Mark the position of the valves with the skin marker
pen. Take a photograph of the valve-mapped arm.
POINTS OF INTEREST

When drawing blood, injecting into a vein or putting

up an IV line, insert the needle above or some
distance below a valve. Avoid injecting straight into
a valve to avoid damage or complications.
In some individuals, the valves show up as small
nodular enlargements of the vein and are easily
identified.
Venous valve malfunction
Figure 16a and b: Example of varicose veins leg
Figure 15: Diagram of a normal and a varicose vein
Malfunction of the normal one-way valves in the veins

is the main underlying cause of varicose veins. This
causes venous blood to accumulate in superficial veins
and branches, causing the walls of the veins to distend
(enlarge) and stretch in a convoluted fashion.
62
Predisposing factors for developing varicose veins

include:
Ageaging causes wear and tear on the valves in
your veins.
Genderwomen are more likely than men to
develop this condition.
Hormonal changesespecially during pregnancy,
pre-menstruation, or menopause.
Geneticsvaricose veins tend to run in families.
Obesity.
Prolonged standing.
Varicose veins affect about 20% of the population.
They are more common in women (20-25%), than
in men (10-15%). Pregnancy is often an initiating
event in women. Varicose veins tend to get worse
with age.
Never attempt to use a varicose vein to perform
venipuncture!
BLOOD SAFETY INSTRUCTIONS

The following Projects, when performed on a patient in a real clinical setting, will expose you to blooda
potentially hazardous substance! For your own and your patients safety, these standard precautionary measures
should be in place at the hospital or medical institution to minimize the spread of infectious disease:

Appropriate aseptic and sterile techniques protocol.

Appropriate hygiene practices, particularly hand hygiene routines [See PROJECTS 3A and 3B].
Availability of protective barriers and usage guidelinesincluding the wearing of gloves, gowns, plastic aprons,
masks, eye shields, and goggles [See PROJECTS 3C to I].
Appropriate procedures for the handling and disposal of contaminated wastes.
Appropriate procedures for the handling and disposing of sharps.
Guidelines and procedures for the prompt handling of blood and body fluid spills.
Appropriate waste disposal measures must be in place to ensure that blood, other body fluids/substances, and
other potentially infectious materials are disposed of safely.
An established protocol for preventing, reporting, and handling sharps injuries and other infective agent transfer
incidents (e.g., body fluid splash on a mucous membrane).
PROJECT 6A
PREPARE TO ADMINISTER AN INJECTION
Choose a suitable syringe and needle and draw up medication from various medicine vials
PLEASE TAKE NOTE:

This project offers general guidelines and steps to follow
in a clinical setting.
The various medication vials (containers) are not included
in the kit.
Figure 17: A dental needle (left) and a hypodermic needle (right). Note
that the dental needle has a longer section pointing forwards and a
shorter section pointing backwards. The back end is for penetrating the
diaphragm of the dental cartridge and the front end for injecting.
63
CHOOSE THE CORRECT SIZE

SYRINGE:
0.5ML AND 1ML
(DEDICATED DIABETIC
SYRINGES)
Note: Milliliter (ml) indicates the same volume as cubic
centimeter (cc)
The standard insulin syringe holds one ml (or one cc),
divided into 100ths, which is equal to one UNIT of insulin. It
is vital that you exclusively use a U100 insulin solution with
a U100 syringe. There are some smaller insulin syringes
that only hold 0.5ml but they are still marked properly for
U100 insulin even though they are smaller in size.
The syringe in the kit is a 0.5ml insulin syringe with a
protective cap over the needle and plunger. Remove these
orange colored caps to use. Orange is the color code for
U100 insulin.
1ML SYRINGE (TB SYRINGE)
IMPORTANT NOTES:
Always keep your and your patients safety as your
first priority!
Use insulin syringes only for insulin.
Too high a dose of insulin may cause a hypoglycemic
coma, or irreversible brain damage. It can even be lethal!
Too low a dose given to a diabetic may lead to a
hyperglycemic coma.
Use safety needles whenever possible according
to the manufacturers instructions and discard in a
dedicated sharps safety container after use.
In all cases when preparing more than one syringe of
different medications or if you are not administering
the medication straight away, clearly label the syringe
above the volume markings the type of medication
and the concentration (e.g., ketamine 100 mg/ml).
Always take great care to avoid needle stick injuries
when working with sharps!
If you need to recap a needle use the one hand
scoop technique (see below).
Never recap a blood-contaminated needle.
Used for Heparin SQ or TB Intradermal skin testing. It holds

1ml and has 0.1ml markings on the side. NEVER draw up
insulin in this syringe.
3ML 5ML SYRINGES

Commonly used for IM injections or for mixing or drawing
up other medications. Use the smallest syringe that will
hold the dose properly.
10ML 12ML SYRINGE

Used for mixing or drawing up other medications, for central
line flushing, and to inflate/deflate Foley catheter balloons,
as well as for urine specimen collection from a Foleys port.
CHOICE OF NEEDLE GAUGE

SIZES (ADULTS):
Subcutaneous injections: 25-27 gauge, 10-16mm (3/8-5/8
inch)
IM injection (need 2 needles): 21-25 gauge, 25-38mm (11 inch)
Drawing up from vials: 18-21 gauge, 25mm (1 inch)
Figure 18: The one hand scoop technique for recapping a needle
64
YOU WILL NEED:

Syringe with attached needle (10ml or 12 ml and

18G-21G needle)
10 ml glass vial of sterile water
Alcohol wipes
Sharps container
Sticker paper or a strip of strapping for labeling
A pen for labeling
remove the protective cover from the safety syringe,

see PROJECT 1B).
Important: DO NOT touch the needle!

HOW TO DRAW UP
MEDICATION
Carefully remove the needle cap from the syringe (or
Turn the vial horizontally and insert the needle into

the vial.
Gently pull back the plunger and allow the medication
In each of the projects to draw up medication in various

ways, follow begin each time with these steps:
to fill the syringe. Withdraw the required amount of
GENERAL PREPARATION*
medication as specified. Avoid drawing air by keeping
the needle tip below the fluid meniscus of the
Clean the work surface with an antiseptic solution.

Open a clean work surface cover.
Gather all the items to be used with the outer package
intact.
Prepare your hands hygienically.
Don clean gloves (optional).
Open the syringe on the work surface cover.
Partially open the needle at the hub end.
Connect the needle to the syringe and place on the
cover
Tear open an alcohol wipe and drop it on the work
surface cover
HOW TO DRAW UP
MEDICATION FROM A GLASS
VIAL
FOLLOW THESE STEPS

General preparation (*see above)

Hold the vial upright between your fingers and swivel
the vial two to three times in a circular motion to ensure
that all medication is in the bottom of the vial and not
in the top section. Do not flick your finger against the
vial as you may break the vial and injure your finger.
Identify the small dot on the vial and face it towards
you. Hold the main body of the vial between the
thumb and index finger of the one hand and the top
part of the vial between the thumb and index finger of
the other hand.
Crack the vial open by bending the top backwards in a
single definite action, and place it upright on the work
surface.
medication. Withdraw the needle from the vial.

To remove air bubbles, hold the syringe vertically with

needle pointing up. Tap the syringe gently to move
any air bubbles toward the needle.
Gently push the plunger to remove the air and possibly

bubbles mixed with a couple of droplets of medicine.
Label the syringe by placing a sticker with the name
and concentration of the medication noted legibly.
Do not stick the label over the volume markings.
Prepare to administer the medication using the

appropriate route (See PROJECTS 8, 9 or 11D). If
IMI injectionappropriately discard the needle used
to draw up the medication and place a new needle
(preferably a safety needle) on the syringe.
65
IMPORTANT NOTE
REGARDING WITHDRAWING
MEDICATION FOR AN IM
INJECTION

Most training centers recommend a standard twoneedle protocol when performing an IMIthe first
needle for withdrawing the medication and the
second sterile needle for injecting the patient.
Be careful when changing needles. You may use a
conventional needle to draw up the medication, but
use a safety needle when injecting the patient.
A single needle protocol for IMI injections is not
recommended for the following reasons:
The fine, sharp needle tip is easily damaged when
hit against the bottom of the glass vial. This is not
too uncommon and increases pain on subsequent
injection!
The first needle may touch a non-sterile surface and
become contaminated with microbes.
HOW TO DRAW UP
MEDICATION FROM A
GLASS VIAL WITH A RUBBER
MEMBRANE
YOU WILL NEED:

Syringe with attached needle

Vial of medication
Alcohol wipes
Sharps container
FOLLOW THESE STEPS:


Carefully remove the protective cap from the vial
and swab the top of the vial thoroughly with a fresh
alcohol wipe. Allow time to dry.
Determine the volume of medication required in ml
(cc). Draw in an equal amount of air by pulling back
on the syringe plunger.
Carefully remove the needle cap from the
syringe (or remove the protective cover
from the safety syringePROJECT 1B)
Important: Do not touch the needle!
66
Insert the needle into the center of the rubber

membrane of the vial.
Turn the vial upside down and slowly inject air from
the syringe into the vial of medication.
Gently pull back on the plunger, allowing the
medication to fill the syringe, and withdraw the
required amount of medication as specified. Avoid
drawing air by keeping the needle tip below the
fluid meniscus of the medication. Withdraw the
needle from the vial.
Hold the syringe with needle pointing upwards
and tap the syringe gently to move any air bubbles
towards the needle.
Push the plunger gently to remove the air and air
bubbles, possibly mixed with a couple of droplets
of medicine.
appropriate route (See PROJECTS 8, 9 or 11D). If
IMI injection, appropriately discard the needle used
on the syringe.
HOW TO DRAW UP
MEDICATION FROM A
PLASTIC CONTAINER


Open the plastic container (usually containing sterile
water or normal saline solution for injection) by using
a 180 twist-and-open action.
Carefully remove the needle cap from the syringe (or
remove the protective cover from the safety syringe
PROJECT 1B).
Important: Do not touch the needle!
Turn the vial horizontally and insert the needle into
the vial.
Gently pull back the plunger and allow the medication
to fill the syringe. Withdraw the required amount of
medication as specified. Avoid drawing air by keeping
the needle tip below the fluid meniscus of the
medication. Withdraw the needle from the vial and
remove any air and air bubbles in the syringe.
appropriate route. If IMI injection appropriately
discard the needle used to draw up the medication
and place a new needle on the syringe.
SAFETY
Plastic vials are safe from the point of view that it eliminates
the possibility of a sharps injury to the clinician.
On the down side, one can accidentally stick a needle in
an unused vial and unintentionally contaminate it, or stick
the needle right through the container and cause a needle
stick injury.
HOW TO DRAW UP
MEDICATION FROM
A CONTAINER WITH THE
MEDICATION IN POWDER
FORM.
(MANY ANTIBIOTICS COMES
AS A POWDER IN A VIAL.)
SINGLE UNIT


Open the specific solvent (e.g., sterile water) and
withdraw the required amount into a syringe.
Carefully remove the protective cap from the vial
and swab the top of the vial thoroughly with a fresh
alcohol wipe. Allow time to dry.
Let the syringes needle penetrate the rubber
membrane of the powder vial.
Squirt the solvent into the powder and mix it
thoroughly by repeatedly injecting and withdrawing
the medication a couple of times.
Gently pull back on the plunger of the syringe, allowing
the medication to fill the syringe, and withdraw the
required amount of medication as specified. Avoid
drawing air by keeping the needle tip below the fluid
meniscus of the medication. Withdraw the needle
from the vial and remove any air and air bubbles in
the syringe.
appropriate route (SEE PROJECTS 8, 9 OR 11D). If
IMI injection appropriately discard the needle used
on the syringe.
Press down on the plastic activator to force diluent

into the lower compartment.
Gently agitate to effect solution.
Remove plastic tab covering center of stopper.
Sterilize top of stopper with a suitable germicide
(alcohol wipe).
Insert needle squarely through center of stopper until
tip is just visible. Invert vial and withdraw dose.
HOW TO DILUTE
MEDICATION IN A 1:10 RATIO

Use a 10ml or 12ml syringe with 18G needle attached.

Open a 1ml medication vial (e.g., epinephrine).
Withdraw the full volume of the vial into the syringe.
Open 10 ml of solvent (e.g., sterile water or normal
saline for injection vial) and withdraw 9 ml into the 10
ml (or 12 ml) syringe.
Discard the 1 ml of water remaining in the vial.
appropriate route.
NOTE:
It is safer to administer a medication that has potentially
serious or even life threatening side effects by diluting it
and injecting it slowly!
Directions for using a vial with a powder and

a solvent compartment (e.g., the ACT-O-VIAL
system)
67
POINTS OF INTEREST
STUDY THE CDC GUIDELINES FOR INJECTION
SAFETY:
What is injection safety?
Injection safety, or safe injection practices, is a set of
measures taken to perform injections in an optimally safe
manner for patients, healthcare personnel, and others. A
safe injection does not harm the recipient, does not expose
the provider to any avoidable risks, and does not result in
waste that is dangerous for the community (e.g., through
inappropriate disposal of injection equipment). Injection
safety includes practices intended to prevent transmission
of infectious diseases between one patient and another,
for example between a patient and healthcare provider,
and also to prevent harm such as needlestick injuries.
What is aseptic technique?
In this context, aseptic technique refers to the manner
of handling, preparing, and storing of medications and
injection equipment/supplies (e.g., syringes, needles and
IV tubing) to prevent microbial contamination.
What are some of the unsafe injection practices that
have resulted in transmission of pathogens?
The most common practices that have resulted in
transmission of hepatitis C virus (HCV), hepatitis B virus
(HBV), and/or other pathogens include:
Using the same syringe to administer medication
to more than one patient, even if the needle was
changed or the injection was administered through
an intervening length of intravenous (IV) tubing;
Accessing a medication vial or bag with a syringe that
has already been used to administer medication to a
patient then reusing contents from that vial or bag for
another patient;
Using medications packaged as single-dose or singleuse for more than one patient;
Failing to use aseptic technique when preparing and
administering injections.
68
What are some procedures that have been associated

with unsafe injection practices?
Unsafe injection practices that put patients at risk for HBV,
HCV, and other infections have been identified during
various types of procedures. Examples include:
Administration of sedatives and anesthetics for surgical,
diagnostic, and pain management procedures;
Administration of IV medications for chemotherapy,
cosmetic procedures, and alternative medicine
therapies;
Use of saline solutions to flush IV lines and catheters;
Administration of intramuscular (IM) vaccines.
The medications used in these procedures were in singledose or single-use vials, multi-dose vials, and bags. What
they had in common was the vials or bags were used for
more than one patient and were entered with a syringe
that had already been used for a patient; or the syringe
itself was used for more than one patient.
The above is an excerpt from the CDC website on
injection safety.
For more information and answers on frequently asked
questions go to the DCD website: http://www.cdc.gov/
injectionsafety/providers/provider_faqs_general.
html
PROJECT 6B
HOW TO PREPARE THE PUNCTURE SITE ASEPTICALLY
(ROUTINE VENIPUNCTURE)
A simple but essential step to prevent infections
INFORMATION
The skin harbors, in large numbers, a variety of bacterial
species, as well as other microorganisms. These microbes
(also called flora) can be divided into two groups:
resident flora (lives in and on the skin) and transient flora
(temporary visitor microorganisms). Resident and transient
flora do not normally cause diseases on the skin but if they
enter the body they may cause diseases. For example,
Staphylococcus epidermidis lives quite innocently on the
skin in great numbers but may cause sub-acute bacterial
endocarditis (SBE) under certain conditions if they enter
the blood stream.
It is impossible to sterilize (kill all known microorganisms
and spores) on a patients skin but one can reduce and
weaken these skin bacteria to the extent that it would be

unlikely for them to cause problems. Isopropyl alcohol is
the most common substance used for this purpose when
performing venipuncture/phlebotomy procedures.
Isopropyl alcohol is a colorless, flammable chemical
compound with a strong odor with the molecular formula
C3H8O. It is used in medical disinfecting pads (alcohol
preps), which typically contain a 6070% solution of
isopropyl alcohol in water. It kills bacteria by causing each
bacterium cell membrane to lose its structural integrity.
Then the isopropyl alcohol enters the bacterium cell
and denatures the proteins within, causing intracellular
dehydration. This is why allowing the alcohol to completely
evaporate spontaneously is so important in killing bacteria
before performing venipuncture.
REQUIREMENTS
You will need:
Antiseptic soap for handwashing or alcohol hand rub
A clean work surface cover
A tourniquet (re-usable)
Clean gloves
Alcohol prep swabs
69
FOLLOW THESE STEPS:
POINTS OF INTEREST
STEP 1
The total number of microorganisms on a persons skin is

estimated at 1012 (1,000,000,000,000).
Common species include:

Staphylococcus epidermidis

Staphylococcus aureus

Micrococcus species

Neisseria species
Streptococci
Diphtheroids

Small numbers of other organisms
Unfold the clean work surface cover and open it on your

working area. Place the following items on this cover:

Clean gloves

Alcohol prep swabs
STEP 2
Prepare your hands hygienically (wash or alcohol hand
rubPROJECT 3A/B). Choose a venipuncture site, apply
a tourniquet, and select a suitable vein.
STEP 3
Tear open an alcohol prep sachet and place on the work
surface.
Put on clean gloves and remove the alcohol-saturated square.
STEP 4
Cleanse in a circular fashion for 30 seconds beginning at
the intended puncture site then make circular motions
outwards (see the diagram below).
Figure 19: Correct and incorrect methods of cleaning an intended

venipuncture site
Allow the skin to air dry. It is imperative to allow the alcohol

to evaporate spontaneously. Give it enough time to dry
(minimum 30 seconds) and dont fan it dry with your hand.
STEP 5
The next step will be performing the venipuncture
procedure (PROJECTS 11A, B, C and D) for the purpose
of this project you may now remove the tourniquet.
70
IMPORTANT:
Adhering to a meticulous sterility and aseptic protocol will
dramatically reduce the number of infective complications
that your patients could experience. Insignificant
deviations from the recommended protocol make a big
difference!
Ensure that the alcohol prep square is saturated with clear
alcohol. If the square is dry or semi-dry, cloudy or colored,
then discard it and use a new one.
PROJECT 6C
(COLLECTING BLOOD FOR BLOOD CULTURE)
Minimize the chances of contaminant bacteria of entering the blood culture bottle
This project is for your information only as there are no blood culture bottles supplied in the kit.
Labs usually supply dedicated cleaning kits for the purpose of aseptically preparing the puncture site before taking blood
samples for culturing.
STEP 1
STEP 5
Prepare your hands hygienically (wash or alcohol hand

rubPROJECT 3A/B). Choose a venipuncture site, apply
a tourniquet, and select a suitable vein.
Position patient appropriately, apply tourniquet to palpate

and identify appropriate vein.
STEP 2
Use a 2% chlorhexidine gluconate in 70% alcohol solution,
as well as 3-6 sterile swabs opened onto the sterile field.
Alternatively a 2% iodine tincture or 10% povidone iodine
may be used in place of the chlorhexidine gluconate and
alcohol solution.
STEP 3
Remove the cap of each blood culture bottle and use a
non-touch technique to scrub the vial stoppers well with a
fresh chlorhexidine and 70% alcohol swab. Allow these to
dry for 30 seconds.
STEP 4
Ensure that all the items and equipment for drawing blood
are ready and prepared.
STEP 6
Perform hand hygiene for the second time.
STEP 7
Put on CLEAN gloves (do not touch the venipuncture site
after skin preparation. If palpation is absolutely necessary
then STERILE GLOVES must be used prior to palpation).
STEP 8
Using swabs saturated with 2% chlorhexidine in 70%
alcohol, disinfect the venipuncture site in a scrubbing
motion. Perform 2-3 scrubs using a fresh swab for each
scrub, with the last scrub starting at the intended puncture
site and spiraling out in a circular motion towards the
periphery. Clean for a total of 1-2 minutes, and then allow
the site to dry for approximately 30 seconds.
(If tincture of iodine is used, remove with 70% ethanol after
the procedure.)
71
STEP 9
better tolerated, doesnt negatively affect wound
In a real patient scenario, you will now perform the

venipuncture for blood culture/s using a vacutainer.
creating the so-called remnant or persistent effect.
healing, and leaves a deposit of active iodine thereby

The great advantage of iodine antiseptics is their wide
POINTS OF INTEREST:

Using a sound skin preparation technique and

protocol the specimen contamination rate should be
in the low single figures range (definitely < 9%)
Iodine is usually used in an alcoholic solution, called
tincture of iodine, as a pre- and post-operative
antiseptic. It is not recommended to disinfect minor
wounds, because it induces scar tissue formation
and increases healing time. Povidone-iodine is much
72
scope of antimicrobial activity, killing all principal

pathogens and, given enough time, even spores.

See conclusion made by researchers is this interesting

article: [CLICK HERE FOR FULL ARTICLE]
Chlorhexidine is a better alternative to iodine tincture

because it has a comparable effectiveness and is safer,
cheaper, and preferred by staff. (Of course it should
not be used on patients who are sensitive or allergic to
Chlorhexidine.)
PROJECT 6D
(COLLECTING BLOOD FROM BLOOD DONOR)
Prevent bacterial contamination of donated blood
WHO GUIDELINES (2010) ARE AS FOLLOWS:

If the site selected for venipuncture is visibly dirty, wash the area with soap and water, and then wipe it dry with single-use
towels.
ONE-STEP PROCEDURE
TWO-STEP PROCEDURE
(recommended takes about one minute):

use a product combining 2% chlorhexidine gluconate
in 70% isopropyl alcohol;
cover the whole area and ensure that the skin area is
in contact with the disinfectant for at least 30 seconds;
allow the area to dry completely, or for a minimum of
30 seconds by the clock.
(if chlorhexidine gluconate in 70% isopropyl alcohol is not

available, use the following procedure takes about two
minutes):
STEP 1 use 70% isopropyl alcohol;

cover the whole area and ensure that the skin area is in
contact with the disinfectant for at least 30 seconds;
allow the area to dry completely (about 30 seconds);
STEP 2 use tincture of iodine (more effective than

povidone iodine) or chlorhexidine (2%);
cover the whole area and ensure that the skin area is
in contact with the disinfectant for at least 30 seconds;
allow the area to dry completely (about 30 seconds).
Whichever procedure is used, DO NOT touch the
venipuncture site once the skin has been disinfected.
73
Venipuncture Course and Kit | COLLECTING BLOOD
CASE STUDY 3:
MY LIFE CHANGED DRASTICALLY IN A SPLIT SECOND
Dr. Louise Weimar wore a cream wedding gown and her

groom, Scottish engineer Mark Mynhardt, wore a kilt.
From an outsiders perspective they looked perfect on the
happiest day of their lives. But behind the wedding music,
cake and champagne lay a devastating story of how an
accidental needle stick changed a life.
Dr. Louise Weimar performed her medical duties at a
remote public hospital. On a day like any other, she
was drawing blood from a 3-month-old baby. After an
unsuccessful first attempt she reached for a second needle
to re-attempt the procedure but just as she turned around,
the baby pulled loose from the nurses arms and bumped
Dr. Louises hand right into the first needle. It penetrated
the little finger of her right hand to the bone. Dr. Louise
followed protocol and reported the incident. A sample of
the babys blood was immediately sent to the lab to be
tested for HIV. It was positive.
Both the hospital authorities and the health department
were unsupportive, and she started with the recommended
antiretroviral medication far too late. Ironically, on
December the 1st, International AIDS day, Dr. Louise was
informed that she had contracted HIV from her needle
76
prick injury. The pathologist simply remarked: Good luck!

She told her fianc about her disease, fearing that this
might be the end of their relationship, but to him it was
a simple decision. She was the woman of his dreams and
they married two weeks later.
Sadly, Dr. Weimar had to approach a human rights lawyer
for some form of compensation.
Lets survey some lessons learned:
Always use safety needles in all clinical and laboratory
settings when working with blood or any other bodily
fluids/secretions/excretions.
Discard used needles in an appropriate sharps waste
container immediately after use.
Start the recommended PEP (Post Exposure
Prophylaxis) protocol as soon as possible after
exposure to an infective agent requiring PEP.
CAPILLARY BLOOD COLLECTION USING A LANCET:

WARNINGS:

During the following projects you will be working

with sharp items. Take great care to avoid self-injury
or injury to others.
Observe age recommendations (18 years and
older/15-17 adult guidance and supervision).
Choose a place to practice where the fake-blood

used in this project wont stain any valuable items
of clothing, carpets, etc.
Do not use any of the items in the kit for real
patients not even in an emergency!
PROJECT 7A
DRAW CAPILLARY BLOOD ADULT
A useful method of sampling a couple of drops of blood
VIDEO
The student is allowed to perform this project under supervision of a suitably qualified medical professional. If
you have friend or family member who is a diabetic then offer to test their blood glucose level.
INFORMATION
Blood from a finger stick differs from blood collected from
a vein in the fact that it is a mixture between venous,
(mainly) capillary and arterial blood, as well as minute
amounts of tissue fluid.
If properly executed, blood collected from a finger (or
heel stick) will offer surprisingly accurate bio-chemical
information. Keep in mind that the following readings may
be slightly different:
Lower concentrations of potassium, total protein, and
calcium.
Higher glucose.
Relative contraindications for finger prick blood collection:

General contraindications: Patients with general edema
and patients with severe dehydration may not be good
candidates.
Local contraindications: Injury of the finger or hand,
infection of the finger/nail area, scar tissue, previous
burns, mastectomy with axillary lymph gland resection
(on the side of the intended finger puncture site),
Raynauds disease.
Patients with cold fingertips: Warm to increase the
blood-flow before puncturing.
77
REQUIREMENTS
STEP 6
You will need:

A sterile lancet
Alcohol prep swabs
Clean gauze squares
Gloves
Clean work surface cover
Alcohol hand rub
A mini-blood receiver/container (not supplied in the
kit)
A suitable volunteer
The puncture should be made perpendicular to the

fingerprint ridges to prevent the drop of blood running
in the grooves. Stab the finger with the sterile lancet in a
single brisk stab movement. Puncture the flesh right up to
the shoulder of the lancet at 90 to the skins surface.
FOLLOW THESE STEPS

AS IF IN A REAL-LIFE
CLINICAL SITUATION:
Collect drops of blood into the collection device by gently

massaging the finger. Avoid excessive pressure that may
squeeze tissue fluid into the drop of blood.
STEP 1
Open the above items on the clean work surface cover.
STEP 2
Greet the patient, introduce yourself and positively identify
the patient.
Do short medical history (allergies, bleeding tendencies,
and anticoagulant medication). Verify the patients status
regarding fasting, dietary restrictions, medications taken
(and time), and other relevant information. Properly fill out
and make appropriate notes on the lab requisition form
including the specific tests requested.
STEP 3
Prepare your hands hygienically.
STEP 4
The patient should be comfortably positioned sitting or
lying down. Extend the patients arm, keeping the hand
relatively open.
Choose a suitable puncture site. Use the pads of the
middle or fourth fingers of the non-dominant hand and
somewhat to the side of the finger pad.
Avoid:
The thumb, index finger, as well as the fifth fingers if
possible
The tip-area and central pad area of the finger
Puncturing a finger that is cold or cyanotic, swollen,
scarred, or covered with a rash
STEP 5
Ensure that the fingertip is clean with no visible dirt. Wipe the
fingertip with an alcohol prep swab. Wait 30 seconds to air dry.
78
STEP 7
Wipe away the first drop of blood which may contain
excess tissue fluid.
STEP 8
STEP 9
Cap then rotate and invert the collection container to mix
the blood collected.
STEP 10
Have the patient hold a small gauze pad over the puncture
site for a couple of minutes to stop the bleeding.
STEP 11
Dispose of contaminated materials in their designated
containers.
Important note: All lancets are single-use only and
must be disposed of in an approved sharps container
immediately after use.
STEP 12
Label all appropriate tubes at the patient bedside and
deliver specimens promptly to the laboratory.
POINTS OF INTEREST
A number of disposable spring-loaded skin puncture
devices are available that will ensure a safer procedure. The
spring-load mechanism should be pre-activated. The lancet
will automatically puncture the skin when the auto-stab
mechanism is released, and will then immediately retract
back into the housing of the device. This virtually eliminates
the possibility of accidental needlestick injury to the medical
professional performing the procedure.
Regular venipuncture tubes generally hold 5-10 ml (adult)
and 2-4 ml (pediatric) of blood. Tubes for finger sticks or heel
sticks generally hold one-half ml or less.
PROJECT 7B
DRAW CAPILLARY BLOOD BABY
A useful method of sampling a couple of drops of blood
VIDEO
INFORMATION
Warning: This project is intended for your information only. Under no circumstances may you use a baby to
practice this technique!
A blood sample obtained from a heel puncture is a useful and simple way of collecting a blood sample from a newborn
baby up to about 6 months of age.
It is commonly used for the following purposes in
babies:
Metabolic and genetic screening tests
Bilirubin levels (to monitor jaundice of the newborn)
Blood glucose and Lactate analysis
Newborn bloodspot screening tests

Full blood counts
Levels of certain drugs
Blood gases
Urea and electrolytes
REQUIREMENTS
You will need:

A sterile lancet (an appropriately sized automated
lancet devised for use on infants is recommended)
Alcohol prep swabs
Cotton wool
Receiving mini-blood container, capillary tube, and/or

blood bottle
Clean gauze squares
Clean gloves
Alcohol hand rub
79
FOLLOW THESE STEPS AS

IF IN A REAL-LIFE CLINICAL
SITUATION:
STEP 1
Open the above items on the clean work surface cover.
STEP 2
Check the patient for correct identity.
Check the medical history with the babys parent (allergies,
bleeding tendencies, medication, etc.). Verify the patients
status regarding the physicians specific orders. Properly
fill out and make appropriate notes on the lab requisition
form including the specific test(s) requested.
STEP 3
Ensure that the baby is lying comfortably, warm and
secure (for example, safely on a bed or on a persons lap).
Ask a parent or a nursing professional to assist by passively
restraining the baby.
Wash your hands. See handwashing guidelines and put on
clean gloves (PROJECT 3A, 3B and PROJECT 3C).
Clean the site with warm water/saline and gauze or cotton
wool. Do not use alcohol wipes to clean the skin of a baby.
STEP 4
Hold the babys heel with the non-dominant hand. It
may be necessary to compress the foot beforehand to
get a good flow of blood. With the foot flexed (see Fig.
14), prick the heel, preferably with a loaded automated
lancet or with a disposable lancet, to a depth of 1-2mm in
the plantar surface of the heel (see Fig. 15). The puncture
should be made perpendicular to the heel-print ridges. If
you must use a regular lancet, then use a sterile single-use
lancet to stab the heel at 90 to the skins surface in a single,
brisk stabbing movement.
Figure 21: Permissable areas to perform a heel prick procedure
STEP 5
Gently but firmly compress the babys heel (avoid excessive
pressure). Release the tension, wipe away the first drop of
blood, and then re-apply the tension to allow the blood to
collect in globules, which can then be collected into the
blood bottle.
STEP 6
Cap then rotate and invert the collection container to mix
the blood collected.
STEP 7
Apply pressure to the site with gauze and maintain the
pressure until bleeding has stopped. Tape a small piece
of gauze or cotton wool over the puncture site using
hypoallergenic tape.
STEP 8
Dispose of contaminated materials in designated
containers.
Important note: All lancets are single-use only and must be
disposed of in an approved sharps container immediately
after use.
STEP 9
Take a consecutive blood sample from the alternate heel.
Vary the puncture site positions.
STEP 10
Figure 20: How to hold the heel when performing a heel prick procedure
80
The person performing the skin puncture should wash

their hands.
STEP 11
Label all appropriate tubes at the patient bedside and
deliver specimens promptly to the laboratory.
POINTS OF INTEREST
To avoid irritating, and even possible mutilating
complications the operator should adhere to a very strict
procedural protocol (as above).
Complications that can arise in capillary sampling
include:
Damage to nerves, blood vessels, and bones

Osteomyelitis of the heel bone
Excessive scarring
Skin breakdown from repeated use of adhesive strips
Skin necrosis
Excessive blood loss
Cellulitis and abscess formation
Hemolysis of the sample (will require a re-sampling)
Increased pain (compared to venipuncture)
Sore heels
PROJECT 8
HOW TO GIVE A SUBCUTANEOUS INJECTION
Deposit medication in the subcutaneous layer of the skin
VIDEO
*If you have an insulin dependent diabetic friend or family member, offer to administer their next insulin
subcutaneous injection. Strictly follow the physicians orders!
INFORMATION
The skin is made up of different layers. Underneath the
epidermis and dermis, which contain sweat glands and
hair follicles, is a layer of fat. Subcutaneous injections are
given into this area. As a general rule, suitable areas for
subcutaneous injections are those areas with a substantial
amount of fat below the skin, for example, the thighs,
buttocks, and abdomen.
81
CROSS SECTION OF THE SKIN
Some medicines work best when they are injected under

the skin into the fatty layer. These medicines require slower
absorption compared to medication taken by mouth
or injected into a vein. Examples of medicines given
subcutaneously include growth hormone, insulin and
epinephrine (adrenalin).
Medication for injection comes in various containers
(bottle, vial, etc.), each with its own specifications on
opening the container, maintaining sterility, withdrawing
medication, etc. See PROJECT 6A.
Three basic types of devices for giving subcutaneous
injections are available: a syringe (for small volumes with a
narrow gauge needle), an auto-injector and a pen device.
In this project we will use a syringe.
REQUIREMENTS
You will need:
Alcohol wipe
Clean gloves
Ampule of medication
Small syringe (0.5 ml)
30 gauge needle (preassembled on syringe)
Cotton wool or gauze
The Venipuncture Trainer
82
To simulate a subcutaneous injection using the

Venipuncture Trainer, see Step 12.

SITUATION:
STEP 1
Greet the patient and positively check the identity of the
patient.
Check the following on the medication ampule or vial
before proceeding:
The correct medication name, amount (or volume,
e.g., 10 ml) and concentration, (e.g., 5 mg/ml).
The expiration date. Never use expired medication.
Abnormalities regarding consistency and color of the
medication in the container. If in doubt, send it back
to the pharmacy.
STEP 2
Follow the steps described in Project 6A to draw up the
medication for SQ injection.
STEP 3
Choose the injection site for this dose and expose the
area (if working on a real patient). There are several areas
of the body suitable for giving subcutaneous injections, as

shown in figure 17. Enquire about the patients previous
injection site.
STEP 4
(sterile gloves are not required).
Some experts say that if you keep to the suggested

injection sites, aspiration is unnecessary, specifically
for subcutaneous injections as there are no major
blood vessels in these specific subcutaneous injection
site areas. (See safe subcutaneous injection sites
diagram below).
STEP 5
Open an alcohol prep swab and wipe the intended area
for SQ injection in a circular motion and allow to air dry.
STEP 6
Spread the index finger and thumb of the non-dominant
hand about 5 cm (2 inches) apart and place them on either
side of the planned injection spot. Pinch (bunch-up) the
skin in the chosen injection area between your thumb and
index finger.
Warnings: Stay clear of your own fingers. Take great
care not to prick your own finger!
Use a safety needle in a clinical setting.
Note: In a home-care situation, no aseptic preparation
of the skin is required, presuming reasonable personal
hygiene. When a medical professional gives the SQ
injection, skin prepping is advisableespecially in a clinic
or hospital where medical professionals need to maintain
a sterile chain, unlike the home-care situation.
STEP 7
Continue to hold the skin and insert the needle into
the skin in the center of the skin fold so that the needle
is at an angle of 45-90. *Aspirate if your hospital/unit
recommends aspiration when giving a subcutaneous
injection.
STEP 8
Push the syringe plunger to inject the medicine. It is
recommended that you count slowly from 1 to 10 while
injecting the medication.
Remove the needle from the skin and release the skin.
*Comments:
As a general rule, aspirating before injecting is a good
habit and is thus recommended.
How to aspirate:
With the needle in the injection site, gently
withdrawing the plunger, exerting negative
pressure before injecting the medication. This is
done to make sure that you are not in a blood vessel,
and thus administering an inadvertent IV injection
and causing a possible medical emergency!
Figure 23: Permissible areas for giving a subcutaneous injection
STEP 9
Press a piece of cotton wool or gauze lightly over the
injection site for a couple of seconds (optional). Do not
massage the injection site.
STEP 10
Discard the used syringe and needle in the sharps waste
container. Do not recap or remove the needle! Remove
gloves and discard in suitable medical waste bin.
STEP 11
Mark the puncture site, date, and time of the injection on a
suitable chart or diagram.
STEP 12
Simulate the project by following Steps 1-10 using the
unassembled Venipuncture Trainer. Do not inject in the
blood vessel areas.
Use 2ml of air or withdraw 2ml of fluid from the In of one
of the IV fluid bags to use as medication when doing the
simulation exercise.
83
POINTS OF INTEREST
Safe areas for giving subcutaneous injections:
Abdomen: Uncover the abdomen from about 5 cm
(2 inches) below the umbilicus up to the waist area. You
may give a shot below the waist, to just above the hipbone,
and from where the body curves at the side to about
5 cm (2 inches) from the middle of the abdomen. Avoid
the umbilicus.
Thigh: Uncover the leg from the knee to the hip. The midsection of the thigh, from mid-front to mid-side on the
outside area of the thigh, is a safe site. Gently, grasp the
area with index finger and thumb to ensure that you can
pinch one to two inches of skin.
Upper Arm: Uncover the arm to the shoulder. Have the
patient stand with hand on hip. Stand to the side, slightly
behind the patient. Find the area halfway between the
elbow and shoulder. Gently grasp the skin at the back of
the arm between your thumb and first two fingers. You
should have 1-2 inches of skin.
Various other areas see Figure 23.
When a patient receives multiple injections over a period
84
of time, ensure that you vary the injection sites to reduce

pain and irritation. In other words, dont give the injection
at the same spot every time. Instead, use a new spot each
time in an organized rotational way. A site rotation chart
for marking injection sites is recommended for patients
who need subcutaneous injections on a regular basis (e.g.,
diabetics). It may be helpful to mark the injection site with
a small plaster as a reminder for next time.
Injecting the medicine into the same area all of the time
will cause scarring or a fatty lump (lipohypertrophy) to
form, causing medication to be absorbed more slowly.
Intradermal injections are often used for conducting

skin allergy tests. With the intradermal injection, a small
thin needle of 25 or 27 gauge and 3/8 to 3/4 inch (1-2 cm)
is inserted at a 10 to 15 angle to the skin of the forearm,
with the bevel facing upward.
Intradermal injections are also used by Plastic Surgeons to
deposit fillers and Botox into the skin for cosmetic reasons.
PROJECT 9
HOW TO GIVE AN INTRAMUSCULAR INJECTION
Deposit medication in a suitable muscle
VIDEO
INFORMATION
Medication is injected well into the muscle layer below the
various layers of skin.
Medication causing little to moderate chemical

irritation. It is not intended for medication that will
cause a severe tissue reaction.
Medication with low to moderate viscosity.
Other considerations are the age of the patient (baby,
child, or adult), the patients size, weight, and muscle mass
(e.g., emaciated patients with small, friable muscles).
Needle size (gauge and length) depends on factors such
as the injection site, type of medication, and size of the
muscle, as well as the patients weight and amount of
subcutaneous fat.
REQUIREMENTS
Figure 24: An intramuscular injection
This route for injection is recommended for:

Medication requiring a relatively fast absorption
speed for fast onset of action with a duration of
action of anything from hours up to several weeks
(variation dependent on the type and specifics of the
medication)
A fairly small volume of medication (2-5 ml) depending
on the muscle (deltoid maximum 2ml and gluteus
up to 5 ml).
You will need:

Alcohol wipe
Clean gloves
Container with medication
Syringe (5ml)
Two needles preferably safety needles (Gauge 18 or 20)
Adhesive bandage strip
IV bag
85
SIMULATE A
SUBCUTANEOUS INJECTION
USING THE VENIPUNCTURE
TRAINER. SEE STEP 12.
SITUATION:
STEP 1
Greet and positively check the patients identity.
Check the following on the medication ampule or vial
before proceeding:
The correct medication, name, amount (or volume,
e.g., 10 ml), and concentration (e.g., 5 mg/ml).
The expiration date. Never use expired medication.
Abnormalities regarding consistency and color of the
medication in the container. If in doubt, send back to
the pharmacy.
STEP 2
Follow the step-by-step instructions on withdrawing
medication for an IM injectionsee PROJECT 6A.
STEP 3
(sterile gloves not required).
STEP 4
Choose the injection site for the dose and expose the area
(if working on a real patient). There are several areas of
the body suitable for giving intramuscular injections (IMI),
shown on the diagrams.
STEP 5
Swab the injection site with an alcohol pad for 30 seconds
in a circular outward motion, up to 5 cm around. Allow
the alcohol to air dry (30 seconds). Spread the index finger
and thumb of the non-dominant hand about 5 cm (2
inches) apart and place them on either side of the planned
injection spot. Gently spread your index finger and thumb
to tense the tissue. Ask the patient to relax and then to
take a deep breath. As the patient inhales, make a quick
dart-like motion to insert the needle at a 90 angle to an
appropriate depth, ensuring that the needle tip enters the
muscle properly.
Warning: Stay clear of your own fingers. Take great care
not to prick your own finger!
86
STEP 6
It is essential to aspirate before depositing the medication
into the muscle. To do this, gently withdraw the plunger
before injecting the medication into the muscle, in order
to avoid an inadvertent intra-vascular injection and thus a
possible medical emergency.
If you aspirate blood, withdraw the needle and prepare a
new syringe.
STEP 7
If no blood is aspirated, continue to hold the skin and
push the syringe plunger to inject the medicine. It is
recommended that you count slowly from 1 to 10 for
every milliliter (ml) being injected.
STEP 8
When all of the medication has been injected, promptly
withdraw the needle and apply pressure to the injection
site using a gauze square to prevent bruising or a
hematoma; this will also minimize medication seeping into
the subcutaneous space. Certain medications may require
massaging of the injection area for a minute or two, but
for others this may be contraindicated. Apply an adhesive
bandage strip if necessary.
STEP 9
Discard the used syringe and needle in a designated
sharps waste container. Do not recap or remove the
needle! Remove gloves and discard in a suitable medical
waste bin.
STEP 10
Document the time, medication, dose, route, site, and
patients response to injection.
STEP 11
Perform the project by following Steps 1-10 using the
unassembled Venipuncture Trainer. Do not inject in the
blood vessel areas.
Withdraw 2ml of air or withdraw 2ml of fluid from the In
of one of the IV fluid bags as medication when doing the
simulation exercise.
POINTS OF INTEREST
Relatively safe sites for IM injection are the deltoid, dorsal gluteal, ventrogluteal, and vastus lateralis (especially for children
under two years of age).
Deltoid Muscle: The deltoid muscle is located in the
upper arm, just below the shoulder. To mark this site, place
the palm of your hand on the shoulder and spread your
thumb away from the four fingers in an upside down
V shape. Ensure that the middle of the patients arm is
centered in your V. You will want to give the injection into
the middle of this V.
Ventrogluteal Muscle: This muscle is located in the hip

area. To mark this site, have the person lie on their back.
You should stand facing their hips. Place the palm of your
hand on the side of the hip, with your wrist lining up with
the thigh, the thumb is pointed towards the groin and the
fingers pointed towards the patients head. You should feel
the border of the bony iliac crest along the middle finger
to small finger. Spread your index finger and middle finger
into a V and give the injection between those fingers.
Figure 15a and b: Giving an intramuscular injection in the deltoid muscle
Vastus Lateralis Muscle: This muscle is located in the

thigh. To properly mark this muscle, divide the front of the
thigh into thirds from the top to the bottom of the thigh.
The needle should go into the middle third.
Figure 27a and b: Giving an intramuscular injection in the ventral gluteus

muscle
Dorsogluteal Muscle: This is the large buttock muscle.

Divide one buttock into quadrants, halfway down the
middle and halfway across. You will always want to give
the injection in the outer, upper quadrant, almost towards
the hip.
Figure 26a and b: Giving an intramuscular injection in the vastus lateralis muscle
Figure 28a and b: Giving a intramuscular injection in the dorsal gluteus
muscle
87
PROJECT 10 A
SET UP THE VENIPUNCTURE TRAINER FOR PHLEBOTOMY
How to prepare the trainer for performing various practical projects
VIDEO
INFORMATION
REQUIREMENTS
In the final analysis, phlebotomy is a clinical skill. The

Apprentice Doctor Venipuncture Kit is designed so you
can get acquainted and feel at ease with phlebotomy
skills before being confronted with real human or
animal patients in a clinical setting. The Venipuncture
Trainer might not look like a real arm or like the much
more expensive plastic arm simulators (available from
the Online Store), but it is a fantastic affordable tool
to practice phlebotomy and IV skills repeatedly. It
resembles the real clinical feel of in/out/missed the
vein or right through the vein situations superbly
well. Practice makes perfect. You will notice your in
the vein rate increase dramatically as you continue
practicing. You will be able to use the versatile trainer
for practicing venipuncture on a large diameter vein, as
well as a smaller diameter vein, drawing arterial blood,
performing an intramuscular injection, a subcutaneous
injection, and infiltrating a wound with local anesthetic
before suturing.
So lets start setting up this effective yet simple training
apparatus.
You will need:

Venipuncture Trainer
Lumen stoppers/connectors
IV line adult
Small IV fluid package
Syringe 5 ml
Syringe needle 22 gauge
Red colorant
A shallow container, (e.g., a kidney dish, not
supplied in kit)
88
Choose a suitable, easily cleanable work surface.
FOLLOW THESE STEPS

(SEE THE ACCOMPANYING
DIAGRAM):
STEP 1
Inspect the Venipuncture Trainer. It represents a fake
arm with two veins, covered by skin. The slightly wider
diameter tube represents a regular vein and the smaller
tube a smaller vein.
Additional and replacement Venipuncture Trainers can
be ordered online. [ORDER HERE]
about halfway. When fake blood starts to flow from the

tube, close the flow control, and then block the outflow
opening with a lumen stopper.
STEP 7
You are ready to start with the phlebotomy projects.
(PROJECTS 11-14)
stand
STEP 2
Inspect the IV fluid bag. Note the two ports marked as
In and Out.
IV bag
STEP 3
in port
out port
Connect the syringe and needle. Draw up to 1 cc of

red colorant and inject the contents into the IV fluid bag,
using the In port. Mix the colorant within the IV bag.
drip chamber
STEP 4
Connect the adult IV line to the bag using the Out
port. Connect the other end to one of the tubes
(Venipuncture Trainer veins) using a connector. Ensure
that the connection is secure and doesnt leak.
IV line
flow-control clamp
STEP 5
Place or suspend the IV-fluid bag about a meter ( a
yard) above the work surface. Suspend it from a hook
or nail in the wall or place it on a shelf above the work
surface.
connector
IV Trainer
simulation veins
STEP 6
Keep the lumen stoppers nearby. Place a shallow
container at the outflow end of the Venipuncture
Trainer. Open the infusion flow-speed mechanism. Press
and release the drip chamber once or twice to fill it
lumen stoppers
PROJECT 10 B
SET UP THE VENIPUNCTURE TRAINER FOR IV PROJECTS
For PROJECT 11D HOW TO SETUP AN IV LINE, you will have to modify the Venipuncture Trainer setup as follows:
Close or occlude the near side of both veins with the lumen stoppers.
Place a shallow container (e.g., a kidney dish) at the far, open ends of the veins to receive the IV fluid following
a successful venipuncture procedure.
Proceed with PROJECT 11D.
89
PROJECT 10 C
SET UP THE VENIPUNCTURE TRAINER FOR ARTERIAL BLOOD
For PROJECT 12C DRAW ARTERIAL BLOOD you will have to modify the Venipuncture Trainer setup as follows:
Fill a 10 ml syringe with fake blood and connect to the smaller vein, and let it run through the tube.
Now tightly occlude one side of the smaller vein.
Ask another person to sit opposite you and then to press down on the plunger of the syringe. They can use a moderate
pulsing pressure to simulate the pulsations of an artery.
Perform the simulation procedure for drawing arterial blood PROJECT 12C.
TAKING CARE OF THE

VENIPUNCTURE TRAINER
THERAPEUTIC PHLEBOTOMY
(BLOODLETTING)
Put your Venipuncture Trainer away when you are finished

with projects:
Close the flow-speed mechanism.
Empty the fake blood inside the tubes into the plastic
container and discard.
Pack all of the components and place them into your
kit.
Keep the kit in a secure location and out of reach of
young children.
Important note: Keep in mind that the red colorant may
leak and stain clothes, tablecloths, carpets, etc.
Therapeutic phlebotomy (therapeutic bleeding) is a

controlled removal of a relatively large volume of blood
(usually 500 ml to one pint or more). The procedure is
performed to reduce blood volume and consequently, red
blood cells and iron stores. Therapeutic phlebotomy may
be indicated as part of the treatment for:
Hemochromatosis (including hereditary
hemochromatosis)
Polycythemia vera
Porphyria cutanea tarda
Sickle cell crisis
A number of other conditions, but rarely
Specific indications and parameters are in place for the
conditions listed above. In the Middle Ages, bloodletting
was a common procedure for a variety of diseases. Today
it is well established that bloodletting is not effective in
treating most diseases and frankly, may be detrimental
(the above list excluded).
REFILLING THE IV FLUID BAG

If the IV fluid runs dry, refill the bag using a 10 ml syringe
and an 18 gauge needle and homemade saline (one
teaspoon of salt in a glass of lukewarm water). Stir it well,
draw 10 ml into the syringe and inject it into the In port of
the IV bag. Repeat 10 times to add 100 ml. Add 5 ml of red
food colorant to create fake blood.
MAXIMUM ALLOWABLE
TOTAL BLOOD DRAW
VOLUMES
The maximum allowable total blood draw volumes
depends on the patients body weight, blood Hb
(Hemoglobin) level, and the general condition at the time
of the draw.
[CLICK HERE] to see and print the Table for Maximum
Allowable Total Blood Draw Volumes.
90
PROJECT 11A
DRAW VENOUS BLOOD USING A VACUUM TUBE
One of a number of methods to draw venous blood
VIDEO
INFORMATION
It is strongly recommended that the student read the WHO
guidelines on drawing blood: Best Practices in Phlebotomy
before proceeding with this project.
Notes on choosing a venipuncture site:
The most commonly used veins are the larger and
easily accessible median cubital or cephalic veins of
the arm, followed by the basilic vein on the dorsum of
the arm or dorsal hand veins.
The veins of the foot are a last resort because of the
higher probability of complications.
Other veins, like the external jugular vein, are rarely
used.
A good vein will be both visible and palpable.
However, occasionally you may have to depend only
on your sense of palpation.
To make it easier to see the veins, warm the arm for 10
minutes with a hot pack or let the hand hang down.
If you feel a pulse when palpating the blood vessel,
you may be looking at a superficial artery. Inspect the
area further to identify a definite vein.
Avoid inserting the catheter into a bifurcation (where
the vein splits) or near large valves.
Certain areas are to be avoided when choosing a site:

Areas with extensive scars from burns or previous
surgery. It is difficult to penetrate skin through scar
tissue.
The arm on the side of a previous mastectomy. Test
results may be affected because of lymphedema.
A hematoma may cause inaccurate results.
The arm on the side that is being used for intravenous
therapy (IV) / blood transfusions, as the fluid may
dilute the specimen. Collect from the opposite arm if
possible.
Cannula/fistula/heparin lock. In general, blood should
not be drawn from an arm with a fistula or cannula.
Edematous extremities. Tissue fluid may cause
inaccurate test results.
Extremities with extensive injuries (external wounds
or fractured bones).
Extremities with a joint replacement. Use an alternative
site/extremity.
91
REQUIREMENTS
You will need:
Laboratory specimen labels (only in clinical setting)
Pen for writing
Laboratory forms
The sharps waste container
Alcohol wipe
Clean gloves
A Vacutainer holder (hub)
A Vacutainer needle
Vacutainer tubes
An Autosafe Safety Phlebotomy Device (safety
needle preassembled on hub/holder)
Strapping (adhesive bandage strip)
A fully set up Venipuncture Trainer
See PROJECT 10A
A phlebotomist will also need leak-proof transportation
bags and containers (not supplied in kit).
IMPORTANT NOTE:

Use either the Autosafe Safety Phlebotomy Device

or the standard Vacutainer hub and needle.
If you choose the Autosafe Safety Vacutainer
Phlebotomy Device, familiarize yourself with PROJECT
1B HOW TO USE AUTOSAFE-REFLEX SAFETY
DEVICES
The BD Vacutainer system is used in the Video clip
demonstration for more information visit the BD
website: [CLICK HERE]
FOLLOW THESE STEPS

AS IF IN A REAL-LIFE
CLINICAL SITUATION THEN
SIMULATE DRAWING BLOOD
USING THE VENIPUNCTURE
TRAINER:
STEP 1
Greet the patient; introduce yourself and then pause to
confirm the following:
Correct patientpositively identify the patient.
92
Correct procedurescheck the requisition order form

against the labels.
Then:
Conduct a short medical history (allergies, bleeding
disorders, etc.). See PROJECT 2.
Position and prepare the patient.
Verify the following regarding the patient: fasting,
dietary restrictions, medications, timing, medical
treatment, and any other relevant information.
Make notes on the lab requisition form.
STEP 2
Open a clean work surface cover. From the REQUIREMENTS
list above, gather the relevant items and equipment (open
outer plastic wrapping) and place on this cover. Set out
all of the tubes you will need by the order of the draw*
and have any necessary tools (tourniquet, alcohol swabs,
sharps waste container, and biohazard waste bag) nearby.
Tear open the alcohol prep sachet.
Assemble the Vacutainer by attaching the Vacutainer
needle to the Vacutainer hub or use the Autosafe Safety
Vacutainer Phlebotomy Device (with needle preassembled
to the hub).
STEP 3
Perform hand hygiene. See PROJECT 3A A TECHNIQUE
FOR PROPER HANDWASHING and PROJECT 3B
CLEANING HANDS WITH AN ANTISEPTIC RUB.
STEP 4
Select the site, preferably at the cubital (antecubital) area
(i.e., the inner bend of the elbow).
Locate the anatomic landmarks. Inspect and palpate the
veins in the intended venipuncture site. If necessary, one
may apply a tourniquet temporarily, about 4-5 fingers
above the intended venipuncture site in order to facilitate
the inspection and palpation. Remove the tourniquet until
ready to proceed.
Note: To make it easier to see the veins, warm the arm for
10 minutes with a hot pack or let the hand hang down.
STEP 5
When ready for drawing the blood, apply the tourniquet
about 4-5 finger widths above the selected venipuncture
site.
STEP 6
Ask the patient to form a fist to make the veins more
prominent.
Important note: Dont ask the patient to pump (repeatedly

open and close) the fist.
STEP7
Put on clean (non-sterile) gloves.
STEP 8
Disinfect the site using 70% isopropyl alcohol for 30
seconds and allow it to dry completely (30 seconds).
DO NOT touch the site again once the alcohol (or other
antiseptic) has been applied! If you must touch it again to
feel the vein, touch a clean alcohol pad first to aseptically
treat your glove.
STEP 9
Anchor the vein by holding the patients arm and placing
the thumb of the opposite hand below the venipuncture
site.
DO NOT insert the needle where veins are branching as
this will increase the chance of a hematoma.
STEP 10
Enter the vein swiftly at a 15-30 angle. Ensure that the
bevel of the needle is pointing up. DO NOT bend the
needle.
Note: Angling the needle less than 15 increases the
chance of the needle staying above the vein and an angle
of more than 30 increases the chance of penetrating the
deep wall of the vein.
STEP 11
Support the Vacutainer tube holder, then push the
Vacutainer tube into the hub and check for blood flow.
Allow the tube to fill and then remove it from the tube
holder, all the time gently supporting the tube holder to
prevent the needle from slipping out of the vein. When
blood flow stops, remove the tube by holding the hub
securely and pulling the tube off the needle.
The tourniquet must be released after a maximum of

2 minutes** irrespective of whether or not you have
completed the venipuncture task.
**WHO guidelines. Some experts recommend a maximum
tourniquet time of 1 minute.
STEP 13
Withdraw the needle gently and then give the patient a
clean gauze or dry cotton-wool ball to apply to the site
with firm pressure for 2-3 minutes to achieve hemostasis
and avoid a hematoma. Ensure that the patient has
stopped bleeding and then apply tape and gauze to the
venipuncture site.
STEP 14
Discard sharps (e.g., the used needle/s and broken glass
and syringe or blood-sampling device) into a punctureresistant sharps container. Place other items like used
gloves and all items contaminated with blood or body
fluids into the infectious waste.
STEP 15
Check the labels and forms for accuracy.
STEP 16
Perform hand hygiene.
STEP 17
Simulate the project by following Steps 1-16 using the fully
setup Venipuncture Trainersee PROJECT 10A.
Ensure that the tubes are filled with fake blood, that the IV
fluids tubing flow-speed regulation device is set on open,
and that the ends of the tubes have lumen stoppers in
position.
STEP 12
If tube used has additives mix the contents by gently
inverting the tube 5-8 times (do not shake). Fill the
remaining tubes and repeat the mixing routine after each
tube has been filled.
Once sufficient blood has been collected, release the
tourniquet BEFORE withdrawing the needle.
Note:
When filling additional tubes determine what tests
are ordered and what tubes will be necessary *BEFORE
you begin drawing blood, follow the correct sequence
of drawing blood for these tubes (SEE TABLE 3).
93
POINTS OF INTEREST
Tubes
Additives
Tests
Yellow
SPS
Blood Culture Tube
Blue
Sodium Citrate
PT,PTT, APTT All Coagulation Studies
Red
No Additive (Serum tube)
Electrolyte, Lipid Panel, Hepatic

Function, Digoxin, Bilirubin, HCG
(pregnancy)
Red-gray or gold top
Contains a gel at the bottom to separate

blood from serum on centrifugation
Chemistries, immunology and serology
Green
Sodium Heparin or Lithium Heparin
Ammonia Level
Light green
Lithium heparin anticoagulant and a gel

separator
Various chemical studies
Lavender
EDTA
CBC, Hemoglobin, Hematocrit, ESR

(Erythrocyte Sedimentation Rate)
Pale yellow
Acid citrate dextrose
HLA tissue typing, paternity testing,

DNA studies
Gray
Potassium Oxalate, Sodium Fluoride
All Glucose Studies Anticoagulant
Table 3: *Recommended order of draw for plastic vacuum tubes (may differ slightly from your hospitals protocol).
DO
DO NOT
DO carry out hand hygiene (use soap and water or alcohol

rub), and wash carefully, including wrists and spaces between the fingers for at least 30 seconds
DO NOT forget to clean your hands
DO use one pair of non-sterile gloves

per procedure or patient
DO NOT use the same pair of gloves

for more than one patient
DO NOT wash gloves for reuse
DO use a single-use device for blood

sampling and drawing
DO NOT use a syringe, needle or lancet

for more than one patient
DO disinfect the skin at the venipuncture site
DO NOT touch the puncture site after disinfecting it
DO discard the used device (a needle and syringe is a single unit) immediately into a robust sharps container
DO NOT leave an unprotected needle

lying outside the sharps container
Where recapping of a needle is unavoidable, DO use the

one-hand scoop technique (see figure xx)
DO NOT recap a needle using both hands
DO seal the sharps container with a tamper-proof lid
DO NOT overfill or decant a sharps container
DO place laboratory sample tubes in a sturdy rack before

injecting into the rubber stopper
DO NOT inject into a laboratory tube while

holding it with the other hand
DO immediately report any incident or accident linked to a

needle or sharp injury, and seek assistance; start PEP
(see below) as soon as possible, following protocols
DO NOT delay PEP after exposure to potentially

contaminated material;
beyond 72 hours, PEP is NOT effective
Table 4: The rules of safety when performing phlebotomy
PEP (post-exposure) prophylaxis - for more information [CLICK HERE]

Credit: WHO, World Health Organization
Always use the one-hand scoop technique for recapping a needle see Figure 18
94
ADDITIONAL SAFETY
RECOMMENDATIONS:

If at all possible, use specially designed safety devices

to minimize the risk of accidental needle injuries
Dont re-use the tube holder (Vacutainer hub) it is

intended for single-use only
Safety syringes have a safety mechanism built into the
syringe. The needle on a safety syringe can be detachable
or permanently attached. On some models, a sheath is
placed over the needle or the needle retracts into the barrel
following injection in order to protect healthcare workers
and others from accidental needle stick injuries. The

importance of the safety syringe has increased; legislation
requiring it or an equivalent has been introduced in many
countries since needlestick injuries and re-use prevention
became the focus of governments and safety bodies.
Important note: In the final analysis there are simply no
substitutes for taking CARE. Be careful at all times. You and
your patients health and life depend on it!
Also see:
W.H.O. Injection Safety Toolbox [1]
W.H.O. Injection Safety [2]
Centers for Disease Control Injection Safety [3]
VIDEO
95
PROJECT 11 B
DRAW VENOUS BLOOD USING A SYRINGE AND NEEDLE
VIDEO
INFORMATION
REQUIREMENTS
It is strongly recommended that the student read the

WHO guidelines on drawing blood: Best practices in
phlebotomy before proceeding with this project.
As a matter of preference, or for specific reasons, a
phlebotomist may prefer using a syringe and needle to
perform a venipuncture. Using a syringe and needle will
necessitate that the blood specimen be transferred from
the syringe to the labs blood sample tube/s using specific
methods with the emphasis on avoiding accidental needle
prick injuries and minimizing the risk of cross infection.
You will need:

Laboratory specimen labels
Pen for writing
Laboratory forms
The sharps container
Alcohol wipe
Clean gloves
Syringe (20ml)
Needle preferably a safety needle (20 gauge or
larger)
Fully setup Venipuncture Trainersee PROJECT 10A
A phlebotomist will in addition to the above items, also
need leak-proof transportation bags and containers.
96
MEMORIZE THESE STEPS TO

BE FOLLOWED IN A REALLIFE CLINICAL SITUATION
THEN SIMULATE DRAWING
BLOOD USING THE
VENIPUNCTURE TRAINER:
STEP 1
Greet the patient, introduce yourself, and then pause to
Correct patient positively identify the patient
Correct procedure/s check requisition order form
against labels
Then:
Do short medical history (allergies, bleeding disorders,
etc.) See PROJECT 2
Position and prepare the patient
Verify the following regarding the patient: fasting,
dietary restrictions, medications, timing, medical
treatment and any other relevant information
Make notes on the lab requisition form
STEP 2
Open a clean work surface cover then gather and open the
relevant items and equipment. Assemble equipment (see
REQUIREMENTS above). Set out all of the tubes you will
need and have all the necessary tools (e.g., tourniquet and
alcohol swabs) nearby. Tear open the alcohol prep sachet.
The needle should be 21g or wider in order to minimize
hemolysis. ALL needles and syringes are single-use only.
Briefly inspect the needle, especially the tip, to ensure it is
sharp and undamaged.
Remove the syringe from the packaging and insert the
nozzle of the syringe firmly into the exposed hub of the
capped hypodermic needle. Move the plunger within the
barrel to ensure free movement.
Note: Use safety needles in all clinical settings. When
simulating the procedure you may use a regular needle
but take great care not to injure yourself.
STEP 3
See PROJECT 3A A TECHNIQUE FOR PROPER
HANDWASHING and PROJECT 3B Cleaning hands
with an antiseptic rub.
STEP 4
Select the site, preferably at the cubital area.
veins in the intended venipuncture site. One may apply a
tourniquet temporarily, if necessary, 4-5 fingers above the
intended venipuncture site to facilitate the inspection and
palpation. Remove the tourniquet until ready to proceed.
Note: Warming the arm with a hot pack or hanging the
hand down may make it easier to see the veins.
STEP 5
When you are ready to draw blood, apply the
tourniquet about 45 finger widths above the selected
venipuncture site.
STEP 6
STEP 7
Ask the patient to form a fist so that the veins are more
prominent.
Important note: Dont ask the patient to pump his/her fist.
STEP 8
Disinfect the site using 70% isopropyl alcohol for 30
seconds and allow it to dry completely (another 30
seconds).
treat your glove.
STEP 9
Anchor the vein by holding the patients arm and
placing the thumb of the opposite hand below the
venipuncture site.
Do not insert the needle where veins are branching, as this
will increase the chance of a hematoma.
STEP 10
Enter the vein swiftly at a 15-30 angle. Ensure that the
bevel of the needle is pointing up. D NOT bend the
needle. Hold/stabilize the barrel of the syringe and gently
withdraw the plunger until the required amount of blood
has filled the syringe.
Note: Angling the needle less than 15 increases the
chance of the needle staying above the vein and an angle
of more than 30 increases the chance of penetrating the
deep wall of the vein.
97
STEP 11
STEP 15
Once you collect sufficient blood, ask the patient to relax

the fist, and then release the tourniquet.
Note: The tourniquet must be released after a maximum
of two minutes according to *WHO guidelines, irrespective
of whether or not you have completed the venipuncture
task or not. Some experts recommend a maximum
tourniquet time of one minute.
Discard sharps (e.g., the used needles, syringes, as well

as any glass items) into a puncture-resistant sharps
container. Place other items like used gloves and all items
contaminated with blood or body fluids into the infectious
waste.
STEP 12
Withdraw the needle gently and place clean gauze or a
dry cotton-wool ball with strapping to the site. Apply firm
pressure to achieve hemostasis and avoid a hematoma.
Inspect the site after 2-3 minutes to ensure that the patient
has stopped bleeding.
STEP 13
**Always use a safety transfer device for transferring blood
from a syringe to the vacuum tubes or the blood culture
bottles. [Click here] for more information on the method
of transferring blood with a safety device.
If no safety transfer device is available, place the vacuum
tubes in a test tube rack before inserting the needle into
the vacuum tube. Carefully penetrate the needle through
the tubes stopper and let the blood passively fill the tubes.
Warnings when transferring blood:
Do not hold vacuum tube in your hand!
Do not exert pressure on the plunger of the syringe.
This ensures that you avoid hemolysis or causing the
needle or stopper to pop off thus creating a spray of
blood droplets with the danger of exposing you and
others to bloodborne pathogens.
STEP 14
If the tube used has additives, mix the contents by gently
inverting the tube 5-8 times (do not shake). Fill the
remaining tubes and repeat the mixing routine after each
tube has been filled.
STEP 16
Recheck the labels and forms for accuracy.
STEP 17
STEP 18
fully setup Venipuncture Trainersee PROJECT 10 A.
Ensure that the tubes are filled with fake blood, that the IV
fluids tubing flow-speed regulation device is set on open,
and that the ends of the tubes have lumen stoppers in
position.
POINTS OF INTEREST:
Comments on safety and avoiding injury to you and
your patient
Students of phlebotomy should be aware of the most
recent information regarding the safety aspects related to
safety needles and other devices by visiting the following
websites:
*WHO (World Health Organization) http://whqlibdoc.
who.int/publications/2010/9789241599221_eng.pdf
**OHASA (Occupational Safety and Health Administration)
http://www.osha.gov
USA: Safety holders (preferably disposable), safety
needles, safety blood transfer devices, and shields are
mandatory, regardless of the blood collecting system
used. See Occupational Safety and Health Agency
(OSHA) guidelines.
Other countries: visit your countrys governmental
Occupational Health and Safety Department.
98
PROJECT 11C
DRAW BLOOD USING A BUTTERFLY NEEDLE
VIDEO
INFORMATION
Winged infusion sets, commonly known as butterfly
infusion sets or butterfly needles, are frequently used to
perform venipuncture procedures. They are especially
useful when doing venipuncture on patients with spastic,
thin, or rolling veins. Winged needles are most commonly
used when the available veins are very small, fragile, and
difficult to access or when veins are in a location that
would make a standard evacuated tube system difficult to
use. Winged needles are also used on very shallow veins
because the design allows the needle to be inserted at a
much shallower angle (10-15) compared to a standard
evacuated tube system. Winged needles are nearly always
used when drawing blood from the hand, wrist, or other
places where veins are very close to the skin.
Due to the fact that the winged needle is attached to a
flexible tube, there is less chance of the needle slipping out
or perforating the deep end of the vein. This can happen
if either the patient or the phlebotomist moves during the
procedure, especially when drawing blood for multiple
tubes. Winged needles are usually 21g (green label) or 23g
(blue label). Rarely, a 25g (orange label) is used, mostly in
pediatrics or in very difficult cases; a needle of such small
diameter may cause hemolysis, thus invalidating test
results.
The needle is held by the wings and placed into the vein,
generally at a fairly shallow angle. The wings allow the
phlebotomist to grasp the needle very close to the end
to ensure accurate insertion into a vein. When the needle
enters the lumen of a vein a flash of blood can be seen. The
flash is a small amount of blood that flows back into the
tubing when the needle enters a vein. The phlebotomist
can then push vacuum tubes into the hub or use a syringe
to draw blood.
REQUIREMENTS
You will need:
Pen for writing
Laboratory forms
Alcohol wipe
Clean gloves
Winged infusion set21 gauge
Syringe (10ml or 20ml)
Cotton wool or gauze square
Fully setup Venipuncture Trainersee PROJECT 10A
Phlebotomist, in addition to the above items, will also
need leak-proof transportation bags and containers.
99

SITUATION THEN SIMULATE
DRAWING BLOOD USING
THE VENIPUNCTURE
TRAINER:
STEP 1
Greet, identify, position and prepare the patient, and then
ask relevant medical questions. Check the requisition order
against labels. Verify the following patient information:
fasting, dietary restrictions, medications, timing, medical
treatment, etc.
Make notes on the lab requisition form.
STEP 2
Assemble equipment (see REQUIREMENTS above). Set
out all of the tubes needed and have all the necessary
tools (tourniquet and alcohol swabs, etc.) nearby. The
butterfly needle should be a 21 gauge or wider in order to
minimize hemolysis. ALL needles and syringes are singleuse only. Open the outer packaging of all items to be used,
including the butterfly needle and syringe.
Insert the nozzle of the Vacutainer or the syringe firmly
into the hub end of the butterfly needle tubing.
Note: Use safety butterfly needles in all clinical settings.
When simulating the procedure you may use a regular
needle but take great care not to prick yourself.
STEP 3
See PROJECT 3A A technique for proper handwashing
and PROJECT 3B Cleaning hands with an antiseptic rub
STEP 4
Select the site, preferably at the cubital (antecubital) area.
veins in the intended venipuncture site. One may apply a
tourniquet temporarily, if necessary, 4-5 fingers above the
intended venipuncture site to facilitate inspection and
palpation. Remove the tourniquet until ready to proceed.
Note: Warm the arm with a hot pack or hang the hand
down to make it easier to see the veins.
STEP 5
When ready to draw the blood sample, apply the
tourniquet about 4-5 finger widths above the selected
venipuncture site.
100
STEP 6
STEP 7
prominent.
Important note: Dont ask the patient to pump the fist.
STEP 8
Disinfect the site using 70% isopropyl alcohol and allow to
dry completely (clean for 30 seconds and allow to dry for
another 30 seconds).
Do not touch the site again once the alcohol (or other
feel the vein, first touch a clean alcohol pad to aseptically
treat your glove.
STEP 9
Anchor the vein by holding the patients arm and placing the
thumb of the opposite hand below the venipuncture site.
DO NOT insert the Butterfly needle where veins are
branching as this will increase the chance of a hematoma.
STEP 10
Use the butterfly needle to enter the vein with a swift
movement at a 15 to 30 angle. Ensure that the bevel of
the needle is pointing up. DO NOT bend the needle. Keep
your eyes open for the flash-back of blood appearing in
the tube lumen indicating a successful venipuncture.
STEP 11
Draw blood by using either a Vacutainer or a syringe
connected to the butterfly tubing (some winged
needles have the Vacutainer hub pre-attached). See
PROJECT 11A or PROJECT 11B.
Note: If you have to draw a tube for a coagulation
specimen (citrate/light blue top) as the first specimen,
then draw blood using a clear top* (no additive) vacuum
tube before the citrate tube in order to fill the empty
tube space with blood, thereby ensuring the proper
blood-to-additive ratio (discard this tube after use).
*Preferably a clear top but any other color top tube will be
good.
STEP 12
Once you collect sufficient blood, ask patient to relax the
fist, and then remove the tourniquet.
Note: The tourniquet must be released after a maximum
of two minutes* regardless of whether or not you have
completed the venipuncture task.
*WHO guidelines. Some experts recommend a maximum

tourniquet time of one minute.
STEP 13
Gently withdraw the butterfly needle and give the patient
a clean gauze or dry cotton-wool ball to apply firm pressure
to the site to achieve hemostasis and avoid a hematoma.
Ensure that the patient has stopped bleeding, and then
apply tape and gauze to the venipuncture site.
STEP 14
Always use a safety transfer device for transferring blood
from a syringe to the vacuum tubes or the blood culture
bottles. [CLICK HERE] for the method of transferring
blood with a safety device.
If no safety transfer device is available place the vacuum
tubes in a test tube rack before inserting the needle into
the vacuum tube. Carefully penetrate the needle through
the tubes stopper and let the blood passively fill the tubes.
Warnings when transferring blood:
DO NOT hold the vacuum tube in your hand!
DO NOT exert pressure on the plunger of the syringe
to avoid hemolysis or causing the needle or stopper
to pop off, thus creating a spray of blood droplets
with the danger of exposing you and other people to
bloodborne pathogens.
STEP 15
If the tube used has additives, mix the contents by gently
inverting the tube 5-8 times (do not shake). Fill remaining
tubes and repeat the mixing routine after each tube has
been filled.
STEP 16
Discard sharps (e.g., the used needles and broken glass)
and syringe or blood-sampling device into a punctureresistant sharps container. Place other items like used
tubing flow-speed regulation device is open, and that the

ends of the tubes have lumen stoppers in position.
POINTS OF INTEREST:
Notes on safety:
Two examples of butterfly needles with built-in safety
features are:
The Punctur-Guard uses an internal blunt needle.
The mechanism is activated after blood is drawn.
The Angel Wing is activated by sliding a safety shield
over the needle after venipuncture.
Figure 29: The Angel Wing Safety butterfly needle [For more information]
Important note:
Always use a needle with safety features in a clinical
setting!
Safety needles minimize the risk of needle prick
injuries but do not eliminate these risks completely.
There is no substitute for being careful.
CUTTING DOWN A VEIN

Venous cutdown is an emergency procedure in which the
vein is exposed surgically and then a cannula is inserted
directly into the vein. Common veins used for this purpose
are the saphenous vein at the ankle and the basilic vein
in the cubital area. Venous cut down is indicated when
peripheral veins are very difficult or impossible to access
due to obesity, vascular collapse, or thrombosis.
STEP 17
Recheck the labels and forms for accuracy.
STEP 18
Thank the patient and perform hand hygiene.
STEP 19
Simulate the project by following Steps 1-18 using the fully
set up Venipuncture Trainer. See PROJECT 10B SET UP
THE VENIPUNCTURE TRAINER FOR IV TRAINING.
Ensure that the tubes are filled with fake blood, the IV fluids
Figure 30: How to cut down a vein
Read more on how to perform the procedure at: [CLICK HERE]
101
PROJECT 11 D
HOW TO START AN IV LINE
How to place a venous cannula into a vein
VIDEO
INFORMATION
Mastering the skill of setting up an IV line requires, time,
patience, and a lot of practice.
Figure 31b: Two examples of needle for introducing a peripheral venous

catheter with their protective caps. The example on the top has a side
port with cap for injecting medication.
Figure 31a: The components of an IV line [Photo with labels to be added]
102
Intravenous therapy or IV therapy is the infusion of a liquid

directly into a vein. It is commonly referred to as a drip
because many systems of administration employ a drip
chamber, which allows an estimation of flow rate and
prevents air from entering the blood stream. (Air entering
the blood stream can lead to an air embolism.) Intravenous
therapy is used as a method of delivering medications to
correct electrolyte imbalances for blood transfusions, and
for replacing fluid to correct dehydration. The IV route is the
fastest manner in which to deliver fluids and medications
to the body.
A peripheral cannula is commonly used for intravenous
access. It consists of a short catheter inserted through
the skin into a peripheral vein. This is usually in the form
of a flexible plastic cannula over a needle device. Once
the tip of the needle and cannula are located in the vein
the needle is withdrawn and discarded and the cannula is
then advanced inside the vein and secured into position
with tape.
REQUIREMENTS
You will need:
Alcohol wipe
Clean gloves
MEMORIZE THESE STEPS TO

BE FOLLOWED IN A REALLIFE CLINICAL SITUATION
THEN SIMULATE DRAWING
BLOOD USING THE
VENIPUNCTURE TRAINER:
STEP 1
Greet the patient, introduce yourself, and then pause to
Correct patientpositively identify the patient
Correct procedurescheck and follow the physicians
orders, including specifics regarding IV fluid and
medications (if applicable) to be used.
Then:
Place the patient in the Semi-Fowlers or supine
position.
Do a short medical history (allergies, bleeding
disorders, etc.) See PROJECT 2
Make notes on patients clinical chart
STEP 2
Assemble equipment and all the relevant items using
REQUIREMENTS above. Open the outer packaging of all
the items on the clean work surface cover.
Note: Use safety catheters and safety needles in all clinical
settings. When simulating the procedure, you may use a
regular catheter/needle but take great care not to prick
yourself with the sharp needle.
Cotton wool or gauze square

Strapping
Transparent dressing
IV catheters 18 or 20 or 22 gauge
IV fluid stand (something to hang the IV bag from
about 3 feet/1 meter above your work area level)
IV fluid bag
IV tubing
The Venipuncture Trainer (modified setup required).
See PROJECT 10B
A linen saver (not supplied in the kit)
STEP 3
HANDWASHING and PROJECT 3B CLEANING
HANDS WITH AN ANTISEPTIC RUB.
STEP 4
Connect the IV tubing to the Out port of the IV fluid bag.
Prime the line by pressing the chamber once or twice,
allowing it to fill about halfway. Open the control-flow
mechanism and allow fluid to fill the tube until all air
bubbles are out of the tube.
STEP 5
Select a suitable site for setting up an IV line. Start by
looking for a suitable vein on the dorsal part of the hand.
If no suitable vein is identified (or if you fail with the
venipuncture attempt) move proximally to the side of
the wrist, possibly the forearm, and then the cubital area.
Inspect and palpate the veins in the intended venipuncture
site. If necessary, you may temporarily apply a tourniquet
4-5 fingers above the intended venipuncture site to
facilitate inspection and palpation. Remove the tourniquet
until ready to proceed.
Place a linen saver under the patients arm to protect the
bed linens as it is difficult to avoid a couple of drops of
blood from occasionally flowing out of the vein.
Warning: When setting up an IV line, it is of utmost
importance to ensure that one is placing the cannula in a
vein, and not in an artery. When performing phlebotomy
procedures, an intra-arterial draw might not be the end
of the world, but as medication are often infused with an
IV line, an intra-arterial infusion of medication may have
catastrophic results!
103
STEP 6
STEP 12
Choose your IV catheter needle size with care. The size

will depend primarily on the size of the vein; however the
patients age and gender may also influence your gauge
selection.
Adultsan 18 or 20 gauge catheter will work well for
most cases.
Elderly and pediatric patientsuse a smaller catheter
(larger number, e.g., 22 or 24 gauge).
Emergency fluid replacementuse a larger catheter
(smaller number, e.g., 14 or 16 gauge).
Look for the flashback of blood in the catheters plastic

applicator. Once you see this flash of blood, advance the
catheter slightly, taking care not to go right through the
vein. Remove the needle while advancing the catheter in
one simultaneous movement. Take great care once the
needle is removed to avoid needle prick injury.
STEP 7
When ready to perform the venipuncture, apply the
tourniquet about 45 fingers above the selected
venipuncture site.
STEP 8
Don preferably sterile gloves, otherwise use clean
examination gloves. See PROJECT 3C or 3H.
STEP 9
prominent. (Some clinicians will first ask the patient to
form a fist first, and then don gloves while the veins are
distending).
Important note: If you do not intend performing
phlebotomy before attaching the IV line, you may ask the
patient to clench and open the fist a couple of times to
facilitate vein distention.
STEP 10
Disinfect the site using 70% isopropyl alcohol for 30 seconds
and allow it to dry completely (another 30 seconds).
treat your glove.
STEP 11
Remove the protective cap from the needle section of
the catheter. Anchor the vein by holding the patients arm
and placing the thumb of the opposite hand below the
venipuncture site. Insert the needle, bevel up, at an angle
of 15-20. Some instructors advise students to imagine an
airplane landing on a runway as they insert the needle.
DO NOT insert the needle where veins are branching as
this will increase the chance of a hematoma.
104
STEP 13
Remove the tourniquet.
If required, take the opportunity to draw blood before
attaching the IV line.
STEP 14
Remove the plastic connector cap/plug from the catheters
connector (if applicable).
Apply finger pressure on the vein above the catheter to
prevent the retrograde flow of blood. Apply a small gauze
square under the catheter to catch any escaping blood.
STEP 15
Attach the IV tubing to the catheter. Secure the catheter
with tape and a transparent dressing.
STEP 16
Open up the IV line. If you were successful, you will see
fluid dripping in the drip-chamber of the tubing.
Observe the area for a couple of minutes. If the surrounding
tissue swells, the drip is infiltrating the tissue. Stop the drip,
apologize, and move to another site.
Important note: If you see a drop of IV fluid in the drip
chamber moving in and out in a pulsatile fashion then
you are probably in an artery. Stop the drip immediately,
remove the needle and apply pressure on this site for five
minutes.
To avoid grave complications, never inject medication into
an artery!
STEP 17
Adjust the drip rate to whatever is appropriate for your
patient. To keep the line open, turn the drip rate down to
just a few drops a minute.
STEP 18
Discard sharps (e.g., the used needles) into a punctureresistant sharps container. Place other items like used
fluids into the infectious waste container.
STEP 19
Thank your patient. Compliment pediatric patients for
being brave. Perform hand hygiene.
STEP 20
Simulate the project by following Steps 1-19 using
the Venipuncture Trainer. You will have to modify the
Venipuncture Trainer setup:
Do not attach the tubing to the tubes on the trainer. Place
a lumen stopper on one end of the tube/imitation vein
and a shallow container below the open end. When you
are convinced that you have successfully entered a vein
on the Venipuncture Trainer, attach the free end of the
IV tube to the catheter, and then open the flow-control
mechanism. If you were successful, fluid will flow out of the
open end of the fake vein. If no flow is observed, close the
flow-control mechanism and try again. Keep practicing!
POINTS OF INTEREST:
If you fail, a bit of blame shifting is quite permissible. Blame
it on the vein, on the weather or anything else, as you
need to retain your patients confidence in your abilities
for the next attempt! If you fail for a third time, apologize
and ask for assistance from a more experienced medical
professionalunless that person is you!
The veins of elderly people tend to slip to one or the other
side if you puncture it from the top. Secure the vein with
a finger of your other hand and puncture the skin on the
side of the targeted vein.
How to calculate IV flow rates:

Intravenous fluid must be given at a specific rate. The
specific rate is measured as milliliter per hour (ml/h) or
drops/minute. To control or adjust the flow rate only drops
per minute are used.
Common drop factors are:
10 drops/ml (blood set), 15 drops/ml (regular set), 60
drops/ml (micro-drop).
To measure the rate we must know:
1. The number of drops
2. Time in minutes.
The formula for working out flow rates is:
Volume (ml) x drop factor (drops/ml)

= drops/min (flow rate)
Time (minutes)
Example:
3000 ml IV Saline is ordered over 24 hours. Using a drop
factor of 15 drops/ml, how many drops per minute need
to be delivered?
3000 (ml) x 15 (drops/ml)
= 31.25 drops/minute
24 hrs. x 60 (gives us total minutes)
105
PROJECT 11 E
HOW TO REMOVE THE IV LINE
How to remove a venous cannula from a vein
VIDEO

Shut off the IV by closing the roller clamp of the flow

control mechanism.
Remove the tape and OpSite or Tegaderm from the
tubing and catheter.
Place non-sterile 2x2 gauze over the IV site, remove
the catheter from the arm, and secure the gauze in
place with a piece of tape.
ALTERNATIVES TO IV
INFUSION FOR ACCESSING
THE BLOODSTREAM:
Intraosseous infusion (commonly used in pediatric
patients)
Figure 32: Performing an Intraosseous infusion
106
Maintain pressure over the site for 2-3 minutes to

secure hemostasis.
Discard all sharps into the sharps waste container and
all other items in a biohazard waste bag.
Intraosseous infusion is a temporary emergency

measure indicated in life-threatening situations when
intravenous access fails (3 attempts or >90 seconds).
Use the anteromedial aspect of the tibia.
Insert, pointing slightly inferior in order to avoid the
epiphyseal growth plate.
Use an aseptic technique.
Crystalloids, colloids, blood products, and drugs can
be infused.
Remove as soon as the child has been resuscitated
and intravenous access has been established.
For more information [Click Here].
SPECIAL GROUPS
OF PATIENTS
THE NEONATE PATIENT
THE PEDIATRIC PATIENT
A neonate is a newborn infant, especially one less

than four weeks old. The neonate patient has specific
challenges due to anatomical and physiological variables
that differ substantially from an adult patient. This is
why neonatologists need specialized knowledge and
proficiency with difficult skills.
Below is an excellent article about venous access in
neonates with the abstract below:
Vascular access in neonates and infantsindications,
routes, techniques and devices, complications. By Mller
JC, Reiss I, Schaible T.
The basic principles of phlebotomy and venipuncture in

the pediatric patient are similar to the adult patient yet
differ quite a bit.
The key to successful venipuncture lies with the restrainer
(parent or fellow medical professional).
Look at the recommended technique as suggested by WHO:
phlebotomy
Especially read the section on Practical guidance on
pediatric and neonatal blood Sampling pages 35-40.
This is a must read for any medical professional working
with pediatric patients:
Difficult Venous Access in Children: Taking Control by
Laura L. et al.
Download this excellent article: [Click Here]
Abstract:
Venous cannulation has been in regular use in neonates
since the 1940s. This was at first through the umbilical
vein, but the frequency of complications lead to other
central and peripheral routes being used for infusion of
fluid, nutrients and drugs. Today, peripheral venous access
is preferred except for high volume fluid resuscitation,
reliable infusion of irritant drugs and long-term parenteral
nutrition. Intraosseous infusion provides a reliable
alternative to peripheral veins for rapid infusion of fluid.
Long, thin silastic catheters can be inserted through a
peripheral venous cannulae for parenteral nutrition or
other central venous infusions as an alternative to direct
central venous cannulation using the Seldinger or other
techniques. Broviac or Hickman catheters, inserted through
a subcutaneous tunnel are only considered when central
venous cannulation is likely to be needed for more than six
weeks. The most common serious complication of vascular
access is infection. Infection associated with central
venous catheters is reduced by prophylactic vancomycin
or teicoplanin. Other complications of central venous
infusion are associated with cannulae malpositioning,
bleeding and thrombosis. Distal hypoperfusion may follow
arterial cannulation. Modern emergency and intensive
care paediatrics is impossible without adequate venous
and arterial vascular access; however, no other skill for
neonatal intensive care causes more anxiety among
primary care providers, is more difficult to teach and is
associated with an increased risk of median nerve injury.
For the complete article [Click Here]
107
VETERINARY
VENIPUNCTURE
The animal patient
The basic principles of performing venipuncture procedures on the animal patient are the same as for the human patient.
VIDEO
Generalized differences include:
Most animals do have fur or lots of hair covering the areas with veins suitable for venipuncture. Removal of fur or hair
is often necessary to visualize the veins and successfully perform phlebotomy or set up an IV line.
The temperaments of animals are quite varied and different from the human patient.
Communicating with animals is quite different to communicating with humans.
The general and thus venous anatomy of various animal species may vary considerably.
The skin of certain species of animals, for example reptiles, may be thick and difficult to penetrate.
When treating wild animals, levels of aggression may be dangerous or life threatening. A sedative (i.e., administered by
darting) may be a prerequisite before a successful venipuncture procedure may be safely performed.
Clinicians may need to take specialized protective measures to protect themselves from injury when treating animal
patients.
In veterinary practice, vascular access has many variables
and techniques specific to many different species that
may be encountered. This topic is beyond the scope of
this course. Veterinary students are referred to veterinary
literature and books for detailed information on
venipuncture in animals.
Figure 34: Hematoma cat patient following the neutering operation
Two interesting article abstracts are included below:
108
1. Vascular access: theory and techniques in the small animal emergency patient
Abstract
Acquisition of vascular access in the emergent small animal patient is one of the keys to successful management of
a population of patients that are often unstable with regard to their major body systems. Venous and intraosseus
cannulation allow for the administration of a variety of fluids and potentially life-saving medications. In addition, central
venous and arterial access also serves as conduits for atraumatic blood sampling and intravascular pressure monitoring.
A thorough knowledge of vascular access theory, the dynamics of fluid flow, vascular anatomy, catheter selection criteria,
and placement techniques are critical to the proper and safe use of the vascular access options that are available to small
animal clinicians today.
2. Vascular access techniques in the dog and cat
Abstract
The rapid and reliable attainment of vascular access may prove crucial for the provision of an effective therapeutic solution
in the critically ill or emergency small animal patient. Although in such cases it is more common to consider venous vascular
access for the administration of medication and for the measurement of venous pressures, the attainment of arterial
vascular access may prove just as important, allowing the direct measurement of arterial blood pressure and the sampling
of arterial blood. This article provides guidelines on appropriate catheter selection for vascular access, placement techniques
for both venous and arterial access, and procedures required for the long-term maintenance of these access sites.
Veterinary students will find The Apprentice Doctor Venipuncture Course and Kit a valuable resource for attaining the
basic venipuncture knowledge and skills required by their curriculum.
Here are a number of clinical examples of Venipuncture procedures in the animal patient: [SEE VIDEO CLIP ON PAGE 108]
AIDS
TO ASSIST THE CLINICIAN
VeinViewer
VeinViewer is a medical imaging device that uses nearinfrared light to produce a digital image of a patients veins
and project it directly on their skin.
See this YouTube video: [CLICK HERE]
AccuVein is a similar medical imaging device that uses a
specific frequency of light to produce a digital image of a
patients veins projected directly on their skin.
See: [CLICK HERE]
Breastlight
Breastlight was originally designed as a breast cancer
screening modality for examining the female breast for
nodules. However, it is also quite useful to show blood
vessels or venipuncture purposes!
The frequency of light waves penetrates soft tissue readily,
but shows blood vessels as dark lines.
For more information [CLICK HERE]
It is also more affordable than the previous two products.
Ultrasound
Ultrasound is useful in detecting problems with most of
the larger blood vessels in the body (e.g., the abdominal
aorta and the carotid arteries). Using Doppler ultrasound
technology, the flow of blood through vessels can be
observed and measured. This makes it possible to detect
arterial stenosis and aneurysms.
Ultrasound is also useful in demonstrating superficial or
deep veins and to differentiate between veins and arteries.
[CLICK HERE]
Anesthetists use ultrasound to guide them to correctly
place the needle when performing regional anesthesia.
Radiography
Central lines are commonly placed in critically ill patients. Chest
radiographs are used to ensure proper positioning and to rule
out complications during placement. The ideal location for the
tip of a central line is at the cavoatrial junction, which is where
the superior vena cava meets the right atrium. This allows for
the infusion of large volumes of fluids or medications.
Also see section on interventional radiology.
109
PROJECT 12A
IDENTIFY THE BODYS PULSE POINTS
How to identify the bodys pulse points and how to determine a persons heart rate
INFORMATION
HINTS
Each time the heart contracts (systole), a pressure wave is

perpetuated throughout the arterial system of the body.
A throb or pulse can be palpated anywhere in the human
body where an artery crosses a bony prominence or firm
structure (e.g., a tendon). The pulsation occurs due to a
slight increase in the diameter of the artery coinciding
with an increase in arterial pressure during systole. Arteries
have strong, muscular, elastic walls.
REQUIREMENTS
A suitable volunteer for checking the pulse points
A watch with a minute indicator (if you want to determine
the heart rate)
Use the middle three fingers to feel for a pulse. Do not

feel with the thumb as you may in fact be sensing the
small artery pulsating in your own thumb.
Firmly (but not with too much pressure) press down
with the middle three fingers in the area where you
want to feel for a pulse.
You may have to move the position of these fingers
slightly over the specific area before feeling the pulse.
Do not press too hard as this may block the artery and
stop the pulsations.
Some practice may be necessary before you can
identify a clear pulse.
Take note of the following characteristics of the pulse:

The forcefulness of each individual beat indicates a
weak pulse or a strong pulse.
Is the pulse regular or irregular?
STEP 1
Look at this diagram showing a number of the more common pulse points of the body:
STEP 2
NOTE:
Identify the wrist pulse points. Two arteries supply each

hand with oxygenated blood: the radial and the ulnar
arteries. See if you can identify these two pulse points.
The radial pulse point is situated on the thumbs side of

the wrist and the ulnar pulse on the little fingers side, as
indicated in the illustration.
110
Figure 35a h: Various pulse points of the body
Note: A thorough knowledge of the regional anatomy will be helpful to locate these pulse points.
STEP 3
STEP 6
Identify the bony angel of the mandible. Place two fingers

on this point. Move these fingers 3-5 cm (1-1 inches)
forward and feel for the facial artery pulsating as it crosses
the lower border of the mandible.
Place your fingers on the angle of the mandible again.
Now go down 3-5 cm (1-1 inches) towards the neck.
Press towards the midline in a direction slightly towards
the back. You should feel a strong pulse here; it is the
internal carotid artery pulsating as it carries oxygenated
blood to the brain.
To determine the pulse rate, count the number of beats

or pulsations in one minute. This number is the pulse rate
and equals the heart rate for the specific person it is
measured in BPM (beats per minute).
WARNING
Do not press too hard to find the carotid pulse in the neck.
Do not press on both carotid arteries at the same time. This
may cause fainting!
STEP7
Practice by identifying a variety of these pulse points and
checking the pulse rate of other people.
POINTS OF INTEREST:
STEP 4
Identify the brachial pulse an important pulse point used
for the purpose of taking routine blood pressure readings.
STEP 5
Identify the pulse points as shown in the diagram above.
The femoral pulse is reserved for self-examination.
An arterial line is a thin catheter inserted into an artery.

Its commonly used in intensive care medicine and
anesthesiology to monitor real time blood pressure and
to obtain samples for arterial blood gas measurements.
An arterial line is usually inserted in the wrist (radial
artery) but can also be inserted into the upper arm
(brachial artery), the groin (femoral artery), the foot
(dorsalis pedis artery), or the inside of the wrist (ulnar
artery).
The femoral artery is commonly used by diagnostic
and interventional radiologists, as well as cardiologists
to access the arterial system.
For a more detailed discussion on the pulse rate
see Project 24 in The Apprentice Doctor Foundation
course.
111
PROJECT 12 B
PERFORM A MODIFIED ALLENS TEST
Check the collateral circulation of the hand
VIDEO
INFORMATION
In the majority of the population, two arteriesthe radial and ulnar arteriessupply the hand with oxygenated blood.
These arteries anastomose in the hand. In a minority number of people, this dual blood supply is absent.
The Allens test and the modified Allens tests are used to test the collateral blood supply to the hand, specifically the
patency (openness) of the radial and ulnar arteries. It is performed prior to radial arterial blood sampling or cannulation, as
well as before coronary bypass surgery as the cardiothoracic surgeon may choose to harvest the radial artery to be used
as a graft/conduit for bypass surgery.
112
FOLLOW THESE STEPS TO

PERFORM THE MODIFIED
ALLEN TEST:
STEP 1
With the middle two or three fingers (not the thumb),
locate the pulsating radial and the ulnar arteries on the
palm side of the wrist (see illustration). Keep in mind that
the ulnar artery is smaller and more difficult to locate.
INTERPRETATION:
When you release the occlusive pressure on the ulnar
artery, you should notice a return of normal color to the
palm and nails within 7 seconds. This indicates that the
ulnar artery is patent and has good blood flow.
Negative Allens test: The normal color (flushing) returns
within 7 seconds.
Positive Allens test: The normal color of the hand does
not return (flushing) within the specified time. A negative
modified Allens test indicates that ulnar circulation is
inadequate or nonexistent.
SIGNIFICANCE
Despite the fact that some researchers question the
validity of the Allens test, the following guidelines are still
recommended:
Negative: Allens test (normal pink color returns): You may
use the radial artery for blood sampling, cannulation, or
to harvest as a graft. The ulnar artery will be sufficient for
supplying blood to the hand, even without a patent radial
artery, should occlusion complications occur.
Figure 36: The radial and ulnar arteries
STEP 2
Elevate the hand and ask the patient to make a tight
clenching fist for about 30 seconds.
STEP 3
Positive: Allens test (normal pink color doesnt return):

Dont use the radial artery for blood sampling, cannulation,
or harvesting as a graft in order to avoid serious ischemic
(insufficient blood supply) complications to the hand.
Instead, use the radial artery of the opposite hand
(remember to do an Allens Test first) or use another
artery of the body for the specific clinical task or surgical
procedure.
Apply firm pressure over the ulnar and the radial arteries,
occluding both of them.
STEP 4
Still elevated, the hand is then opened. It should appear
blanched. (Pallor can be observed over the palm, as well
as the fingernails).
STEP 5
Release the ulnar pressure and the color should return
within 7 seconds (between 5 and 15 seconds).
113
PROJECT 12 C
DRAW ARTERIAL BLOOD
Sample arterial blood from an artery
VIDEO
INFORMATION
REQUIREMENTS
This project will describe sampling blood for ABG (arterial

blood gasses) using the radial artery.
Other arteries that may be used for this purpose include
the ulnar artery, the brachial artery, and the femoral artery.
Some medical/surgical emergencies like acute pulmonary
edema, an acute exacerbation of COPD, and surgical shock
reduces the bodys ability to take in oxygen and eliminate
carbon dioxide. Often the patients life depends on the
appropriate action based on the ABG results. ABG may also
be needed when weaning a patient from a ventilator or
administering a general anesthetic to a very sick patient.
The ABG test results include the following: the bloods pH,
the partial pressure of Oxygen (PaO2), the partial pressure
Carbon Dioxide (PaCO2), Oxygen saturation (SaO2), and
bicarbonate (HCO3) levels.
Drawing an arterial blood gas sample is not as difficult as
you may think. Arteries pulsate, making them easier to
locate and unlike some veins they dont roll.
You will need:

Pen for writing
Laboratory forms
A sharps waste container
Alcohol wipe
Clean gloves*
Tourniquet
Syringe (3ml or 5ml)**
Needle (23g Use a safety needle if available.)
Cotton ball or gauze square
Fully set up Venipuncture Trainersee PROJECT 10C
For ABG sampling use:
Sterile gloves* (in most centers)
Eye protection glasses* (recommended)
An ice filled plastic bag*, paper cup* or kidney dish* for
transporting the sample to the lab after the procedure
*Not supplied in the kit
**Most hospitals have ABG kits containing a special preheparinized syringe, as well as all the necessary items
required for the procedure.
114
FOLLOW THESE STEPS

IN A REAL-LIFE CLINICAL
SITUATION THEN SIMULATE
DRAWING BLOOD USING
THE VENIPUNCTURE
TRAINER:
STEP 1
Assemble equipment (see REQUIREMENTS above). Open
the outer packaging of all the items to be used.
Note: Use safety needles in all clinical settings. When
simulating the procedure you may use a regular needle
but take great care not to prick yourself with the sharp
needle.
STEP 2
Greet, identify, and inform the patient. Explain the
procedure shortly (unless comatose) and that they will
experience a small needle prick, a mosquito bite, or
whatever works for you. You can ask them to please, keep
your arm still.
STEP 3
HANDWASHING and PROJECT 3B CLEANING HANDS
WITH AN ANTISEPTIC RUB.
STEP 4
Site selection: as a first choice, select the radial artery of the
non-dominant wrist. See PROJECT 12A IDENTIFY THE
BODYS PULSE POINTS.
Warning: Radial arteries are contraindicated in patients
who have a fistula or shunt in place for dialysis or have had
the radial artery used as a coronary artery bypass graft on
the side of the intended sampling.
STEP 5
Perform a modified Allens test. See PROJECT 12B
PERFORM A MODIFIED ALLENS TEST.
If you have a positive Allens test (normal pink color doesnt
return): dont use the radial artery for blood sampling or
cannulation so as to avoid serious ischemic (insufficient
blood supply) complications to the hand.
Rather use the radial artery of the opposite hand (remember
to do an Allens Test first) or choose another artery.
STEP 6
Position is important! The patient should be seated
comfortably (patients in bed should be in the semirecumbent position) and the arm must be comfortably
extended towards you, wrist up, and the skin over the
radial artery taut. Let the forearm rest on a small pillow;
use a rolled towel or linen under the back of the hand
to facilitate the extended wrist position. Cover the rolled
support with a linen saver.
STEP 7 (OPTIONAL)
Give local anesthetic. Don non-sterile gloves and prepare the
skin aseptically. Infiltrate (e.g., 2% plain Lidocaine 0.2 0.3 ml)
intradermally with a 25G needle to reduce the anticipated
pain associated with the procedure. Remove your gloves.
STEP 8
Perform hand hygiene, don sterile gloves, and disinfect
the site with an alcohol wipe for 30 seconds and allow to
dry completely (allow another 30 seconds).
STEP 9
With the fingertips of your gloved left hand, find the area
of maximal pulsation of the radial artery. In addition to the
pulsation, you should be able to feel the radial artery as a
cord-like structure beneath your fingers.
With the fingers of your left hand over the radial artery,
visualize the course of the radial artery underneath your
fingers in three dimensions.
STEP 10
Hold the syringe with the attached exposed needle in
your right hand like a pencil. Approach the skin at 3045, in line with the radial artery, pointing in the direction
towards the elbow. The needle should enter the radial
artery immediately below the gloved fingers of the left
hand (careful not to slip and injure yourself ). Keep the skin
taut and enter the skin with a brisk movement is the skin
penetration that causes the most pain.
STEP 11
Once in the soft tissue, slowly advance the needle to
where you think the radial artery is. Do not rush; it is easy
to go straight through the radial artery. You may feel a
slight give as the needle penetrates the wall of the radial
artery. Once the needle has entered the artery you should
see a flashback of blood pulsating into the syringe. If you
dont see blood you may have missed the artery or may
have gone right through it. If so, withdraw the needle until
blood starts filling the syringe or you may have to try again
by re-aiming the syringe towards the pulsating artery.
115
STEP 12
STEP 21
Instruct the patient not to move the arm or wrist. If they

do, the needle may become dislodged. Blood gas syringes
fill automatically, stopping at 2 ml. If you are using a
regular syringe you will have to stabilize the syringe with
your left hand and gently withdraw the plunger of the
syringe with your right hand. Once the syringe has filled or
once sufficient blood has been collected, hold it steady to
prevent air aspiration and then withdraw the needle.

fully setup Venipuncture Trainer. See PROJECT 10C.
STEP 13
Immediately place a gauze pad or cotton ball over the
site and firmly apply pressure for 5-10 minutes. Use the
tourniquet over the cotton ball to apply pressure.
STEP 14
Inspect the syringe for air bubbles and slowly eject using
a gauze square. Mix the blood with the heparin by gently
rolling the syringe a couple of times between your fingers.
STEP 15
Seal the needle or tip of the syringe with a rubber stopper
to prevent the influx of air.
STEP 16
Place the syringe onto the ice (pack some ice cubes
over the syringe) and send it off to the lab immediately.
ABG samples should be analyzed within 10 minutes of
collection for accurate results.
STEP 17
Discard all sharps (e.g., the used needles, syringes) and
potential sharps such as glass items into a punctureresistant sharps container. Place other items like used
STEP 18
Recheck the labels and requisition forms for correctness of
the patients name, the date, time, puncture site, etc.
STEP 19
Monitor the site and extremity for a while for any
sign of circulatory problems, nerve damage, or other
complications.
STEP 20
Thank the patient and perform hand hygiene.
116
Unfortunately you wont be able to feel a pulse on the

simulator.
POINTS OF INTEREST:
Although arterial puncture is a fairly complicationfree procedure, you may encounter the following
complications:
Hematoma
Blood under pressure is initially more prone to leak from
an arterial puncture than from a venipuncture site. It is
important to exert sufficient pressure over the puncture
site for 5-10 minutes.
Hemorrhage
Hemorrhage is especially a problem with patients receiving
anticoagulant therapy or patients with blood coagulation
disorders. A longer compression time will be necessary.
Nerve damage
Compression neuropathy secondary to hematoma may
cause temporary numbness of the hand. Direct needle
injury to a nerve may cause permanent numbness of part
of the hand. Know your anatomy and avoid continuous
blind and deep poking of the wrist area.
Aneurysm and AV (Arterio-Venous) Fistula
These rare complications usually occur with repeated
punctures. An aneurism will cause the artery to balloonout due to a weakened muscular wall. An AV fistula is a
communication between an artery and a vein before the
capillary bed.
Arteriospasm
Arterial spasm may decrease the pulse volume and cause
pain but fortunately is temporary.
Thrombus formation
Injury to the artery can lead to clot (thrombus) formation. A
large thrombus can obstruct the flow of blood and impair
circulation to the hand.
Infection of the puncture site
Use sterile/aseptic protocol as recommended by your
institution/hospital.
The following factors will negatively influence the

integrity of the ABG:
Air bubbles remaining in the specimen
Delay in cooling the specimen
Venous blood mixed in ABG sample
Note: The best way to be certain that a specimen is arterial

is by observing the blood pulsating into the syringe.
Improper anticoagulant
Note: Heparin is the only accepted anticoagulant for ABGs.
BLOOD TRANSFUSIONS,
BLOOD TYPE (BLOOD GROUPS) AND AGGLUTINATION
A persons blood type is determined by certain proteins
markers (antigens) on the surface of red blood cells (RBCs).
A total number of 30 human blood group systems are now
recognized by the International Society of Blood Transfusion
(ISBT). There are many types of blood; however, the most
important ones are ABO and the Rhesus factor.
The ABO blood group system

In the ABO blood group system, there are four possibilities
A-antigen (A blood), B-antigen (B blood), both A and B
antigen (AB blood), and lastly neither A nor B antigens
called O blood. A person with Type A blood produces
antibodies against the B antigens and vice versa. A person
with O blood produces both A and B antibodies. See the
illustration below (the antigens sticking out are represented
by the colored shapes on the surface of the red blood cells).
Figure 37: The ABO antigens and antibodies
On average the general population has the following percentages of blood groups (percentages vary from country to country):
0+
A+
B+
AB+
0-
A-
B-
AB-
36%
28%
21%
5,0%
4%
4%
1,5%
0,5%
Table 7: Prevalence of Blood groups in the general population (approximate global averages)
117
Genotype (Genetic type)
Phenotype (Biochemical expression)
AA or A0
BB or B0
AB
AB
00
Table 8: The ABO Genotype and Phenotype
RH BLOOD GROUP SYSTEM

The Rh system (another type of protein that is exposed
on RBC is called Rh-factor) is the second most significant
blood-group system in human blood. The most significant
Rh antigen is the D antigen. You either have it or you
dont. The person who has the D antigen is positive and
one who doesnt is negative. So, someone could be Type
A, B, AB, or O, and then Rh positive or negative (e.g., A
Rh+ or B Rh-). An Rh+ person can donate blood ONLY
to another Rh+ person while an Rh- person can donate
blood to both an Rh+, as well as an Rh- person.
Rh factor is especially important in pregnant women.
Lets say a woman is Rh- and the Rh+ father gave the
baby the genes to be Rh+ as well. This will be fine, as the
babys blood isnt mixing with the mothers or vice-versa.
When it becomes important is when she gives birth to
the baby because theres a break in the blood systems
and small tears cause some of the blood cells from the
baby to cross over into the mothers bloodstream during
birth, which causes the mothers immune system to
recognize those Rh antigens. The Rh-negative mother will
produce Rh antibodies upon exposure to Rh-factor. If the
next baby is Rh+ again, the mothers anti-Rh antibodies
can cross over to the babys system and attack the babys
red blood cells, often ending in the demise of the baby.
The RhoGAM injection was created to minimize Rh-factor
incompatibility reaction with consecutive pregnancies.
It is given to the mother within 72 hours of birth to kill
the Rh+ cells that have crossed into her blood stream to
prevent her from making Rh antibodies.
118
AGGLUTINATION REACTION
(CLUMPING TEST)
Should a medical professional infuse the wrong blood
type to somebody by accident, the result will be that
blood will agglutinate (create clumps of red blood cells
followed by serious life threatening complications). It
is important to test the blood from the donor and the
recipient by mixing a small amount in a test tube or on a
glass slide to test for compatibility. Agglutination will be
noted if the bloods are incompatible. Type O Rh- blood
can be given to anybody because theres nothing on
the blood cells for the person to attack. A person with
type O Rh- blood is considered a Universal donor and
any person in any other blood group may receive type
O Rh- blood. A person with type AB Rh+ blood carries
both A, B, and D (Rh) antigens but neither A nor B nor
D antibodies and can therefore receive anyones blood
(types A or B or AB or O blood Rh+ or Rh-) because they
dont have antibodies to fight antigens. Type AB is known
as a universal recipient.
Recipient
00+
AA+
BB+
ABAB+
0-
0+
A-
A+
B-
B+
AB-
AB+
Table 9: Red blood cell compatibility
119
PROJECT 13
DONATING BLOOD FOR THE BLOOD BANK
Become a blood donor (if you arent a donor already)!
INFORMATION
Study pages 25 30 (Practical guidance on
venipuncture for blood donation) of the WHO
document:
phlebotomy. WHO Publication 2010
Your mission is as follows:
Identify your closest blood bank.
Arrange a date and time to donate blood.
Observe the steps and method used by the
phlebotomist to collect blood from you as a blood
donor and compare it with the information below.
Ask questions and have a hands-on learning
experience!
REQUIREMENTS
You will need:
The contact details of your local blood bank.
Transport to and from your local blood bank.
COLLECTING BLOOD
For collection of blood for donation use the procedure
detailed in Section 2 for blood sampling (e.g., for hand
hygiene and glove use) as far as it is relevant and follow
the six steps given below:
STEP 1

Identify donor and label blood collection bag and test

tubes
Ask the donor to state their full name.
Ensure that:
The blood collection bag is of the correct type.
The labels on the blood collection bag and all its
satellite bags, sample tubes, and donor match.
Records have the correct patient name and
number.
The information on the labels matches with the
donors information.
120
STEP 2
Select the vein
Select a large, firm vein, preferably in the cubital fossa,
from an area free from skin lesions or scars.
Apply a tourniquet or blood pressure cuff inflated to
4060 mm Hg to make the vein more prominent.
Ask the donor to open and close their hand a few
times.
Once the vein is selected, release the pressure device
or tourniquet before the skin site is prepared.
STEP 3
Disinfect the skin
If the site selected for venipuncture is visibly dirty,
wash the area with soap and water and then wipe it
dry with single-use towels.
One-step procedure (recommendedtakes about
one minute):
Use a product combining 2% chlorhexidine
gluconate in 70% isopropyl alcohol.
Cover the whole area and ensure that the skin
area is in contact with the disinfectant for at
least 30 seconds.
Allow the area to dry completely or for a
minimum of 30 seconds by the clock.
Two-step procedure (if chlorhexidine gluconate in 70%
isopropyl alcohol is not available, use the following
proceduretakes about two minutes):
Step 1: Use 70% isopropyl alcohol
least 30 seconds.
Allow the area to dry completely (about 30
seconds).
Step 2: Use tincture of iodine (more effective
than povidone iodine) or chlorhexidine (2%).
least 30 seconds.
Allow the area to dry completely (about 30
seconds).
Whichever procedure is used, DO NOT touch
the venipuncture site once the skin has been
disinfected.
STEP 4
Perform the venipuncture
Perform venipuncture using a smooth, clean entry
with the needle. Take into account the points given
below which are specific to blood donation.
In general, use a 16 gauge needle, which is usually
attached to the blood collection bag. A retractable
needle or safety needle with a needle cover is
preferred, if available, but all should be cut off at the
end of the procedure (as described in step 6 below)
rather than recapped.
Ask the donor to open and close their fist slowly every
10-12 seconds during collection.
Remove the tourniquet when the blood flow is
established or after 2 minutes, whichever comes first.
STEP 5
Monitor the donor and the donated unit
Closely monitor the donor and the injection site
throughout the donation process. Look for:
Sweating, pallor, or complaints of feeling faint
that may precede fainting
Development of a hematoma at the injection
site
Changes in blood flow that may indicate the
needle has moved in the vein and needs to be
repositioned
About every 30 seconds during the donation, mix the
collected blood gently with the anticoagulant, either
manually or by continuous mechanical mixing.
AFTER A BLOOD DONATION

Donor care after the blood has been collected:
Ask the donor to remain in the chair and relax for a
few minutes.
Inspect the venipuncture site. If it is not bleeding,
apply a bandage to the site. If it is bleeding, apply
further pressure.
Ask the donor to sit up slowly and ask how they are
feeling.
Before the donor leaves the donation room, ensure
that they can stand up without dizziness and without
a drop in blood pressure.
Offer the donor some refreshments.
IMPORTANT NOTE!
If you are not already one consider becoming a regular
blood donor.
POINTS OF INTEREST
Current FDA guidelines allow a maximum of 10.5 ml/
kilogram body weight of whole blood to be collected every
eight weeks. The majority of blood collection facilities use
500 ml whole blood bags, with an additional 50 ml (10%)
allowed to be drawn for mandated screening tests.
Great advances have been made with minimizing the
need for blood during surgery. See Bloodless surgery for
more information: [Click Here]
STEP 6
Remove the needle and collect samples
Cut off the needle using a sterile pair of scissors.
Collect blood samples for laboratory testing.
121
Venipuncture Course and Kit | RELATED TOPICS OF INTEREST
CASE STUDY 4:
DESPITE ALL THE TRAINING AND THE NECESSARY CARE, ACCIDENTS DO HAPPEN
Michelle, an experienced phlebotomist, has been

working in a kidney transplant unit for years. On this
specific occasion, she receives a requisition order for
drawing venous blood for kidney function tests. The
necessary items for drawing blood are collected but
the safety needle container is empty. I will just use
a regular needle for now and get new supplies in a
moment, Michelle whispers to herself. The blood draw
proceeds quite smoothly until, for some unknown
reason, the patient suddenly and unexpectedly jerks
away. In an instant the needle slips out of the patients
arm and penetrates Michelles index finger. The
124
required protocol is followed and the patient is asked

for permission to draw more blood sampleswith the
necessary explanations and relevant forms to be filled
out. Eventually, later in the day, the patients blood
results arrive.
Michelle is summoned to the Infection Control Officers
office. They discuss the results of the blood tests after
which the Infection Control Officer asks Michelle, When
was your previous Hepatitis B inoculation? An ice-cold
shiver goes down the phlebotomists spine as she
realizes that it is long, long overdue.
Three months later, after a slow decline in health and
despite the best of medical attention by specialists in

their fields and the best treatment medical science
had to offer, the able phlebotomist succumbs to
complications of sub-massive viral liver necrosis and all
ends in tragedy.
Warnings:
In all clinical settings use safety needles and dont
allow for any exceptions.
Ensure that your Hepatitis B inoculations are up to date.
CENTRAL VENOUS LINE

A central venous catheter (central venous line) is a catheter
placed into the internal jugular vein or the subclavian vein
or, less commonly, the axillary vein or femoral vein.
Figure 39b: An introducer and a central venous catheter
Figure 38: Central Venous Line Insertion
Depending on its use, the catheter is monoluminal,

biluminal, or triluminal, dependent on the actual number
of lumens (1, 2 and 3 respectively).
Figure 39a: Examples of a central venous catheters
Figure 39c: Placing a central venous catheter under sterile conditions
The indication for the use of a central venous line is when

frequent or persistent need for intravenous access is
required for:
Monitoring of the central venous pressure (CVP) in
acutely ill patients to quantify fluid balance
Long-term parenteral nutrition
Administering long-term medications
Infusing drugs that are prone to cause damage or
phlebitis in peripheral veins (e.g., chemotherapeutic
agents)
Frequent blood drawing for blood tests
Administering fluids
Determining the mixed venous oxygen saturation
Dialysis
Need for intravenous therapy when peripheral venous
access is impossible
125
Central venous catheters usually remain in place for a

longer period of time than other venous access devices.
Possible complications include:
Pneumothorax
Central-line associated bloodstream infections
Thrombosis
Other complications
Air embolism (rare)
Hemorrhage and formation of a hematoma
ARTERIAL
CATHETERIZATION
An arterial line is a thin, hollow tube that is inserted
into an artery the most common being the radial
or femoral arteries. It is often used in intensive care
medicine and anesthesia to monitor the blood pressure
real time and/or to obtain multiple samples for arterial
blood gas measurements. The arterial line must be
clearly marked to avoid accidental intra-arterial injection
of intravenous drugs.
Figure 40: Inserting a catheter into the radial artery
COMMON REASONS FOR ITS USE ARE:

Severe hypotension or hypotensive shock
Life-threatening hypertension
Severe pulmonary problems
126
RISKS INCLUDE
Pain: Discomfort can result from the needle stick and
placement of the catheter at the time it is inserted.
Consider infiltrating the skin over the intended
insertion site before catheterization.
Infection: As is the case with all catheters inserted
into the body, bacteria can travel up the catheter from
the skin and into bloodstream causing bacteremia or
septicemia. The longer the catheter remains in the
artery, the more likely it is to become infected.
Thrombus formation: If blood clots form on the tips
of arterial catheters, the clots may block blood flow
and, very rarely, may cause the loss of a hand or a
leg. This complication can be minimized by regularly
checking the flow of blood in the relevant extremity.
Bleeding: Bleeding may occur at the time of inserting
the catheter. Patients on anticoagulation therapy are
at high risk. The bleeding usually stops spontaneously,
but in some cases the catheter may require removal
followed by the application of pressure to the site.
CORONARY
ARTERIOGRAPHY
A cardiologist may catheterize the coronary arteries,
usually via a femoral artery access to evaluate the coronary
arteries or to perform an interventional procedure, such as
placing a stent.
A coronary angiogram is an X-ray of the coronary arteries

showing the coronary arteries. Radiologists inject a
contrast medium into the artery to assess the patency of
the blood vessel.
VIDEO
INTERVENTIONAL
RADIOLOGY
Interventional radiologists utilize minimally invasive,
image-guided procedures to diagnose and treat diseases
in nearly every organ system. The concept behind
interventional radiology is to diagnose and treat patients
using the least invasive techniques available in order to
minimize risk to the patient and improve health outcomes.
Interventional radiologists pioneered modern minimally
invasive medicine using X-rays, CT, ultrasound, MRI, and
other imaging modalities. Interventional radiologists
obtain images which are used to direct interventional
instruments throughout the body. These procedures are
usually performed using needles and catheters instead of
making large incisions into the body as in conventional
surgery.
Many conditions that once required surgery can now be

treated non-surgically by interventional radiologists, thus
minimizing the physical and psychological trauma to the
patient, with reduced risk of infection and often drastically
reduced recovery time.
127
KIDNEY
DIALYSIS
Conventional chronic hemodialysis is usually done
three times per week for about 3-4 hours per dialysis
treatment, during which the patients blood is drawn
out through a tube at a rate of 200-400 ml/min. The
tube is connected to a 15, 16 or 17 gauge needle
inserted into the dialysis fistula or graft, or is connected
to one port of a dialysis catheter. The blood is pumped
through the dialyzer and then the processed blood is
pumped back into the patients bloodstream through
another tube connected to a second needle or port.
During the treatment, the patients entire blood volume
(about 5000 cc) circulates through the machine every
15 minutes.
AV (arteriovenous) fistulas are recognized as the

preferred access method for gaining access to the
bloodstream. Fistulas are usually created in the nondominant arm and may be situated on the hand, the
forearm or the elbow by a vascular surgeon who
surgically joins an artery and a vein together. Since this
bypasses the capillaries, blood flows rapidly through
the fistula and this rapid flow of blood is necessary for
withdrawing and replacing relatively large volumes of
blood during dialysis.
Figure 41a: Placement of In and Out lines for renal dialysis
Figure 41b: An AV fistula for renal dialysis
128
KIDNEY
DIALYSIS
A port is most commonly inserted as a day surgery procedure in a hospital or clinic by a surgeon or an interventional
radiologist under conscious sedation.
Implantable ports are often used to give chemotherapy treatment and/or other medicines to cancer patients.
Chemotherapy is relatively toxic to normal cells and can damage skin and muscle tissue, as well as small veins.
Figure 42a: A diagram of a venous access port
Figure 42b: A clinical example of a venous access port
A PORT MAY SERVE THE

FOLLOWING PURPOSES:

For the delivery of TPN (Total Parenteral Nutrition)

To deliver coagulation factors in patients with
severe hemophilia
For withdrawing and returning blood to the body in
patients who require frequent blood tests
For withdrawing and returning blood to the body in
hemodialysis patients
To deliver antibiotics to patients requiring them for
a long period of time or frequently
For delivering medications to patients with immune
disorders
To deliver radiopaque contrast agents which
enhance contrast in radiography (e.g., CT imaging)
When no longer needed, the port can be removed in

the operating room.
129
PARENTERAL NUTRITION
(TPN)
Parenteral nutrition is given intravenously.
Partial parenteral nutrition supplies only part of daily
nutritional requirements, supplementing oral intake.
Many hospitalized patients are given dextrose or amino
acid solutions by this method.
TPN supplies all daily nutritional requirements. TPN

can be used in the hospital or at home. Because TPN
solutions are concentrated and can cause thrombosis
of peripheral veins, a central venous catheter is usually
required.
For more information: [CLICK HERE]
ANESTHESIA
LOCAL ANESTHESIA
A local anesthetic is a drug that causes reversible local
anesthesia (loss of sensation), inducing the blocking of
pain impulses to the brain with the aim of performing a
pain-free procedure.
Topical anesthetics are usually in the form of a
cream, gel, or spray and are applied to the skin or
mucous membrane before penetrating it with a needle.
Applications include ophthalmology, dentistry, the relief
of symptoms (e.g., sun burn), and before venipuncture.
130
Topical anesthetics when used before venipuncture

penetrate mucosa with ease (mucosa will be fairly
numb within 1-3 minutes), but are slow to penetrate
skin. Clinicians need to follow instructions precisely. The
anesthetic cream is required to be in contact with the skin
for 30-60 minutes!
Infiltration local anesthesia is widely used for minor
surgery on the skin and mucous membranes, as well as
for dental procedures. The local anesthetic is deposited
diffusely in the region of intended surgery.
PROJECT 14
INFILTRATING A WOUND WITH LOCAL
ANESTHETIC BEFORE SUTURING
Two methods of infiltrating a wound with a local anesthetic solution before debridement and suturing
VIDEO
INFORMATION
REQUIREMENTS
Most minor cuts and some not so minor lacerations can

easily be sutured under local anesthetic as opposed to
subjecting the patient to a general anesthetic. This is, in
most cases, a much more cost-effective option and can be
done on an outpatient basis.
Keep in mind the basic principles of assessing a wound for
suturing remember the acronym LACERATE:
You will need:

Gloves
5ml syringe
20G needle
IV fluid bag
Alcohol hand rub
A suitable volunteer (as usual)
Look at the Wound (Assess it)

Anesthetic Considerations
Clean the Wound
Equipment (Set Up)
Repair the Wound
Assess the Results and Anticipate Complications
Tetanus Immunization Status
Educate the Patient Regarding Wound Care
131
METHOD 1
SITUATION:
STEP 1
Remember the basics: take a medical history, prepare your
hands hygienically, and don clean gloves.
STEP 2
Withdraw some of the fluid from one of the IV fluid
bags from the out port. This will be used as a fake local
anesthetic solution.
STEP 3
Draw a 5 cm (2 inch) line on the Venipuncture Trainer to
represent the laceration.
STEP 4
Insert the needle into the tissue, about 5 mm (1/4 inch)
away from the laceration, beside one end of the laceration.
STEP 5
Deposit a drop or two of local anesthetic and wait for 3040 seconds. Advance the needle parallel to the long axis of
the laceration to the other end of the laceration or to the
length of the needle.
STEP 6
Aspirate to ensure that you are not in a blood vessel, to
avoid accidentally injecting the local anesthetic solution
intravenously.
STEP 7
Inject the local anesthetic solution continuously just below
the skin as you withdraw the needle. Note the skin rising
as you deposit the local anesthetic fluid. With a real patient
you will see blanching (the tissue will become whiter).
STEP 8
If the laceration is longer than the needle, repeat the
same procedure along the next section of skin next to the
laceration but ensure that you enter the skin in already
locally anesthetized skin.
132
STEP 9
Repeat the same procedure on the other side of the
laceration.
STEP 10
Wait 2-3 minutes; test the effectiveness of the local
anesthetic by poking the wound area with a probe or
pinching it with a forceps. You are now ready to prepare
the wound for suturing.
Information:
Do you want to learn all the basics about suturing, such as
how to tie a surgeons knot and learn 12 different suturing
techniques? Get your very own Apprentice Doctor How
to Suture Wounds Course and Kit
STEP 11
Lift the skin, dry the trainer, and discard used needles in
the mini sharps waste container. Clean up and replace all
reusable items in your kit. Keep in a safe place and out of
reach of children!
METHOD 2
For this method, use a thin 27G needle. A short dental syringe and needle will work just fine.
Figure 43a: A dental syringe
Figure 43b: Repair of an ear laceration
Penetrate the laceration through the raw edge of the wound. Starting at one side of the laceration, advance the needle
into the adjacent tissue for about 1 cm (3/8 inch) at an angle of about 30-45. Repeat the same process of injecting local
anesthetic solution every 7 mm (1/4 inch) on both sides of the wound. Follow with Step 9 as above.
By avoiding the penetration of intact skin, the patient experiences significantly less pain compared to Method 1, although
most people would think that injecting straight into the wound should be more painful.
133
POINTS
OF INTEREST
Local and general adverse effects and complications
include:
LOCAL ADVERSE EFFECTS

The local adverse effects of anesthetic agents include
prolonged anesthesia (numbness) and paresthesia
(tingling or pins and needles of the affected area).
Permanent nerve damage after a peripheral nerve
block is rare. The vast majority of symptoms are likely to
resolve within four to six weeks.
GENERAL SYSTEMIC
ADVERSE EFFECTS
Central nervous system
Dangerous side effects involving the central nervous
system usually follow when the safety dosage margins
of the specific drug were exceeded or when an
inadvertent intravenous or intra-arterial injection of the
local anesthetic has occurred. It may either excite or
depress the central nervous system which may manifest
at lower blood levels as convulsions or coma, respiratory
arrest, and death at higher concentrations
Cardiovascular system
Complications related to the conductive system of the
heart include heart palpitations (innocent and usually
due to the vasoconstrictors effects), arrhythmias, and
a complete heart block (extremely rare but potentially
fatal if not treated promptly)
Allergic reactions
An allergy may vary from hypersensitivity (e.g., skin rash
and itchiness) to a life-threatening anaphylactic shock.
A patient may be allergic to any one of the components
in a local anesthetic solution:
The local anesthetic (The two main groups
are esters and amides.)
The vasoconstrictor
The preservative
Ask specifically about allergies to local anesthetics when
preparing for suturing under local anesthetic.
Be prepared with all the emergency equipment to
resuscitate a patient in the case of an allergic reaction.
134
Local anesthetic block a local anesthetic solution is

deposited in the region of a specific nerve stem to numb
the sensory distribution area of that specific nerve. The
clinician needs to know the regional anatomy in detail.
A nerve block should be effective within 3-5 minutes. An
example of a local anesthetic block is the blocking of the
lingual and inferior alveolar nerves before performing a
surgical/dental procedure involving the lower jaw, the
lower teeth, as well as the lip and chin on the side of
injection.
IMPORTANT: It is wise to aspirate before depositing
the local anesthetic to avoid intravascular injections.
The clinician needs an understanding of the relevant
pharmacology, physiology, anatomy, as well as the
knowledge and skills to treat and manage complications.
NOTE: Great numbers of local anesthetic injections are
given daily without aseptically preparing the mucosa.
Despite the hordes of bacteria in the oral cavity, septic
complications related to these injections are extremely
rare. One researcher concluded: the application of an
antiseptic to the mucosa before injection would appear
to be questionable except for patients in whom special
hazards are known to exist.
Reference: [CLICK HERE]
Regional anesthesia is anesthesia affecting only large

parts of the body such as a limb or the lower half of the
body, as opposed to local anesthesia, which affects a
fairly small part of the body such as a tooth or an area
of skin.
Central regional anesthesia includes procedures
like epidural anesthesia and spinal anesthesia, while
peripheral techniques include procedures like plexus
blocks (e.g., brachial plexus blocks) and single nerve
blocks.
Regional anesthesia may be performed as a single
shot or with a continuous catheter through which
medication is given over a prolonged period.
Intravenous regional anesthesia (Bier block) is a specific
type of regional anesthesia in which the clinician injects
a local anesthetic solution directly into a vein, (e.g., of
an arm) with the venous flow impeded by a tourniquet.
General anesthesia
Prerequisite before starting the administration of a
general anesthetic is a dependable venous access
route for injecting the induction agent, various other
medications, as well as possible emergency medications.
Total Parenteral Anesthesia (TPA) is the term used when
the anesthetist administers a general anesthetic using
intravenous drugs, which are infused with an infusion
pump, instead of maintaining the anesthetic with
volatile anesthetic gasses.
Infusion pumps
External infusion pumps are medical devices that
deliver fluids, including nutrients and medications (such
as anesthetic agents, antibiotics, chemotherapy drugs,
and pain relievers) into a patients body in controlled
amounts. Many types of pumps, including large volume,
patient-controlled analgesia (PCA), elastomeric, syringe,
enteral, and insulin pumps, are used worldwide in
healthcare facilities such as hospitals and in the home.
NEW
DEVELOPMENTS
Scientists and bioengineers are developing amazing
new technologies. Here are a few examples:
Microprobes for continuous monitoring
Instead of frequently sampling blood and then sending
it to the lab and waiting for results, certain biochemical
substances can be monitored very accurately and in
real time using an indwelling microprobe. This has
especially useful applications in diabetics with real time
monitoring of blood glucose.
[CLICK HERE] for more information
Needleless injections
In future, people who have a fear of needles one may
barely perceive receiving a needleless injectionat
most they may feel the discomfort of a nail-scratch!
How it works:
Commercially available needleless injection systems:
Have a look at this pain-free, needleless dental injection:
[CLICK HERE]
And other pain-free injections: [CLICK HERE]
135
SHORT NOTES
ON OTHER BODILY SECRETIONS
SALIVA
BREAST MILK
The term saliva is used for the watery substance freshly

secreted from the ducts of the salivary glands. Saliva
is secreted by the six major salivary glands (the paired
parotids, submandibular, and sublingual glands), as
well as the multiple hundreds of minor salivary glands
situated within the submucosa of the lips, cheeks, and
palate.
Breast milk may be analyzed for nutritional composition/

values. Measured nutritional components are glucose,
lactose, triglyceride, and protein. Deficiency of any of
the measured or calculated parameters is suggestive
of decreased nutritional quality of human breast milk.
It can also be analyzed for the presence of pollutants
such as heavy metals (Mercury) or organic pollutants
(Persistent Organic Pollutants or POP).
The laboratory testing of saliva samples is a fairly new

and exciting field of clinical pathology, measuring
various hormones, biochemical substances, drugs, etc.
It has a number of applications in forensic medicine as
well.
Saliva testing has many advantages over blood testing.
Saliva specimen collection does not require a blood
draw and there are no risks to patients. Saliva collections
are convenient and can be done at work or at home.
When stored properly, saliva samples are stable for
several weeks.
With an accuracy of 92-96%, saliva testing is as accurate
as blood testing and, in some cases, more accurate.
Another advantage of saliva testing is the ability to
collect specimens over a period of time with ease.
This offers providers more information than a single
collection would. Compared to blood testing, saliva
testing is also more affordable.
SPUTUM
Sputum refers more to the mucous substance secreted
by the mucous glands in the throat and upper airways
(nasal mucosa, trachea, bronchi, and bronchiole).
Sputum needs to be coughed up and spit out by the
patient into a specimen collection container. Sputum
is usually sent to the microbiology lab and is especially
useful in the diagnosis of tuberculosis (deep early
morning sputum collected three consecutive days).
136
SEMEN
Basic semen analysis: Almost all laboratories will report
on the following information using values established
by the World Health Organization.

Concentration: This is a measurement of how many

million sperm there are in each milliliter of fluid.
There are various techniques for obtaining this
number; some prove to be more accurate than
others. Average sperm concentration is more than
60 million per milliliter (>60 million/cc). Counts of
less than 20 million per milliliter (<20 million/cc) are
considered sub-fertile.
Motility (sometimes referred to as the mobility):

This describes the percentage of sperm that are
moving. Fifty percent or more of the sperm should
be moving.
Morphology: This describes the shape of the sperm.

The sperm are examined under a microscope and
must meet specific sets of criteria for several sperm
characteristics in order to be considered normal.
Most commercial laboratories will report World
Health Organization morphology. By WHO criteria,
30% of the sperm should be normal.
Volume of the ejaculate: Normal is 2 milliliters (2

ccs) or more.
Total Motile Count: This is the number of moving

sperm in the entire ejaculate. There should be
more than 40 million motile sperm in the ejaculate.
Standard Semen Fluid Tests: Color, viscosity (how

thick the semen is) and the time until the specimen
liquefies should also be measured.
SWEAT
The sweat chloride test (sweat test) measures the
concentration of chloride that is excreted in sweat. It is
used to screen for cystic fibrosis (CF).
Sweating is stimulated by applying a colorless, odorless
chemical that causes sweating. An electrode is applied
over a circumscribed area of the body for about five

minutes. Sweat is collected on a piece of filter paper
and then sent to the laboratory for testing. Increased
chlorine levels will make the diagnosis of CF unlikely,
possible, or likely, depending on the specific level.
SHORT NOTES
ON OTHER BODILY EXCRETIONS
URINE
FECES
Urine tests are very useful for providing information to

assist in the diagnosis, monitoring, and treatment of a wide
range of diseases and conditions. Hormonal levels in the
urine test can indicate whether a woman is ovulating or
pregnant.
Urine can also be tested for a variety of substances,
including illegal drug use in general, as well as in the world
of professional sport.
Urine may be submitted to the cytology lab to detect
cancerous cells or to the microbiology lab for microscopy
and culturing to identify specific microbes involved in
urinary tract infections.
A doctor may order a stool collection to test for a variety of

possible conditions, for example to:
Evaluate certain allergies, such as milk protein allergy
in infants.
Assist with identifying diseases of the digestive tract,
liver, and pancreas.
Screen for colon cancer by checking for hidden
(occult) blood.
Examine for the presence of parasites, such as
pinworms or Giardia lamblia.
Ascertain the cause of an infection, such as bacteria
(e.g., Salmonella, Shigella, fungi, and viruses).
Assist with finding the cause of symptoms affecting
the digestive tract, including prolonged diarrhea,
bloody diarrhea, increased flatulence, nausea,
vomiting, loss of appetite, bloating, abdominal pain,
cramping, and fever.
Check for poor absorption of nutrients by the digestive
tract (malabsorption syndrome).
URINALYSIS
The urine can be tested very quickly using a strip of special
paper, which is dipped in urine just after urination. This will
show if there are any abnormal products in the urine such
as sugar, protein, or blood.
If more tests are needed to get more details, the urine will
be analyzed at a laboratory.
Normally urine is sterile, but skin contaminant bacteria
may be added to the sample during urination.
The patient should be instructed to wash genital areas
before taking the sample, specifically taking the midstream urine.
A urine sample for the lab is collected in a standard lab
collection container (100-150 ml required).
A fresh stool sample is collected in a sterile container. Stool

samples should be taken to the laboratory within an hour
after collection. Infant stool samples are usually collected
with a rectal swab.
Notes:
Wash hands thoroughly before and after sampling.
Use clean gloves and other barrier techniques if
indicated!
137
SHORT NOTES
ON OTHER BODILY FLUIDS
Cerebrospinal fluid (CSF) is a clear, colorless bodily fluid
produced in the choroid plexus of the brain and occupies
the subarachnoid space, the ventricular system around
and inside the brain, as well as the central canal of the
spinal cord.
CSF can be tested for the diagnosis of a variety of
neurological diseases. It is commonly obtained by a
procedure called a lumbar puncture. Lumbar puncture
is performed in an attempt to count the cells in the fluid
and to detect the levels of biochemical constituents like
protein and glucose. These parameters alone may be
extremely beneficial in the diagnosis of subarachnoid
hemorrhage and central nervous system infections such
as encephalitis and meningitis. Microbiological CSF culture
examination may yield the specific microorganism causing
the infection.
By using more sophisticated methods, such as the
detection of the oligoclonal bands, conditions like multiple
sclerosis may be recognized.
Beta-2 transferrin is almost exclusively found in the
cerebrospinal fluid. It is not found in blood, mucus, or tears,
thus making it a specific marker of cerebrospinal fluid and
the detection of leakage like CSF rhinorrhea.
Figure 44: Cerebrospinal fluid fills the ventricles and surrounds the brain
and spinal cord.
ASCITES is an accumulation of fluid in the peritoneal

cavity. It is most commonly caused by severe liver disease,
like cirrhosis or metastatic liver cancer, but its presence
may also indicate other important medical conditions.
138
Diagnosis of the cause is usually done with blood tests, an

ultrasound scan of the abdomen, and direct removal of
the fluid by needle (paracentesis). Treatment may be with
medication (diuretics), paracentesis, or other treatments
directed at the cause.
Diagnostic blood tests should include a complete blood
count (CBC), basic metabolic profile, liver enzymes, and
coagulation profile. Most experts recommend a diagnostic
paracentesis be performed; the fluid is then examined
for its gross appearance, protein level, albumin, and cell
counts (red and white). Additional tests will be performed
if indicated, such as Gram stain and cytopathology.
The Serum-Ascites Albumin Gradient (SAAG) is probably
a better discriminant than older measures for discerning
the causes of ascites. A high gradient indicates the ascites
is due to portal hypertension, while a low gradient points
away from portal hypertension as the primary etiology.
EFFUSION is the escape of fluid from the blood or
lymphatic vessels into the surrounding tissues or into a
body cavity.
PLEURAL EFFUSION is excess fluid accumulating
between the two pleural layers that surround the lungs.
Pleural fluid is drawn out of the pleural space in a process
called thoracentesis. A needle is inserted through the back
of the chest wall in the sixth, seventh, or eighth intercostal
space on the mid-axillary line into the pleural space. The
fluid may then be evaluated for the following:
Chemical composition including protein, lactate
dehydrogenase (LDH), albumin, amylase, pH, and
glucose
Gram stain and culture to identify possible bacterial
infections
Total and differential cell counts
Cytopathology to identify cancer cells and to assist in
identifying possible infective organisms
Other tests as suggested by the clinical situation
lipids, fungal culture, viral culture and specific
immunoglobulins
JOINT EFFUSION is the presence of increased intraarticular fluid, a fairly common finding in the inflamed
knee joint, but any joint may be affected. It may happen as
a result of trauma, inflammation, hematologic conditions
or infections.
EXUDATES AND
TRANSUDATES
AN EXUDATE is any fluid that filters from the circulatory
system into lesions or areas of inflammation.
It is rich in the protein and cellular elements that ooze out
of blood vessels due to inflammation and is deposited
in surrounding tissues. The altered permeability of blood
vessels permits the passage of large molecules and cells
through the blood vessel walls.
A TRANSUDATE is an accumulation of fluid that passed
through a membrane due to increased pressure in the veins
and capillaries forcing the fluid through the vessel walls.
This process filters out most of the protein and cellular
elements, thus yielding a watery solution. Transudates are
caused by disturbances of hydrostatic or colloid osmotic
pressure and not by inflammation.
There is an important distinction between transudates and
exudates. Exudates have a higher protein content and thus
a higher specific gravity, while transudates have a lower
protein content and thus a lower specific gravity.
PUS
Pus is a viscous, yellowish-white fluid formed in infected
tissue, consisting of white blood cells, cellular debris,
necrotic tissue and masses of bacteria, both dead and alive.
The following are recommended steps to take for
sending a pus sample from a closed abscess to the
microbiology lab for MC&S (Microscopy, Culture and
Sensitivity).
FOLLOW THESE STEPS:

Ensure sterile conditions and have relevant barrier

techniques in place.
Test for fluctuation and determine the point of
maximum fluctuation.
Clean the skin/mucosa with an appropriate

antimicrobial agent. If needed, remove excess
cleaning agent with a sterile gauze square to avoid
contamination.
Use a 5-10 ml syringe and a large bore needle and
puncture the abscess at the point of maximum
fluctuation or just below this point (within the limits
of wisdom regarding the local anatomy). Aspirate
enough pus; more is better than less.
Transfer to an aerobe as well as an anaerobe lab
transfer medium/bottle.
Mark as urgent, for immediate transfer to the lab.
Proceed with the formal surgical incision and drainage
procedure. (Needle aspiration is an insufficient
method of evacuating all the pus in an abscess cavity.)
Alternatively, incise the abscess then use a pus swab
to take the sample when pus emerges and then insert
the swab in a dedicated transport medium.
Warning: Use safety needles and take extreme care
not to inoculate yourself or someone else with this
septic content!
COMMENT:
Pus aspirated in a syringe is always preferable to a
swab.
Sample pus, if possible, before initiating antibiotic
therapy.
Contaminant bacteria (normal resident bacteria),
such as Staphylococcus epidermidis (skin) and
Streptococcus viridians (mouth and throat), grow
easily and often overgrow the pathological bacteria in
the lab giving valueless results.
The empirical treatment of an abscess is incision and
drainage.
External heat therapy increases the blood flow to the
area and assists with localizing the pus.
Antibiotics and analgesics play a supportive role in
treating infections. Not even the strongest antibiotic
will clear a pus-producing abscess!
As far as possible, use a narrow spectrum antibiotic
with proven sensitivity rather than treating the
infection blindly.
139
Venipuncture Course and Kit | COMPLICATIONS
CASE STUDY 5:
A ROUTINE VENIPUNCTURE CASE
Judy has always had a problem with difficult veins.

Questions like, Are your veins hiding today? and Did
you leave your veins at home? are common remarks by
medical professionals when attempting to draw blood or
put up an IV line. Today is no exception as Candice, RN on
duty, tries to draw blood from Judys arm veins. The nurse
tries three unsuccessful attempts on the right arm and two
on the left arm. Finally she successfully draws blood from
the right foot. But the next day, the leg starts swelling. A
physician is called in, but while waiting for some hours for
the busy physician, Judy starts to have difficulty breathing
and slowly gravitates into a coma. When the physician
142
eventually arrives, all hell breaks loose. The physician

demands action STAT*!! Emergency medications are called
for and emergency procedures follow, after which an
urgent transfer to the Intensive Care Unit is done. Despite
the brave efforts of competent medical professionals, Judy
drifts deeper into the coma. Two days later, the consulting
neurosurgeon declares her brain dead. The autopsy
findings report a massive pulmonary embolism as the
cause of death.
Although not recommended for routine venipuncture,
the veins of the lower extremity are quite permissible.
This particular patient, however, had a history of
repeated episodes of DVTs (deep venous thrombosis).

This venipuncture was complicated by a phlebitis and
thrombus formation, triggering the cascade of events,
leading to the fatal outcome.
*STAT is short for statim, the Latin word for immediately.
Important to remember:
Always take a short medical history (or check the
medical history in the patients records) before
performing venipuncture or setting up an IV line.
Use the veins of the foot as a last resort, especially if
any contraindications are noted.
VASOVAGAL RESPONSE
AND VASOVAGAL SYNCOPE
A vasovagal attack is a disorder that causes a rapid drop
in blood pressure and heart rate, resulting in decreased
blood flow to the brain, followed by fainting. It is most
often evoked by emotional stress associated with fear or
pain. The clinician will notice the following signs: pallor,
nausea, sweating, bradycardia, a rapid fall in arterial blood
pressure, and eventually, loss of consciousness. Symptoms
include lightheadedness, nausea, the feeling of being
extremely hot (accompanied by sweating), ringing in the
ears (tinnitus), an uncomfortable feeling in the heart, and
incoherent thoughts.
It is not too uncommon to see a vasovagal attack or syncope
(fainting) during or following venipuncture.
Not drive home (and not drive at all) on the day blood
is drawn.
The emergency treatment to simply restore the patients

blood flow to the brain is to reposition the body. Use one of
the following positions:
Clinicians should:
Anticipate the possibility of a vasovagal syncope
and prevent injury to the patient by assisting and
supporting the patient.
Reassure the patient frequently.
Not show off their equipment in front of the patient,
especially sharp needles.
Have calming music in the background.
Have the patient comfortably seated, or if prone to
vasovagal attacks, in the supine position.
Have simple monitor equipment available: a blood
pressure meter and a basic pulse Oximeter.
When reporting for venipuncture or donating blood,
patients should:
Have a light meal before the procedure (unless they
have specific instructions regarding fasting).
Sit down comfortably for a couple of minutes after the
procedure (under supervision) before leaving.
Have a light refreshment after the procedure, especially
after donating blood.
Leave with a responsible person, instructed to support
the patient and what to do if syncope occurs.
Consider asking for a wheelchair instead of walking to
their transport.
Figure 45: Various patient positions
143
ALLERGIC
RESPONSES
A number of different allergic reactions may be
encountered during routine venipuncture procedures,
including the following:
CONTACT DERMATITIS
This usually manifests as an increased redness of the
skin where a specific strapping was placed.
Remove strapping
Apply a suitable cortisone-containing ointment
and give instructions on further use.
Inform the patient regarding the specific brand
of strapping. Ask them to avoid it in future and to
inform medical professionals when necessary.
SKIN RASH/
urticaria following the infusion of medication or
administration of a local anesthetic
Stop the infusion immediately and inform the
medical professional in charge of the patient.
Treatment with IV or oral antihistamines and/or
cortisone will usually suffice as definitive treatment.
Inform the patient regarding the specific
medication so that they can avoid it and inform
medical professionals accordingly in the future.
The patient should arrange for a Medical Alert
bracelet engraved with relevant information.
ANAPHYLAXIS (ANAPHYLACTIC SHOCK)

Anaphylaxis is a life threatening allergic reaction that is rapid in onset.
Figure 46: Anaphylactic shock diagram
144
CAUSES
Any medication may potentially trigger anaphylaxis.
Other causes include severe latex allergy and food
allergens.
DIAGNOSIS
Anaphylaxis is diagnosed based on clinical criteria.
When two or more of the following signs occurs
within minutes or hours of exposure to an allergen,
there is a high likelihood of anaphylaxis:
a. Involvement of the skin or mucosal tissue
(an itchy rash and/or urticaria)
b. Respiratory difficulty
c. Low blood pressure
d. Gastrointestinal symptoms
TREATMENT
Anaphylaxis is a medical emergency that may require
resuscitation measures such as airway management,
supplemental oxygen, large volumes of intravenous
fluids, and close monitoring.
If not qualified to treat the emergencycall for

assistance!
Administration of epinephrine (adrenalin) is the first
line of treatment, with antihistamines and steroids
often used as an adjunctive treatment. Nebulized
salbutamol may be effective for bronchospasm that
does not resolve with epinephrine.
It is recommended that an epinephrine solution be
given intramuscularly (e.g., the mid-anterolateral
thigh) as soon as the diagnosis is suspected. The
injection may be repeated every 5 to 15 minutes if
there is insufficient response. You may consider an IV
as an alternative route, but ensure that you administer
1/10 diluted epinephrine in sterile water SLOWLY.
Position the patient in the supine or Trendelenburg
position.
Apply an oxygen mask or nasal cannula and
supplement oxygen intake.
Monitor the vital signs, especially blood pressure and
oxygen saturation.
A 24-hour period of in-hospital observation is
recommended for patients once they have recovered
due to the possibility of biphasic anaphylaxis.
NEEDLE PENETRATION
THROUGH THE VEIN
Withdraw the needle somewhat, re-angulate the needle
a bit more superficially, and enter the vein lumen. If
unsuccessful, apply pressure and move to another site. As
a general rule, if performing phlebotomy (drawing blood
for the lab), move to a more distal site from the previous
attempt (not proximal), or move to another extremity. If
putting up an IV line, change to a more proximal site from
the previous attempt (not distally).
HEMATOMA
If a hematoma forms under the skin adjacent to the
puncture site release the tourniquet immediately and
apply firm pressure while withdrawing the needle. Move
to another site. Older patients are prone towards forming
hematomas.
Considerations for preventing a hematoma:
Use the major superficial veins.
Puncture the uppermost wall of the vein only.

Remove the tourniquet before removing the needle.
Ensure that the needle fully penetrates the upper most
wall of the vein as partial penetration will cause blood
leaking into the surrounding soft tissue.
Apply pressure to the venipuncture site following
phlebotomy.
145
ECCHYMOSIS
Even in the best of hands mild bruising may occur
occasionally, especially so in very fair skinned patients and
older patients.
Management:
For mild bruising, a simple explanation to the patient
will usually be sufficient.
For more severe bruising, apply a cold pack with
pressure to help limit bruising.
A physical therapist can apply ultrasound to help
break down a blood clot and diffuse ecchymosis.
Figure 47: Extensive ecchymosis in an elderly patient
NEEDLE/
CANNULA IN THE TISSUE
If performing phlebotomy and you land up in the tissue surrounding the vein, you have one of the following choices:
Go a bit deeper, if you are right above the vein.
Go laterally towards the vein, if you are on the side of a vein.
If you saw a flashback of blood and it disappears, you may have to withdraw the needle a bit as you may have
gone right through the vein.
If no luck, move to another site or ask a more experienced colleague to assist.
TISSUE INFILTRATION
(EXTRAVASATION)
If the needle lands up in the tissue during IV infusion
of fluid/medication, the IV fluid will infiltrate into the
surrounding tissue. The tissue will swell around the IV
needle, becoming edematous and cool to the touch.
The patient will complain about pain and discomfort.
Stop the infusion immediately!
Start the IV in a new spot on the patients body at
the correct rate for the given dosage.
Observe the infiltrated area for 24 hours for
possible complications. Treat these complications
empirically.
146
Most infiltrations have only minor sequelae. However,

certain drugs infused can cause serious complications
such as compartment syndrome, permanent nerve
damage, necrosis, soft tissue loss, scarring around
nerves, joints, and tendons leading to contractures and
deformity. Severe tissue injuries may require extensive
surgical debridement, tissue grafting, surgical release of
contractures to restore function, or even an amputation.
CANNULA/
CATHETER BLOCKED (OCCLUDED)

Use appropriately fibrinolytic (thrombolytic)

agents, (e.g., Cathflo) to dissolve small clots as per
physicians orders.
Adhere to the appropriate flushing procedure for
any needleless connector system.
Flush the catheter immediately after a bolus of
medication has been infused.
Inspect the tissue surrounding the IV site. Did the

cannula slip out and is it infiltrating the tissue?
Figure 48: A blocked peripheral IV cannula
Prevention is better than cure!

Keep the IV fluid running; dont close the infusion for
long periods of time. Dont let it run dry.
The IV fluid bag must be at least 1 meter (3 feet)
above the patient for gravity to overcome the venous
pressure and guarantee a positive flow of IV fluid.
Dont allow the IV fluid bag to be at the level of the
patient, or worse, lower than the patient, for any
significant time.
Use appropriately anticoagulant preparations to prevent
blood clots from forming as per physicians orders.
Check the IV bag and line. Is the IV bag empty?

Inspect the tubing and cannula for kinks.
If you cant find a remediable reason, remove the IV
cannula and place the IV line at a new site.
Warning: Do not force flush with saline! You may just
cause a small embolus by doing this!
More information: [CLICK HERE]
CATHETER-RELATED
INFECTIONS
Central venous catheter-related infections are common
and an estimated 80,000 central venous catheter
related bloodstream infections occur in intensive care
units each year. Students should study the following
CDC publication for detailed information including
prevention guidelines. [CLICK HERE]
infection the CDC advises in their guideline that the

catheter needs to be replaced every 96 hours (4 days).
See [SUPERFICIAL PHLEBITIS] for more information.
Peripheral venous catheter infections are treated

empirically remove the catheter, elevate the limb
and treat with local and/or systemic anti-inflammatory
medication. Local or systemic antibiotics therapy is
rarely indicated. Because of the risk of insertion-site
147
INTRA-ARTERIAL POSITION OF NEEDLE/

CANNULA DURING PHLEBOTOMY
If you are drawing blood and you suspect an intraarterial position:
If you havent started withdrawing blood, remove
the needle/cannula, apply pressure for at least five
minutes, then move to a positively identified vein
and proceed with the phlebotomy procedure.
If you are more than halfway finished with the task

and then suspect that you are in an artery, complete
the task, then remove the needle/cannula and
apply pressure for at least 5 minutes (or until the
bleeding stops).
INADVERTENT INTRA-ARTERIAL INJECTION OF MEDICATIONINSTEAD OF

INTRAVENOUS INJECTION
Some drugs can cause severe endothelial damage to
the arteries, but worse damage to the capillary bed
of the tissues within the arterial blood supply area.
This can cause tissue damage or necrosis, resulting in
disfigurement or loss of function. In severe cases, it
can require the amputation of a hand, foot, or other
extremity.
This complication is much better avoided than treated
afterwards.
If you suspect an accidental intra-arterial injection
and if you havent injected any medication,
remove the needle/cannula, apply pressure for five
minutes and move to positively identified vein for
venipuncture.
If you start injecting and the patient experiences
148
pain in the extremity distal to the injection site,

stop immediately and presume an intra-arterial
injection. Observe the hand/foot for any changes
in color.
If some medication has been injected, keep the
arterial access; it may be required by the medical
professional (experienced vascular surgeon or
anesthesiologist) treating the complication.
Get urgent assistance from an experienced vascular
surgeon or anesthesiologist.
Treatment may require a combination of intraarterial flushing, local anesthetics, cortisone, and
sympathetic blocks. Later surgery may be necessary
if the following ensue: compartment syndrome,
tissue necrosis, or scarring around nerves, joints,
and tendons.
CLINICAL DIFFERENTIATION
BETWEEN ARTERIES AND VEINS

Position: Veins are usually more superficial while

arteries anatomically run a deeper course. Keep in
mind that there are exceptions; arteries may run a
superficial course in areas or as an anomaly.
Color: Veins often have a bluish hue, especially
noticeable in fair skinned people.
On palpation: Arteries pulsate (throb/thump).
Arterial walls are firmer and thicker than those of
veins.
On puncturing: The pressure in arteries is much
higher than the pressure in veins, thus arterial
blood may squirt spontaneously into the syringe
(but not always).
During an ultrasound examination: While
exerting light pressure with the examination probe,
you will notice pulsating movement with arteries,
while veins will simply collapse with mild pressure.
On setting up an IV fluid bag/drip set: You will
notice either a retrograde flow of bright red blood
into the plastic tubing or you will notice that the
intravenous fluid resists flowing into the blood

vessel. You may also see the drop of fluid in the drip
chamber growing bigger and smaller in a pulsatile
manner. (Attaching a drip to the needle/line can
assist one in differentiating between an intravenous
and an intra-arterial position).
On removal of a needle: Arteries are more
prone to bleed profusely due to the high pressure
(compared to veins). Therefore, after removing a
needle, always apply firm pressure on the spot for at
least five minutes. Inspect the area, if it is bleeding,
repeat the pressure.
WARNINGS:
NEVER inject any medication or fluids into a blood vessel
unless you are 100% sure you are inside a VEIN!
When setting up an IV line and if you suspect that the
needle has entered an artery stop the procedure, remove
the needle, and apply firm pressure as instructed above.
SUPERFICIAL
PHLEBITIS
Superficial phlebitis, also called superficial throm
bophlebitis, is a condition where a vein close to the surface
of the body becomes tender, swollen, red, and develops
a blood clot. This is differentiated from thrombophlebitis
of the deep veins of a limb (usually a lower limb), which
is called deep vein thrombosis or DVT.
Sometimes phlebitis may occur at the site where
a peripheral intravenous (IV) line was started. The
surrounding area may be sore and tender along the vein.
Thrombophlebitis may be caused by damage to a veins
wall as a result of injecting substances that cause irritation
or introduce bacteria into the vein from a contaminated
needle/cannula as well as the prolonged insertion of
a cannula for intravenous infusion.
ramify to smaller feeder veins as it progresses. On palpation,

the vein will feel hard and warm with tenderness. The area
will begin to burn and throb if acute inflammation ensues.
The patient may become febrile.
The initial treatment for phlebitis, especially if associated
with pain, is to stop the infusion and remove the peripheral
venous cannula (PVC).
Elevate the affected limb and apply an anti-inflammatory
cream or gel to the area. In addition, anti-inflammatory
medication and analgesics can be used when necessary.
It usually starts with tenderness and redness along the

superficial veins on the skin, showing as a red line as the
inflammation follows the path of the superficial vein. It may
149
SEPTIC THROMBUS
If a thrombus becomes septic, or invaded by pathogenic bacteria, the patient will become febrile with all the local
and systemic signs and symptoms of infection (raised white blood cell count, etc.). In severe cases, septic shock may
ensue. Treat empirically with relevant antibiotic therapy and supportive treatment. Blood cultures may be required.
DEEP VEIN
THROMBOSIS (DVT)
It is not recommended to use veins, for either
phlebotomy or setting up an IV line, in the lower
extremities of adults due to possible complications that
include, but are not limited to, phlebitis and/or DVTs
especially in high risk individuals:
Patients with a history of thrombosis
Patients who will be immobile for an extended
period of time (e.g., orthopedic traction patients)
The elderly
Diabetics
People with blood disorders
Women who take oral contraceptives (birth control
pills)
People who have just undergone major surgeries or
have just suffered a bone fracture
Signs and symptoms of deep vein thrombosis
include:
Tenderness in the calf
Leg tenderness
Pain in the leg
Swelling of the leg
A warmer than normal leg
Redness in the leg
Bluish skin discoloration
Discomfort when the foot is flexed
Treatment of DVT includes:
Bed rest. Individuals with DVT usually require bed
rest until symptoms are relieved. The leg should be
elevated to a position above the heart to reduce
swelling. Moist heat may be applied to the affected
150
region to relieve pain.

Compression stockings. Physicians frequently
recommend compression stockings to reduce DVT
symptoms and to improve the venous return of
blood to the heart.
Anticoagulation medication (blood-thinning drugs).
The anticoagulant drugs, heparin and warfarin, are
used primarily to prevent the formation of new clots
and reduce the chance of pulmonary embolism.
Thrombolytic agents are used to help dissolve
existing clots and reopen clogged veins. The most
commonly used thrombolytic agents are urokinase
and streptokinase.
Surgery. Surgery is considered a last resort. Removal
of the thrombus (venous thrombectomy) or the
insertion of a filter device into the inferior vena cava
to trap any blood clots headed towards the lungs
are procedures that may be considered.
EMBOLISM
Lung embolism from a dislodged deep vein thrombus
is a life-threatening condition requiring treatment in an
intensive care environment by suitable qualified and
experienced specialists in this field.
Definitive diagnosis is usually by a D-dimer blood test,

pulmonary artery angiography, or CT scan.
Immediate full anticoagulation is mandatory for all
patients suspected of having pulmonary embolism.
Clinical signs and symptoms for pulmonary embolism

are nonspecific and may include unexplained difficulty
in breathing, fast respiratory rate, and chest pain.
AIR
EMBOLISM
An air embolism is caused by air bubbles in the vascular
system. Venous air embolism can result from the
introduction of air through intravenous lines, especially
central lines, and generally must be substantial to block
pulmonary blood flow and cause symptoms.
Small amounts of air often get into the blood circulation
accidentally during surgery and other medical
procedures, but most of these air emboli enter the
veins and are stopped at the lungs. Thus, a venous air
embolism that shows any symptoms is very rare.
The risk of catheter-related venous air embolism is
increased by a number of factors:
Breakage or detachment of catheter connections
Failure to occlude the needle hub/catheter during
insertion or removal
Dysfunction of self-sealing valves in plastic
introducer sheaths
Presence of a persistent catheter tract following the
removal of a central venous catheter
Deep inspiration (inhalation) during insertion
or removal, which increases the magnitude of
negative pressure within the thorax

Hypovolemia, which reduces central venous
pressure
Upright positioning of the patient, which reduces
central venous pressure
Treatment:
The primary aim is to identify the reason for air entry
and prevent further air embolization.
Supportive care includes the use of mechanical
ventilation, vasopressors, and volume restoration.
The following may be of value:
High-flow supplemental oxygen
Hyperbaric therapy
Placing the patient in the Trendelenburg position
and other positional maneuvers may help in
dislodging the air embolus
Closed-chest cardiac massage
Aspiration of air from the venous circulation
With air embolism, prevention is better than cure!
151
NEEDLESTICK INJURIES
Needlestick injuries may involve the patient or the
medical professional.
There are very specific legalities to be aware of, ways to
minimize you and your patients risk factors and steps to
take if such an incident should occur.
Kindly familiarize yourself with the most current
information on the subject.
Study the legalities: (USA) [OSHA Occupational
Safety & Health Administration]
Medical professionals outside of the USA, contact your
countrys Health and Safety authorities for information
regarding legalities and other specifics.
For sensible guidelines and more information see:
[Click Here]
Also read: WHO Publication on Sharps injuries:

Assessing the Burden of Disease From Sharps Injuries to
Health-Care Workers at National and Local Levels.
[Click Here]
In conclusion, a number of comments from the author:
Take great care to avoid this type of injury.
Use appropriate barrier techniques.
Use safety items and equipment at all times, if at all
possible.
Accurately follow the guidelines of your unit or
institution.
If an accident occurs, immediately contact the
hospitals Infection Control Officer and follow the
appropriate directives as soon as possible. Initiate
the correct antiretroviral medication if applicable.
VIDEO
152
LOCAL
TISSUE DAMAGE
The skin surrounding the venipuncture site may (rarely)
break down, usually due to infection.
Applying a local antiseptic or antibiotic ointment may be
all that is required.
NERVE DAMAGE
The two nerves with the highest risk of being injured
during a venipuncture procedure are the radial and
median nerves. Permanent nerve damage is a difficult
complication for the patient to come to grips with and
carries a high medicolegal risk.
occur.
Recognize the signs and symptoms of nicking a nerve
and take appropriate action.
If your patient complains of an electric shock sensation
radiating down into the hand while the needle is
being inserted, remove the needle immediately to
minimize nerve injury.
Danger areas:
The distal part of the radial nerve just above the
thumb (radial nerve)
The inner/medial cubital fossa (median nerve)
The inner aspect of the wrist above the palm of the
hand (median nerve)
Although it is considered safe to use the cephalic vein in the
lateral aspect of the antecubital fossa area, risk of damage
has occasionally been described to the lateral antebrachial
cutaneous nerve of the arm following phlebotomy.
Figure 49: Diagram of the main nerves of the arm
Recommendations to minimize the risk of nerve

injury:
Acceptable sites are the median cubital area and the
dorsum of the hand. Identify the most prominent of
the acceptable veins: median cubital, cephalic, and
basilic.
If possible, avoid the basilic vein. Rather use the
cephalic vein or median cubital vein as the basilic vein
also runs near the brachial artery.
Avoid high-risk nerve injury areas. The three-inch area
above the thumb and the three-inch area on the inner
aspect of the wrist should always be avoided.
Avoid wrist veins.
Do not probe excessively.
Do not make an excessive number of attempts (two
or, at most, three attempts).
Use a good clinical technique
Stabilize the vein before inserting the needle
Insert the needle at an approximate angle of 15-30
Avoid hematomas and treat them promptly if they
Figure 50: Diagram of the main nerves of the arm
Arterial cannulation
Brachial artery cannulation is associated with an increased
risk of median nerve injury.
153
Venipuncture Course and Kit | EVALUATION MODULE
ASSESSMENT
MODULE
(Available online) [CLICK HERE]
The evaluation module consists of two sections:
Section 1. Short multiple choice questions (20 marks)
Section2. A selection of one practical project performed
by the student and assessed by a designated evaluator
(20 marks)
CONGRATULATIONS
AND FINAL REMINDERS
Congratulations you have completed The Apprentice
Doctor Venipuncture Course!
May we remind you carefully close the sharps waste
container and to hand it to a medical professional at a
hospital, a medical clinic, or to your family doctor for
proper sharps waste disposal.
Warning:
Never discard the sharps into a regular waste bin or bag!
Dr. Anton Scheepers and the staff at the Apprentice

Corporation wish you all of the best with your studies and
trust that we may have contributed in a small way to your
success in practicing venipuncture!
Let us know if you liked the course, and in you didnt,
inform us as well.
[CLICK HERE] to access The Apprentice Doctor
Venipuncture Course and Kit evaluation questionnaire. Thank
you for your time!
EPILOGUE
In essence, the simple technique of venipuncture is a minor surgical procedure and all the rules common to surgery
apply. On occasion, simple procedures may become complicated due to various reasons. The most serious complication
following a simple venipuncture procedure is deathusually as a complication of a complication.
Be alert and minimize the risks to your patients for developing complications and your risk regarding medicolegal
consequences.
REFERENCES
1. Mario Saia,et al. Needlestick Injuries: Incidence and Cost in the United States, United Kingdom, Germany, France,
Italy, and Spain. Biomedicine International 2010; 1: 41-49.
2. Preventing Needle-stick Injuries in Health Care Settings. CDC Publication 1999.
3. Sharps Injuries: Assessing the burden of disease from sharps injuries to health care workers at national and
local levels. WHO Publication 2005.
4. WHO Guidelines on Hand Hygiene in Health Care. WHO Publication 2009.
5. Kouji Yamada et al. Cubital Fossa Venipuncture Sites Based on Anatomical Variations and Relationships of
Cutaneous Veins and Nerves. Clinical Anatomy. 2008 21: 307313.
6. Joan Barenfanger et al. Comparison of Chlorhexidine and Tincture of Iodine for Skin Antisepsis in Preparation for Blood
Sample Collection. J Clin Microbiol. 2004 May; 42(5): 22162217.
156
7. WHO guidelines on drawing blood: best practices in phlebotomy. WHO Publication 2010.
8. Mller JC, Reiss I, Schaible T. Vascular access in neonates and infantsindications, routes, techniques and devices,
complications. Intensive Care World. 1995 Jun; 12(2):48-53
9. Laura L et al. Difficult Venous Access in Children: Taking Control. JOURNAL OF EMERGENCY NURSING September
2009; 35:5
10. Beal MW, Hughes D. Vascular access: Theory and techniques in the small animal emergency patient. Clin Tech
Small Anim Pract. 2000 May; 15(2): 101-9.
11. Rob White. Vascular access techniques in the dog and cat. In Practice 2002; 24: 174-192.
12. Guidelines for the Prevention of Intravascular Catheter-Related Infections. CDC Publication 2011.
CREDITS
Facilities for videos and photography:

Rhesa Van Der Merwe: Hospital Manager, Union

and Clinton Hospitals

Hans Van De Zee: Specialist Veterinary Surgeon,

Valley Farm Animal Hospital in Pretoria
Our gratitude to all the skillful veterinary practitioners and
staff at Valley Farm Animal Hospital.
[CLICK HERE] to meet the team.
Patient models:
Anton Scheepers
Elna Van Der Hever
Jacquiline Sumerville
Rgardt Scheepers
Ruan Klut
Stfan Scheepers
Graphic design:
Maria Andor
Package, DVD, EBook, Brochure, and various other
graphic design aspects.
Portfolio site:
http://www.behance.net/marcsiandor
Production:
Open Window School of Visual Communication Hub
Arthur Twigge (Coordinator)
Chase Jordan Coetzee (Assistant videographer)
Dagan Read (Software development and final
compiling)
Natalie Scheepers (Photography - Dip Visual
Communication)
Stephan Calitz (Games and other interactive
components)
Wihann Strauss (Videographer and editing of
videos)
Illustrations:

Kevin Berry: Medical and General Illustrator

Drawing Conclusions:

www.drawingconcusions.co.za
Professional RNs:

Adelle Du Toit, RPN

Annette Klut, RPN

Lili Van Der Zee, RPN
Linguistic care:

Eizabeth Scheepers

Jacqui Summerville

Natalie Scheepers
Voiceovers:
Female:

Suehyla El-Attar

Voice123.com
Male:

Craig Gildner

Voice123.com
Stories (narration):

Dave Pettitt

Voice123.com
Final proof reading:

American Proofreading Company,

Peggy Wendel, Sr. Copy Editor,

www.ameriproof.com
Model:

Gizela Marais

Box/package cover and DVD

Email: Giz.lubbe@gmail.com
157
OTHER PRODUCTS
BY THE APPRENTICE CORPORATION
After completing The Apprentice Doctor Venipuncture course, would you like to be able to confidently tie surgical knots
and suture wounds?
THE APPRENTICE DOCTOR

HOW TO STITCH UP WOUNDS SUTURING COURSE & KIT
Basic principles of wound care, hygiene and asepsis

How to tie a surgeons knot and various other knots
How to suture wounds correctly and avoid common
mistakes
Why eversion is important in suturing skin lacerations
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158
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159
GLOSSARY
KINDLY NOTE:
The Apprentice Doctor Venipuncture Course glossary does not include most of the common anatomical nomenclature
(terminology). Students are referred to their anatomy resources for definitions of those terms.
ABG Arterial Blood Gas.
ABO blood group The major human blood type system
which depends on the presence or absence of antigens A
and B.
Absorb To suck up or take in, as through pores.
Acid-citrate-dextrose (ACD) An anticoagulant containing
citric acid, sodium citrate, and dextrose.
Acquired immunodeficiency syndrome (AIDS) A disease
caused by an infection of the human immunodeficiency
virus (HIV-1, HIV-2).
Acute Of short duration. Rapid and abbreviated in onset in
reference to a disease process.
Adsorb To attract and retain other material on the surface.
Adult Respiratory Distress Syndrome (ARDS) A life
threatening inflammatory reaction of the lungs in response
to various forms of injuries or acute infection.
Aerobic Referring to organisms requiring an oxygenated
environment to grow and live.
Agglutination The process of cells clumping together,
such as red blood cells or bacteria, with the formation of
clumps of cells.
AHF Antihemophilic Factor. See Factor VIII.
AIDS Acquired Immune Deficiency Syndrome, caused by
human immunodeficiency virus (HIV).
Air Embolism (Emboli) An air embolism is a potentially
fatal pathological condition caused by air bubble/s in a
blood vessel and/or one or more of the heart chambers.
Albumin Main protein in human blood.
Allens test (Modified Allens test) Allens test is used to
test blood supply to the hand, specifically, the patency of
the radial and ulnar arteries.
Allergen A substance capable of producing a
hypersensitivity reaction (allergy).
Allergy An unusual sensitivity to a normally harmless
substance that provokes a strong reaction in a persons
body.
Ambulatory Mobile, walking around.
Anaerobic Organisms that can grow, live, and multiply in
the absence of oxygen.
Anaphylaxis (Anaphylactic Shock) A serious allergic
reaction that is rapid in onset and may cause death. It
160
typically causes a number of symptoms including an itchy

rash, throat swelling, and low blood pressure.
Anastomosis Refers to connections between tubular
structures such as blood vessels or between loops of
intestine.
Anatomy The branch of science that studies the physical
structure of animals, plants, and other organisms.
Anemia The condition of having less than the normal
number of red blood cells or hemoglobin in the blood.
Anesthetic A drug that causes unconsciousness or a loss
of local or general sensation.
Anomalous Deviating from the norm or from what people
expect.
Antecubital fossa See cubital fossa.
Antecubital vein See cubital vein.
Anterior Towards the front of the body.
Antibacterial agent A synthetic preparation or drug that
destroys or inhibits the growth of bacteria. It is used to treat
bacterial infections in patients.
Antibiotic Antibacterial substances used to treat infection.
Antibody A molecule produced by immune cells with an
affinity for a specific antigen.
Anticoagulant A natural or synthetic agent that prevents
the formation of blood clots.
Antifibrinolytics Used to inhibit fibrinolysis (the process of
dissolving a blood clot).
Antigen A substance that is capable of producing a
specific immune response with a specific antibody.
Antihemophilic factor Coagulation (clotting) factor
number VIII.
Antihistamine A drug that antagonizes the action of
histamine. It is used to treat allergies.
Anti-platelet agents Medications that, like aspirin, reduce
the tendency of platelets in the blood to clump and clot.
Antiseptic A substance that discourages the growth of
microorganisms.
Antiseptic rub An agent that reduces or prevents
infection, especially by eliminating or reducing the growth
of microorganisms that cause disease.
Apheresis A technique in which blood products (e.g.,

platelets) are separated from a donor, the desired elements
collected, and the rest returned to the donor.
Arterial catheterization The placement of a thin, hollow
tube into the lumen of an artery to measure real time
arterial pressure. The catheter can also be used to get
repeated blood samples to frequently measure the levels
of oxygen and/or carbon dioxide in the bloodstream.
Arterial line Catheter inserted into an artery. It may be
used for withdrawing blood, measuring arterial pressure,
and rarely IV Infusion under pressure.
Arterial Referring to a blood vessel that is part of the
system carrying blood under pressure from the heart to
the rest of the body.
Arteriole A small branch of an artery that leads to a
capillary.
Arteriovenous fistula The surgical joining of an artery
and a vein under the skin for the purpose of hemodialysis.
Artery Blood vessel carrying blood from the heart to the
cells of the body.
Ascites An accumulation of serous fluid in the peritoneal
cavity, causing abdominal swelling.
Aseptic Pertaining to protocols used by medical
professionals to prevent microbial contamination.
Aseptic technique Protocols used by medical professionals
to prevent microbial contamination.
Aseptically Preventing infection from pathogenic
microorganisms.
Aspirate (aspiration) Exerting negative pressure with
the plunger of a syringe before injecting to ensure
an intravascular position of the needle or to avoid an
inadvertent intravascular injection. Aspiration is the act of
removing liquid or gas by suctioning (e.g., blood or pus
from a body cavity).
Auscultation Gathering information about the patient by
listening to bodily sounds, usually with a stethoscope.
Autohemolysis Hemolysis of red blood cells of a person
by his own serum.
Autopsy The medical examination of a dead body in order
to establish the cause and circumstances of death.
Autosafe-Reflex The branded commercial name of
safety needles designed to prevent or minimize needle
stick injuries.
Backflow Refers to the reflux of blood into the catheter
lumen upon disconnection of a cannula or needle.
Bacteremia The presence of viable bacteria circulating in
the bloodstream. Diagnosed with blood cultures.
Barrier techniques Methods of using a variety of items
intended to protect the medical professional, as well as
the patient from transferring infection to either, and to
minimize the chances of cross infection.

Basal state Early in the morning, approximately 12 hours
after the last ingestion of food or other nutrition.
Basilic vein Large vein on the inner side of the arm.
Basophil A subtype of leukocyte with a granular cytoplasm
staining with basophilic dyes.
Betadine The trade name of a popular topical antiseptic
agent that contains iodine; povidone-iodine.
Bicarbonate (HCO3) Bicarbonate is alkaline, and a vital
component of the human bodys pH buffering system
(maintaining acid-base homeostasis).
Bleeding time A test that measures the time it takes for
small blood vessels to close off and stop bleeding.
Blind stick Performing a venipuncture with no apparently
visible or palpable vein.
Blood The fluid in the body that contains red cells, white
cells, platelets, proteins, plasma, and other elements.
Blood bank A blood bank is a cache of blood or blood
components, gathered through blood donation, then
stored and preserved for later use in blood transfusion.
Blood cells Cells normally found in blood (red blood cells
or erythrocytes, white blood cells or leukocytes, and blood
platelets or thrombocytes).
Blood clot The conversion of blood from a liquid form to
solid through the process of coagulation.
Blood clotting factor A number of different factors, which
work together when activated to form a blood clot.
Blood count The determination of the proper number of
red blood cells, white blood cells, and platelets present in
the patients blood.
Blood culture A test which involves the incubation of a
blood specimen overnight to determine if bacteria are
present.
Blood culture A microbiological culture of blood used to
detect infections that spread through the bloodstream.
Blood donation Donated blood used for transfusions
or to be made into specialized blood components or
medications by a process called fractionation.
Blood donor A person who regularly donates blood.
Blood film A sample of blood that is applied to a
microscope slide and then studied under the microscope.
Blood groups A specific antigen manifesting on specific
persons red blood cell surfaces for example A, B, or Rh
antigens.
Bloodletting The act of letting blood or bleeding, by
opening a vein or artery, or by cupping or leeches,
especially as applied to venesection.
Blood plasma The pale yellow or gray-yellow, proteincontaining fluid portion of the blood in which blood cells
and platelets are normally suspended.
161
Blood serum Blood serum is whole blood minus both the

cells and the clotting factors.
Blood smear A sample of blood is applied to a microscope
slide and then studied under the microscope.
Blood Stream Infection (BSI) Blood infection often
believed to be introduced via an IV catheter.
Blood transfer device A safety device designed to transfer
blood from one container into another.
Blood transfusion The process of receiving blood or blood
products intravenously into the circulation. Transfusions
are used in a variety of medical conditions to replace lost
blood or blood components.
Blood types See blood groups.
Blood vessel All the vessels lined with endothelium
through which blood circulates.
Bloodborne pathogen Microorganism present in blood
that can cause disease.
Bloodborne pathogens Any disease-producing
microorganisms that are spread through direct contact
with contaminated blood.
Blunt cannula A non-sharp plastic or metal needle. Also
refers to a needleless system where the blunt cannula
accesses a pre-slit injection port.
Bodily secretions Bodily fluids produced by exocrine
glands such as the salivary and tear glands.
Bolus Dosage of medication, usually administered within
a short period of time, given via IV push, either directly into
a vein or through a port on the IV tubing.
Breast milk Milk produced by the breasts (or mammary
glands) of mammal females (including human females) for
infant offspring.
Bruise A reddish-purple traumatic injury of the soft tissues,
which results in breakage of the local capillaries and
leakage of red blood cells. Also called a contusion.
Bruit The term for the unusual sound that blood makes
when it rushes past a partial obstruction due to turbulent
flow in an artery.
Butterfly A small needle with two plastic wings attached
which are squeezed together to form a tab that is used to
manipulate the needle.
Butterfly needle See winged infusion set.
Cannula A flexible tube for insertion into a duct, vein, or
cavity in order to drain away fluid or to administer drugs.
Capillaries An extensive network of microscopic blood
vessels that supply oxygen and nutrients to cells and
remove CO2 and waste products.
Capillary Any one of the minute vessels that connect the
arterioles and venules. Together, capillaries form a network
in nearly all parts of the body.
Carbamate hemoglobin A hemoglobin compound
162
bound with carbon dioxide in the red blood cells.

Carbon Dioxide (CO2) One of the mediators of the local
autoregulation of blood supply. When levels are high,
capillaries expand to allow a greater blood flow to that
tissue.
Carboxyhemoglobin Hemoglobin that has been bound
with carbon monoxide.
Catheter Hollow tube of variable size used for intravenous,
arterial, as well as body cavity/organ (e.g., bladder) access.
Catheter introducer Needle device that is used to insert a
catheter into the artery or vein. The catheter slides off the
introducer needle, which is then disposed of.
Catheter Malposition/Migration Movement of a
catheter which can cause trauma within the vein or artery
and interrupt IV therapy.
Catheter Related Sepsis (CRS) Blood infection believed
to be introduced through an IV catheter.
Cathflo Activase (Alteplase) A medication used for the
restoration of function to central venous access devices
(CVADs) as assessed by the ability to withdraw blood.
CBC Complete Blood Count.
CDC (Centers for Disease Control and Prevention) A
United States federal agency that protects public health
and safety by providing information to enhance health
decisions. CDC promotes health through partnerships
with state health departments and other organizations.
Central Line See central venous line.
Central Venous Catheter (CVC) A small, flexible plastic
tube inserted into a large vein in the neck, chest or groin
where the tip of the catheter resides in the superior vena
cava.
Central venous line Also called a central venous catheter
or central venous access catheter. It is a catheter placed
into a large vein in the neck, chest, or groin, which is used
to administer medication or fluids, obtain blood tests, and
directly obtain cardiovascular measurements such as the
central venous pressure.
Centrifuge A laboratory apparatus that separates mixed
samples into homogenous component layers by spinning
them at high speed.
Cephalic vein One of the larger arm veins that empty into
the axillary vein.
Cerebrospinal fluid (CSF) Cerebrospinal fluid is a clear,
colorless bodily fluid produced in the choroid plexus of
the brain.
Chelate Combining with a metallic ion into a ring complex.
Chemotherapy Treatment of disease with chemical
reagents that have a specific and toxic effect upon the
disease-causing microorganism or cancer cells.
Chlorhexidine Antiseptic agent commonly used to

eliminate, reduce, or weaken microorganisms.
Circulation The movement of blood in a circuitous course.
Circulatory system The circulatory system is composed
of the heart, arteries, capillaries, and veins.
Citrate Citrate chelates (binds) calcium ions, preventing
blood clotting. It is, therefore an effective anticoagulant.
Citrate phosphate dextrose (CPD) A type of
anticoagulant.
Citrate phosphate dextrose adenine (CPDA-1) An
anticoagulant used for the preservation of whole blood
and red cells.
Cleaning The removal of all visible foreign material from
objects using water, detergents, or mechanical means.
Clot A semisolid mass of blood found outside of the
circulatory system.
Coagulate The process of clot formation.
Coagulation factors Group of plasma protein substances
(Factor I thru XIII) contained in the plasma, which act
together to bring about blood coagulation.
Collateral circulation Blood which is carried through
secondary channels after the primary vessels of a particular
area has been obstructed.
Colloid solution IV fluid containing large proteins and
molecules that tends to stay within the blood vessels.
Coma A coma is a state of unconsciousness lasting more
than six hours, in which a person cannot be awakened and
fails to respond normally to painful stimuli, light, or sound.
The comatose person lacks a normal sleep-wake cycle and
does not initiate voluntary actions.
Comatose Unconscious (in a coma).
Complete blood count (CBC) The number of red blood
cells, white blood cells, and platelets present in a blood
sample (per cubic millimeter).
Complications A disease or problem that arises in addition
to the initial condition during or following the medical or
surgical treatment of a patient.
Conduction anesthesia A comprehensive term which
encompasses a great variety of local and regional
anesthetic techniques.
Contact dermatitis Inflammation of the skin due to
contact with an allergen, resulting in a range of symptoms
such as redness, swelling, itching, or blistering.
Contagious May be transmitted from one person to
another person.
Contamination The introduction of pathogenic organisms
into a wound.
Contusion A bruise or injury without a break in the skin.
Coronary arteriography A test that uses X-rays to help a
doctor/radiologist/cardiologist find narrowing or blockage
in the coronary arteries.

Cortisone A steroid hormone secreted by the adrenal
cortex. Synthetic cortisone medications used to treat
allergic responses and other medical conditions.
Coumadin Trademark name for warfarin, an anticoagulant.
Crystalloid solutions IV fluids containing varying
concentrations of electrolytes.
CT scan (CAT scan) Computed Tomography or Computed
Axial Tomography. A medical imaging procedure that
utilizes computer-processed X-rays to produce slices of
specific areas of the body.
Cubital fossa (antecubital fossa) The cubital fossa (or
elbow pit) is the triangular area on the anterior view of
the elbow of a human. It contains the radial and median
nerves, the brachial artery, the tendon of the biceps
muscle, as well as several more superficial veins.
Cubital vein The cephalic vein when it crosses the cubital
fossa. It communicates with the basilic vein in the cubital
fossa via the median cubital vein.
Cutaneous Referring to the skin and its appendages.
Cytoplasm The cell contents excluding the nucleus with
all the organelles suspended in it.
D5W Dextrose 5% in water.
D-dimer blood test D-dimer is a fibrin degradation
product (or FDP), a small protein fragment present in the
blood after a blood clot is degraded by fibrinolysis.
Dead space (residual volume) The residual volume
withheld in an IV device. Refers to the amount of fluid
remaining in a connector, not delivered to the patient.
Deep Vein Thrombosis (DVT) A thrombus that formed in
one of the deep veins, usually of the leg.
Defibrinated blood Blood that has been deprived of
fibrin.
Dehydration The lack of water in the body resulting from
inadequate intake of fluids or excessive loss of water and
electrolytes through sweating, vomiting, or diarrhea.
Dermatitis Inflammation of the skin from any cause,
resulting in a range of symptoms such as redness, swelling,
itching, or blistering.
Dextrose A carbohydrate (sugar) solution used in
intravenous drips.
Dialysis The process of cleansing the blood by passing it
through a special machine.
Dialyzer The dialyzer is the heart of the hemodialysis
machine used to replace the functions of the kidneys in
kidney failure patients.
Differential A count of the different types of leukocytes
in a stained blood smear. The proportion is expressed as a
percentage.
163
Disinfectant A substance capable of killing a wide range

of microorganisms.
Disinfection Process that eliminates many or all infectious
micro-organisms except bacterial and fungal spores.
Displacement The volume of fluid displaced in a catheter
when a needleless intravenous (IV) connector is connected
or disconnected.
Distal Further away from the torso. Further away from the
IV solution bag.
Distended Expanded, swollen, or inflated.
Dorsal Referring to or situated on the back of the body,
the upper parts of the hands (opposite side of the palms),
and feet (opposite side of the soles).
Drip chamber Clear, plastic tube (chamber) used as a
reservoir and measuring device on IV lines just below the
solution bag.
D5W Short for 5% dextrose in water.
Ebola (Ebola hemorrhagic fever) A viral disease
transmitted by contaminated blood or body fluids, often
recognized by the leakage of blood and bodily fluids,
usually resulting in death.
Ecchymosis A diffuse collection of blood outside the
blood vessels within the tissue.
Edema The swelling of soft tissues as a result of excess
fluid accumulation.
EDTA (Ethylenediaminetetraacetate) A calcium
chelating (binding) agent that is used as an anticoagulant
for laboratory blood specimens.
Effluent An outflow, usually of fluid.
Effusion The oozing of fluids from blood or lymph vessels
into body cavities or tissues as a result of inflammation.
Electrolytes Ions in cells, blood, or other bodily fluids
with many physiological functions like assisting with
maintaining normal pH levels, nerve impulse conduction,
and muscle contraction.
Embolism The blockage of a blood vessel due to an
embolus, usually a blood clot formed at one place in the
circulation and then lodging in another area.
Embolus A dislodged and displaced blood clot, or some
other substance, causing obstruction in blood vessels at
a distant site.
EMLA cream A topical anesthetic cream used locally
on children for mildly invasive procedures such as
venipuncture.
Endothelium The layer of cells lining the closed internal
spaces of the body such as the blood vessels and lymphatic
vessels.
Eosinophil An eosin (red) staining leukocyte with a
nucleus that usually has two lobes connected by a slender
thread of chromatin.
164
Epidemiology The science concerned with the study of

factors influencing the distribution of disease and their
causes in a defined population.
Epidermis The upper or outer layer of the two main layers
of cells that make up the skin.
Epithelium The outermost layer of skin, mucous
membranes, as well as the lining of the digestive and
respiratory systems.
Erythrocytes Red blood cells, which primarily carry
oxygen and collect carbon dioxide using hemoglobin.
Etiology The cause or origin of a disease or disorder.
Excretions A bodys waste products (e.g., carbon dioxide,
sweat, urine and feces).
Extension Set IV tubing used to provide additional length
or access to the primary IV line.
Extracellular space The space outside the cells consisting
of the intravascular and the interstitial spaces.
Extravasation The leaking of blood or other fluid from a
vessel into surrounding tissue as a result of injury, burns, or
inflammation.
Extremities Limbs of a person or animal, or the parts of a
limbs that are farthest from the body (e.g., hands or feet).
Exudate A fluid rich in protein and cellular elements that
oozes out of blood vessels due to inflammation and is
deposited in nearby tissues.
Exudates (verb) Fluid leaking from a blood vessel, tissue,
or organ.
Factor VIII An important clotting factor known as
antihemophilic factor (AHF).
Faint Sudden loss of consciousness.
Fasting Abstaining from all food and liquids, with the
exception of small sips of water, usually overnight.
Feces The bodys solid waste matter, composed of
undigested food, bacteria, water, and bile pigments,
discharged from the bowel through the anus.
Fibrin Sleeve A buildup of platelets on the exterior of and
indwelling catheter that can lead to thrombus formation.
Fibrin The protein chains formed during normal blood
clotting that is the essence of the clot.
Fibrin Tail A fibrin formation that hangs off the tip of the
catheter like a tail.
Fibrinogen The protein from which fibrin is formed.
Fibrinolytic (Thrombolytic) Fibrinolytic or thrombolytic
drugs are used to dissolve (lyse) blood clots (thrombi).
Finger prick See finger stick.
Finger stick A procedure in which a finger is pricked with
a lancet to obtain a small quantity of capillary blood for
testing.
Fistula An intentional or pathological shortcut between a

vein and an artery. An opening or passage between two
organs or between an organ and the skin.
Flashback The appearance of a small amount of blood
when inserting the needle of a syringe or the tubing of a
butterfly or cannula in a vein indicating that venous access
has been successful.
Flexion In the bent position.
French size Term used to describe external diameter of
catheter. Numerical increase = size increase.
Gauge Typically refers to the inside diameter of a needle or
catheter. Numerical increase = size and flow rate decrease.
General anesthesia A medically induced coma and loss
of protective reflexes resulting from the administration of
general anesthetic agents.
Germicide An agent that kills pathogenic microorganisms.
Glucose The sugar measured in blood and urine specimens
to test for diabetes.
Graft An implant or transplant of any tissue or organ.
Harvesting The collection and preservation of tissues or
cells from a donor for the purpose of transplantation.
Hb Blood hemoglobin level. Normal hemoglobin values
are 14-18 g/dl in adult males and around 12-16 g/dl in
adult females.
Heel prick (heel stick) A procedure in which an infants
heel is pricked with a lancet to obtain a small quantity of
capillary blood for testing.
Hematocrit The ratio of the total red blood cell volume to
the total blood volume, expressed as a percentage.
Hematology The branch of medicine devoted to the
study of blood, blood-producing tissues, and diseases of
the blood.
Hematoma A hematoma is a localized collection of blood
outside the blood vessels within the tissue.
Hematopoiesis (hemopoiesis) The formation of the
cellular components of blood in the blood-forming tissues
of the body, mostly the red bone marrow.
Hemoconcentration A decrease in the fluid content of the
blood (plasma), resulting in an increase in the hematocrit.
Hemodialysis The removal of certain components of the
blood by virtue of the difference in their rates of diffusion
through a semipermeable membrane.
Hemoglobin An iron-containing protein in red blood cells
that transports oxygen around the body.
Hemolysis The breaking of the red blood cells membrane
releasing free hemoglobin into the circulating blood or
blood sample.
Hemostasis To stop bleeding either by vasoconstriction,
coagulation, or by surgical means.
Heparin A natural anticoagulant formed in the liver and
used to reduce or prevent blood clotting.

Heparin cap Injection port.
Heparin Lock The function of administering heparin into a
catheter after use to reduce intraluminal clotting of blood.
Used for intermittent therapies where the catheter is not
being utilized for fluid delivery.
Hepatitis Inflammation of the liver.
Hepatitis B A sometimes recurring or fatal form of hepatitis
that is caused by a virus and transmitted through contact
with infected blood, blood products, and bodily fluids.
Hepatitis C Inflammation of the liver, caused by a virus.
Symptoms include fever, jaundice, abdominal pain, and
weakness.
Hickman catheter A hollow silicone (soft, rubber-like
material) tube inserted and secured into a large vein in the
chest for long-term use to administer drugs or nutrients.
HIV Human Immunodeficiency Virus known to be
responsible for producing Acquired Immunodeficiency
Syndrome (AIDS).
Hub Female connection of an IV device or catheter into
which the male luer is inserted.
Huber needle A needle bent at an acute angle used for
accessing implanted ports.
Humoral Pertaining to humoral (or hormonal) control or
relating to the immune response that involves antibodies
circulating in bodily fluids.
Hyperalimentation Total parenteral nutrition (TPN).
Hyperbaric oxygen therapy The medical use of oxygen
at a level higher than atmospheric pressure.
Hyperbaric Referring to pressures higher than normal.
Hyperglycemia An abnormally high glucose in the blood.
Hypersensitivity A state in which the body reacts with an
exaggerated immune response to a foreign substance.
Hypertonic crystalloid A crystalloid solution that has
a higher concentration of electrolytes than the bodys
plasma.
Hypodermic needle A needle that attaches to a syringe
for the purpose of injections or withdrawal of fluids such
as blood.
Hypoglycemia An abnormally low glucose level in the
blood.
Hypotonic crystalloid A crystalloid solution that has a
lower concentration of electrolytes than the bodys plasma.
Immunoglobulins Antibodies formed by cells of the
immune system that are present in blood and saliva.
Implant Object or material, such as tissue, partially or
totally inserted or grafted into the body of a recipient.
Implantable Port Subcutaneous (below the skin) injection
port having no exterior components when not in use.
In vitro Outside the living body.
165
In vivo Inside the living body.

Infection Control Officer The person in a hospital in
charge of the prevention and management of hospital
infections and related issues.
Inferior Towards the lower aspects of the body.
Infiltration Fluid seeping into the tissue. Local anesthetic
injected diffusely into tissue.
Infusate IV solution to be administered.
Infusion pumps A programmable medical device used
for infusing controlled amounts of fluid or medication into
a patients body usually into the bloodstream.
Injection cap Access point of a catheter where the IV line
administration line is connected.
Inspection The act of gathering visual information about
a patient, done by a medical professional.
Intermittent Therapy Administration of IV therapy which
occurs at intervals.
Interstitial fluid Fluid surrounding the cells of the body
(excluding blood).
Interventional radiology A medical sub-specialty of
radiology that utilizes minimally invasive image-guided
procedures to diagnose and treat diseases in nearly every
organ system.
Intra-arterial Pertaining to the inside of an artery or the
arterial system.
Intracellular fluid The fluid within the cells.
Intradermal injections An injection of medication into
the skins dermis layer (below the epidermis).
Intramuscular injection (IMI) An injection of medication
into one of the large muscles of the body.
Intrathecal injection An injection into the sub-arachnoid
space.
Intravascular volume The volume of blood contained
within all the blood vessels (arteries, veins, and capillaries).
Intravenous fluids Chemically prepared solutions that are
administered to a patient via an IV route.
Intravenous (IV) Therapy Infusion therapy given to a
patient via intravenous access.
Intravenous line A tube with a needle or cannula placed
directly into a vein and used to correct electrolyte
imbalances, to deliver medications, for blood transfusion,
or as fluid replacement to correct conditions such as
dehydration.
Iodine Usually used in an alcohol solution, called tincture
of iodine, as a pre- and post-operative antiseptic and
occasionally for preparing the skin aseptically before
venipuncture.
Irrigation To push fluid though an IV line, usually with
normal saline solution.
Isotonic crystalloid A crystalloid solution that has the
166
same concentration of electrolytes as the body plasma.

IV line See intravenous line.
IV Setup Equipment and items required for starting an IV
infusion.
IV Skills (Intravenous skills) The ability to perform
phlebotomy and to put up an intravenous line.
IVH Intravenous hyperalimentation.
Joint A part of the body where bones are connected (e.g.,
the knee, elbow, or skull).
Keep Vein Open (KVO) Refers to a slow continuous
IV infusion for keeping the vein open and the cannula
unobstructed.
Kidney dialysis Kidney dialysis is a process for removing
waste and excess water from the blood, and is used
primarily to provide an artificial replacement for lost kidney
function in people with renal failure.
Lactated Ringers (LR) See Ringers Lactate
Laminar flow hood Safety cabinets with air flow in such a
direction as to carry any harmful materials or fumes away
from the worker.
Lancet A small sharp blade for puncturing the skin for
collecting small amounts of capillary blood.
Lateral Away from the midline of the body.
LAV Luer activated valve.
Leukocytes (leucocytes) White blood cells or leukocytes
are cells of the immune system involved in defending the
body against both infectious disease and foreign materials.
Lipids (Interlipids) Emulsified fat for IV infusion for
nutritional therapy.
Lipohypertrophy Medical term that refers to a lump
under the skin caused by accumulation of extra fat at the
site of many subcutaneous injections of insulin.
Local anesthesia The prevention of sensory impulses,
especially pain impulses, in a localized area of the body
from reaching the brain by depositing a local anesthetic
solution in the area or near a sensory nerve stem supplying
the area.
Luer lock A secure connecting and locking mechanism
between a male luer fitting and a female luer fitting. The
female fitting screws into threads in the sleeve on the male
fitting.
Luer slip Conical male luer that achieves a friction
connection when inserted into a female hub and turned a
quarter turn clockwise.
Lumen The internal space within catheter artery, vein,
intestine, or tube.
Lymph Fluid found in lymphatic vessels and nodes derived
from tissue fluids.
Lymphedema A type of swelling that occurs in lymphatic

tissue when excess fluid collects in the arms or legs because
the lymph nodes or vessels are blocked or removed.
Lymphocytes Mononuclear, non-phagocytic leukocytes
that are found in the blood and lymph; the bodys
immunologically competent cells.
Macrophage Any of the many forms of mononuclear
phagocytes found in tissues and originating from stem
cells in the bone marrow.
Magnetic resonance imaging (MRI) A medical imaging
technique used in radiology to visualize internal structures
of the body in detail by using nuclear magnetic resonance
(NMR) to produce sliced images of the body.
Malaria An infectious disease caused by a parasite
transmitted by the bite of carrier mosquitoes.
Mandible Lower jaw.
MCH (Mean Corpuscular Hemoglobin) The average
hemoglobin content in a red blood cell.
MCHC (Mean Corpuscular Hemoglobin Concentration)
The average hemoglobin concentration in red blood cells,
expressed as a percentage (g/dL).
MCV (Mean Corpuscular Volume) Average volume of red
blood cells (erythrocytes), expressed in cubic micrometers.
Medial (mesial) Towards or closer to the midline of the
body.
Medial cubital vein The communicating vein between
the cephalic and basilic veins in the cubital fossa commonly
used for venipuncture.
Median antecubital vein See medial cubital vein.
Medical history The systematic questioning of a patient
by a medical professional to gather information for
diagnosing a condition or disease.
Medication A drug used to treat a disease or condition or
to alleviate a symptom (e.g., pain).
Mesial See medial.
Micron Filter IV filter used to capture and eliminate air and
contaminates in the IV system.
Microorganism A microscopic organism or microbe.
Some types can cause a variety of diseases, wound, and
blood infections.
Milliliter A thousandth of a liter; it equals a cc (cubic
centimeter).
Monocyte A mononuclear, phagocytic leukocyte with an
oval to kidney shaped nucleus.
Mononuclear A cell containing only one nucleus.
Multi-sample adapter A device used with a butterfly and
Vacutainer holder to allow for the withdrawal of multiple
tubes of blood during a venipuncture.
Mural Thrombosis A fibrin buildup on the wall of the
vessel often caused by trauma during catheter insertion
and can lead to vein thrombosis.

Needle A thin, sharp metal tube attached to a syringe for
injecting a patient or the sharp usually semi-curved metal
structure at the one end of a suture thread.
Needlestick injury Accidental injuries sustained by
medical professionals while working with sharp needles.
Injuries may be clean (before injecting) or contaminated
(after injecting a patient).
Negative air pressure Pressure less than that of
atmosphere.
Neonate A newborn child, especially one less than one
month old.
Neutrophil A polymorphonuclear granular leukocyte
having a nucleus with 3-5 lobes connected by slender
threads of chromatin and cytoplasm containing fine
inconspicuous granules.
Normal saline solution An isotonic crystalloid solution
that contains 0.9% sodium chloride dissolved in sterile
water.
Nosocomial infection An infection whose origin is from
the hospital environment.
Occluded The stopping of flow of intravenous fluid or
blood due to a blockage (e.g., a blood clot (thrombus),
pressure tourniquet, or kinking of the plastic tube or
cannula).
Occlusion Blocked artery, vein, IV catheter, or tubing. Also,
refers to an occlusion alarm on a pump that sounds when
the IV setup becomes blocked.
OHASA Acronym for Occupational Health and Safety Act.
Oncology Scientific and medical study of cancer.
Order of draw The order in which blood sample tubes
should be drawn using a multi-sample technique.
OSHA Occupational and Health Safety Administration,
part of the United States Department of Labor.
Osmosis The movement of water across a semipermeable
membrane from an area of lower solute concentration to
an area of higher solute concentration.
Oxygen-carrying solutions Chemically prepared
solutions that can carry oxygen to the cells.
Oxygen saturation (SpO2) Oxygen saturation or (O2 sats)
measures the percentage of hemoglobin binding sites in
the bloodstream occupied by oxygen.
Oxyhemoglobin Hemoglobin that has been bound with
oxygen in the lungs for the purpose of transport of oxygen
to cells of the body.
PCA Patient-Controlled Analgesia (pain medication).
Packed red blood cells In transfusion medicine, packed
red blood cells are red blood cells that have been separated
from whole blood for transfusion purposes.
167
Pallor Paleness; increase in the absence of skin color; the

absence of color in skin.
Palmar Referring to the palm surface or side of the hand.
Palpate To examine or feel with the hand.
Palpation The act of gathering information about the
patient with the medical professional using the sense of
touch.
Parafilm A thin film of paraffin used primarily in the
laboratory to seal open containers such as test tubes.
Parenteral nutrition (PN) Parenteral nutrition is feeding
a person intravenously, bypassing the usual process of
eating and digestion.
Patent (patency) Generally referring to an open, clear (not
occluded) IV catheter.
Pathogen Any microorganism that produces disease.
Pathogenesis The development and progression of a
disease.
Pathogenic Having the capability of producing disease.
Pediatric Referring to the medical care of children
including the prevention and treatment of childrens
diseases.
PEP (Post-exposure prophylaxis) Steps to take to
prevent or minimize the risk of infection after a patient or
healthcare worker has been exposed to a known pathogen
(e.g., HIV).
Peripheral blood Blood circulating in blood vessels
outside of the heart and major blood vessels.
Peripheral Line Any IV line placed on the periphery of the
body (e.g., arm, leg, hand, or foot).
Peripherally Inserted Catheter (PIC) Catheter that is placed
on the periphery of the body (e.g., arm, leg, hand, or foot).
Peripherally Inserted Central Catheter (PICC) Catheter
that is placed on the periphery of the body, generally from
the arm with the catheter tip positioned in the superior
vena cava.
Peritoneal dialysis Dialysis through the peritoneum.
Peritoneum The membrane lining the abdominal and
pelvic wall.
PH A scale from 0-14 indicating the level of acidity or
alkalinity (< 7 is acidic, 7 = neutral and > 7 is alkaline).
Phagocytosis A phagocyte is any cell capable of ingesting
particulate matter.
Phlebitis Inflamed, irritated vein.
Phlebotomist One who practices phlebotomy.
Phlebotomy Needle puncture of a vein for the purpose of
drawing blood (venipuncture).
Physician A doctor who diagnoses and treats diseases
and injuries using methods other than surgery.
Physiology The branch of biology that deals with the
internal workings and functions of living organisms.
168
Piggyback Accessing a primary IV line at a secondary port

(Y-site).
Pipet A glass or transparent plastic tube used to accurately
measure small amounts of liquid.
Plasma Blood plasma is the liquid component of blood,
making up around half of the total blood volume. It consists
of about 90% water, the balance being proteins, minerals,
clotting factors, hormones, and immunoglobulins.
Plateletpheresis The selective separation and removal of
platelets from withdrawn blood.
Platelet-rich plasma (PRP) Platelet-rich plasma has been
used as an adjunct to wound healing for several decades.
Platelets See thrombocytes.
Pleural Pertaining to the thin transparent membrane that
lines the chest wall and doubles back to cover the lungs.
Plunger Piston-like part of a syringe for exerting pressure
for injecting or negative pressure for aspirating.
Polymorphonuclear A white blood cell with a nucleus so
deeply lobed so as to appear to have multiple nuclei.
Ports A port is a small medical appliance that is installed
beneath the skin with a catheter connecting the port to a
vein. Under the skin, the port has a septum through which
drugs can be injected and blood samples can be drawn
many times.
Posterior Towards the back of the body.
Povidone-iodine A topical antiseptic occasionally used in
phlebotomy.
Primary Line Main IV tubing. Secondary lines will be
piggy-backed into the main line.
Priming The elimination of air in the IV setup by infusing
solution prior to IV administration.
PRN Adapter Injection port.
P.r.n. (Latin: pro re nata) Means as needed or as the
situation arises. Used when prescribing medication only to
be used if necessary.
Prone Lying face down, as opposed to supine.
Prophylaxis A preventative treatment; medication
prescribed with the intent to prevent complications that
may develop following a surgical procedure.
Protocol Guidelines written to prescribe safe and effective
clinical practice. Intended to be followed by all clinical
personnel and set as a benchmark for what and when
specific procedures or steps of procedures should happen
and in what order it should happen.
Proximal Nearer to the head and torso or nearer to the IV
fluid bag.
Pulse points Specific areas or points on the human body
where an arterial pulse or throb can be palpated on mild
digital (fingertip) pressure.
Pus The yellowish or greenish fluid that forms at sites of

infection, consisting of dead white blood cells, dead tissue,
bacteria, and blood serum.
QNS Quantity Not Sufficient
Radiography The use of X-rays to view the internal
structures of a human or an animal body.
Radiology The branch of medicine that deals with the use
of X-rays and radioactive substances such as radium in the
diagnosis and treatment of diseases.
Red blood cells See erythrocytes.
Regional anesthesia Anesthesia that affects a large part
of the body such as a limb or the lower half of the body.
Residual Volume The volume withheld in an IV device.
Refers to what amount of fluid resides in a connector and
is not delivered to the patient.
Reverse isolation An isolation procedure for protecting
patients whose immune response has been greatly
reduced from contracting disease.
Reverse Trendelenburg Patient lying on the back with the
bed angulated so the feet are about 15-30 lower than the
head.
Rh system A specific type of human blood group
responsible for hemolytic disease of the newborn.
Ringers Lactate An isotonic crystalloid solution containing
the solutes sodium chloride, potassium chloride, calcium
chloride, and sodium lactate, dissolved in sterile water.
RN (Registered Nurse) A nurse who has graduated from a
nursing program at a college or university and has passed
a national licensing exam.
Safety-engineered needles Needles designed to prevent
or minimize needle stick injuries.
Saline Solution of salt and water used as a carrier for all IV
drugs and hydration. Normal saline is a 0.9% solution with
the same osmotic pressure as that of blood.
Saliva The clear liquid consisting of water, mucin, protein,
and enzymes, secreted into the mouth by the salivary
glands. It moistens food and starts the breakdown of
starches.
SASH Saline flushAntibioticSaline flushHeparin.
Sclerosis The hardening of an artery or vein, usually seen
in the elderly.
Scrubs The shirts and trousers or gowns worn by nurses,
surgeons, and other operating room personnel when
scrubbing in for surgery. Scrubs are now commonly worn
by any hospital personnel in any clean environment.
Secondary Line IV line used to access a main/primary line
at a secondary port (Y-site).
Seldinger Technique Over the wire insertion method used
for catheter insertion.
Semen The liquid that contains sperm produced by the

male sex organs.
Semipermeable Permitting the passage of certain
molecules and hindering others.
Sepsis A localized or systemic state of inflammation
caused by disease forming bacteria and their products
(e.g., toxins).
Septic See sepsis.
Serum Referring to blood, the clear liquid portion of blood
that separates out after clotting has taken place.
Sharps injury An injury occurring when a sharp object
penetrates the skin or mucous membranes.
Sharps Objects or devices with acute rigid corners, edge,
points, or protuberances capable of cutting or penetrating
the skin (hypodermic needles, scalpels, blades, lancets,
broken glass, etc.).
Sodium The most common electrolyte found in animal
blood serum.
Solute Particles that are dissolved in the sterile water
(solvent) of an IV fluid.
Solvent The liquid portion of an IV solution that the solute
dissolves into. The most common solvent is sterile water.
Sputum A mucus or phlegm-like substance coughed up
from the respiratory tract.
SQ See subcutaneous injection.
Standard precautions The routine use of safe work
practices and protective barriers to minimize the spread of
infectious diseases and prevent sharps injuries.
Stat Abbreviation for the Latin word statim, meaning
immediately.
Sterile procedure Referring to an invasive procedure
where a special sterile and aseptic protocol is followed to
minimize the risk of causing and transmitting infection.
Subcutaneous injection (abbreviated as SQ or SC) An
injection of medication into the subcutaneous layer of the
skin (below the dermis and epidermis).
Submucosa A layer of loosely meshed microscopic fibers
and associated connective tissue cells beneath a mucous
membrane.
Superficial Relating to, affecting, or located on or near the
surface of something.
Superior Towards the upper aspects of the body.
Supine Patient lying on the back and with the face
upwards.
Suturing The closure of a wound by joining the edges.
Swan-Ganz Catheter A catheter with a balloon at the tip,
passed via one of the major veins into the right side of the
heart and the arteries leading to the lungs, which monitors
the hearts function, blood flow, and intravascular pressure
in these vessels.
169
Sweat The clear salty liquid that passes through minute

pores to the surface of the skin when somebody is hot as a
result of strenuous activity, fear, anxiety, or illness.
Syncope Fainting.
Syringe A medical device commonly used for injecting
medication into the body or withdrawing fluid (e.g., blood
or pus) from the body. The basic parts of a syringe are the
barrel, plunger, and tip.
Therapeutic phlebotomy (letting blood) A therapeutic
procedure to remove blood from the bloodstream
primarily for medical reasons.
Therapeutic Promoting healing or a healing agent.
Third space The third space is space in the body where
fluid does not normally collect in larger amounts, or where
any significant fluid collection is physiologically nonfunctional (e.g., peritoneal, pleural space, etc.).
Thrombocytes Very small, irregularly shaped, clear cells
derived from fragmentation of precursor megakaryocytes.
Platelets are involved in hemostasis leading to the
formation of blood clots.
Thrombocytopenia Decrease in the number of blood
platelets below normal values.
Thrombosis A buildup of blood fibrin and platelets in the
circulatory system which can lead to embolism or clotting.
Thrombus A blood clot that forms in a blood vessel and
remains at the site of formation.
Tissue infiltration Intravenous fluid seeping into the
surrounding tissue instead of flowing into a vein.
Topical anesthetic The numbing of the surface of a
mucous membrane or the skin in an attempt to avoid or
reduce pain experienced by the patient on needle pricking
or minor surgical procedures.
Total body water The total amount of water contained
within the cells, around the cells, and in the bloodstream.
Total Parenteral Nutrition (TPN) IV fluids used as a
complete nutritional replacement for a period of time.
Tourniquet A band applied around an arm or leg in order
to temporary reduce or stop the venous or arterial blood
flow in a limb.
Tournistrip The registered trade name of an easy to use,
single-use tourniquet.
Transplant An organ or tissue taken from the body for
grafting into another part of the same body or into another
individual.
Transudate A transudate is a bodily fluid that passes
through a membrane, filtering out most of the protein and
cellular elements, thus yielding a watery solution.
Transudates A fluid that passes through the pores or
interstices of a membrane.
Trendelenburg Patient lying on their back with the bed
170
angulated so the head is about 15-30 lower that the feet.

Ultrasound A technique that uses high-frequency sound
waves for medical diagnosis and treatment (e.g., to create
images of internal organs).
Urinalysis The analysis of the physical, chemical, and
microbiological properties of urine, carried out to help
diagnose disease, monitor treatment, or detect the
presence of specific substances.
Urine The yellowish liquid containing waste products that
is excreted by the kidneys and discharged through the
urethra.
Urticaria A skin rash, usually occurring due to an allergic
reaction, marked by itchiness and small pale or red
swellings.
Vacutainer The brand name and often generically term
used to describe the equipment used to draw or aspirate
blood from a vessel by venipuncture.
Vacutainer holder A cylindrical shaped holder that
accepts a Vacutainer tube on one end and a Vacutainer
needle on the other.
Vacutainer needle The needle used to attach to a
Vacutainer holder.
Vacutainer system The combination of a Vacutainer
holder, needle, and sample tube which allows for a more
automated method of drawing blood.
Vacutainer tube Blood sample tubes containing a
vacuum.
Vacuum tube A sterile glass or plastic tube with an
evacuated closure to create a vacuum inside the tube
facilitating the draw of a predetermined volume of liquid.
Valve A membranous structure in a hollow organ or vessel
such as the heart or vein that ensures the unidirectional
flow of blood passing through it by closing intermittently.
Vascular graft Harvesting an artery or vein and
transplanting it to another site.
Vascular Pertaining to or composed of blood vessels.
Vasoconstriction A decrease in the inside diameter of
blood vessels leading to a decrease in blood flow.
Vasovagal response The vasovagal response is the
development of inappropriate cardiac slowing and
arteriolar dilatation.
Vasovagal syncope Fainting due to a vasovagal response.
Vein A blood vessel that carries blood towards the heart.
Venesection Surgically opening of a vein for the purpose
of collecting blood.
Venipuncture The puncturing of a vein for any
medical purpose (e.g., to take blood, to feed somebody
intravenously, or to administer a drug). The act of inserting
a needle or catheter into a vein.
Venous access Insertion of a cannula into a vein allowing

entrance to the circulatory system to infuse medication or
solutions, or to draw blood.
Ventral Referring to or situated on the front of the body,
the palms of the hands, and soles of the feet.
Venule A very tiny vein continuous with the capillaries.
Veterinary Pertaining to diseases of animals and their
treatment.
Vial A small glass, plastic vessel, or bottle used to store
medication as liquids or powders.
Warfarin A synthetic anticoagulant.
White blood cell count The number of white blood cells
(leukocytes) found in the peripheral blood and measured
per cubic millimeter.
White blood cell See leukocyte.
WHO Acronym for World Health Organization.
Whole blood Whole blood is a term used in transfusion
medicine, meaning human blood from a standard blood
donation.
Winged infusion set A type of needle used in venipuncture
(phlebotomy) often used with people who have difficult
venous access.
Y Site Injection port that branches off primary lines. Used
for piggybacking medications into primary set.
171

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FOR FUTURE MEDICAL PROFESSIONALS

A BASIC COURSE IN PHLEBOTOMY AND IV TECHNIQUES

A product developed and marketed by

THE APPRENTICE CORPORATION: COPYRIGHT INFORMATION

First edition - October 2013

Venipuncture Course and Kit |

hospitals and training institutions. The basic principles

Venipuncture Course and Kit |

proficiency, knowledge, and confidence to be successful in

Re-use items only in a non-clinical practice

Venipuncture Course and Kit |

KEYS TO SYMBOLS USED IN THE PRACTICAL PROJECTS

A definite possibility of blood contamination exists when performing these procedures in a

Venipuncture Trainer is required see PROJECT 10 to set up the Venipuncture Trainer.

Venipuncture Course and Kit |

CLINICAL PROCEDURE: RESTRICTED

CLINICAL PROCEDURE: VOLUNTEERS ALLOWED

The supplier disclaims all liability for any direct or indirect

Venipuncture Course and Kit |

The Apprentice Corporation, its employees,

of using the kit or applying the information from the

material in your possession then repackage the kit with

Venipuncture Course and Kit |

knowledge of related complications and how to

Venipuncture Course and Kit |

OBJECTIVES OF THE COURSE

On completion of this course, students should have

The course explains the art and science of phlebotomy,

The objectives of the course are to assist students in

The importance of taking a medical history before

Collecting capillary blood

Venipuncture Course and Kit |

HOW TO USE THE APPRENTICE DOCTOR VENIPUNCTURE KIT

OBJECTIVES OF THE COURSE

Case study 1: An Avoidable Accidentan Unnecessary Death

Types of intravenous fluids

PROJECT 1A FAMILIARIZE YOURSELF WITH YOUR VENIPUNCTURE KIT

SAFETY PROTOCOL AND SAFETY ITEMS

PROPER SHARPS DISPOSAL AND ILLEGAL INJECTION DRUG USERS

PROJECT 1B HOW TO USE A SAFETY NEEDLE/DEVICE

BASIC ANATOMY OF THE CIRCULATORY SYSTEM

Main Blood VesselsFull Body

Veins and arteries of the head and neck

Arteries of the arm

Veins of the arm

Veins of the arm (close-up)

Veins of the hand

Arteries of the leg

Veins of the leg

Anomalous superficial arteries in the arm

Packed red blood

SHORT NOTES ON MEDICAL HISTORY

PROJECT 2 TAKE A MEDICAL HISTORY

SHORT NOTES ON STERILITY AND ASEPSIS

PROJECT 3A A TECHNIQUE FOR PROPER HANDWASHING

PROJECT 3B CLEANING HANDS WITH AN ANTISEPTIC RUB

PROJECT 3C HOW TO DON (PUT ON) CLEAN GLOVES

PROJECT 3D HOW TO SAFELY REMOVE USED GLOVES

Venipuncture Course and Kit |

*PROJECT 3E HOW TO CHANGE INTO THEATER ATTIRE

*PROJECT 3F HOW TO SCRUB FOR A STERILE PROCEDURE

*PROJECT 3G HOW TO GOWN FOR A STERILE PROCEDURE

PROJECT 3H HOW TO DON STERILE GLOVES