 Skin punctures like fingersticks and heel sticks are commonly used to obtain small blood samples from patients. Heel sticks are preferred for infants less than 1 year old because the heel has more tissue and no nerves, bones, or tendons nearby.  Earlobe punctures are mainly used to measure bleeding time by introducing a small wound and timing how long it takes to stop bleeding. Normal bleeding time is 1-3 minutes.  When performing punctures, it is important to clean the site, use the proper lancet or needle size for the patient, and control blood flow to obtain an adequate sample for testing while minimizing patient discomfort.

1. TYPES OF
PUNCTURES
By Dr Fatehia Awny
Faculty of Health Sciences .
BAU 2015

2.  Skin puncture Earlobe puncture.
Types of punctures:
Finger puncture heel stick

3. 1. for patients in whom venous access is difficult,
2. when small quantities of blood are sufficient for
testing.
In newborns, heel sticks are the preferred
collection method for small volumes of
blood.
Why Perform a Skin Puncture?

4. CAPILLARY COLLECTIONS MAY BE
PREFERABLE OVER VENIPUNCTURE:
 Severely burned patients
 Obese patients
 Patients with thrombotic tendencies
 Elderly patients or others in whom superficial veins
are very fragile or inaccessible
 Patients performing self-testing
 Point-of-care testing
 Newborn testing
 Patients who have a paralyzing fear of needles
 Differences Between Skin Puncture Blood and
Venipuncture Blood!!!!!!!!!!!!!!!!!!!!!!!

6. FINGER PUNCTURE:
Preparation for finger stick
1. Place all collection materials
on top of disposable pad.
Open the lancet, alcohol
swabs, gauze, bandage, and
other items. Have all items
ready for blood collection.

7. FINGER PUNCTURE:
CHOOSE THE FINGER CAREFULLY
 Best locations for a finger
stick is the 3rd and 4th
fingers of the non-
dominant hand.
 Avoid the 2nd and 5th
fingers if possible.
 Perform the stick off to
side of the center of the
finger.
 NEVER use the tip or
center of the finger.

8. FINGER PUNCTURE:
Massage or Warm the site
• Avoid fingers that are cold,
cyanotic, swollen, scarred
or covered with a rash.
• Massage to warm the
finger and increase blood
flow by gently squeezing
from hand to fingertip 5-6
times.

9. FINGER PUNCTURE:
Clean and DRY the site
 Cleanse fingertip
with 70% isopropyl
alcohol
 Wipe dry with clean
gauze or allow to air
dry.
 Caution: Alcohol can
falsely elevate or lower
blood glucose results.

10. FINGER PUNCTURE:
Hold the finger in an upward
position and lance the
finger (across the
fingerprint) between the
side and the pad with the
proper size lancet
(adult/child). Press firmly
on the finger when making
the puncture. Doing so
will help you to obtain the
amount of blood you need.

11. FINGER PUNCTURE:
Finger Stick location
• Using a sterile
lancet, make a skin
puncture just off the
center of the finger
pad.
• Wipe away the first
drop of blood (which
tends to contain
excess tissue fluid).

12. 5. Apply slight pressure
to start blood flow.
Blot the first drop of
blood on a gauze pad
and discard in
appropriate biohazard
container.
FINGER PUNCTURE:

13. Keep the finger in a downward
position and gently massage it
(but do not “milk”) to maintain
blood flow.
FINGER PUNCTURE:

15. SUMMARY

16.  If child is <12 months of age, the lancet
 must have a depth of 2 mm or less, and a
 fingerstick MAY NOT be performed – must
 do a heel stick instead

17.  The heel is used for dermal punctures on infants
less than 1 year of age because it
 contains more tissue than the finger, and has not
yet become callused from walking.
 No nerves ,bones or tendons near by
WHY HEEL STICK?

18.  Hatched areas (arrows)
indicate safe areas for
puncture site.
heel stick:

19.  Warm site with soft cloth
moistened with warm water
(up to 41
o
C) for 3 – 5
minutes.
HEEL STICK:

20.  Cleanse site with
alcohol prep.
 Wipe DRY with sterile
gauze pad.
HEEL STICK:

21. Puncture heel.
Wipe away first
blood drop with
sterile gauze pad.
Allow another
LARGE blood drop
to form.
HEEL STICK:

22.  Mainly used for bleeding time .
 Principle
 The bleeding time is the time it takes for a small
standardized wound, introduced into the capillary bed
of the finger or earlobe,to stop bleeding. It is
dependent upon:
1- the elasticity of the skin and capillary vessels,
2-the efficiency of the tissue fluids
3-the mechanical and chemical action of the
thrombocytes (blood platelets).
EARLOBE PUNCTURE:

23.  Make a small wound 3 mm deep in the lateral aspect of
a fingertip or the lower portion of the ear lobe, using a
suitable lancet. The wound should be sufficiently deep
to give a free flow of blood without squeezing.
 Start the stop watch immediately after the puncture is
made. Though the stop watch is started a few seconds
after puncturing the skin, very little error results in the
bleeding time.3.
 At intervals of one-half minute gently blot the blood from
the wound with a piece of filter paper, being careful not
to touch the skin.4.

EARLOBE PUNCTURE:

24.  The interval of time between the puncture and the
cessation of bleeding is the bleeding time. The
blood should fail to appear on the filter paper in 1-3
minutes. All abnormal findings should be
rechecked.
NORMAL : 1-3 minutes
EARLOBE PUNCTURE:

25. Specimen Types
 Blood
– Proper collection vial
– Collection comprised of two bottles:
Aerobic
Anaerobic
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26. Blood culture bottles.
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29. SPECIMEN TYPES
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30. PHLEBOTOMY
 Phlebotomy procedure
 Important to all laboratory testing
 Sample’s quality determines accuracy of its final result
 Anticoagulant
 Mixed with blood to prevent coagulation
 Three anticoagulants are used in the hematology
laboratory
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31. PHLEBOTOMY
 Anticoagulant
 EDTA – prevents coagulation by chelating Ca2+
 Use for tests: CBC, Hct, Plt, Retic, peripheral blood smear
examination, flow cytometry
 Sodium citrate – prevents coagulation by binding Ca2+
 Used for coagulation studies
 Lithium heparin – prevents coagulation by interacting
with antithrombin
 Used for osmotic fragility: not appropriate for routine
hematology testing
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32. EQUIPMENT
 Sample collection tubes
 Evacuated sample collection tubes
 Sterile
 Color coded to indicate type of anticoagulant present or the
lack of anticoagulant
 Only small amounts of sample for analysis necessary
 Interior of a sample collection tube is a vacuum
 Capillary punctures
 Microcollection tubes
 Do not contain a vacuum
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33. CAPILLARY PUNCTURE
 Collection tubes
 Should be properly labeled with patient’s name, unique
ID number, date, and time of collection
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34. SPECIMEN COLLECTION
 Anticoagulant of choice
 Sodium citrate, 3.2%
 Ratio of anticoagulant : whole blood is 1:9
 > 55% hematocrit
 Smaller volume of plasma relative to citrate
 Excess free citrate binds calcium in the test procedure
 Falsely prolonged clotting times
 Adjust citrate concentration
 Citrate tubes are available that draw 4.5 mL, 2.7 mL, 1.8 mL
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35. SPECIMEN COLLECTION
 Anticoagulant to blood ratio
 1:9 ratio critical for valid results
 If under-filled – ↑ citrate, bind calcium in test procedure
 Falsely prolonged test results
 If overfilled – insufficient calcium bound
 Clotting can occur in tube
 Falsely prolonged results
 Accurate labeling of tube
 Include pre-or postinfusion, time of draw
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36. SPECIMEN COLLECTION
 Specimen draw time
 Check patient history of receiving blood products
 If testing done within the half-life of administered clotting factor
then test may measure transfused component as well as the
patient's component
 Fibrinolytic factors – diurnal variability
 Platelet studies – medication history
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37. SPECIMEN PROCESSING
 Plasma for coagulation testing
 Citrated whole blood is centrifuged
 Platelet-poor plasma (PPP)
 Platelet-rich plasma (PRP)
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38. SPECIMEN PROCESSING
 Platelet-poor plasma
 Citrated specimen centrifuged for 15 minutes at 2500xg
 < 10 x 109/L platelets
 Depending on coagulation instrumentation
 Leave plasma on top of packed cells or
 Remove plasma with plastic pipette – plastic tube with cap
 Leave small amount of plasma on top
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39. SPECIMEN PROCESSING
 Use platelet-poor plasma because
 Platelets contain PF4
 Neutralizes heparin
 Platelets contain phospholipids
 Affect LA testing and factor assay testing
 Platelets contain proteases
 Alter results for von Willebrand testing
 Any clot in specimen
 Specimen unacceptable
 After removing PPP, twirl applicator stick in packed cells to
detect clots
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40. SPECIMEN PROCESSING
 Platelet-poor plasma
 Separated plasma
 Stored at 18-24°C or 2-8°C for up to 4 hours
 If testing is delayed > 4 hours
 Stored at -20°C for up to 1 week
 Stored at -70°C for up to 6 months
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41. SPECIMEN PROCESSING
 Platelet-poor plasma
 Frozen specimens
 Thawed rapidly at 37°C
 Excessive heating can destroy Factor V and VIII
 Never store in self-defrost freezers
 Special testing may require special collection and
storage procedures
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