How to use the Butterfly needle
1. Identify the patient NOTE: A patient has the right to refuse a blood collection.
2. Assemble collection materials at the patient's bedside/chairside
a - Butterfly needle
b - Disposable vacutainer holder
c - Tourniquet
d - Alcohol prep pads/70% Isopropyl Alcohol
e - Appropriate vacutainer tubes (as per tests ordered)
f - Gauze/Cotton Balls
g - Tape
h - Lab requisition or Trip list
i - LIS labels or hospital labels (if available)
g - Sharps disposal container
3. Wash your hands with soap and water.
4. Put on a new pair of gloves for each new patient to avoid infection
5. Insert the needle into the vacuatiner holder
* Open up the Butterfly needle package and remove the set.
* NOTE: the sheathed end of the needle is exposed; grasp the set by the plastic
portion closest to the sheathed end (furthest away from the “butterfly clips”)
when handling and inserting into the vacutainer holder.
* Screw the sheathed end of the needle in a right twisting motion in the
6. Determine the order of draw for the blood collection tubes
7. Place the first tube to be drawn loosely in the vacutainer holder The first tube to be drawn is a light blue top (Sodium Citrate) or black top (Excyte tube)
* A discard tube must be drawn before filling the tube
for analysis. A minimum volume of 1ml is required.
* NOTE: the discard tube must be the same as the tube
collected for analysis (e.g. if collecting a light blue top
tube, use a light blue top tube for the discard tube)..
8. Ensure the patient is either in a sitting position or is lying down
* Never draw blood from a patient who is standing.
9. Have the patient extend their arm
* The patient should extend their arm in a manner which creates a straight line from the shoulder to the wrist.
* The patient’s hand should be facing upwards, exposing the inside ante cubital fossa region of the arm.
10. Tie the tourniquet
* The tourniquet should be applied approximately 7-10 centimeters away from the intended puncture site. NOTE: Stretch the tourniquet before applying to
prevent pinching the skin).
* Tie the tourniquet tight enough that the veins in the arm are distended, but not too tight that it causes patient discomfort or to cause purple/blue discoloration to the patient's arm.
11. Have the patient close their hand and make a fist
* NOTE: the patient should not “pump” their fist. Pumping of the fist can lead to
hemoconcentration and erroneous test results.
12. Choose the appropriate venipuncture site
* Using your fingertips feel for the vein.
* Feel for the median cubital or median cephalic veins located in the ante cubital
fossa region of the upper arm. (See Appendix A for diagram).
* NOTE: The order of choice for anatomical site for venipuncture is the:
c- Foot - only as a last resort. Inform patient’s nurse that a foot collection will be attempted.
* NOTE: If a patient is receiving a transfusion and a blood sample needs to be collected, delay the collection (if possible) 15-60 minutes post transfusion (the longer the better) and obtain the sample from an alternate site (i.e. opposite arm). If a sample must be collected during transfusion, obtain the sample from an alternate site. NOTE: for a more accurate hemoglobin, obtain the blood sample 1 hour post transfusion. A 15 minute post transfusion sample is adequate for a platelet count.What to Look for
* Locate a vein that is palpitable/has some bounce to it.
* Note the location of the vein.
* Note the direction in which the vein is running.
What Areas to Avoid
* Extensive scarring
* Superficial surface veins
* Underside of wrist
* IV Site.
* Side of body where mastectomy was performed. Refer to Blood
Collection Sites on Mastectomy Patients, RSCCSX00004.
13. Have the patient release their fist then release the tourniquet
* NOTE: if the collector can perform Steps 14-21 in less than 1 minute then they may leave the tourniquet on the patient and complete the collection.
* It is very important for sample integrity that the tourniquet is not left on a patient for more than 1 minute.
14. Clean the site with an alcohol prep pad (70% isopropyl alcohol)
NOTE: If collecting alcohol, methanol and/or ethanol, use iodine to clean the site. If the
patient is allergic, then use warm water and soap.
* Clean site in an outward concentric circular motion.
* This technique should be repeated until there is no visible dirt or debris on the
alcohol prep pad. This will ensure the site is clean.
* NOTE: do not blow on, waft air over or wipe off the alcohol. Allow the alcohol to air dry, approximately 30 seconds.
15. If tourniquet was removed, retie the tourniquet and have the patient make a fist
* NOTE: the patient should not “pump” their fist. Pumping of the fist can lead
to hemoconcentration and erroneous test results.
* The tourniquet can only remain on the patient for a maximum of 1 minute.
16. Grasp the wings of the butterfly set, pinching them together between the thumb
and index finger
* Grasp the “rough” side of the butterfly wings; this is to ensure a firm, non-slip
17. Remove the plastic guard on the butterfly end of the needle
* Hold the bevel side up.
18. Anchor the vein
* Grasp the patient’s arm and use your thumb to pull the skin taut just below the intended venipuncture site. This should stabilize the vein and prevent it from rolling during blood collection.
* Allow your fingers to rest on the patient’s forearm and the needle to rest just above the intended puncture site
19. Puncture the vein using a quick small thrust
* The needle should be at a 10-15 degree vertical angle to the patient’s skin.
* When viewed from above, the needle should be resting in the same direction as the vein.
* The penetration of skin and vein should occur in one smooth motion.
* Blood will enter the tubing when the vein has been successfully entered.
20. Push the first tube in the vacutainer holder onto the sheathed portion of the needle
* Once the vacutainer is securely on the needle, blood should begin to flow into the vacutainer.
* Ensure the tube remains at a level below the puncture site to prevent tube additives flowing back into the patient.
If… Then…The patient experiences any type of adverse reaction during the collection
* Stop the collection immediately.
21. When blood flow is established have the patient release their fist and remove the
If the first collection attempt fails
* Repeat steps 5-22.
* NOTE: A phlebotomist is allowed two attempts at venipuncture per patient per day. The lab is allowed four attempts at venipuncture per patient per day. After four consecutive unsuccessful attempts by the lab, that collection and any subsequent collections become a Doctor to Draw for a 24-hr period.
* NOTE: A blood culture collection is a procedure that requires two separate blood collections from the patient.The procedure is considered to be one attempt at collecting
a patient’s blood.
22. When the tube is finished filling, pull the tube off the needle
* When the tube is full, the shut off valve will close to prevent leakage or backflow.
You will observe that the tube is no longer filling.
23. Continue to collect the remainder of the tubes in the correct order of draw.
* Gently mix the tubes 8-10 times while waiting for the next tube to fill.
* NOTE: Only mix coagulation tests tubes 3-4 times. Over mixing of coagulation tubes may trigger the blood clotting cascade-pathway.
* It is important to ensure proper mixing of tubes so that the tube additive is adequately blended with the blood.
24. Once the last tube has been filled and removed from the vacutainer, retract needle
* Position a few pieces of gauze just above the puncture site.
* Activate the safety lock by: 1) using one hand and pulling back on the “tailend” of the tubing until the needle has retracted into a protective plastic cover or 2) pressing the push button on the barrel of the butterfly to retract the needle.
25. Apply pressure to the puncture site
* If your patient is able, they may apply pressure themselves to the puncture site. If they are unable to do so, you must apply pressure until the bleeding has stopped.
26. Dispose of the needle into a sharps container
* Discard the needle and holder together into a sharps container.
* Caution must be taken when disposing of butterfly collection sets as the needle is attached to the tubing and may dangle or hang loose and be difficult to work with when disposing.
* Some patient care units have sharps disposal containers that are wall mounted; these may be used to discard the needle.
27. Label the tubes
* Always label a blood collection at the patient’s bedside/chairside.
28. Complete the requisition/trip list/ log sheet
29. Check the patient to ensure bleeding has stopped
* Apply a bandage or tape and clean gauze to the patient ONLY if the patient is >2 years of age.
* NOTE: Bandages or gauze are not to be used on patients <2 years of age as they pose a choking hazard to the infant. For patients < 2 years of age, using gauze apply pressure until the bleeding stops.
30. Inform the patient the procedure is now complete
*The patient may remove the bandage or tape/gauze after 15 minutes.
* If the patient is in OPL instruct them not to carry anything heavy using that arm for several hours to avoid bruising.
31. Remove and dispose of your gloves
* NOTE: In certain situations, such as patients on psychiatric wards or in secure holding units, all supplies must be removed from the patient’s room (e.g. needle, gloves, gauze, tape, etc).
32. Wash your hands * Hands must be washed with soap and water.
NOTE: In certain situations, such as patients on psychiatric wards or in secure holding units, all supplies must be removed from the patient’s room (e.g. needle, gloves, gauze, tape, etc).