Principles of Medical Laboratory Science Practice 2 (LEC) 1

Chapter 1: Introduction to Phlebotomy phlebotomist is dispatched to the laboratory to either

nursing units or outpatient areas
History in Phlebotomy o The phlebotomist who works the evening and night shift
o Phlebotomy is the process of collecting blood and is waits until a test us ordered to be collected. This single-
defined in Webster’s dictionary as “the act or practice of skilled role for phlebotomist often results in times of no
bloodletting as a therapeutic measure” work and other times of more work. This time of waiting
o It was once thought that the practice would rid the body for work to do is called waiting-to-serve-time
of diseases and provide a cure for almost all ailments o The decentralized phlebotomy approach to phlebotomy is
o In the 12th century, bloodletting was practiced by barbers, how 15% of the hospitals work. With this approach, more
whose red-and-white barber poles became the symbol of people are collecting blood samples during the busy times
their trade o The nurse needs to learn how to collect blood samples and
o Historically, phlebotomy used two (2) basic methods: the phlebotomist needs to learn some of nursing duties.
venesection and cupping This is commonly called patient-focused care
 Venesection was the most common. A sharp lancet- o Phlebotomist collects blood samples, handles patient care,
type instrument pierced the veins and made them and does point of care laboratory test such as blood
bleed. Lancing the veins was thought to eliminate the sugar/glucose in the patient’s room. This multi-skilled
“bad” blood and remove the disease. It was often training for the phlebotomist makes him/her versatile and
used to reduce fever or to produce a faint an asset to the organization. This position is known as
 Cupping, a heated glass cup was placed on a person’s patient care technician
back. As the cup cooled, it created a suction that o Studies have shown that with decentralized phlebotomy,
pulled blood to the capillaries under the cup. Then a there is an increase in hemolyzed samples, patient
spring-loaded box containing multiple blades cut the identification errors, and contaminated blood cultures but
area to produce massive scarring it has been effective in many health care facilities
o In December 1799, George Washington had a severe sore o Hybrid phlebotomy is a blend of centralized and
throat and the cure for the infection was heavy bleeding. decentralized phlebotomy
He bled more than 9pints of blood in less than 24 hours
Areas of the Hospital and Health Care Setting
and died on December 14, 1799
o In the middle of 19th century, bloodletting was NO longer o The phlebotomist is the “laboratory representative”
considered as the cure for all illness. Blood began to be o Phlebotomist often encounters staff from
examined for diagnostic purposes. Urine and feces had Electrocardiography department which does
been examined since medieval times  Electrocardiograms (EKG) recording of impulses
o A more modern method was to use leeches. A leech is of the heart
placed on the end of the finger to remove the excess  Electroencephalograms (EEG) record the
blood and relieve the symptoms electrical activity of the brain
o Bleeding of individuals to reduce the patient’s amount of o Pharmacy department of the hospital is much different
blood does occur today to treat diseases called from the corner drug store
polycythemia and hereditary hemochromatosis. It o Physical therapy department works with patients who,
involves withdrawing 500 mL of blood through therapeutic due to disease or injury, are no longer able to function to
phlebotomy. It is primarily done to find the cure and not as their full physical capacity
the cure itself. o Occupational therapy department where patients work to
o Blood collection has changed from being therapeutic to overcome their physical handicaps so they can be
diagnostic productive again
o Speech therapy department is where patients who have
Phlebotomy’s Role in Health Care difficulty speaking or who have lost the ability to speak
o The phlebotomist’s primary role is to collect blood for because of a stroke or disease are retaught how to speak
accurate and reliable rest results as quick as possible with o Radiology is an area of the hospital that has changed
the least discomfort rapidly.
o The phlebotomist is usually cross-trained in venipuncture,  Radiologist used to just x-ray lungs or broken
capillary collection, patient care, receptionist duties, bones but the field has expanded to include
sample processing, and computer work cardiac catheterization, computed tomography
o Phlebotomist represent the laboratory, and the health (CT) scans, magnetic resonance imaging (MRI),
care center, direct patient contact, perform tasks that are and ultrasound
critical to patient’s diagnosis o The largest department the phlebotomist works with is the
o The traditional role of phlebotomist in a hospital is only department of nursing
one job: to collect blood samples. 85% of hospitals follow o Clinical laboratory may be in one location or may be
this centralized phlebotomy approach where the decentralized in a variety of locations.

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 2

anticoagulant therapy, patients with bleeding or

This includes: clotting disorders, as well as pre-surgical patients
1. the main laboratory o urinalysis section staffs performs qualitative and
2. ambulatory care laboratory (outpatient laboratory) quantitative chemical and microscopic examinations of
3. stat laboratory urine to detect urinary tract infections, diabetes, and liver
4. surgery laboratory or kidney disease
o Chemistry section works with the fluid portion of the
Ancillary Hospital Areas (and their purpose) blood (serum or plasma) or other body fluids
1. Administration— Keeps the hospital in compliance
2. Electrocardiography (EKG)— Monitors patients with Laboratory Sections (and their purpose)
cardiovascular disease 1. Administrative Office—Responds to telephone calls, handles
3. Electroencephalography (EEG)— Diagnosis of specimen collection requests, and handles some specimens
neurophysiological disorders 2. Phlebotomy (Sample Collection)—Collects samples from
4. Environmental Services— Maintains a clean facility patients and processes samples for testing or transport
5. Food Services— Provides diets to patients 3. Hematology—Studies the blood in normal and diseased states.
6. Gastrointestinal (GI) Laboratory— Diagnoses gastrointestinal Usually limited to the study of cellular components and not the
disorders chemistry of blood
7. Laboratory— Provides testing of patients samples Example of tests: Complete Blood-cell Count (CBC),
8. Medical Records—Maintains patient records Hemoglobin, Hematocrit, Platelet count, Sedimentation rate,
9. Nursing— Provides direct patient care body fluid cell counts
10. Occupational Therapy— Provides therapy to help maintain 4. Coagulation—Study of blood clotting mechanism as an aid in
living skills diagnosis or monitoring patient therapy
11. Pharmacy— Dispenses drugs and advises on drug usage Example of tests: Prothrombin Time (PT, Activated partial
12. Physical Therapy—Provides therapy to restore mobility Thromboplastin Time (aPTT), D-dimer factor VII, Fibrinogen
13. Radiology— Uses imaging for diagnosis and treatment assay, Heparin level, von Willebrand factor (ristocetin)
14. Respiratory Therapy— Provides therapy to evaluate the lungs
5. Urinalysis— study of urine to aid in patient diagnosis to follow
15. Speech Therapy— Provides therapy to restore speech
the course of disease or the body’s metabolism

Areas of Nursing and Type of Care Example of tests: Urinalysis, reducing substance, urine pH,
urine glucose
1. Coronary Care Unit (CCU)— increased care of the patient due
to a heart condition 6. Chemistry— Performs biochemical analysis of blood and body
2. Emergency Department— Emergency treatment of patients fluids to determine the status of a patient
3. Geriatric— Elderly patients Example of tests: Comprehensive metabolic panel, iron studies,
4. Home Health Care— Follow-up care of a patient at home renal panel, carcinoembryonic antigen (CEA), glucose, alanine
5. Intensive Care Unit (ICU)— Increased care due to the critical aminotransferase (ALT), aspartate aminotransferase (AST),
needs of the patient cholesterol
6. Neonatal— Newborn care 7. Microbiology— Cultures samples to determine if pathogenic
7. Nephrology— Patients on dialysis organisms are present in a sample and determines the
8. Obstetrics— Patients in labor of childbirth organisms’ sensitivity to antibiotics (culture and sensitivity)
9. Oncology— Patients with cancer  Microbiology studies organisms that are so small they
10. Orthopedic— Patients with broken bones can only be seen only with the aid of microscope. Once
11. Pediatrics— Infants and children the organism that is causing the problem is determined,
12. Recovery— Recovery treatment of patients a test called a sensitivity is run to determine what
o Point of Care Testing – testing done at the patient’s antibiotic would be best to eliminate the problem
bedside organism
o The hematology staff studies blood cells and performs Example of tests: Blood cultures, throat cultures, anaerobic
qualitative and quantitative analyses along with cultures, urine cultures, parasite identification, stool culture,
microscopic examinations mycobacterial (tuberculosis) culture, virus cultures, fungal
o Complete Blood-cell Count (CBC) – a routine test, cultures, genital cultures, mycoplasma cultures, antibiotic
providing the physician with a large amount of valuable susceptibility testing
information about a patient’s state of health 8. Immunology— Studies antigens and antibodies to determine
o Coagulation/hemostasis is usually in the same area as immunity to disease or presence of disease
hematology  Immunology section studies antigen-antibody reactions.
 This is the study of the clotting of blood. Staff Antigens are substances seen as being “foreign” in the
from this section monitors patients on body, and antibodies are proteins made by the body to
combat specific antigens

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 3

Example of tests: Human immunodeficiency virus (HIV) testing, Correct use of all equipment
rubella, syphilis, rapid plasma reagin (RPR), hepatitis testing Sample preparation or centrifugation
Proper preparation of sample aliquots
9. Immunohematology (Blood Bank)— determines compatibility
Maintaining the sample integrity until the examination
of blood and blood products that are to be administered to
(analytical) process can begin
patients
 Blood bank section, sometimes called 2. Examination is a set of operations to determine the value or
immunohematology, studies antigens and antibodies as characteristics of a property.
they relate to blood cells. This section performs ABO RH This includes the following:
blood-typing, type and screen testing, cross- Sample testing
matching/compatibility testing, and screening for Maintaining testing equipment and reagents
antibodies
3. Post-examination is the process whereby the results of the
Example of tests: Compatibility testing, antibody screens or
testing are communicated to the physician.
ABO, Rh determination These consist of the following:
10. Cytogenetics— studies of deficiencies related to genetic Reporting of results
diseases Ensuring accuracy and reliability of delivery results
 Cytogenetics studies deficiencies that are related to Follow-up to repeat testing or address physician concerns
genetic diseases Storage of samples after the examination
Example of tests: Chromosome analysis, prenatal chromosome
screening Laboratories in the 21st Century
o Health maintenance organization (HMOs) were formed to
11. Molecular Diagnostics— Using polymerase chain reaction (PCR)
provide health coverage for both hospital and physician
technologies to study the presence of various diseases or services
infections o The Affordable Healthcare Act has been enacted to help
 Molecular diagnostics detects levels of deoxyribonucleic those that could not afford insurance. This requires all
acid (DNA) and ribonucleic acid (RNA), proteins, or people to have health insurance
metabolites to determine the severity or presence of o Two methods are being used to treat patients faster with
less of a wait on the test results: point of care testing ,
various diseases or infections. Most laboratories use
patient service centers (PSCs)
polymerase chain reaction (PCR) technology for testing
Example of tests: Methicillin-resistant Staphylococcus aureus Laboratory Staff
(MRSA) infections, HIV and other infectious diseases 1. Pathologist— Physician who reads and interprets the results of
laboratory tests or examines tissues under a microscope to
o Pathology – the area of cytology and histology that diagnosis and monitor disease.
examines tissues and cell smears for evidence of cancer,  Pathologists are experts in diagnosing such diseases as
infection, or other abnormalities cancer, diabetes, acquired immunodeficiency syndrome
o Short Turn-around Time (STAT) Laboratory— handles (AIDS), hepatitis, and thyroid conditions
STAT (emergency) requests.  The American Board of Pathology requires five (5) years of
o Ambulatory care laboratory (outpatient laboratory)-- training following graduation from medical school to be
provides rapid turnaround of results on frequently ordered eligible to take examinations leading to board certification
tests for outpatients as clinical/anatomic pathologist
o Three phases of sample testing:  Pathologist is the person in the laboratory with the most
1. Pre-examination education. Pathologist is a physician who has completed
2. Examination additional schooling and internship to specialize in
3. Post-examination. pathology
2. Medical Laboratory Scientist (MLS) or Clinical Laboratory
These were previously referred to as pre-analytical, analytical, Scientist (CLS) — Holds a minimum of baccalaureate degree
and post-analytical. and is responsible for performing a full range of laboratory
tests, confirming the accuracy of test results, and reporting
1. Pre-examination all steps that it takes to collect the sample and laboratory findings to the pathologist and other physicians.
get it to the point in which the testing of the sample can occur.  Medical technologist work in five major areas in the
 first step of patient identification laboratory: blood-banking, chemistry, hematology,
 the most important step in the process
immunology, and microbiology
 Phlebotomist is mainly involved this phase
This include the following:  A medical laboratory scientist (technologist) has a
bachelor’s degree and a medical technology or clinical
Clinician’s request
Patient identification and information laboratory scientist certification
Correct sample collection 3. Medical Laboratory Technician (MLT)—under the supervision
Correct primary sample identification of the medical technologist, performs general tests. Medical

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 4

laboratory technicians have special training in addition to a high o Organization defines the relationship among tasks, individuals
school diploma or an associate degree and workplace. The basis for this relationship is authority,
 A technician has 2-year associate degree in medical responsibility, and accountability.
technology and a certification o Authority is attached to the position
4. Phlebotomy Technician (PBT) — Collects blood samples to be o Responsibility is the tasks or duties assigned to the
used in many laboratory tests to detect and monitor treatment. position within the organization
Phlebotomists have training In addition to a high school o Accountability is the obligation to someone higher on the
diploma organizational chart
 The phlebotomist must have a special demeanor to o Organizational chart is a multilevel vertical hierarchy that
perform the job signifies the relationship of one position to another.
Sometimes referred to as the chain of command.
 The phlebotomist needs a high school education and
specialized training in phlebotomy; minimum of 40 hours
Laboratory organizational chart
of classroom training and 100 hours of clinical or practical
training is the standard set by the American Society for
Clinical Pathology
 Even if phlebotomists are certified by another
organization, they must meet the Californian standard.

There are now three separate categories of California

phlebotomy techniques requiring three separate
qualification standards:
1. Limited Phlebotomy Technician – only able to
perform skin punctures. Must perform 25 skin The Patient Care Partnership
punctures (fingersticks) before meeting o The American Hospital Association drafted a Patient’s Bill
qualifications for this standard of Rights in 1973, revised it in October 1992, and replaced
2. Phlebotomy Technician I – performs skin it with Patient Care Partnership in 2003
puncture and venipuncture. Must perform 50
venipunctures and 10 skin punctures Patient Rights
(fingersticks) and pass an approved national o Patient’s rights can be exercised on the patient’s behalf by
certifying organization’s exam a designated surrogate or proxy decision maker if the
3. Phlebotomy Technician II – performs skin patient lacks decision-making capacity, legally
puncture, venipuncture and arterial puncture. incompetent, or minor
Must perform 20 arterial punctures and meet o Following is a list of patient rights:
the requirements of the Certified Phlebotomy 1. The patient has the right to considerate and
Technician I respectful care.
2. The patient has the right to and is encouraged to
5. Cytotechnologist (CT) — Examines cells under the microscope
obtain from physicians and other direct care givers
to detect signs of cancer in the earliest stages, when a cure is
relevant, current, and understandable information
most likely.
concerning diagnosis, treatment, and prognosis.
 Cytotechnologists must hold baccalaureate degrees and
3. The patient has the right to make decisions about the
have special training to search out the smallest
plan of care prior to and during the course of
abnormalities in color, shape, or size of cells
treatment and to refuse a recommended treatment
6. Histotechnologist (HTL) — Prepares body tissue samples for
or plan of care to extent permitted by law and
microscopic examination by the pathologist using sophisticated
hospital policy and to be informed of the medical
techniques such as immunohistochemistry.
consequences of this action.
 Histotechnologist must hold baccalaureate degrees and
4. The patient has the right to have an advance directive
have special training to freeze, cut, mount, and stain the
(such as a living will, health care proxy, or durable
tissues.
power of attorney for health care) concerning
 Often while the patient is still in surgery, thus playing a
treatment or designating surrogate decision maker
major role in the diagnosis of malignancy
with the expectation that the hospital will honor the
 Histologic Technician prepares the tissue samples for
intent of that directive to the extent permitted by law
microscopic examination in the histology section. A 2-year
and hospital policy.
associate degree program
5. The patient has the right to every consideration of
 The agency that is accepted worldwide in laboratories for all privacy.
certification and registries is American Society for Clinical
Pathology (ASCP)

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 5

6. The patient has the right to expect that all 11. Continuity of care. The samples should be obtained
communications and records pertaining to his or her and processed expeditiously to facilitate the care of
care will be treated as confidential by the hospital, the patient.
except in cases such as suspected abuse and public 12. The patient has the right to examine and receive an
health hazards when reporting is permitted or explanation of his or her bill.
required by law.
7. The patient has the right to review the records o Part of a caring philosophy is not only to care for physical
pertaining to his or her medical care and to have the and spiritual needs of those in our care but also to
information explained or interpreted as necessary, recognize their dignity.
except when restricted by law.
8. The patient has the right to expect that, within its Professional Attitude
capacity and polices, a hospital will make reasonable o Everyone must follow a professional code of conduct in
response to request of a patient for appropriate and the treatment of patients.
medically indicated care and services. o It is not the events of the day that shape the phlebotomist,
9. The patient has the right to ask and be informed of it is how the phlebotomist deals with those events.
the existence of business relationships among
hospital, educational institutions, other health care Professional Grooming
providers, or payors that may influence the patient’s o The dress code will have restrictions such as the following:
treatment and care. 1. No visible tattoos
10. The patient has the right to consent to or decline to 2. No body piercing other than a maximum of two in the
participate in proposed research studies or human ears
experimentation affecting care and treatment or 3. No fingernails longer than ¼ inch
requiring direct patient involvement and to have 4. No blue jeans or casual attire
those studies fully explained prior to consent. 5. No open-toed shoes
11. The patient has the right to expect reasonable 6. No t-shirts or sweatshirts
continuity of care when appropriate and to be
informed by physicians and other care givers of Advance Directives
available and realistic patient care options when o All states now follow the Patient Self-Determination Act of
hospital care is no longer appropriate. 1990. This act requires all hospitals participating in
12. The patient has the right to be informed of hospital Medicare or Medicaid programs to ask all adult inpatients
policies and practices that relate to patient care, if they have advance derivatives.
treatment, and responsibilities. The patient has the o Formal advance directives are documents written before
right to be informed of the hospital’s charges for incapacitating illness that give instructions about persons’
services and available payment methods health care if, in the future, they cannot speak for
themselves.
o Most of this rights and responsibilities can be directly o A health care advance directive contains two parts.
applied to duties as a phlebotomist: o The first part names an agent who can make decisions for
1. Patient has the right to considerate and respectful a person in the event he or she is unable.
care. o The second part lists predetermined directions on a
2. The physician is the patient’s primary source person’s health care that will give some indication of his or
concerning diagnosis and treatment. her wishes to the agent
3. Informed consent. o Several organizations are helpful in developing an advance
4. Right to refuse treatment. directive, including the following:
5. Consideration of privacy. 1. American Association of Retired Persons (AARP)
6. Confidentiality. 2. ABA Commission on Legal Problems of the Elderly
7. The patient has the right to know about his or her 3. American Medical Association
medical care and can look at his or her records. o In the absence of any advance directive by the patient, the
8. The patient has the right to expect a reasonable decision is left to the patient’s family, physician, and
response to requests for services hospital, and sometimes a court of law.
9. The patient has the right to know of professional o If the hospital is a religious-based institution, then its
relationships and the names of those who are religious affiliation also has an influence on the decisions
rendering care
10. Experimentation. Patients who are involved in a Standards used in the Laboratory
medical experiment, be it a new drug or treatment, o The types of patient the laboratory serves determine
must first be informed of the proposed course of whether that laboratory is governed by a variety of rules
action. and regulation

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 6

Regulatory Agencies Clinical Laboratory Standards Institute

The Joint Commission o Formerly NCCLS
o Sets standards of care to ensure quality and reliability of o Establishes laboratory guidelines and procedures
health care Surveys are accepted by Medicare o Consists of representatives of the laboratory and
(reimbursement) laboratory industry
o Laboratory tests must meet The Joint Commission’s o Maintains uniformity of laboratory procedures on a
accuracy standards national basis
o Laboratories must meet procedure standards o CLSI is a nonprofit educational organization which issues
o A large body of regulations govern hospital laboratories, publications that describe laboratory procedures, bench
and various agencies issue these regulation and standards. and reference methods, and evaluation protocols in all
o The Joint Commission sends a team of inspectors to the specialties of laboratory
hospital. The inspector focuses on the organization’s
performance and processes that strive for improving Clinical Laboratory Improvement Act of 1988
patient outcomes o Enforced by a committee of inspectors
o Main goal is to protect patients from receiving inaccurate
The inspectors base their inspection on the following: results
1. Tracing the care delivered to the patients o This act mandated comprehensive regulation of
2. Verbal and written information provided to the Joint laboratories involved in interstate commerce
Commission o The laboratories are monitored by the Health Care
3. On-site observations and interviews by the inspectors Financing Administration (HCFA) of the U.S. Department of
4. Documents provided by the health care organization Health and Human Services (HHS)
They have designated four categories of testing:
o The Joint Commission Web site offers the patient the 1. Waived test – simple, unvarying, and require a
opportunity to submit a complaint about any health care minimum judgment with interpretation
organization accredited by the Joint Commission 2. Physician-performed microscopy tests – test which
o The most serious of events is called sentinel event. It the physician personally looks under the microscope
defined as an unexpected occurrence involving death or and makes the judgment and interpretation
serious physical or psychological injury or risk. Serious 3. Moderate-complexity test – test that require more
injury specifically includes loss of limb or function complex testing equipment and moderate amount of
judgment and interpretation.
The investigation and response would include:  Moderate-complexity laboratories must have
1. Investigation into the root cause of the event employees who can serve as a director, technical
2. Corrective action and developing a process to prevent consultant, clinical consultant, and testing
the recurrence personnel
3. Monitoring the new process to determine 4. High-complexity test – test that require most
effectiveness complex testing equipment and a large amount of
judgment and interpretation.
College of American Pathologist  Highly complex laboratory has an additional
o Proficiency samples are sent to laboratories by CAP for category of general supervisor
accuracy checks
o Inspects lab procedures and laboratory results Category Education Experience
o The Joint Commission accepts CAP inspections 1. Director M.D./D.O., pathologist 1 year of experience
M.D./D.O. 1 year of experience
o College of American Pathologist (CAP) inspects the
Ph.D. 1 year of experience
laboratory and requires it to meet additional standards of
M.S. 2 years’ of experience
performance by sending proficiency test samples to the or training
laboratory throughout the year B.S. 4 years’ of experience
o If the samples continue to fall outside the range, it or training
indicates to the laboratory that the procedure needs to be 2. Technical Consultant M.D./D.O., pathologist 1 year of experience
changed in some way to change deficiency M.D./D.O.
o CAP also sends a team of inspectors to the laboratory to Ph.D. or M.S. 1 year of experience
or training
inspect its performance and record keeping
B.S. 2 years’ of experience
or training
State Board of Health 3. Clinical Consultant M.D./D.O., pathologist 1 year of experience
o This type of inspection can range from a detailed M.D./D.O.
inspection to just a walk-through of the laboratory Ph.D. Board certified
M.D./D.O. State licensed

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 7

4. Testing personnel M.D./D.O. Ph.D., M.S. o Philosophies used to improve both the quality and the
B.S. In appropriate science profitability of the laboratory are Six Sigma and Lean
Associate degree In appropriate science o Six Sigma works to identify and improve processes using
High school diploma Appropriate training data and customer requirements to reduce errors
5. General Supervisor Director M.D./D.O.
o Six Sigma concept describes different levels to achieve
Ph.D., M.S. or B.S. 1 year of experience
Associate degree 2 years’ of experience depending on the error rate
o Lean philosophy helps develop work-flow programs to
streamline laboratory operations
Occupational Safety and Health Administration (OSHA)
o The Occupational Safety and Health Act of 1970 regulates
the safety and protection of the associate doing testing. Sigma Level % Accuracy Defects per Million
6 99.9997 3.4
National Accrediting Agency for Clinical Laboratory Sciences 5 99.98 233
o Regulations enforced by a committee of inspectors 4 99.4 6,210
o Establishes and enforces safety standards for employees 3 93.3 66,807
2 96.1 308,537
o Can issue fines if there are violations
o NAACLS is an international agency for the accreditation
and approval of educational programs for clinical
Quality Assurance and Quality Control
laboratories and other health care professions
o Quality assurance of how well the phlebotomist performs
is checked early in the training of phlebotomist by
Quality Assurance in Phlebotomy
completion of competency checklist
o The most common error is administrative (clerical), where These processes meet the following quality assurance standards
the phlebotomist spells the name wrong, mislabels a of The Joint Commission
sample, or draws the incorrect sample tube
1. Assigning responsibility for the phlebotomist
o To monitor compliance with these standards, rules, and
2. Delineating the scope of care the phlebotomist can
regulations, several programs within the health care
give
facility are used
3. Identifying what aspect of care the phlebotomist can
o One such program is a quality assurance program. This
perform
strives to guarantee that all areas of the healthcare facility
4. Noting corrective action needed to help the
are providing the highest quality and most appropriate
phlebotomist meet the standards of care
patient care
5. Assessing the effectiveness of these actions
The Joint Commission has outlined 10 steps to a quality 6. Documenting that relevant information for the
assurance plan: procedure was communicated to the phlebotomist
1. Assign responsibility
2. Delineate scope of care o Quality control of the phlebotomist and the task of
3. Identify important aspects of care drawing blood are monitored by gathering data from
4. Identify indicators related to these aspects of care several sources
5. Establish thresholds of evaluation o Quality control would be to determine if the phlebotomist
6. Gather and organize data is meeting this minimum level of threshold
7. Evaluate care when thresholds are reached
There should be a room for comments on these surveys and also
8. Take corrective action
a checklist for patients to mark from excellent to poor
9. Assess the effectiveness of the ac icns; document
categories such as:
improvement
1. Facility cleanliness
10. Communicate relevant information
2. Professionalism and appearance of staff
3. Satisfaction with wait time
o To supplement this plan, the health care facility must also
4. Time spent waiting to be served
have a Total Quality Management (TQM) and Continuous
5. Overall experience
Quality Improvement (CQI) plan in place
6. Skill of the phlebotomist
o TQM plan is a management plan that ensures that the
quality expected can be met
o Calling patients the day after they visited a draw site will
o As the inappropriate sample moves through the process of
give valuable immediate feedback
examination and post-examination, more labor and
o Secret shopper is a person hired by the laboratory to come
materials are involved. This are called failure cost. The
to a draw site with an order from a physician. The secret
highest failure cost is when failure causes harm to patient

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 8

shopper will then report back to the supervisor on how b.Indirect contact – transfer of infective material
well the phlebotomist met the standards of performance via an object. (Fomites – inanimate objects such
as bed linens)
Whatever the method is used to monitor performance, quality c. Droplet – droplets that travel 1 meter or less
control consist of multiple facets, including: from the infected individual
d. Vehicle – transfer of infective material through
1. Monitoring the performance of the procedure contaminated items, such as food
2. Determining how well that that performance meets e. Airborne – droplets that transfer on air
the standard of care currents, such as tuberculosis.
3. Documenting what did not meet the standard of the f. Vector – transmission by insects, such as
procedure malaria transmitted by mosquitoes.
4. Portal of Entry
4. Instituting corrective action to correct the deficits
a. Mucous membrane
o The review and monitoring of the outcomes of these b. Gastrointestinal tract
processes in order to continually improve them is quality c. Respiratory tract
improvement d. Broken skin
o The information that was discovered through surveys, 5. Susceptible Host
secret shoppers, and calling patients is used to strive a. Immunosuppressed Patient
b. Diabetic Patient
toward continuous improvement in performance.
c. Burn Patient

CHAPTER 2: Safety in Phlebotomy

UNIVERSAL PRECAUTIONS, BODY SUBSTANCE ISOLATION AND
STANDARD PRECAUTIONS
Infection – invasion and multiplication of microorganisms
to the body of the host that will result to signs and symptoms as
Universal Precautions – developed in 1985 by the Centers for
immunological response.
Disease Control and Prevention.
Infection Control – prevent the spread of infection
- Any patient has the potential to be infected with these
Nosocomial Infection – also known as health-care associated or
blood-borne pathogens
hospital-acquired infection.
- Assumed that all blood and most body fluids were
- Infection that develops in a patient 48 hours or more after
potentially infections
admission to a hospital or health facility.
- Other fluids, such as stool, urine, vomitus, and oral
Community-acquired infection – if the infection occurs before 48
secretions, are NOT included in universal precautions,
hours after admission.
UNLESS they contain visible blood.

Local infection – an infection restricted to one area of the body. Body Fluids and Their Sources
Systemic infection – affects the entire body. Fluid Source
Amniotic Fluid surrounding an unborn child
Communicable diseases – can be spread from person to person. Pleural Fluid from the lungs
Noncommunicable diseases – cannot be spread from person to Peritoneal Fluid from the abdominal area
person. Edematous Fluid that has built up in the body tissue
Pericardial Fluid surrounding the heart
KEY TERMS: Seminal Ejaculated fluid from the penis
o Pathogenicity – ability of the microorganism to cause disease Synovial Fluid from the joints
o Virulence – disease severity
Cerebrospinal Fluid from the spinal column
o Infective dose – level or number of microorganisms needed to
initiate and infection
Body Substance Isolation (BSI) – evolved from universal precautions
o Viability – ability to survive outside the host
- The key change was the requirement that gloves be worn
when a health care provider is in contact with any body
CHAIN OF INFECTION
substance.
People Standard Precautions – developed in 1996 by CDC as revised
1. Source of Infection universal precautions
a. Human - Combined principles of universal precautions with
Equipment
b. Animal techniques from BSI
c. Non-animal - Maintain then personal protective equipment and barrier
Autogenous infection – infection from the controls must be worn, WHETHER OR NOT blood is visible.
source’s own flora - The goal is to reduce the risk of transmission of
2. Portal of Exit microorganisms from both recognized and unrecognized
a. Excretions sources of infection.
b. Secretions
c. Droplets Five Main Points of Standard Precautions:
3. Means of Transmission 1. Wash hands when changing gloves and between
a. Direct contact – physical transfer of infective patients
material from the source to susceptible host

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 9

2. Wear gloves when likely to touch body substances, Personal Protective Equipment– used to protect the phlebotomist
mucous membranes, or non-intact skin and during all from infectious material contacting street clothes, skin, mucous
blood drawing. membranes.
3. Wear protective cover when clothing is likely to be 1. Gloves – prevent health care associates from transmitting
soiled their own microflora to the patient
- Prevent the transmission of microorganisms
4. Wear a mask and eye protection in addition to a
from one patient to another
protective body cover when likely to be splashed with
- Prevent the associate from becoming infected
body substances.
with what is infecting the patient.
5. Place intact needle/syringe and sharps in designated 2. Masks – used to prevent the transmission of infectious
sharps containers. Do not bend, break, or cut needles. agents through the air
3. Gowns – necessary when soiling of clothes is possible
REDUCING EXPOSURE RISK while taking care of patients. It should be fluid resistant to
Six major tactics to reduce the risk of exposure to blood-borne prevent any blood or body fluids from soaking through and
pathogens: getting on the health care associate.
1. Engineering controls 4. Goggles/Face Shields – needed anytime there is the
2. Work practices potential for splattering of blood or body fluids.
3. Housekeeping
4. Hepatitis B virus (HBV) vaccination ISOLATION TECHNIQUES
5. Private rooms Isolating a patient occurs to help the health care team break
6. Personal protective equipment the chain of infection
- Limits the amount of contact time a patient has to spread
A. Engineering Controls – physical and mechanical devices that an infection
are available to the health care associate to reduce or A description of isolating patients to prevent the spread
eliminate the potential to transfer infectious diseases. ofdisease was first published in 1887 – infectious patients were
Examples: separated from noninfectious patients.
o Self-sheathing needles 1910 – cubical system of isolation was introduced whereby
o Autoclaves – steam-sterilize contaminated materials patients are separated, and hospital personnel were instructed to
o Puncture-proof sharp containers – used for contaminated wash hands and disinfect items contaminated by the patients.
harp objects such as needles and breakable contaminated 1960 – patients with infectious disease were placed in single-
objects such as glass blood collection tubes. (to be filled patient isolation rooms or in regular single rooms
only to 80% of capacity. 1970 – CDC recommended that hospital used one of the seven
B. Work Practice Controls – practices that are incorporated into isolation categories, called category-specific isolation.
all health care associates’ work habits to prevent the spread of
infection. Category-Specific Isolation – required knowing that a patient
- Antiseptic technique – used on skin surfaces because the needed to be isolated.
solutions are safe to human skin.
Types of Category Specific Isolation
Types of Antiseptics Strict Isolation
70 percent isopropyl alcohol
A patient with a contagious diseases such as chickenpox,
Tincture of iodine or povidone-iodine Used for skin preparation diphtheria, or pneumonia.
for blood cultures or arterial
punctures Contact Isolation
2 percent chlorhexidine gluconate Used for skin preparation A disease that is transmitted by direct or contact with the patient,
and 70 percent alcohol for blood cultures such as scabies, caused by infestation with the mite
Benzalkonium chloride An alternate skin cleanser Sarcoptesscabiei
Zephrin chloride Respiratory Isolation
Hydrogen peroxide Alternate for persons who A patient with a disease transmitter through the air, such as
are allergic to alcohol mumps, pertussis, or rubella. Anyone who is susceptible to the
infection must wear a mask upon entering the room.
- Disinfection hard surfaces – the least expensive and most Tuberculosis Isolation
effective is 10% household bleach Sometimes called AFB (acid-fast bacillus) isolation, is the isolation
- Eating, drinking, smoking, applying cosmetics or lip balm, of a patient with tuberculosis. The isolation technique is similar to
and handling contact lenses – prohibited in work areas respiratory isolation. Tuberculosis, an opportunistic type of
C. Housekeeping – Good housekeeping is the responsibility of all disease, infects individuals whose immune system has been
health care associates weakened by some other disease process, such as AIDS or simple
D. Hepatitis B Vaccination old age.
E. Private Rooms – reduces the possibility of transmission of Drainage/Secretion Precautions
infection by separating the patient with a disease from other Sometimes called wound and skin precautions are used for
patients ang health care associates. patients with open wounds.
- Should have anteroom where anyone can wash their Enteric Precautions
hands and change protective garments. For patients with severe diarrhea due to contagious bacteria such
F. Handwashing – the single most important way to prevent the as Salmonella, Shigella, or Vibrio cholerae.
spread of infection. Protective or Reverse Isolation
Does the opposite by protecting the patient from health care
“If you don’t love it, you’re going to fail.”
Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 10

worker. This is done by the following OSHA functions:

 Develop and promote health and safety standards for
Disease-Specific Isolation – established in 1983 to overcome the all occupations
short-comings of category-specific isolations. The category of blood  Develop and issue regulation
and body fluid precaution was added so that it could include  Determine the level of compliance with health and
substances other than blood. safety regulations
- The protective or reverse isolation is eliminated  Level fines for noncompliance with health and safety
- Tuberculosis isolation was updated to recommend the use regulations
of a private room with negative air pressure and the use of
high-efficiency particulate air (HEPA) filter respirators
instead of surgical masks.

Transmission-Based Precautions – intended for patients with or

suspected of having a specific transmissible disease.
1. Airborne precautions – for patients known or suspected to
have illness transmitted through small-particle (5
micrometers or smaller) airborne droplets, which may
remain suspended in the air, or dust particles containing
the infectious agent.
2. Droplet precautions– for patients known or suspected to
have illness transmitted through larger droplets (larger Hazard Identification
then 5 micrometers in size) containing microorganisms. - Hazards can be identified on the container by a hazard
3. Contact precautions – for patients known or suspected to emblem designed by the National Fire Protection
have illness transmitted through the transfer of Association.
microorganisms by direct or indirect contact.
Fire Safety
Transmission-Based Isolation Precautions  Class A – include foam, loaded-stream, and multipurpose
Airborne Droplet Contact dry chemical extinguishers.
Precautions Precautions Precautions o Includes fires of ordinary combustible materials
Example of Measles Diphtheria, Clostridium in the laboratory, such as wood, plastics, and
Disease Involved (rubeola), mycoplasma, difficile, paper.
virecella pneumonia, Escherichia  Class B – include carbon dioxide, dry chemical, foam, and
(chickenpox), pertussis, coli, Shigella,
loaded-stream extinguishers.
tuberculosis influenza, hepatitis A,
mumps, rubella herpes o Includes fires of flammable liquids and gases
simplex,  Class C–include carbon dioxide and dry chemical
scabies, extinguishers.
Staphylococcus o Fires in energized electrical equipment
(open wound)  Class D – contain a dry powder medium that does not
Private Room Yes Yes Yes react or combine with the burning materials
Respiratory Yes, with No No o Includes fires of combustible ad reactive metals
Protection tuberculosis
such as sodium, potassium, magnesium, and
Mask Persons Yes, if working No
lithium. These fires pose special problems, since
susceptible to 3 feet or 1
measles or meter of explosion and spreading can easily occur.
varicella should patient
avoid contact The National Fire Protection Association’s key word for action is
Patient Transport Use surgical Avoid contact Use surgical “RACE”.
mask on patient with other mask on
persons or patient R– Rescue anyone in danger.
equipment
A– Sound the Alarm
Gloves Follow standard Yes, if Follow
precautions contacting standard
C – Contain the fire by closing doors and/or windows.
contaminated precautions E – Extinguish/Evacuate. Extinguish the fire if possible; if the fire
material is too large to extinguish, start to evacuate anyone in the fire’s
Gown No If you suspect No path
clothing will be
contaminated
P– Pull the pin. It is there to prevent accidental discharge.
A– Aim low at the base of the fire. This is the where the fuel
OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION STANDARDS source is.
S– Squeeze the lever above the handle. Release to stop the
OSHA – an agency of the federal government that investigates the flow.
possibility of unsafe practices in the work environment. (Some extinguishers have a button instead of a lever)
- Was the result of the Occupational Safety and Health Act S– Sweep from side to side. Move toward the fire, aiming low at
of 1970. its base. Sweep until all flames are extinguished. Watch for re-
- The goal is to promote safety for the health care workers igniting. Repeat as necessary. Have site inspected by fire
and their environment. department.

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 11

Chapter 3. BASIC ANATOMY AND PHYSIOLOGY - Within are chromosomes that contain deoxyribonucleic
acid (DNA)
DNA – stores the hereditary information of the cell and is
Anatomy – the study of the structure and morphology of the body.
passed from one generation to another.
Physiology – the study of the functions of the body parts
- has nuclear membrane that both protects the nucleus and
allows material to pass through, that is connected to the
BODY POSITIONS
endoplasmic reticulum
Anatomic position – standing erect with face forward, arms at the
Endoplasmic reticulum – tubular structure serves as a channel for
side, and palms forward.
the transport of material in and out of the nucleus
Median (sagittal) plane – an imaginary line that divides body in
o Rough ER – contains ribosomes that help with protein
equal right and left side sections
synthesis
Proximal – any structure toward the point of attachment to the
o Smooth ER – assists in cholesterol synthesis, fat
body
metabolism, and detoxification of drugs
Distal – structures farthest from the point of attachment
Mitochondria – serves as sites for cell respiration and energy
Medial – any structure toward the midline of the median plane in
production
reference to another structure
- Break down carbohydrates, fats, and protein molecules
Lateral –any structure away from the median plane
into energy to be stored in the cell as adenosine
Frontal (coronal) plane – an imaginary vertical cut at a right angle to
triphosphate (ATP)
the median plane
Anterior (ventral) – anything in front of this frontal plane Golgi apparatus – also known as golgi bodies or golgi complex
Posterior (dorsal) – structures at the back of the coronal plane - Assists the mitochondria in keeping the cell alive
Transverse plane – a horizontal plane that divides the body into - Consists of layers of membranes that synthesize
upper and lower halves. carbohydrates and combine them with protein molecules
Superior (cranial) – structures above - There packages that are created are then secreted from
Inferior (caudal) – structures below the cell
Supine position – lying on his or her back, facing up Lysosomes – spherical bodies in the cytoplasm that contain
Prone position – lying on his or her front powerful digestive enzymes to break down complex cellular
components into more usable sugars, amino acids, fatty acids, and
BODY SYSTEMS glycerol
- They also expel all their enzymes directly into the
Two of the main bodily functions:
cytoplasm of the cell to break down the cell itself when it
 Homeostasis– when all parts work together to maintain a
is old or weak (suicidal process known as autolysis)
steady state
 Metabolism – the process of making substances or
breaking down substances so the body can function TISSUES
o Catabolism– process of producing energy by Tissues – cells that group together
breaking down complex compounds into simpler 1. Epithelial Tissue – protects the body by covering internal
ones. and external surface (skin)
o Anabolism – constructive part of metabolism in o Can also absorb, as in the lining of the small
which the body uses simple substances to build intestine
complex substances o Secretion in the body is also through this
o All glands, such as exocrine and endocrine glands
CELL STRUCTURE 2. Connective Tissue–supports and connects organs and
tissues of the body
Cell – basic unit of the human body (there are trillions of them in a
o Adipose and areolar tissue – store fat and
human body)
support both nerve cells and blood vessels
- It is a complex system made up of a variety of parts
o Ligaments, bone, cartilage, blood, and lymph
Cell membrane – semipermeable and regulates the passage of
fluid
certain molecules in and out of the cell.
3. Muscle Tissue– has the ability to shorten, thicken, or
- Gives the cell structure and separates it from other cells
contract
and the outside environment
o Cardiac muscle – makes up the walls of the heart
Cytoplasm – semifluid inside the cell membrane
o Skeletal muscle – connects to the skeleton to
Organelles – structures embedded in the cytoplasm that help the
provide movement
cell function
o Smooth muscle – walls of the digestive tract,
Nucleus – the most important organelle of the cell genitourinary tract, respiratory tract, blood
- Controls cell division and activities of the cell vessels, and lymphatic vessels
- Often seen as the “brain” of the cell

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 12

INTEGUMENTARY SYSTEM - Striated with the purpose of moving blood through the
- Skin of the body circulatory system.
- Offers a protective covering; regulates body temperature;
manufactures vitamin D; contains nerve endings; stores Direct biopsy and muscle enzyme testing analyze the muscular
glucose, water and salts; and has the ability to absorb system
certain drugs and chemical substances.
Epidermis – outermost covering and has no blood vessels present Basic Tests for Skeletal Muscle Damage
(avascular) 1. Aldolase
Dermis –made up of connective tissue and contains blood vessels 2. Alanine aminotransferase (ALT)
(vascular) 3. Aspartate aminotransferase (AST)
- Layer of the skin that the phlebotomy needle enters for 4. Creatine kinase
the purpose of blood collection 5. CK-MM
Age – has the most dramatic effect in integumentary system 6. Myoglobin
- Sebaceous glands secrete less lubrication and the skin
becomes more fragile and dry NERVOUS SYSTEM
- Loss of fat causes wrinkles, lines and sagging of the skin. Central Nervous System – provides the communication lines for the
- Elasticity of the skin is lost because elastin fibers shrink, different systems and knows what each system needs,
becoming more rigid - Receives stimuli from all over the body
- Dermal vascular network’s ability to respond to heat and - Brain interprets the message, responds to the message
cold (hypothermia and hyperthermia and carries out an activity
- Skin is more sensitive to ultraviolet radiation Peripheral Nervous System – consists of nerves that connect to the
brain and spinal cord with sensory receptors, muscles, and glands
SKELETAL SYSTEM Autonomic Nervous System – carries impulses to involuntary
- Supports movement muscles and glands; does not require a command sent from the
- Provides support and shape to the body as the main brain
function (206 bone)
- Provides protection to the parts of the body Basic Tests for Nervous System Disorders
Axial Skeleton 1. Cerebrospinal fluid (CSF) analysis (hematology,
o Cranium (skull) – provides protection to the brain, inner microbiology, and chemistry/serological testing
ear, and eyes 2. Serotonin
o Ribs and breastbone – protect the lungs and heart
o Spinal cord – protects the vertebral (spinal) column RESPIRATORY SYSTEM
Appendicular Skeleton – provides an anchor for the muscles so that - Maintains the body’s ability to exchange gases
movement of the body can occur
External respiration – known as breathing or ventilation
Bone – the storehouse for minerals, especially calcium and for the The lungs take in oxygen and transfer it to red blood cells. At the
production facility for the blood same time, the lungs expel the carbon dioxide that the red blood
Bone marrow – site for blood production (hemopoiesis or cells have brought back from all parts of the body. Gases are
hematopoiesis) exchanges between the alveoli and the blood in the pulmonary
Long bones, sternum, and ilia – locations of blood cell formation arteries.
Internal respiration – occurs when oxygen-rich blood diffuses the
The health of the skeletal system can be analyzed by checking the
oxygen into the tissue cells. This is the exchange of gases between
patient’s analytes, such as calcium and phosphate levels and
the tissue cells and the blood in the systemic capillaries which
synovial fluid
provide much needed blood to the tissue cells.

MUSCULAR SYSTEM
Drawing arterial blood gases and having blood gases analyzed is the
- Responsible for both internal and external movement, method of testing the respiratory system.
body shape, and maintenance of body temperature,
Skeletal muscles – voluntary, striated and attached to the bone to
URINARY SYSTEM
help provide movement. (Also known as voluntary muscles)
- Primary function is to eliminate fluids and wastes through
Smooth muscles – non-striated and involuntary in movement. They
the urine.
are slower to react.
- Consists of two kidneys, two ureters, bladder, and a
- Walls of the digestive tract, genitourinary tract, respiratory
urethra.
tract, blood vessels, and lymphatic vessels
Kidneys – main part of this system and work to regulate the amount
Cardiac muscles – found only in the heart
of water and solutes the body system expels.

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 13

- Filter large amounts of fluid from the bloodstream and Celiac disease – diarrhea, abdominal pain, and weight loss caused by
eliminate wastes, drugs, and toxins from the body. gluten-sensitive conditions
- Reabsorb needed substances and return them to the
bloodstream. This regulates the volume and concentration
of the blood Basic Tests for Digestive System Disorders
- Amount of hydrogen ions in the blood regulates the pH 1. Complete blood count
Substances produced by kidneys: 2. Celiac difficile toxin
o Renin – used to regulate blood pressure 3. Clostridium difficile toxin
o Erythropoietin – stimulates red blood cell production in the 4. D-xylose absorption
bone marrow
5. Food allergy testing
o Convert vitamin D to its active form (calciferol) – used by
6. Helicobacter pylori tests
the body for the development of teeth and bones, along
7. Lactose intolerance test
with the control of calcium and phosphorus metabolism
8. Ova and parasites
Ureter – have smooth muscle fibers that help push the urine into
the bladder
ENDOCRINE SYSTEM
Bladder – reservoir that can hold about 500 milliliters of urine.
 Random urine – like a snapshot of how the urinary system - Composed of glands that manufacture and secrete
is performing at the time of collection hormones needed in the body
 24-hour collection – averages the cycles of the urinary - Exerts chemical control of the body within certain narrow
system into one sample ranges (homeostasis)
Dialysis – most common treatment for kidney failure - Releases products directly to the bloodstream
Hemodialysis – purifying blood by passing the blood through a - Includes pituitary glands, thyroid and parathyroid glands,
dialyzer and pancreas
- Control growth, shape and the way the body reacts to
Basic Tests for Urinary Disorders feelings of fright or anger
Diabetes mellitus – most common disorder in endocrine system
1. Blood urea nitrogen (BUN)
- Deficiency in insulin production
2. Creatinine
- Chronic elevation of glucose in the blood (hyperglycemia)
3. Microalbumin
Some other disorders are infertility, thyroid disease, and growth
4. Urinalysis
abnormalities.
5. Urine calcium
Endocrinologist – endocrine specialist
6. Urine creatinine
7. Urine culture
Basic Tests for Endocrine Disorders
8. Urine total protein
1. Adrenocorticotropic hormone (ACTH)
2. Aldosterone
DIGESTIVE SYSTEM
3. Catecholamines, plasma and urine
- Helps the body absorb food that the tissue cells needed to
4. Cortisol
generate energy and build substances
5. Dehydroepiandrosterone sulfate (DHEAS)
Steps to process food:
6. Electrolytes
 Ingestion of the food takes place and the chewing of the
7. Estrogen
food breaks down the food into smaller pieces
8. Follicle-stimulating hormones (FSH)
 Peristalsis – the physical movement of the food along the
9. Human chorionic gonadotropin (HCG)
digestive tract
10. Progesterone
 Digestion – the breakdown of the food chemically by
11. Triiodothyronine (T3)
digestive juices into the end products of fat,
12. Thyroxine (T4)
carbohydrates, and protein
13. Testosterone
 Nutrients are absorbed into the blood capillaries as the
14. Thyroid-stimulating hormone
food moves through the small intestine.
 Defecation – eliminates the wastes from the body
Liver, gallbladder, and pancreas – assists by producing enzymes and REPRODUCTIVE SYSTEM
hormones, including glucagon, insulin, and bile which accelerate the Female
digestive process. Gonads: Ovaries, produce egg cells (ova)
Hormones: Estrogen and progesterone
Peptic stomach ulcers and chronic active gastritis – infection by
Helicobacter pylorimicroorganism. (breath test or microbiological Male
test) Gonads: Testes, produce sperm
Hormones: Testosterone

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 14

Infertility is due to:

o Low sperm count
o Fallopian tube damage
o Insufficient egg production
o Hormonal imbalance
Testing for sexually transmitted diseases is done through blood
tests, vaginal or urethral culturing, and urine cultures
Common STDs include:
 Syphilis
 Trichomonas vaginalis
 Genital herpes
 Genital warts
 Human papilloma virus (HPV)
 Chlamydia trachomatis infection
 Neisseria gonorrhoeae infection
 Acquired immunodeficiency syndrome (AIDS)

LYMPHATIC SYSTEM
- Closely associated with the circulatory system
- Consists of lymph, lymph nodes, lymph vessels, spleen,
thymus gland, lymphoid tissue in the intestines and tonsils
- Primary function is to drain protein-containing fluid that
escapes from the blood capillaries
Interstitial fluid – lymph fluid that is moving between the tissue
cells
The functions of the lymphatic system are varied:
 Lymph fluid acts as a fluid between the blood in the
capillaries and the tissue
 Lymph vessels transport this fluid back into the blood
capillaries
 Lymph nodes produce white blood cell lymphocytes and
filter out harmful bacteria and foreign matter
 The spleen is a filter system for the blood, removing old red
blood cells. Platelets and white blood cells are stored in the
spleen, which acts as a holding chamber for blood in case of
emergency
 The thymus gland produces T-lymphocyte cells, which are
necessary part of maintaining immunity

Study of the Different Body Systems

Physician Specialization Area of Specialization
Cardiology Study of the heart
Dermatology Study of the skin
Endocrinology Study of the endocrine glands
Gastroenterology Study of the stomach and intestines
Gynecology Study of female diseases
Hematology Study of the blood
Neurology Study of the nerves, brain and spinal cord
Oncology Study of malignant disease and cancer
Ophthalmology Study of the eye
Pathology Study of disease
Psychology Study of the mind and mental disorders
Rheumatology Study of joint diseases

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 15

Chapter 4. ANATOMY AND PHYSIOLOGY OF THE CIRCULATORY Anemic – too little hemoglobin; decreased number of erythrocytes
SYSTEM Plasma – where antibodies are found, which can react with antigens
foreign to the individual.
Circulatory System – the transportation system for the body to Type and Cross-match (T&C) – process of determining if a person
transfer substances and wastes from one system to another. will react after a transfusion; blood bank section of the laboratory

TWO PARTS OF THE CIRCULATORY SYSTEM Leukocytes – produced by bone marrow and lymph nodes.

1. Pulmonary System – circulates the blood through the lungs, - Starts as undifferentiated stem cells, then form into blast
where the blood in enriched with oxygen and the waste cells, maturing through several stages until they are
carbon dioxide is removed. releases into the blood as mature cells.
2. Systemic System – supplies the cells with oxygen, fats, - Vary greatly in size.
carbohydrates, and other energy source, while at the same - Appear as large white cells that have purple centers
time removing waste products (nuclei) when viewed in a stained blood smear.
- Staining characteristics – help to identify the different
Bone marrow – the primary factory for production of blood cells. cells (pink, blue, or orange).
Lymph nodes, thymus, and spleen – also sites for production of
blood cells.
Blood – carry oxygen to body tissues and to remove waste product
carbon dioxide

 Also carries nutrients to all parts of the body and moves

the products to the lungs, kidneys, liver, and skin.

During one blood draw, only 2.5 percent of an individual’s blood can
be taken. No more than 5 percent of the total patient’s blood
volume should be taken within a 30-day period.

45 percent of blood consists of formed cellular elements

55 percent is a fluid portion, called plasma

Formed Cellular Elements include:

 Erythrocytes (Red blood cells)

 Leukocytes (White blood cells)
 Thrombocytes (Platelets)
White blood cell differential count – counts at least a hundred of
Undifferentiated hemopoietic stem cells – first form of blood cells leukocytes and classifies them according to the percentage of cell
types that are found.
as they begin their formation in the bone marrow and lymph nodes.
- Indicate whether a person has a viral infection, bacterial
- Hemopoiesis (Hematopoiesis) – process of the maturation
infection, appendicitis, and so on.
of blood cells through different stages, slowly decreasing
- Part of a complete blood cell count (CBC), with number
in size.
- Matured cells leave the bone marrow and enter the RBCs, hemoglobin and hematocrit.
bloodstream. -
Thrombocytes (platelets) – smallest of the formed elements.
If immature cells are found in the bloodstream, this is indicative of a
hematologic problem.
- Fragments of cells that break off from a large cell called
metamegakaryocyte, found in the bone marrow.
Mature erythrocytes – average of 6 to 8 micrometers in diameter
- Aid in the clotting process.
and are biconcave.
- First cells to go to the site of the cut or wound.
- Matures from an undifferentiated stem cell.
-Can live about 120 days once they enter the bloodstream.
-Have no nucleus.
WBC RBC Platelet
-Contain antigens on the surface that determine the (Leukocyte) (Erythrocyte) (Thrombocyte)
individual’s blood type and variety of factors specific for FUNCTION Body defense Transport of Stoppage of
that individual. oxygen and bleeding
- Consists of a membrane that encases hemoglobin. carbon dioxide
Hemoglobin – the iron-containing pigment of the RBCs. (intravascular)
FORMATION Bone marrow, Bone marrow Bone marrow
- Holds oxygen molecules that were absorbed through the lymphatic
membrane as the erythrocytes passed through the lungs. tissue
- Releases the oxygen to tissues and brings carbon dioxide SIZE/SHAPE 9-16 6-8 1-4 micrometers;
micrometers; micrometers; fragments of
back to the lungs to be released as a waste product.
“If you don’t love it, you’re going to fail.”
Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 16

different size, biconcave disc; megakaryocytes In the body, the liquid portion is called plasma.
shape, color; no nucleus in When the blood is removed from the body, the blood clots and the
nucleus (core) mature cells
liquid portion is called serum.
LIFE SPAN Varies; 24h to 100-120 days 9-12 days
yrs Clot – contains all the formed elements intertwined together in a
REFERENCE 3,500– 3.8–5.9 150,000– fibrin mass.
VALUES 11,000/cubic million/cubic 400,000/cubic
millimeter millimeter millimeter Steps to a clot
REMOVAL Bone marrow, Bone marrow, Spleen 1. Uncoagulated blood
liver, spleen liver, spleen
2. Calcium utilized
3. Prothrombin converts to thrombin
4. Fibrinogen converts to fibrin
Arteries – where blood flows away from the heart.
5. Clot formation with serum extracted
Veins – where blood flows back to the heart.
Capillaries – connecting most of the arteries and veins.
Serum – a clear straw-colored liquid that is used for many tests done
Arteries Veins in the laboratory
Carry blood from the heart, Carry blood to the heart, carry Centrifuge – instrument used to speed then removal of the serum
carry oxygenated blood deoxygenated blood (except Centrifugal force – induces the separation of the blood
(except pulmonary artery) pulmonary vein)
Normally bright red in color Normally dark red in color Clot is at the bottom, while the serum is on the top layer
Elastic walls that expand with Thin walls/less elastic
surge of blood To produce a plasma sample – clotting must be prevented
No valves Valves Anticoagulant – chemical substance that prevents the blood from
Has a pulse No pulse blotting by preventing the fibrinogen from converting to fibrin.

Bottom layer contains the erythrocytes, and there is a thin layer of

buffy coat which contains a mixture of leukocytes and
thrombocytes. On top of all these layers is the plasma layer, which
contains fibrinogen and usually is slightly hazy.

THE HEART

- The organ that keeps all the blood flowing.

- A muscle with four distinct chambers: right atrium, right
ventricle, left atrium, and left ventricle.
Right and left atrium – where blood enters the heart.
Right and left ventricles – where blood leaves the heart.
Right ventricle – responsible for oxygenating the blood by pumping
Artery – has a thick wall that helps it withstand the pressure of the it to the lungs.
pumping blood; constantly expanding and contracting Left ventricle – pumping the blood to all parts of the body.
Arterioles – branching from the arteries Arteries, arterioles, capillaries, venules, and veins – where blood
Capillaries – branching from the arterioles flows through the body.
Venules – where capillaries start forming together, which then Septum – a muscular wall that divides the right and left sides of the
forms the vein heart.
Artery-capillary-vein – path which the blood flow follows Blood Flow Chart
Superior/Inferior Vena Cava

Right Atrium

Right Ventricle

Pulmonary Artery to Lungs

Pulmonary Vein from Lungs

Body gets warm – capillaries in the extremities dilate (enlarge in Left Atrium
diameter) and let off heat, which cools the body. 
Body gets cold – capillaries constrict (get smaller in diameter) and Left Ventricle
less blood flows through, therefore conserving heat for the rest of 
the body. Aorta

Valves – keep the blood flowing in a one-way direction
Arteries

- Let the blood pass through but close if the blood tries to Arterioles
flow backward. 
Capillaries

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 17

 - Known as the pacemaker of the heart

Venules - Creates an electrical impulse that is transmitted to the
 atrioventricular node (AV node).
Veins

Back to Superior/Inferior Vena Cava

Superior vena cava – where deoxygenated blood enters the heart Atrioventricular node (AV node)
from the upper part of the body.
Inferior vena cava – where deoxygenated blood from the lower part - Causes the atria to contract
of the body enters the heart. - Bundle of His (Atrioventricular bundle) – length of
Right atrium – first chamber of the heart this deoxygenated blood conduction fibers
enters. - Purkinje fibers – causes the ventricle to contract
Tricuspid valve – where blood passes through as it enters the right
ventricle. It is a one-way valve that keeps the blood from flowing Systolic pressure – the pressure when the heart is contracted.
back into the right atrium. Diastolic pressure – the pressure when the heart is relaxed between
Pulmonary semilunar valve – where deoxygenated blood passes beats.
through from the right ventricle into the left and right pulmonary Blood pressure cuff (Sphygmomanometer) – used to measure blood
arteries. pressure.
Pulmonary arteries – leave the heart and enters the lungs which mm Hg – refers to millimeters of mercury.
branches into millions of capillaries; only arteries in the body that
carries deoxygenated blood. VEINS AND ARTERIES OF THE CIRCULATORY SYSTEM

In the lungs, the blood releases the carbon dioxide it picked up while Veins that the phlebotomist will use are located in the:
passing through the body and becomes oxygenated.
 Antecubital fossa (bend of the arm)
Pulmonary veins – where blood leaves the lungs then enters the
 Back of the hand
heart once again; only veins in the body that carries oxygenated
 Wrist
blood (bright red appearance).
 Ankle or foot
Left atrium – where pulmonary veins enter the heart
Bicuspid valve (Mitral valve) – where oxygenated blood of the left
Antecubital fossa – usual location where the phlebotomist chooses
atrium flows through, into the left ventricle.
to draw blood.
Left ventricle – pumps the blood through another valve called
semilunar valve (aortic valve). - Veins are near the surface and large enough to give access
Aorta – largest artery in the body which receives the oxygenated to the blood
blood from aortic valve.
- Frequently form M- or H-shaped pattern
1. Median cubital vein – center of the antecubital fossa
- This branches to become the entire artery system in the
o Forms a bridged pathway between cephalic and
body.
basilic veins
Left ventricle – produces extreme pressure; has such a thick and
o Vein that is used to majority of the time
strong wall.
o Easiest to palpate and has less tendency to roll
than other veins
Examples of Tests for Heart Disease 2. Cephalic veins – second choice for venipuncture
1. Alanine aminotransferase (ALT)
o Follows along the thumb side of the arm
2. Aspartate aminotransferase (AST) o Not prone to rolling, but it slightly more difficult
3. Blood gases to feel
4. Brain natriuretic peptide (BNP) 3. Basilic veins – third choice for venipuncture
5. CK isoforms (Creatine kinase isoforms) o More difficult to feel and has tendency to roll
6. CK-MB (Creatinine kinase, MB) o Underlying is the brachial artery and median
7. Complete blood count (CBC) cutaneous nerve
8. Comprehensive metabolic panel (CMP)
9. C-reactive protein (CRP) Brachial artery – arteries in the arm along brachial region
10. Homocysteine Radial and ulnar arteries – arteries along the wrist
11. LDH1(Lactose dehydrogenase 1)
12. Myoglobin
13. Troponin

Electrical stimuli – control the pumping acting of the heart.

Conduction system of the heart – specialized cardiac tissue
controlling the electrical stimuli

Sinoatrial node (SA node)

- Begins the process
- Needs no outside stimulus to cause it to start a heart beat

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 18

CHAPTER 5: Phlebotomy Equipment Breathing the Syringe technique— used to breathe the syringe
Metric System— Group of units used to make measurements, such before it is used since plunger on the syringe often sticks
as length, volume, temperature, weight and time Evacuated Tube System (ETS)
Knowledge of the metric system is necessary in the health care  Usually called the Vacutainersystem (misnomer, because
setting the term is a brand name for ETS manufactured by Becton
Meter (m) — basic unit for measuring length; slightly longer than a Dickinson Company)
yard  Tube with a vacuum already in it attaches to the needle
Centimeter (cm) or millimeter (mm) – used to measure short and the tube’s vacuum is replaced by blood
lengths Consists of:
Volume measurements— tell the size of a box in terms of cubic Double pointed needle/ multi-sample needle
units o a straight hollow type with double points and a screw
Cubic centimeter (cc) and milliliter (mL) are used interchangeably hub near the center
Kilogram (kg) — basic unit of weight in the metric system o the basic needle is straight with no safety devices
Gram (g) — is used for smaller weight and equal one thousandth of attached(requires safety shield attached to the
a kilogram holder)
Celsius (oC) – measurement in the metric system in terms of o the alternate needle has the safety device attached to
temperature it
37o – Normal Body Temperature o thought as the pipeline that delivers blood from the
Hours, minutes, and seconds— time in the metric system patient to the tube
Syringe and Needles o needle extending from the holderhas the proper
bevel to pierce the skin and enter the vein
Syringe and Needle Method o needle within the holderpierces the rubber stopper
 one of the oldest methods known that does not destroy on the ETS
the integrity of the vein o Rubber sleeve works as a valve that stops the flow of
 similar apparatus have been found in Egyptian tombs blood when the tube is removed
Gauges Available: 20, 21,(most common) & 22
 Purpose of system before: not to draw blood but rather
Gauge— refers to the size of the opening (bore) in the needle shaft,
used as a pus extractor for a miniature flame thrower
also known as the lumen of the needle
 Limited by the capacity of the syringe (if a large amount of
Bevel
blood is needed, a butterfly collection set should be used)
 slanted opening at the end of the needle; must always be
Syringe
facing upward when the needle is inserted into the vein
 Made of either glass or plastic; majority being plastic  cut at an angle to ensure maximum blood flow through
 The larger the syringe, the greater the amount of vacuum the needle (achieved through 15o (shallow vein)to
obtained 30o(deep vein)angle)
 Generally, used for difficult-to-draw patients who have
Plastic Holder
fragile, thin, or “rolly” veins (Pediatric or geriatric patients
typically have these veins) o Makes the task of collecting blood sample easier
 Used in special procedure, when the blood must be drawn o It gives the phlebotomist something more substantial
and then transferred to a different container to hold on to and a way to center the needle into the
stopper of the evacuated tube
 Requires to have safety shields
o Comes in two sizes:adult venipuncture and small-
Composed of:
diameter tubes in pediatrics
Barrel— graduated into mL o Constantly changing in an attempt to reduce
Plunger— creates a vacuum within the barrel needlestick injuries
Both varies in volume (1mL to 60mL) o Have changed from basic type to style that cover
Needle— consists of: hub, cannula (shaft), and a point cut at a needle after use
precise bevel; recommended length: 1 inch to ½ inch
Reuse of ETS Holder
Luer lock— threaded insert where the hub is screwed
 The entire device must then be discarded with the needle
Needle Gauge
still attached (fulfills OSHA requirements)
27, 25, 23, 22, 21, 20, 18& 16 – gauges of needles used in healthcare
 Eliminate the use of all devices in which the needle or
(from smallest to largest)
butterfly is removed from the needle holder
22, 21, & 20— gauge needle used for venipuncture
 Reuse of needle holder has been scrutinized for the safety
22— used for small veins and for pediatric patients
reason of contamination of the holder with blood after
23— used in combination with butterfly collection set
even on use
25— used for intermuscular injections; cannot be sued for
 Cost of discarding the holder is not restricted to the
venipuncture, because RBCs would be destroyed when the blood is
additional cost of the holders but also involves the cost of
pulled through the bore of the needle
filing the sharps containers more quickly
27— used for administration of a purified protein derivative (PPD)
 Some of the cost can be offset by price reductions due to
tuberculosis skin test
increase usage. Less expensive disposable holders can be
18 & 16 – used for the intravenous (IV) infusion fluids or blood
sued
products or the removal of blood during the donor process
 Self-clapping needles can be used but the entire device
Used for smaller needle may destroy RBCs as they are pulled
holder and needle must be discarded intact
through the needle bore

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 19

Evacuated Collection Tubes  Winged needle is inserted approximately 5-degree angle

 Contain vacuum with a rubber stopper sealing the tube and the threaded into the vein
 Most has silicon coating  Offer flexibility to start drawing blood with a syringe and
then finish with the ETS
 Ranges in volume from 2 to 15mL
 Have sterile interior to prevent contamination of the  Butterfly is not used for all collection;
sample of the patient expensiveConsist of:
 Sterile tube does not contaminate the blood, any backflow o sleeve that slides over the needle immediately after
of blood is inconsequential use or a needle that retracts from the patient’s arm
 Either glass or plastic (primary one used in health care o 3 to 12 inch tubing leads – works as a pressure relief
setting; manufactured w/ or w/o anti-coagulant) valve. A large evacuated tube or large syringe can be
attached to the tubing and the vein will not collapse
 Vary in length from 65 to 127mm with an external
as would normal occur
diameter of 10, 13, or 16mm
o Syringe attached to a butterfly: offer flexibility
10mm fits into the pediatric holder
13mm – 16mm fits into the adult holder o Butterfly attached to an evacuated needle holder and
Luer adaptor–similar to an ETS needle, but in place of
 Traditional rubber stopper popped as the top was
the needle is a port to attach to the butterfly
removed to access the sample creating aerosol that could
be inhaled or ingested When discarding the butterfly device, do not push the tubing
 Tube are good until the end of the month stamped on and attached holder and needle into a sharps container. Drop the
them head into the sharps container first then allow the remainder of the
 Tubes past the expiration date compromises the integrity device to drop into the sharps container with the holder
of the sample and can give questionable results
Hemogard Coagulation
 Developed by Becton Dickinson
 Has a plastic sleeve that fits over the rubber stopper to Hemostasis
contain any aerosols that might be dispersed when the cap  Coagulation process causing the formation of a blood clot
is removed when an injury occurs and then lysing of that blood clot
 excellent safeguard for technologist working with the when the injury has been repaired
sample Primary hemostasis
Additives o First step of the process
o Damaged vessel constrict to limit the blood flow to
 not anti-coagulants or preservatives
the injury
 used to improve the sample quality or to accelerate
o Vasoconstriction— limits bleeding from the injury
sample processing
o Platelet Aggregation— Platelet clump
Tubes with Silicon Coating o Platelet adhesion— platelet clump then adhere to the
 silicon fills the microscopically rough surface of the tube injured area
that the cell can stick to o Traditionally been test by the bleeding time test
 silicon fills in these cracks to crevasses and prevents the o Inaccuracy of the test lead the discontinuation of the
cells from adhering to the surface reducing the chance for test; preferred test is no the platelet function test
hemolysis and makes the slide slicker so the cells can Secondary hemostasis
centrifuge faster o Needed for more serious injuries and includes the
 have red stopper, red/black stopper, or gold stopper formation of a fibrin clot
 glass tube for serum testing will activate clot formation in o Involves complex series of interactions in which one
the tube factor activates the next factor
 glass serum tubes have a clot activator added to speed the Coagulation cascade is divided into two pathways:
clotting process Intrinsic Pathway
 clot activator consists of silica particles on the sides of the  Factor XII measured by activated partial
tubes that initiate the clotting process thromboplastin(aPTT )test—is also used to monitor
Thrombin an individual’s heparin therapy
o Used for stat (emergency) testing Extrinsic Pathway
o Hastens the clotting process faster than the silica  Factor VII measured byprothrombin time (PT) test—
particles also used to monitor warfarin therapy
o Serum and Plasma tubes can also purchase with a In the common pathway:
thixotropic separator gel (inert material that  Prothrombin to thrombin
undergoes a temporary change in viscosity during  Fibrinogen to fibrin to form fibrin plug (hemostatic
centrifugation; has density that is intermediate to plug)
cells/clot and plasma/ serum o Once injury is repaired, fibrinolysis occurs to break
Butterfly (Winged Infusion Set) Collection System down the fibrin clot into smaller fragments called
 Combines the benefits of the ETS and syringe system fibrin degradation products (FDPs)
 Has 21 or 23 gauge needle with attached plastic wings on Coagulation Cascade
one end  Blood tubes that contain an anti-coagulant prevent the
 Used for small veins that are difficult to draw with other coagulation cascade from progressing to completion in the
systems tube

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 20

 Important in preventing collected blood from clotting in  Citrate is also found in yellow-stoppered tube. (Additive:
the tubes ADV) the tube has a variety of uses in testing in blood baks
 Anti-coagulants— works by stopping the clotting process with tissue typing, DNA Testing and paternity testing)
by removing the calcium through the formation of calcium Sodium Citrate
salts or by inhibiting the conversion of prothrombin to  Prevents the coagulation by binding calcium in a non-
thrombin ionized form
 Calcium and thrombin are part of the coagulation cascade  3.8% Sodium Citrate or 3.2% Sodium Citrate
concentrations (most widely used)
 1 anti-coagulants:9 parts of blood
 Prevents the blood from clotting by binding calcium
Solution A and B (ACD)
 Label as a Solution A or Solution B
 Contains variations of a mixture of trisodium citrate, citric
acid, and dextrose
 Used for DNA and paternity testing, human leukocyte
antigen (HLA) phenotyping, and some immunohematology
studies
Sodium PolyanetholSulfonate (SPS)
 Main function: allow bacteria to grow so they can be
cultured
 (a) Inhibits the phagocytosis of the bacteria by the white
blood cells; (b) Inhibits serum complement, which would
destroy the bacteria; and, (c) Inhibits certain antibiotics in
case a patient is already on an antibiotic
Ethylenediamineteraacetic Acid (EDTA)
 Binds Calcium to prevent Coagulation
 K3EDTA – used in glass tubes and is in liquid form
 K2EDTA – used in plastic tubes and is in spray-dried
powder form; anticoagulant in Hematology; preserved cell
morphology for CBC and differential blood smears;
provides stable haematocrit results
Heparin
 Stops the coagulation by inhibiting the conversion of
prothrombin to thrombin and thus the following stages
that lead to a clot
 Naturally occurring substance that is present in most of
our tissues but at low levels
 Produces least stress on erythrocytes and minimizes
hemolysis
 For pH determinations, electrolytes studies, and arterial
blood gases
Anti-coagulants  Comes in three forms: lithium heparin, sodium heparin
 Removes one of the steps in the coagulation cascade and (heparins found in Evacuated tubes)and ammonium
the blood does not clot heparin
Potassium Oxalate/ Sodium Fluoride  Not acceptable for blood sample that may be stored for
 Works by precipitating out the calcium in the blood and more than 48 hours before testing
therefore stopping the coagulation cascade EDTA White-stoppered Tubes
 Primary function: Glycolytic inhibitor  Contain EDTA as an anti-coagulant and also a gel separate
 Fluoride preserves the glucose in the blood sample by from the plasma from the cell
inhibiting the enzyme involved in breakdown of the  Helpful in working with human immunodeficiency virus
glucose (glycolysis) (HIV)— positive patients; provides greater safety for
 As a blood sample sits without the fluoride, the glucose is phlebotomists
broken down at a rate of around 7% per hour  Used for molecular diagnostic tests such as polymerase
 Are used to detect clotting problems: PT, aPTT and chain reaction (PCR) or branched DNA amplification
fibrinogen assay techniques
 Citrate tube containing citrate, theophylline, adenosine, Trace Elements Tubes
and dipyridamole (CTAD) used for platelet function assays  Used for trace element studies analysis of: lead, zinc,
and some routine coagulation determinations arsenic or copper
 Used extensively has the anticoagulant in routine blood  In the normal manufacture of the glass and rubber
donor bags (Citrate-phosphate-dextrose-adenine-1 (CPDA- contained within the tubes, the trace elements are present
1) prevents the blood from clotting and preserves the  Trace elements tubes use specially refined glass, plastic,
vibility of the erythrocytes) and rubber to avoid trace elements leach out of the glass
and rubber stopper
“If you don’t love it, you’re going to fail.”
Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 21

 Three varieties: (1) contain no anti-coagulant and

produces a clot sample (2&3) have sodium heparin or
disodium EDTA as an anti-coagulant

All tubes that have different type of additive must be gently inverted
immediately after collection. The additives do not mix with the
blood as the blood enters the tube; Vigorous mixing will cause
hemolysis
Anticoagulant tubes that are partially filled should never be poured
together to obtain a full tube, this will cause increased amount of
anticoagulant to blood in that tube. This can potentially cause
erroneous test results for the patient

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 22

Chapter 6: Phlebotomy Techniques  Phlebotomist’s errors are usually restricted to patient

misidentification or mislabeling of blood sample
Venipuncture – detailed procedure requiring careful attention to  U.S. laboratories found out that the median labeling error
each of the following steps rate is 1.31 per 1,000 labels
 Errors in patient name, age, sex, and identification
Steps in Blood Collection Technique numbers are undetected despite many checking
1. Prepare accessioning order for the patient procedures
2. Greet and identify the patient
3. Verify diet/drug restrictions and allergies Technical skill
4. Wash hands, assemble supplies, and inspect equipment  Means obtaining blood successfully with minimal pain
5. Reassure the patient  Consists of whatever method is used to complete the
6. Position the patient procedure: venipuncture, arterial sample, or
7. Verify paper works and tubes microcollections through capillary puncture.
8. Apply tourniquet
9. Cleanse the venipuncture site Note: Social, administrative, and technical skills are used in each
10. Put on gloves patient contact and are intertwined in each step of taking blood
11. Perform the venipuncture
sample. Muscles of a tense patient tighten over the blood veins,
12. Fill the tubes in the correct order of draw or fill the syringe
13. Remove the tourniquet making them more difficult to access. Relaxed patient is more
14. Dispose of sharps in the proper container cooperative and easier to draw.
15. If a syringe was used, fill the tubes using a transfer device
in the correct order of draw Greeting the patient
16. Label the tubes 1. Before any attempt is made to collect a sample from the
17. Chill the sample or protect it from light (only for certain patient, you must gain the patient’s trust, it is done
tests) through properly greeting the patient
18. Remove gloves 2. Proper greeting will decrease the patient’s anxiety and
19. Check on the status of the patient for reactions to improve patient compliance
phlebotomy 3. Always greet the patient in a positive manner and
20. Eliminate diet restrictions establish eye contact
21. Time-stamp or computer verify paper work 4. Introduce yourself to the patient, giving your name, and
22. Send the correctly labeled tubes to the proper laboratory your immediate role in his or her care
departments 5. Explain how long this will take and explain what you are
going to do
Little attention is given to these basic steps. Our state-of-the-art 6. Always be attentive to the patient’s tone of voice and
sophisticated laboratory technology is often riddled with errors body language.
because of misidentification and poor sample collection 7. The more relaxed you can make the patient, the easier the
techniques. job of phlebotomy
8. After positive greeting, start be verifying you have the
correct patient. Only verifying that the patient
SKILLS USED IN APPROACHING THE PATIENT
identification bracelet confirms the patient’s full name is
acceptable identification
Social skills
 Social skills are important Patient Identification
 Always be polite and friendly with patients  Cannot be repeated often enough that proper patient
 Whatever the patient says, it is inappropriate to counter identification is essential to accurate patient testing
with unprofessional remarks.  Results will be wrong if the sample is not identified
 Easiest way to defuse an upset patient is to be as polite as accurately
possible and explain that the doctor’s orders need to be  Hospital patients have a hospital identification bracelets
carried out that includes their first and last names, hospital numbers,
 Reputation of the entire laboratory rests with the birth date, and physician
phlebotomist  Proper greeting of the patient is essential in correct
identification of the patient and putting the patient in ease
Administrative skills  Ask the conscious patient to state his/her full name and
 Administrative/clerical skills are used constantly spell the last name
 Contribute to the most errors in the health care setting  If the patient does not have an identification bracelet, do
 Most administrative errors are the result of clerical errors not draw blood. Request the nurse to attach an
in result reporting or patient and sample identification identification bracelet to the patient. If it is impossible, the
 Preparation of the blood for transfusion (cross-match) nurse needs to identify the patient and sign the requisition
would not be done on the correct blood, patient could or tube label indicating that he/she positively identified
then receive units blood that were not compatible, side the patient
effects of this error could be kidney failure or death  When a patient whose identity is unknown, comes to an
 Administrative errors can occur at any step during the care emergency department, he/she is given a temporary
of a patient identification number and identification bracelet. The

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 23

patient will be given a name such as “unidentified male” or 5. When using a computer label, most of this information is
”unidentified female” on the printed label.
 Once the patient is identified, a permanent identification
number is assigned and the temporary number is cross- The phlebotomist will need to add the following:
referenced to the permanent number  The collection date
 Traditionally the phlebotomist would print barcode label in  The time the sample was collected
the laboratory and take them to the nursing units  The initials or name of the person collecting the
 Sample would then be labeled with the bar code label sample
 Verbal identification of the patient is also completed 6. The purposes of the interface and use of barcodes are to
before blood is collected speed computer entry of results and eliminate clerical
 Once the blood is collected, the samples are sent to the errors
laboratory by the pneumatic tube system 7. Labels used for ample identification are usually adhesive
so they can be attached directly to the tube
Test Request Form 8. Smaller labels can also be printed at the same time for
1. Sometimes used instead of labels only. smaller aliquot samples
2. Lists the information needed for the phlebotomist to 9. One label must be carefully compared to the other to
compete the task and collect the correct samples ensure that each label is for the same person, date, and
time.
Following information should be included on the form: 10. Do not label the tubes before the blood sample is drawn
 The patient’s complete name and age or date of birth 11. All samples must be labeled after the sample is drawn and
 A patient identification number before the phlebotomist leaves the patient
 The date and time the sample is to be obtained 12. Phlebotomist initials the label attached to the tube to
 The type of test to be collected identify himself or herself as the person who drew the
 An accessioning number blood
 The physician’s name 13. The American Association of Blood Banks (2014) sets the
 The department or location where the work is to be done standards for labeling of blood bank samples.
 Other information that is necessary to accurately collect
As quoted in its technical manual:
the sample, such as specific time of collection, whether
“The intended recipient and the blood sample shall be
the patient should be fasting, and so on
positively identified at the time of collection. Blood
 ICD10 diagnosis codes for outpatients
samples shall be obtained in stoppered tubes identified
with a firmly attached label bearing at least the recipient’s
3. Order forms can be a manual requisition that is usually first and last names, identification number, and the date.
made up of carbon form that lists many of the test The competed label shall be attached to the tube before
available leaving the side of the recipient, and there must be a
4. An alternate form is a manual requisition that is imprinted mechanism to identify the person who drew the blood.”
from an imprinting plate that prints the patient’s name,
identification number, physician and room number
5. Legibility errors of a prescription pad and handwritten Accession Order
orders can be eliminated through the use of computerized
 Each request for a blood sample may include an accession
tests requisitions or requisitions with tests check marked
number – a number to identify all paper work and supplies
by the physician
associated with each patient
 This unique number can be used to trace back that sample
Sample Labeling and Identification
and patient
 It ensures accurate and prompt processing of various
1. Identification of the sample is as important as
forms required when performing a venipuncture and
identification of the patient
analyzing the results
2. All samples should be labeled after the blood is drawn and
before the phlebotomist leaves the patient Positioning the Patient
3. When hand labeling an inpatient sample, use the patient’s
armband to get the correct information. Use the  The position of the patient is critical for proper blood
requisition information for an outpatient after verifying collection
with the patient that the information is correct  Patient must be in a seated or reclined position before any
4. When computer labels are not available, such as when a attempt is made to draw blood
manual requisition is used, the tubes or containers must  Do not allow patients to sit on a tall stool or stand while
be hand held. you are drawing blood. There is always a possibility that a
patient will faint and injure themselves
Following is the minimum information needed:  Sitting position requires a chair with adequate arm
 The patient’s first and last names supports that are adjustable for the best venipuncture
 An identification number such as date of birth position. Reclined position is the ideal position from which
 The collection date to draw the patient
 Time the sample was collected  A pillow may be required to help support the patient’s arm
and keep it straight
 Initials or name of the person collecting the sample

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 24

 Have patients lie down whenever they indicate that they

are apprehensive or have fainted in the past while having Edema
their blood drawn  Arms with edema are usually swollen because of fluid in
the tissue
 Veins are not prominent, and the tourniquet will be
ineffective due to swelling
Selecting the Appropriate Venipuncture Site
Arms with IVs
Appropriate Venipuncture sites:  Patient on IV therapy should have samples collected from
 Upper arm (antecubital fossa) the opposite arm
 Back of the hand  Blood should never be collected from a running IV
 Wrist (in line with the thumb)
 Ankle or foot Cannulas and fistulas
 Venipunctures should be performed on the opposite arm

Antecubital fossa Areas of scarring

 The primary vein used in the upper arm is the median  Also to be avoided because of possible injury to the
cubital vein patient or excessive pain
 The basilica, cephalic, median veins can be used as a
second alternative Hematoma
 After the median cubital vein, cephalic vein is the next  Samples collected from hematoma may cause erroneous
preferred site test results
 The basilica vein is the least preferred vein because along  Sample is collected distal from the hematoma
this vein are the brachial artery and major nerves
 Next step is to go to the back of the hand to obtain Mastectomy
venous access  Because of potential harm to the patient due to
lymphostasis, the arm on the side of mastectomy should
Back of the hand be avoided
 Veins in the back of the hand have the tendency to roll  If the patient has had a double mastectomy, a physician
more than the arm veins because they are not supported should be consulted prior to drawing the blood. Usually
by as much as tissue and are near the surface the draw will be performed on the side opposite the
 To avoid this, hold or anchor the vein in place below the newest mastectomy
puncture site with your thumb while you use a smaller-
gauge needle or a butterfly Performing a safe Venipuncture
 The hand veins are ideal for a butterfly (winged infusion Locating a vein
set) with a 23 gauge needle  The phlebotomist then looks for a vein. The term look is
often misused in selecting a vein. Actually a vein is being
Wrist felt for
 Wrist veins are also an alternative but generally are much  The vein must be felt for with the tip of the index or
more painful than the other sites middle fingers
 Appropriate wrist vein is the vein that is present when the  Palpate and trace the path of the vein several times
hand is positioned so the thumb is facing up  Avoid using the thumb because it has a pulse and is not as
 Do not use veins that are present on the palm side of the sensitive as the rest of the fingers
wrist. This area is used for arterial punctures  Vein will feel soft and bouncy to the touch
 Determine the roundness, direction, and depth of the vein
Foot and ankle  If no veins become prominent. Retie the tourniquet
slightly tighter but not so tight as to stop the flow of
 Some hospitals have restrictions on the use of ankle or
arterial blood into the arm
foot veins, and the patient’s physician must give a
permission to use them  An alternative is to use a blood pressure cuff instead of a
tourniquet. The blood pressure cuff should be inflated to
 These veins are often restricted because the physician is
between systolic and diastolic pressure of the patient. This
concerned about clots forming in the legs
will provide a wider band of constriction on the arm to
 the veins may be used for heart bypass surgery and they
make the veins prominent
cannot be damaged with needle punctures
Patient restrictions
Sites to avoid:
 Some tests require that the patient fast or eliminate
 Edematous arms
certain foods before any blood samples can be taken
 Arms in casts
 Time and diet restrictions vary according to the tests
 Arms with IVs
 Patient may also be on certain drug restrictions
 Cannulas
 Collection is specifically times do that enough time has
 Fistulas
passed since the last medication
 Areas of scarring
 Side of mastectomy
“If you don’t love it, you’re going to fail.”
Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 25

Assemble supplies  make the patient as comfortable as possible and instruct

 before a venipuncture can be performed, all supplies and him/her to breathe deeply and slowly
equipment must be assembled  apply cold compress to the patient’s forehead
 it is best to go over the list of tests to draw and even write
down what tube is needed for what teas
 Keep all supplies within your peripheral vision. As the Diabetic shock
sample is drawn, be sure you can reach the tubes you  patients can go to a diabetic shock or experience
need without crossing over the patient or stretching and hypoglycemia because they have fasted
possibly moving the needle after it is in the patient  This is usually the result of too much insulin in their blood
stream. The first signs are cold sweat and pale face
Greet the patient  the patient becomes weak and shaky, followed by a
sudden metal confusion that appears as an instant
 Patient must be reassured that the procedure is going to
personality change
be simple and only a slight inconvenience
 if patient is conscious enough to swallow, a glass of orange
 Be friendly and outgoing and talk to the patient explaining
juice or cola will help temporarily
the procedure
 Explaining what is being done often prevents the
Convulsions
nonresponsive patient from moving when the blood is
drawn  a patient who goes into convulsions becomes unconscious
and exhibits violent or mild convulsive motions
 Conversation with patients gives them the feeling
someone cares for them  do not try to restrain the patient, but move objects or
furniture out of the way to prevent injury
 While talking to the patient, verify the paperwork and
tubes to be certain everything is correct
Cardiac arrest
 Ask the patient to state his/her full name and then ask the
patient to spell his/her last name. next ask to check the  a person with heart problems could go to cardiac arrest
identification bracelet  Patient falls into unconsciousness and has no pulse or
respiration, dilated eyes and blue or gray skin tone.
Syringe versus evacuated tube sample collection Immediate cardiopulmonary resuscitation or CPR is
Locating a vein necessary to avoid patient death

 after the patient has been identified, next step is to tie the Continued bleeding
tourniquet  normally the bleeding will stop in approximately 2 minutes
 After tying the tourniquet have the patient to close his/her  some patients have continuous bleeding at the
hand. Do not ask the patient to pump his/her fist. This will venipuncture site for longer than 5 mins continue to apply
raise the potassium level of the blood and cause pressure to the site by wrapping an elastic gauze bandage
erroneous results around the arm over a pad for at least 15 mins

Pain Hematoma
 most common patient reaction to venipuncture  a patient can react by leaking blood under the kin at the
 avoid deep, probing venipunctures, especially in the area site of the venipuncture
of the basilica vein because this vein is close to a major  only uppermost wall of the vein should be punctured to
nerve prevent a hematoma
 immediately discontinue the venipuncture if the patient  the puncture should not be so deep that the top and
indicates sharp, piercing pain bottom walls of the vein are punctured
 Petechiae— small red dots that are indications of small
Nerve damage amount of bleeding under the skin surface. These are
 deep, probing venipunctures can result in nerve damage often result of low platelet counts or other coagulation
problems. The patient may bleed excessively after the
 if the nerve was damaged, numbness could be permanent
venipuncture
 deep punctures can not only cause nerve damage but can
also result in puncture of an artery
Skin allergies
 Some patients are allergic to tape or iodine. This is usually
Syncope
the result of the patient having a latex sensitivity
 is preceded by the patient turning pale, perspiring and  gauze or cotton can be held in place with hypoallergenic
starting to breathe shallowly tape or non-latex elastic wrap
 this is followed by drooping eyelids, weak, rapid pulse; and
finally unconsciousness Anemia
 if the patient faints, wipe the patient’s forehead and back
of the neck with a cold compress is necessary Patient anemia is caused by four factors:

Nausea  decrease in erythrocytes

 having their blood drawn is so upsetting to some patients  decrease in hemoglobin
that they become nauseated and vomit  deficiency of hemoglobin
 abnormal hemoglobin

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 26

 Slight pressure holding the tube into the holder will reseat
 the patient has lack energy, pale skin, fatigue, and the tube and remedy this problem
shortness of breath  Tube being could have been on or too tight

Types of genetic or disease-related anemias:  Blood flow can also be stimulated by massaging the arm in
 sickle cell anemia – hereditary disease which the an upward motion below the venipuncture site
erythrocytes have an abnormal sickle shape with abnormal  Probing of the site is not recommended because it is
hemoglobin painful to the patient and may cause a hematoma
 iron-deficiency anemia – a condition resulting in excessive  Never attempt a venipuncture more than twice
iron loss caused by nutritional deficiencies that create low  If a blood sample cannot be obtained in two tries, do a
erythrocyte production capillary collection if possible, or have another person
 hemolytic anemia- hereditary condition in which attempt the draw
erythrocytes are destroyed faster than normal
 thalassemia- hereditary disease which hemoglobin Intravenous and indwelling lines
production is suppressed  When an IV solution is being administered into one arm,
 Iatrogenic anemia- anemia caused by drawing excessive blood should not be drawn from that arm. The IV solution
quantities of blood from a patient during the care of the in that arm has the potential to contaminate the blood
patient; usually of most concern with premature infants sample
 To avoid this kind of error, look for a blood-drawing site in
Hemolysis the opposite arm
 is a breaking or rupturing of the membrane of the red  Satisfactory samples can be drawn below the IV and never
blood cells above by following several precautions
 Contents of the red blood cells then contaminate the
serum or the plasma being tested. Serum or plasma If the IV cannot be shut off, there are three options:
appears red. The darker the red, the more cells that have 1. Do a finger stick if the tests ordered can be done by
been hemolyzed. capillary collection
2. Obtain permission from the physician to draw from the
Causes of hemolysis are: ankle or foot
 drawing from a hematoma 3. Wait until the IV is taken out and then draw the blood
 rupturing of the red blood cells by using a needle that is sample
too small
 alcohol on the site of the venipuncture that enters a blood Drawing from Vascular Devices
sample  These devices consists of plastic tubing that is placed in
 leakage of air and frothing of the blood through a needle the patient for access to give fluids and medication or to
not attached to the syringe tightly enough draw blood
 pulling back the plunger of the syringe too forcibly  To keep blood from clotting in the line, heparin or saline is
 temperature extremes used to flush the line
 After blood is pulled from the line, heparin or saline is
Jaundice injected into the line until all the blood is pushed back into
 patient’s serum or plasma that contains a large amount of the patient
bilirubin because of jaundice has a yellow to orange color  For coagulation tests, the capacity must be discarded at
 Patient’s skin and the sclera or the eyes may also be least 5 to 6 times
yellow to orange.  At least 7 ml of blood is usually sufficient as a discard to
 Serum or plasma with this coloration is called icteric clear all the heparin/saline
 To draw blood from the line, a luer adapter is used
Lipemia  A luer adapter looks like an evacuated tube needle
 Large amount fats and lipids in a patient’s blood gives the without a needle
serum and plasma a white milky color  Cannula- a type of tubing connector used on patients with
 This type of serum or plasma is known as lipemic kidney transplant or on dialysis
 Fistula- is an artificial shut connection done by a surgical
The Failed Venipuncture procedure to fuse together a vein and an artery
 Rotate the needle half a turn. The bevel of the needle may
be against the wall of the vein Prioritizing the sample collection
 If the needle has penetrated too far into the vein, pull Stat test
back. Always pull out slowly when the venipuncture has  Indicates that the sample collection is critical to the
been unsuccessful immediate treatment of the patient
 Stat test must be collected before the other samples
Several reasons for venipuncture failure:  Should be taken immediately to the appropriate
 The tube may have pulled back out of the holder laboratory
 Tubes often will not stay pushed all the way into the
As soon as possible (ASAP) – Order priority is sometimes used to
holder while the blood is being collected
indicate that the sample needs to be collected generally within an
 Tubes slides back out, and then it stops filling with blood
hour of the order time

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 27

Ammonia – the sample must be placed on ice and then delivered to brachial artery, resulting in debilitating nerve damaged if
the laboratory within 20 mins they are punctured.
 Must be drawn last and then delivered immediately to the  The femoral artery is one of the largest arteries in the
laboratory body. It is located in the groin and can be palpated and
punctured easily due to its size. The femoral artery is
Arterial Punctures commonly used for cardiac catheterization. Femoral
 Are used to obtain a sample for blood gas analysis. The Artery puncture, it is one of the last choices for arterial
blood gas determines the effectiveness of a patient’s blood gases
ability to use oxygen and expel carbon dioxide  Arterial punctures must be done with special arterial blood
 The dissolved oxygen in the blood is the PO2. The dissolved sampling kits.
carbon dioxide is the PCO2
 The pH of the blood is a measure of the acid-base balance
Basic equipment consists of the following:
of the blood.
 The body carefully regulated the blood pH , maintaining it 1. An anti-septic solution such as povidone-iodine or
within a narrow range of 7.35 to 7.45 betadine
 The arterial blood has a uniform composition of gasses in 2. Gauze squares
all parts of the body. 3. A preloaded arterial blood gas syringe with a heparin
solution of 1,000 international units/mL
 Venous blood gas varies depending on the cell location
4. Various hypodermic needles, generally 22 gauge and 3/8
 Arterial blood is the sample of choice for blood gas
inch to ½ inches in length; length depends on location of
analysis
puncture sites
 Blood gas analysis is best done during a period of steady
5. Syringes can be 1 to 5 Ml
state
6. Ice water solution or bag of crushed ice
 A period of 20-30 mins is need for a patient to reach
7. Glass has traditionally been the preferred type of syringe
steady state after a physical activity or treatment
because of the limited exchange of gas through the glass
and the ease with which the arterial pressure fills the
Hazards syringe
8. Plastic syringes have now become more effective with
Two hazards of arterial blood collection: prefilled heparin and ease of filling without manual
1. Because of the higher pressure of arterial blood compared aspiration
with venous blood, a hematoma is more likely 9. Evacuated tubes should not be used for arterial blood
o The older the adult has a decrease in elastic sampling
tissue and therefore an increase in the possibility
of hematoma Arterial Blood Gas Procedure
o a patient on anticoagulant therapy has an even
 patients who are to have arterial blood gases drawn are
greater chance of a hematoma
either on room air or are on an enriched oxygen mixture
2. Arteriospasm – a reflex condition of the artery in response
 The amount of oxygen the patient is receiving and expiring
to pain or anxiety
must be recorded before the blood gases are drawn.
Arterial sites  This is recorded as a fraction of inspired oxygen (FiO2) in
percent or prescribed flow rate in liters per minute (L/M)
 a newborn infant during the first 24 to 48 hours of life has
large umbilical arteries
 A sick infant’s respiratory system must be monitored
frequently by the measurement of arterial blood gases.
The measurement is completed by catheterization of the
umbilical arteries.
 The preferred puncture site in adults is the radial artery,
located on the thumb site of the wrist. It is easy to palpate,
and the patient is less hesitant about a puncture there.
 Collateral circulation by the ulnar artery must be check by
use of the Allen test before puncture is made in the radial
artery

Allen Test
 Allen Test - checks the patient for collateral arterial
circulation. This is done so that when accessing the radial
artery for blood gas analysis, an alternate artery is
functional and supplying arterial blood to the hand. The
procedure follows several simple steps.
 The brachial artery can be used for arterial punctures but
has several disadvantages. Its location deep within the
muscles and connective tissues make palpating and
puncture difficult. Major nerves run in the location of the

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 28

Chapter 7. THE CHALLENGE OF PHLEBOTOMY  Earlobe – not recommended except in extreme cases such
as severely burned patient.
 Ring finger
VENIPUNCTURE ON CHILDREN
 Great (middle) finger
Holding still – one of the most critical factors in obtaining an
Capillary puncture in an adult is on the palmar surface of the distal
accurate blood sample from children, because fighting and crying
phalanx of either the ring finger or great (middle) finger.
will change blood values.
Limit venipuncture in children younger than 2 years old to
Puncture the finger across the fingerprint line – delivers the best
superficial veins through butterfly collection set and a 23-gauge
possible blood flow and facilitates the formation of drops of blood.
needle.

CLEANING THE SITE

PERFORMING A CAPILLARY PUNCTURE
 Use 70 percent isopropyl alcohol – if not dried, will sting
Capillary Puncture – the method of choice in children under 1 year
and sample will become hemolyzed.
of age and for adults whose veins are inaccessible.
 Do not use povidone-iodine (Betadine) – elevates
- Done by puncturing the skin and underlying capillaries.
potassium, bilirubin, phosphorus, or uric acid.
Adult: done in the finger
Children under 1 year of age: foot is the puncture site of choice
 Capillary puncture of the earlobe is not recommended PUNCTURE OF THE FINGER FOR CAPILLARY BLOOD
because the blood flow is not adequate. Retractable puncture device – in which the phlebotomist pushes the
 The blood from a capillary bed is predominantly blade into the finger or the blade is activated when the puncture
arterial (generally acceptable as a substitute for device is pressed against the finger.
venous blood) Two different principles:
a. Blade that punctures straight down with a guillotine-
Capillary punctures in adults are used in several situations: type action and then retracts back into the holder.
b. Gauged for the age of the fingerstick patient. (the
1. Patients who are severely burned
smaller the patient, the shallower the puncture)
2. Patients with cancer whose veins are reserved for therapeutic
First drop – needs to be wiped away because it has interstitial fluid.
purposes
0.5 mL of blood can be collected from a single puncture.
3. Patients who are obese and whose veins are too deep to
locate
4. Geriatric patients or other patients whose veins are COLLECTION OF THE SAMPLE
inaccessible or very fragile Free flow of blood into the collection device – optimize the amount
5. Point of care testing (POCT) in a health care facility of blood.
6. Patients performing tests on themselves  Scraping of blood (hemolyzes cells)
7. Special procedures that require capillary blood - Results in clot before it is mixed with the anticoagulant
Anticoagulant samples should be mixed by inverting 8 to 10 times
Patients who cannot produce adequate capillary puncture blood once they are capped.
sample:
 Severely dehydrated or have poor circulation (in shock) OBTAINING A BLOOD SAMPLE FROM BABIES
 Extremely cold Heel – puncture site of choice on infants and young children.
- Medial or lateral surface of the plantar side of the heel
The patient’s hand needs to be warmed before capillary puncture if (MLPH – Make Little People Happy)
there is any coolness. On the inside (medial, or big toe side) of the heel is the
 Warm the hand with warm wet washcloth (42C) for only posterior tibial artery near the curvature of the heel.
3 to 5 minutes. The outside of the heel (lateral, little toe side) is the primary
o The washcloth will have a cooling effect due to area of choice for use to avoid possible dame to posterior tibial
evaporation instead of a warming effect if left on artery.
longer.  Do not do punctures in the central arch area of the foot –may
Heat– enlarges the capillaries, blood flows faster (sevenfold), and result in damage to nerves, tendons, and cartilage and offers
the phlebotomist obtains a better bleed. no advantage over a heel puncture.
Massaging the patient’s finger – an alternative to warming when Osteomyelitis (bone marrow) or Osteochondritis
warming is not convenient. (cartilage)

SITE SELECTION FOR CAPILLARY PUNCTURE DEPTH OF PUNCTURE

 Infant heel  0.85 mm – premature infants with capillary bed of 0.35
to 1.6 mm

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 29

 2 mm – full-term infants with distance to bones and

main nerves of 1.2 to 2.2 mm
COLLECTION OF THE SAMPLE
Excessive crying – elevated leukocyte counts; will not return for up
to 60 minutes.
Quick Heel by Becton Dickinson Company – spring loaded puncture
device for infant heel stick procedure.

PREACAUTION
Hemolysis – the greatest concern with microcollection samples.
- Hemolysis as measured by the concentration of free
hemoglobin in the serum or plasma of the blood may not
be readily apparent.
- In cases of infants with elevated bilirubin: yellow color of
serum may mask hemolysis.
- Potassium is elevated in all hemolyzed samples.

Causes of Hemolysis
a. The alcohol used to clean the skin was not allowed to dry.
b. The finger or heel was squeezed too vigorously in an
attempt to produce greater blood flow.
c. Newborn infants have increased red cell fragility and high
red blood cell volume.
d. Blood was scraped off, instead of allowing it to flow into
the microcollection container.

Differences in Laboratory Values in Capillary Blood in

Relationship to Venous Blood
Test Difference in Values from Venous Blood
Glucose Higher in capillary blood
Total Protein Lower in capillary blood
Calcium Lower in capillary blood
Potassium Lower in capillary blood; increased with
presence of hemolysis or excess tissue fluid

ORDER OF DRAW
1. Blood glucose
2. Slides/smear
3. EDTA
4. Heparin
5. Other additives
6. Non-additive (serum)

THE PATIENT ON ANTICOAGULANT THERAPY

- Susceptible to continued bleeding and hematomas

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 30

Chapter 8. CARING FOR THE PEDIATRIC PATIENT o Egocentric – unable to view others’ thoughts/feelings;
does not understand the reason for blood collection
Patient’s comfort – should be of primary importance. o Fantasies and misconceptions about the equipment used
o Limited understanding of body functions or procedures
o Painful and frightening procedures
KEYS TO CARING PEDIATRIC PHLEBOTOMY
Ways to minimize stress:
1. Be calm and confident. o Use restraints but at a minimum
2. Get down on the child’s level. o Prepare the patient for all the procedures using medical
3. Explain every step of the procedure. play and equipment
4. Role-play with the child by showing with a stuffed animal o Explain what is going to be done
or doll what will happen. o Use simple coping strategies
o Reinforce the reason for treatments/hospitalization as not
A CHILD’S UNDERSTANDING OF ILLNESS due to the child’s behavior or actions; he or she has not
The First 2 Years been “bad”
 They have limited understanding of illness beyond “being o Support parents emotionally and prepare for child’s
sick”. reactions
 They feel stress due to separation from familiar care givers
and changes in home routine. DEVELOPMENTAL REACTIONS TO PAIN
Ages 2 to 6 Years
 Magical thinking creates misconceptions and fantasies.
Infants
 Medical care may be viewed as punishment for bad
behavior. Babies rely on a caregiver to notice pain by seeing the following
 Internal organs/parts are difficult to understand. signs:
 Medical play is optimal for illness education and medical  Restless, clingy, or whining
procedures.  Decreased activity (sleep more, lose interest in a favorite
6 to 9 Years toy)
 They understand some mechanics of health.  Increased frantic activity
 Concerns of death are more prevalent.  Loss of appetite
 They can understand how procedures and medications  Difficult to console
help the body fight disease and infection and lead to a
cure. Toddlers and Preschoolers (2 to 5 Years)
 Medical play and body drawing are useful tools for Children ages 2 to 5 experience pain but cannot always pinpoint its
education and coping. source or location. At this age, reactions to pain can include the
 They still have some misconceptions and fantasies. following:
Ages 10 and Older  Belief that pain is a punishment
 They have a fairly clear understanding of what illness is  Belief in the magical disappearance of pain
and can explain why they do not feel well.  Resistance during painful procedures
 Require less practice with relaxation
PSYCHOSOCIAL NEEDS OF PEDIATRIC PATIENTS
School Age (6 to 12 Years)
Psychosocial behavior – when they are exposed to both social and
psychological behavior. School-age children are able to locate pain in terms of body parts.
Children ages 6 to 12 experience the following reactions to pain:
 Afraid of their bodies will be damaged or changed
Infants and Toddlers
 Feel injury related to guilt (deserve pain)
Stress factors:  Require more practice with relaxation
o Very vulnerable to separation
o Limited mobility due to the procedure MANAGING PAIN
o Changes in daily schedule and routine
Topical Anesthesia – most direct methods; numb the site of the
o Unfamiliar people, places, and sounds
venipuncture; takes about 30 minutes to fully numb the area
o Sensitive to excess stimulation
 Lidocaine and prilocaine cream (ELA-MAX)
Ways to minimize the stress:
o Encourage parents to allow the patient to bring a comfort  Ametop and 4 percent lidocaine
item Sweet-Ease – sugar-coated pacifier that children suck for comfort
o Talk to the patients in a calm and soothing voice at all
times DISTRACTION
o Provide as much “TLC” as possible Distraction – the idea of moving the child’s attention from the
o Lessen environmental stressors, such bright lights, noise, procedure to something else.
or cold  Bubbles or spinning flashlight
o Support parents emotionally and prepare for the child’s  Large picture books
reactions
SAMPLE COLLECTION FROM AN INFANT OR A PEDIATRIC PATIENT
Preschoolers Fingersticks and heelsticks– usually performed on infants or small
Stress factors: children when the testing requirements are minimal.
o Separation anxiety and stranger anxiety Common Tests:

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 31

 Neonatal screening – filter paper – newborns

 Bilirubin – newborns
 Complete blood cell count (CBC), hemoglobin, and
hematocrit – all ages
Venipuncture – performed on older children or children for whom
several laboratory tests has been ordered. (23-gauge butterfly)
 Routine coagulation studies (Prothrombin time [PT],
activated partial thromboplastin time [APTT])
 Blood cultures
 Lead level (more accurate if performed on venous blood
than capillary blood)
 Tests that require significant amount of blood, such as
allergy testing
High intensity and infrared light – used to illuminate veins in both
adults and infants.

DORSAL HAND VEIN

o Often preferred as an alternative to a heelstick or
fingerstick
o Little trauma to cells (less tissue fluid and hemolysis)
o 25-gauge syring needle

Restraining a child – often necessary to avoid hurting the child while

the sample is collected.
 Papoose boards – used to restrain a child

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 32

CHAPTER 10. SAMPLE PREPARATIONS AND HANDLING Creatinine Increase

Uric Acid Increase
Lactate Increase
Pyruvate Increase
PRE- EXAMINATION VARIABLES
White blood cells Increase
Neutrophils Increase
Patient identification
Glucose Increased with stress
Decreased with exercise
- Pre examination errors comprise to 46 to 56 percent of all
Hemoglobin Decrease
errors encountered for laboratory samples
- Pre examination errors are sometimes calledpreanalytical
errors CHANGES DUE TO POSTURE
- Improper patient identification is the most serious and Analytes Changes from lying down to standing up
potentially dangerous pre examination error Blood Pressure Increase
- Physician may prescribe a harmful or even fatal treatment Blood Volume Decrease
due to misidentification Calcium Increase
Cholesterol Increase
Tourniquets Lipids Increase
Drugs Increase
- Should be on the arm no longer than 1 minute Steroids Increase
- Increases the intravascular blood pressure, resulting in a Thyroid Hormones Increase
push of small molecules and fluid from the capillaries
surrounding tissue
- Reduction of fluids results to hemoconcentration Fasting and Timed Samples
- Inability to circulate causes lowers the pH and causes - Before collecting any samples, determine if the patient is
potassium to be forced out of the blood cells; changes in fasting by asking the patient if he or she has had anything
pH causes an elevation in calcium and magnesium to eat and drink
- Means no food and drink for 8 to 12 hours; should not
Exercise and Posture have had chewing gum, orange juice or anything other
than water—misconception that black coffee is not a
- Can change the patient’s cell permeability; will cause an problem but the coffee as well as smoking can affect
increase in concentration of creatine kinase (CK), aspartate metabolism and test results
aminotransferase (AST), lactate dehydrogenase (LDH), - Fasting Samples: generally collected in the morning after
bilirubin, creatinine and uric acid overnight fasting
- Lactate and pyruvate increase in even moderate exercise - Fasting samples do not have specific time for collection; it
due to the increased metabolic activity of skeletal system must be collected before the patient has anything to eat
- Total white blood cells (WBCs) can increased by as much - Typically, early in the morning but could be afternoon as
as 2,000 as a result of exercise or other stresses; same as long as the patient has not had any to intake
the WBCs of a crying baby - Other tests require that the sample be collected at a
- Extremely tight fist and pumps of the hand can increase specific time because of medication or diurnal rhythm
lactate by as much as 100 percent and more; expect - Collecting sample to determine the drug level at incorrect
hemoglobin, most analytes increase due to exercise and time could result to miscalculation of the next dosage
stress - It is important to control the timing of collection because
- Changes in posture can change blood volume some blood analytes exhibit circadian or diurnal changes
- Patient who goes from lying down to standing will have an - Cortisol can vary as much as 50 percent between samples
increase in blood pressure collected in the morning and evening
- Decrease in blood volume will occur by fluid moving from - Serum iron levels are lower than in the morning than in
the veins through the tissue; those analytes are too large the evening
to pass through the vascular wall will be concentrated - Hormones such as renin, aldosterone, growth hormone
from the blood and thyroid stimulating hormone shows daily changes; can
- Calcium, cholesterol, lipids, drugs, steroids and thyroid be cyclical (weekly or monthly)
hormones will increase - Circannual change is demonstrated by calcium that
- With exercise and prolonged tourniquet application, increase in the summer due to exposure to more sunlight
hemoconcentration occurs and the resultant increase in Vitamin D
- Other analytes also change in different season due to
CHANGES DUE TO EXERCISE AND STRESS
changes in diet and physical activity at different times of
Analytes Change the year
Creatine Kinase Increase
Aspartate Aminotransferase Increase
Lactate Dehydrogenase Increase
Bilirubin Increase

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 33

Evacuated Tubes - 11 percent of syringe- collected EDTA samples clotted,

- Pre examination errors can occur from an incorrect compared with none when an evacuated tube system was
volume of blood in the tube and wrong use of used
anticoagulant - Most of this hemolysis and clotting is the result of the
- Provide the laboratory with properly filled tube to avoid an trauma when transferring the blood from the syringe to
error result or a recall of the patient the tube and the delay before the blood is mixed with
- To have an accurate result, most tubes should be filled at anticoagulant
least 75 percent of the stated volume Cleaning the Puncture Site
- Less blood causes dilutional effect, leading red blood cells
to decrease in size - Generally cleansed with alcohol (70% isopropyl)
- Too much blood into the anticoagulant tube causes the - For blood culture, site must be prepped with povidone
blood to clot because there in not enough anticoagulant iodine (betadine) or tincture of iodine; iodine can increase
for the volume of blood potassium, phosphorus and uric acid
- Most critical tube for correct fill size is citrate tube; - Remove the iodine with an alcohol pad if any testing other
variation of fill can only be plus or minus 10 percent from than blood culture is collected
the stated volume - Cleaning venipuncture site for blood alcohol testing must
- When blood tubes filled partially, another tube must be be done using a non- alcohol cleaner
drawn to obtain proper amount Order of Draw
- Partial tubes cannot be poured together; because
anticoagulant in the tube is doubled resulting in altered - Most common factor that varies test results
results - Blood must be collected from the patient’s arm in the arm-
- Serum and plasma samples generally cannot be mixed down position to prevent anticoagulated blood from
- EDTA in the plasma tube binds calcium; serum tube that is flowing back into the needle and contaminating the next
partially filled with EDTA blood will have a reduced calcium tube
level due to the bound calcium in the plasma volume - Following the correct order of draw prevents the
- If the patient is not available for re-collection, the anticoagulant from one tube from contaminating of the
phlebotomist should send the partially filled tubes to the next tube
laboratory and the laboratory will determine if samples - EDTA and heparin can increase prothrombin (PT) and
can be combined and the testing done; partially filled tube activated partial thromboplastin time (APTT) tests results
may be acceptable for certain tests if they are drawn before the citrate tube
- Defective tubes can give improper fill; tubes should vary - EDTA contamination can give high potassium result if the
no more than plus or minus 10 percent in filling tube drawn after EDTA is tested for potassium; EDTA used
- All anticoagulant tubes must be mixed by inversion to in the tubes can be either dipotassium EDTA or
disperse the anticoagulant with blood; inversion of tubes tripotassium EDTA
must be completed immediately after the tube is pulled - Heparin tube should be drawn before the EDTA tube
from the holder Chilling of Samples
- Failure to invert the tubes will allow microscopic clots to
form - Should be placed in a mixture of ice and water as soon as it
- Most sensitive tubes are lavender stoppered (EDTA) is withdrawn from the evacuated tube holder; delay in
resulting in lower platelet count and sodium citrate tubes icing may altered the results
in which improper inversions results in erroneous - Some tests require prechilling the empty evacuated tube
coagulation test results before drawing the blood
- Proper heparin tubes to use can be confusing; testing for - The longer the delay, the greater the change in test results
sodium heparin tube can indicate the patient has elevated - Chilling an uncentrifuged serum tube releases potassium
sodium value, lithium is increased in lithium heparin tube from the cells and elevates the serum potassium values
and chromosomes studies need sodium heparin because Common test requiring chilling of the specimens
lithium can be toxic to cells 1. Ammonia
2. Acid Phosphatase
Syringe Collection
3. Catecholamines
- Most common problems arise when syringes are used to 4. Lactic Acid
collect blood 5. pH/blood gases
- Clinical Laboratory Standard institute (CLSI) discouraged
the use of syringes
- Difficult draws are best performed by butterfly tube Warming of Samples
system and evacuated tube is the preferred method of
- Tests are maintained at body temperature of 37-degree
collection
Celsius
- If syringe collection is used, there is an increase in
- Best method is to wrap the sample with heel warmer or
hemolysis and the clotting of the samples collected; visual
use a plastic block (warming block); theses blocks have
hemolysis was found in 19 percent of samples drawn in
holes drilled in them to accept different sizes of tubes
syringes and 3 percent drawn in evacuated tubes

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 34

Tests that must be maintained at 37 degree Celsius - Standard camping coolers are excellent for this purpose;
1. Cold Agglutinins whatever secondary container is, a biohazard emblem
2. Cryoglobulin must be attached
- Pneumatic tube system that transport samples are more
traumatic than hand carrying the samples but have the
Exposure to Light advantage of faster delivery
- Detrimental to some samples; bilirubin is vulnerable - Sample should be placed into a padded container to
- Bilirubin samples should be collected to an amber tube maintain integrity of the sample and to prevent trauma
instead of capillary collection tube because they tend to be - Laboratories have local couriers who pick up the sample;
more exposed to light they are trained to handle blood borne pathogens and
- Various tests like Vitamins C, E and K must be protected have special containers to transport the sample; self-
from light sealing bags for these specimens have two compartments
- Most efficient method to protect the sample from light is (1st compartment for the sample and 2nd compartment for
to wrap it in an aluminum foil the requisition)
- Leakage could spread blood- borne pathogens to packages
Criteria for Re-collection or Rejection of Sample delivered to someone’s home
- Primary container is wrapped in absorbent package
Often done to re-check results on patients material; must be sufficient to absorb the entire contents
of the primary container
1. Each sample must have its own label attached to the
- Outside of the shipping container must have the biohazard
sample’s primary container
emblem and wording that container holds an etiologic
2. Each sample must have on the label name of the test to be
agent
performed
- Integrity of the sample must be maintained during
3. Labels must have patient’s complete name and hospital
shipment
number or unique identifier
- Avoid extreme variation in temperature; will rupture the
4. The sample must be collected within the time limit
red blood cells
requested
a. Federal Aviation Administration (FAA) and other
5. Samples in syringes must have needles removed and the
agencies
syringe capped before transport
o regulate the shipment of etiologic agents
6. Urine samples must have label on the container and not
o must have a special documented training in the
on the lid
regulations
7. The appropriate anticoagulant must be used for samples
b. Centers for Disease and Prevention (CDC)
requiring an anticoagulant
o specimen shipments in United States and
8. Anticoagulated blood samples must be free from clots
internationally are regulated either hazardous
9. Certain tests require samples to be free from hemolysis
materials or dangerous good regulations
and lipemia
o Clinical specimens require packaging that meets
10. Blood samples drawn above an intravenous (IV) injection
Department of Transportation (DOT)
site are unacceptable
c. International Air Transport Association (IATA)
11. The sample must be recollected if the results are not
Dangerous Goods Regulations (DGR)
consistent with the previous result from the patient
o classify infectious substances into two
Sample Preparation and Transportation categories; biological substances (category a)
and biological substances (category b)
Transportation
- The phlebotomist, a transporter person or pneumatic tube 1. Biological Substances, Category A: an infectious substance
system usually does the transportation within the facility which in a form that, when exposure to it occurs, it is capable of
- Primary container is the container in which the sample is causing permanent disability, life- threatening or fatal disease
collected; when the sample is transported, primary in otherwise healthy humans or animals
container must be placed in a secondary container so any 2. Biological Substances, Category B: an infectious substance
leakage or breakage of primary container is contained which does not meet the criteria for inclusion in Category A
- Increased use of plastic tubes has reduced the incidence of
breakage but there is still possibility of the cap coming off Medicolegal Transport
the tube - Transportation of samples for blood alcohol testing,
- Plastic self- sealing bag is sufficient as secondary container paternity testing and toxicology testing must be given
- Samples from different patients should not be placed in special consideration
the same bag; all labels must be attached to the sample
tubes before they are placed in the bag
- Large number of samples can be placed in a rack to avoid
spillage or breakage; entire rack placed into a bag or leak
proof box

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 35

CHAPTER 11. COSTUMER SERVICE 1. The sender begins this communication cycle by creating a
message.
- Composed of many facets that can make a customer either
2. The message must be created so that the receiver is able
appreciative of the quality service or angry because the
to interpret it.
entire needs were not met
3. The message is the information that is being
- The phlebotomist who meets the customer’s need is the
communicated.
phlebotomist that provides the best customer service
4. The information can be communicated by (1) speaking (2)
Customer- anyone who is affected by the phlebotomist’s work listening (3) gestures or body language or (4) writing.
External customer- patient (wants a caring and pain- free 5. The receiver must decode the message and then provide
procedure) feedback to the sender.
Internal customer- can be the nurse caring for the patient, the 6. Through the feedback, the sender will know that the
family of the patient (wants a caring and quality person taking message was understood.
care of the family member; wants someone who keeps them 7. The message is made up of both verbal and non- verbal
informed and does not treat them as if they are in the way), the communication.
physician (wants a timely and quality results), etc. 8. The communication must be in the language that the
receiver understands.
If the phlebotomist would put themselves more often in their
Verbal Communication— spoken
customer’s place, the customer service would always be quality
Non- Verbal Communication— postures, gestures, eye contact and
service
facial expressions; body language is known as kinesics
The chain follows: Kinesic slip— when the verbal and nonverbal messages do not
match
1. The phlebotomist is hired to perform the task of collecting
Proxemics— distance
blood and non- blood samples
2. The phlebotomist gives quality service a. Intimate
3. Customer satisfaction improves b. Personal
4. More customers are retained and tell other about the c. Social
quality service d. Public
5. As the profitability of the company goes up, the salaries Appearance
may rise Touch – therapeutic touching- massage
6. More phlebotomists are given jobs to due increase of Contact Profession— ability to listen
customers  Communication needs listening; it is more difficult to
7. The cycle starts again in step 2 maintain
o People can speak at a rate of 100 to 200 words per
Customer Expectations for Quality Service minute and can listen at a rate of 500 to 600 words
1. Know what the customer wants per minute; people can understand and listen at a
2. Determine whether or not the customer is getting the faster rate than they can speak
service
3. Continuously take action to satisfy the customer Active listening requires the listener to follow five steps:
1. Focus on the customer
Communication Skill 2. Limit your talking. This allows the customer to express
 Communication-- one of the primary methods of showing their feelings
the customer that there is an attitude of caring 3. Do not interrupt
 improper communication skills can demonstrate that an 4. Manage your thoughts
attitude of caring is not being communicated, resulting in 5. Listen for feelings, not just words
customer complaints
 proper communication skills can assure the customer that  The goal of communication is to create a common
he or she is the most important person to the understanding between two or more people. Common
phlebotomist; phlebotomist must have an excellent ground of understanding is affected by each person’s
communication skill frame of reference.

Communication- sending and receiving of messages; starts with a The frame of reference consists of a person’s:
sender who creates the message, which is then accepted by the 1. Background
receiver. 2. Education
3. Experience

 Differ in any of the frame of reference, may have difficulty

communicating with each other. Effective communication
must involve common grounds of people
 Different communication levels will mean that the
conversation needs to be in the level of least- educated
individual
 Must find common experience before the effective
communication can be maintained

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 36

Do’s and Don’ts of Communication Skills  is the process in which the situation is analyzed and
appropriate action is taken
Do not say: “I don’t know”
Say: “I’ll find out” Five ways in approaching conflict:
Do not say: “No” 1. Accommodator- smoothing over the conflict is a method
Say: “What I can do is…” of accommodating, pacemaker in the conflict. The goal is
Do not say: “You’re right, this stink” to maintain peace at whatever cost.
Say: “I understand your frustration” 2. Avoider- will ignore the conflict; postponing the conflict or
Do not say: “That’s not my job” changing the subject of the conflict
Say: “This is who can help you” 3. Collaborator- works to understand the conflict and find a
Do not say: “That’s not my fault” solution; works to resolve
Say: “Let see what we can do about this” 4. Compromiser- works to find mutually acceptable
Do not say: “You need to talk to my manager” compromise that partially satisfies all parties; done
Say: “I can help you” through manipulation and domination of the parties in a
Do not say: “You want it by when?” conflict
Say: “I’ll try my best” 5. Controller- tries to overpower everyone and dictate what
Do not say: “Calm down” needs to be done for a resolution
Say: “I apologized for what happened”
Do not say: “I’m busy right now” Coping with Stress
Say: “I’ll be with you in just a moment”  Determine your own attitude
 stress—emotional turmoil that results from distressing
Patient’s Satisfaction thoughts or difficult life event; can be acute (immediate)
 keeping the patient satisfied is one of the primary roles of or chronic (long term)
the phlebotomist
 patient’s major concern is being treated kindly and fairly Acute Stress – caused by a one-time incident (narrowly avoiding
and having a quality sample obtained automobile accident or vocal misunderstanding with someone), can
 affected by factors not always controlled by the last from a minute to hours or even weeks
phlebotomist  affects someone for a short time
 physical facilities—determine what the customer thinks of
the experience Chronic Stress – caused by continuous stressful incidents (difficult
 health care—unique in that most people do not shop for it job environment, depression, etc.)
by price
 third party insurance payer—someone else who pays for Thinking about Stress
the blood test  distorted thinking—causes stress
 irrationality in thinking—leads to obsession and anxiety
Following are reasons a patient chooses a location to have his or her  maintaining a sense of control—key to having a reduced-
blood drawn: stress environment
1. the insurance carrier dictates this is where the patient
should go Reducing Stress
2. the physician directs the patient to a certain location, or 1. laughing is an excellent way to reduce stress
the physician draws the patient in his or her office 2. children- up to 300 times per day
3. the draw site in a convenient location 3. adults- up to 20 times per day
4. the image that the draw site projects is good 4. managing your time and commitment will help to relieve
stress
 laboratory management must contract with the insurance
carriers; laboratory will be the patient’s primary laboratory
insurance
 in-office phlebotomy—contracts for the physician to draw
samples in the office; must satisfy all the internal and
external customers
 professionalism and phlebotomy skills are the attributes
that the phlebotomist contributes to patient satisfaction
 convenience of draw site—best in in- office phlebotomist
 image of the patient service center project—must
highlight professionalism of both phlebotomist and
laboratory

The Smallest Patient Also Need Customer Service

 pediatric patient should not be forgotten in providing
excellent customer service

Conflict Management

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 37

Chapter 12. COMPLIANCE: LEGAL AND ETHICAL ISSUES  Accidental arterial puncture
 Nerve damage
 Mislabeled/unlabeled sample
COMPLIANCE
 Exposure to patient to blood-borne pathogens of another
 Formalized monitoring of an organization’s adherence to
patient
laws and regulations.
 Required to prevent fraud, abuse, and waste in the clinical
laboratory industry while at the same time providing
CRIMINAL CASE
quality service to the customer.
 Concerned with laws designed to protect all members of
 Establish a culture within the laboratory that promotes
society from unlawful acts by others.
prevention, detection, and resolution of instances of
conduct that do not conform to the law.  Violators may be sentenced to death or imprisonment.

Anti-kickback Law eg. Felony (murder, rape, assaults, homicide and others)
and Misdemeanor
 Prohibits the knowing and willful payment or offer of any
remuneration directly or indirectly in return of inducing,
referring, or soliciting services, including laboratory testing CIVIL CASE
paid for by a federal health program.  concerned with actions between two private parties.
 Prohibits payment in money or services to a physician in
order to solicit business from that physician. eg. Breach of Contract and Tort Law (wrongful act other
 It could be given to an employee or relative of the than breach of contract)
physician, and it would still be considered a kickback.
Tort Law
Stark Law
The area of law that protects people from bad acts of others:
 Forbids a physician from referring a sample to a laboratory
in which the physician or an immediate family member has a. Assault – act or threat causing another to be in fear of
a financial interest. immediate harm.
 Prohibits a physician from referring business to a b. Battery – intentional harmful or offensive touching or use of
laboratory in which the physician has a financial interest. force on another person without consent or legal justification.
c. Fraud – fake or deceitful act, false portrayal of facts.
False Claims Act d. Invasion of Privacy – violation of one’s right to be left alone.
 Prohibits knowingly presenting a false claim to the e. Breach of Confidentiality – failure to keep privileged medical
government for service not performed or charging for information private.
more services than were performed. f. Malpractice – type of negligence; careless illegal action by
someone performing a professional duty
Civil Monetary Penalties Law g. Negligence – doing something a reasonable person would not
 Applies to claims for services that are not provided as do or not doing something a reasonable person would do.
claimed. (re ipsa loquitor “the thing speaks for itself”)
h. Standard of Case – each individual should receive samelevel of
ELEMENTS OF A LABORATORY COMPLIANCE PLAN care.
1. Standards of Conduct i. Vicarious Liability – liability imposed by the law on one person
2. Medical Necessity for acts committed by another. (respondeat superior“ let the
3. Billing master respond”)
4. Reliance on Standing Orders
5. Compliance with Fraud Alerts
6. Marketing PATIENT CONSENT
7. Prices Charged to Physicians a. Informed Consent – patient has given voluntary consent
8. Retention of Records after being informed.
9. Compliance as an Element of a Performance Plan b. Expressed Consent – consent give voluntarily with proofs
expressed both verbally or nonverbally
MEDICOLEGAL PROBLEMS c. Implied Consent – act automatically implying a consent
d. HIV Consent– long process with proper counseling
Complications of Phlebotomy that can result in legal action: e. Consent for Minors – patients below 18 years old
 Consent to perform venipuncture f. Refusal of Consent
 Fainting or convulsing patient
 Hematoma

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 38

Chapter 13: Competency The following procedures may have limitations on who is allowed to
perform them:
 A detailed procedure that takes many factors into  Nasopharyngeal swabbing
consideration in performing phlebotomy must be used to  Eye or ear swabbing
document the competency of the phlebotomist  Wound swabbing
 Patient’s age, patient’s physical and mental condition. And  Manipulation or withdrawal of samples from indwelling
the tests being performed on the patient delineate the catheters (intravenous, arterial, urinary)
skills the phlebotomist needs to perform the task  Arterial punctures
 A competency program is based on a stepwise  Therapeutic phlebotomy
training/competency guide that the phlebotomist can  Injections
progress through at his or her own pace
 Tuberculin skin or other skin tests
General Information taught in Phlebotomy Training:  Skin scrapings
o Limits on phlebotomy procedures
o Some procedures require the skills of a pathologist or
o Patient safety
physician
o Patient reactions
o Many of these procedures can be performed by a
o Age-specific care
phlebotomist with proper training and documentation of
o Competency checklists on specific procedures
competency
o How many successful procedures must be completed
during training for each specific procedure
Patient Safety and Developing Competency for all Types of Patient
o Safety for the patient and phlebotomist must be stressed
 A program should consist of an explanation of the in the competency training program
procedure, the written procedure, a competency checklist, o There are several factors to consider in ensuring the safety
and the number of different age groups of patients on and competency training of a phlebotomist
whom the procedure must be performed

The following text details information that is to be covered in a

Fainting or Convulsing patient – even if the phlebotomist does not
competency program
experience such a patient during training, the phlebotomist should
be able to explain the necessary care that would be needed for that
Frequency of Competency Documentation patient
 Any personnel performing procedures must undergo initial
training when starting the job, an evaluation 6 months Hematoma – Elastic bandages should be used at appropriate times,
after the hire date, and an annual competency evaluation such as on patients taking blood thinners
 After the first year of employment, there must be an
annual review of the phlebotomist’s skills Obese Patient – the obese patient’s veins are often difficult to feel
 Each evaluation must clearly indicate what skills were through the layers of tissue
trained, who was being trained, the trainer, and the dates  The tourniquet has to be rather tight to exert pressure
of training deep enough to slow the flow of venous blood
 A final supervisor signature must be on the evaluation  Firm palpitation is necessary to identify depth and size and
 This documentation of competency is used to verify that to estimate the elasticity and response condition of the
the associate is capable of performing the duties of the job vein
 The phlebotomist has a 3-year period to complete a
specific amount of continuing education to maintain Patient with Damaged or Collapsing Veins – this usually result of
certification, if the phlebotomist does not complete the the patient having been burned, scars on the veins from drug abuse,
required continuing education, he or she will no longer be chemotherapy, accidents, or surgical procedures in the areas of the
certified veins
 The goal of the program is to demonstrate to the public  Purple or dark-blue discoloration of the skin indicated mild
that laboratory professionals stay current in their practice or previous bruises caused by overuse of the site for
phlebotomy
Limits on Invasive Sample Collection Procedures by Phlebotomist  If no other site is available, insert the needle at a point
o The limits of what procedures a phlebotomist may lower in proximity to the damaged site and thread the
perform must be stated in the competency program. needle up to the proper position in the vein
 A collapsing vein is weak, the vacuum of the syringe or
Procedures that would be normally performed are as follows: evacuated tubes sucks the walls of the vein together so no
blood can flow
 Routine phlebotomy
 Using a syringe and/or butterfly is the best method to
 Blood cultures
obtain blood from a collapsing vein
 Capillary punctures
 Heelsticks Age-specific Care
 Template bleeding times o Phlebotomy techniques vary as the age of the patient
 Urine collection changes
 Throat (oropharyngeal) swabbing for patients age 3 years o The competent phlebotomist recognizes these differences
and older in patients and adjusts techniques appropriately

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 39

o The phlebotomist works with four age groups o To complete a compliance program, the phlebotomist
must understand the procedures to be followed
Infant – microcollection through capillary puncture is the method of o The competency program must include an explanation of
choice for the infant the procedure, a copy of the procedure, and a detailed
 From birth to about 6 months, the heel is the proper area observed check-off of the procedure.
of capillary puncture. After 6 months, the heel starts to o In a competency training manual, the short explanation of
become too thick, and the fingerstick or large-toe-stick the procedure is in paragraph form, telling about the
may be appropriate procedure and the equipment used
 Both heelstick and fingerstick require a microcollection of o The competency check-off is completed as the trainee is
the sample observed performing the procedure
 The optimal depth of puncture for the heel of a full-term
infant is 2mm An example of the outline of this section of the training manual
 The optimal depth of puncture of an infant’s finger is 1.2 follows:
to 2mm
1. Procedure Explanation – the information is condensed
Pediatric – venipuncture in children younger than 2 years old should version of chapters of a textbook that explain the principle
be limited to superficial veins behind the procedure
 Collection of blood from superficial veins generally is most 2. Procedure – follows the guidelines published by the
successful with a butterfly collection set and a 23-gauge Clinical Laboratory Standards Institute
needle 3. Observed Competency Check-off – the competency check-
 Holding the child properly is the key to any successful off is a form that is used as the supervisor or designated
blood collection trainer observes the trainee’s performance in a procedure.
Only one check-off is necessary for a procedure. This
Youth-Adult – Individuals in this age group can be communicated ensures that the trainee is following all the correct steps of
with and usually understand and cooperate the procedure. An example of the type of check-off to be
 Polite customer service will go a long way to let them used:
know you are professional and knowledgeable in what you
are doing
 Youth-adult veins are supported by more muscle tissue
and do not have a tendency to roll
 Venipuncture with an evacuated tube system holder and
needle is the best method of choice for blood collection

Age-specific Care Groups

Infant Neonate (birth to 28 days)
Infant (29 days to 1 year)
Pediatric Toddler (1-3 years)
Preschool (3-6 years)
School age (6-12 years)
Youth-Adult Adolescent (12-18 years)
Adult (19-65 years )
Older Adult Geriatric (65 years and older)

Phlebotomy Procedures

Procedures that normally are included in the phlebotomy

training manual consist of any procedures possible being done by
the phlebotomist.

An example of the listing follows:

1. Venipuncture, evacuated tube
2. Venipuncture, syringe
3. Venipuncture, butterfly
4. Blood culture collection by butterfly or other methods
5. Capillary puncture
6. Metabolic screen (newborn screen)
7. Template bleeding time Practical Evaluation Form – the practical evaluation helps keep track
8. Bagged urine collection of the number of procedures the phlebotomist has performed
9. Throat culture collection during training
10. Glucose tolerance test o The practical evaluation form is initialed each time a
11. Gestational screen successful phlebotomy procedure is completed
12. Sample preparation and transport

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 40

An example of an evaluation form:

Phlebotomy Competency Examination

 The phlebotomy competency examination is to be taken
before a phlebotomist is approved to perform
independently
 The exam consist of as many questions as the supervisor
feels are necessary to test the knowledge level of the
trainee
 Usually 25 to 50 questions are sufficient
 Multiple-choice format is preferred
 The phlebotomy competency examination must be
completed with at least 70% of correct answers
 If a 70% score was not met, the laboratory must set the
standard as to how to proceed. Possible solutions are to
have a second test available to be taken the next day or a
retraining program for a set of period and then retake the
test

Certification
 On successful completion of all parts of the training
manual, practical evaluation, and written examination,
each trainee is awarded a certificate of completion
 This is not the certification that is completed by a national
testing agency but a certificate of completion of the
competency program

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 41

Quality Improvement Review and monitoring of

Key Terms outcomes to strive toward
continuous improvement in
performance
Chapter 1: Introduction to Phlebotomy
Quantitative Analysis The analysis of a substance to
Advance Directive Document stipulating the kind of determine the amount or
life-prolonging medical care proportions the substance.
permitted for a patient Results will be released as an
Centralized Phlebotomy Sample collection where the amount, such as grams per liter
phlebotomist is part of the Root Cause Analysis of an event to
laboratory team and is determine the actual reason for
dispatched to hospital units to the incident and corrective
collect blood samples action needed to prevent a
Compatible Substances that can be mixed recurrence
without reacting with one Sentinel Event An unexpected occurrence
another involving death or serious
Decentralized Phlebotomy Sample collection where all physical and psychological injury
members of the health care Threshold An acceptable level of
team share responsibility to performance
collect blood samples Venipuncture Collection of blood from a vein
Demeanor The outward behavior of an by penetrating the vein with a
individual needle
Esoteric Type of laboratory tests that are
not routinely done. These tests
Chapter 2: Safety in Phlebotomy
are often sent to another
laboratory that specializes in a Autoclave Instrument for sterilizing that
specific test uses steam under pressure
Professional code of conduct in Autogenous Infection Infection from one’s own flora
Ethics
the treatment of patients. Biohazard Anything that is potentially
Ingrained in this is a moral hazardous to humans, living
philosophy of how the organisms, or the environment
phlebotomist treats the patient Blood-Born Pathogen A pathogen that is spread by
Examination All processes that are done to blood and body fluids containing
perform the tests on the sample blood. Typically, the pathogens
to achieve a result are hepatitis and human
A case when the system does immunodeficiency virus (HIV)
Failure
not meet user or customer Body Substance Isolation (BSI) The type of isolation that
expectations expanded universal precautions
Pathology Study of the nature and cause of to require glove use when
disease contacting all body substances
Phlebotomy Act or practice of bloodletting as Category-Specific Isolation Isolation based on the category
a therapeutic or diagnostic (strict, respiratory, etc.) of
measure isolation
Post-examination (Post- Process in which the results of Chemical Hazard Any element, chemical
analytical) the testing are communicated to compound or mixture of
the health care provider elements and/or compounds
Pre-examination (Pre- All processes that it takes to that causes physical or health
hazards
analytical) collect the sample and get to the
point in which the testing of the Communicable Disease Diseases that is spread from
sample can occur person to person
Qualitative Analysis The chemical analysis designed Disease-Specific Isolation Isolation based on the type of
to identify the components of a disease infecting the patient
substance. The results from this Employee Input Involvement of non-managerial,
analysis are released as a frontline employees in decisions
positive (present) or negative for the use of workplace
(not present) result Engineering Controls Controls that isolate or remove
Quality Assurance Program that strives to have the blood-borne pathogens
health care facility guarantee hazardous for the workplace
that all areas are providing the Exposure Control Plan A plan that identifies those tasks
highest quality and most and procedures in which
appropriate level of care occupational exposure may
Quality Control Methods to monitor processes occur and identifies the
and confirm that processes are positions whose duties include
within the pre-established limits those tasks or procedures

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 42

Irritant Contact Dermatitis Irritation and redness of the skin Catabolism Process of producing energy by
by direct contact with a breaking down complex
chemical irritant compounds into simple
Latex Allergy An allergy to natural rubber compounds
latex. It is an allergy to the latex Connective Tissue Tissue that supports and
proteins that are released in the connects organs and tissues of
use of latex-containing products the body
Local Infection An infection affecting only one Cytoplasm Semifluid inside of cell
area of the body membrane
Nasocomial Infection Also known as health care- Dermis Skin layer underneath the
associated or hospital-acquired epidermis
infection. Infection that Endoplasmic Reticulum Channel for transport of
develops in a patient 48 hours or material in and out of nucleus
more after admission to a Epidermis Outermost covering of the skin
hospital or health facility Epithelial Tissue Tissue that protects the body by
Other Potentially Infectious Human body fluids, unfixed covering surfaces
Material (OPIM) tissue or blood, and organs or Golgi Apparatus Layers of membranes within a
other tissues from experimental cell that synthesize
animals infected with HIV or BIV carbohydrates and combine with
Personal Protective Equipment Equipment that is used to protein molecules
(PPE) protect the health care associate Hemodialysis Process of purifying blood by
from exposure to blood and passing through a dialyzer
body fluids Hemopoiesis (Hematopoiesis) Formation of blood cells
Recordkeeping Maintaining information and Homeostasis Occurs when all parts of the
records of any job-related body work together to form a
injuries steady state
Sharps Container Specially labeled puncture- Lysosomes Spherical bodies in the cell
resistant containers for the cytoplasm that break down
disposal of sharp items such as components
needles, scalpels, and syringes Median Plane Imaginary equally dividing the
Standard Precautions Assumes that all blood and most right and left sides of the body
body fluids are potentially
infectious. A principle Metabolism Process in the body making
maintaining that personal substances and braking down
protective equipment must be substances so the body can
worn for contact with all body function
fluids whether blood is visible or Mitochondria Serve as sites for cell respiration
not and energy production
Systemic Infection An infection affecting the entire Muscle Tissue Tissue that has the ability to
body shorten, thicken or contract
Transmission-Based Precautions Isolation precautions taken for Nervous Tissue Tissue consisting of neurons that
patients diagnosed or suspected have the ability to react
of a specific transmittable Nucleus Part of the cell that controls cell
disease. The precautions are division and other activities of
based on whether the disease is the cell
transmitted by airborne, Psychology Study of the function of each
droplet, or contact body part and how the functions
Universal Precautions A principle to protect health of the various parts coordinate
care associates from infections to form a living organism
as a result to exposure to body Skeletal Muscle Muscles attached to the bone
fluids. A term now preplaced by Smooth Muscle Muscles involved in involuntary
standard precautions movement

Chapter 3: Basic Human Anatomy and Physiology Chapter 4: Anatomy and Physiology of the Circulatory System
Anabolism Process of the body using simple Antecubital Fossa The portion of the arm that is in
substances to build complex
front of the bend of the elbow.
substances
The most prominent veins for
Anatomy Study of the shape and structure venipuncture are located in this
of the body and the relationship area
of one body part to another
Anticoagulant Chemical substance that
Appendicular Skeleton Skeletal system that provides an prevents blood from clotting
anchor for muscles
Basilic Vein The vein on the little-finger side
Axial Skeleton Skeletal system that provides of the arm that runs the length
protection for parts of the body
“If you don’t love it, you’re going to fail.”
Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 43

of the arm capillary tube

Buffy Coat Layer of cells in an anticoagulant Hematoconcentration Concentrating the constituents
tube of blood that is positioned of blood by leaving the
between the red blood cells and tourniquet on too long
the plasma layers. The buffy Hemostasis Process of the formation of a
coat consist of white blood cells blood clot when an injury occurs
and platelets and then lysing of that blood
Centrifuge Instrument that spins and clot when the injury has been
separate blood into layers repaired
depending on the weight of each Palpate To search for a vein with a
layer. The heavier elements are pressure-and-release touch
pushed to the bottom due to Platelet Adhesion The process of platelet clumps
centrifugal force adhering to an injured area to
Cephalic Vein The vein on the thumb side of stop bleeding
the arm that runs the length of Platelet Aggregation The process of platelet clumping
the arm together during hemostasis
Diastolic Blood pressure when the heart Thixotropic Separator Gel A gel material capable of
is at rest forming an interface between
Endocarditis Infection of the inner membrane the cell and fluid portion of the
of the heart blood as a result of
Erythrocytes Formed blood element; also centrifugation
known as red blood cells Tourniquet Any constrictor used to facilitate
Hemopoiesis (Hematopoiesis) Formation of blood cells vein prominence
Leukocytes Formed blood element; also Vasoconstriction Constriction of vessel(s) that
known as white blood cells limits blood flow
Median Cubital Vein The vein in the antecubital fossa Viscosity Degree of thickness or
area of the arm that bridges the resistance to flow of a substance
cephalic and basilica veins
Occluded Blocked; the normal flow of Chapter 6: Phlebotomy Technique
blood is prevented
Aliquot Part of whole sample that has
Plasma Fluid portion of the blood after been taken off for use or storage
clotting has taken place
Arteriospasm Reflex condition of the artery in
Pulmonary System System circulating blood response to pain or anxiety
through the lungs
Cannula Device used for access for
Serum Fluid portion of the blood after dialyzing and for blood drawing
clotting has taken place in patients with a kidney
Systemic System System circulating blood disorder
throughout the body with the Edema Abnormal accumulation of fluid
exception of the lungs in the tissues, resulting in
Systolic Blood pressure when the heart swelling
is fully contracted Fistula Artificial shunt connection done
Thrombocytes Formed blood element; also by surgical procedure to fuse the
known as platelets vein and artery together. Used
for dialysis only
Chapter 5: Phlebotomy Equipment Hematoma Leakage of blood out of the vein
Additive Any material placed in a tube during or after venipuncture
that maintains or facilitates the that cause a bruise
integrity and function of the
sample Chapter 7: The Challenge of Phlebotomy
Capillary Action Adhesive molecular forces Interstitial fluid Fluid located between the
between liquid and solid cellular components of tissue
materials that draw liquid into a Lateral Toward the side of the body
narrow-bore capillary tube Medial Toward the middling, or middle,
Fibrin Degradation Products Fragments of the fibrin/clot of the body
(FDPs) found in the bloodstream Plantar Sole of the foot
Fibrinolysis Process at the end of the
clotting process that breaks
Chapter 8: Caring for the Pediatric Patient
down fibrin into small
fragments, called fibrin Analgesic A drug that is used to give relief
degradation products, that lead from the pain
to disintegration of the clot Papoose Board with Velcro straps to hold
Flea Metal rod used for mixing the a child
blood sample that fits inside a Psychosocial Involving aspects of social and
psychological behavior
“If you don’t love it, you’re going to fail.”
Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 44

Pre-examination All processes that it takes to

Chapter 9: Sample Considerations and Special Procedures collect the sample and get to the
Diurnal Daily variation in blood levels at point in which the testing of the
a particular time of day sample can occur
Fasting Having had nothing to eat for at
least 8 to 12 hours Chapter 11: Customer Service
Gestational Diabetes Diabetes that develops during Diplomatic Skill in handling affairs without
pregnancy raising hostility
Induration A hard, red spot that is the In-Office Phlebotomist A phlebotomist who works in a
result of lymphocytes migrating physician’s office to collect
to the injection site samples from patients but is an
Keloid Fibrous tumor arising from a cut; employee of the laboratory
results in excessive scar tissue Quality Service Superior professional attention
Lyse Process of cell destruction; and assistance to customer’s
results in non-intact cell needs
structure Receiver Person who is being given
Meconium A dark, tarry material passed information by a sender
from the neonate’s rectum in Sender Person communicating to
the first days after birth until someone else verbally or
milk- or formula-based stool nonverbally
spears
NPO Nothing by mouth. From the Chapter 12: Compliance: Legal and Ethical Issues
latin term “nulla” per os The most efficient and effective
Best Practices
Peak Level (Post dose) Drug level in the blood collected way of accomplishing a task,
15 to 30 minutes after the process, or activity based on
dosage has been administered repeatable procedures that have
or when the highest serum proven themselves over time for
concentration of the drug is large numbers of people
expected
Postprandial After a meal CLIA Clinical Laboratory Improvement
Condition in which Act
Septicemia
microorganisms (mainly Compliance The formalize monitoring of an
bacteria) are circulating and organization’s adherence to laws
multiplying in the patient’s and regulation
blood CPT Current Procedural Terminology
Therapeutic Drug Monitoring Collection and testing of blood manual listing a coding of
(TDM) to evaluate and manage procedures and services
medication therapy effectively performed by physicians.
and safely Published by the American
Therapeutic Range Concentration of medication Medical Association
that is effective and not toxic in Ethics Professional Code of conduct
patient management related to treatment of patients.
Trough Level (Pre dose) Drug level in the blood collected Ingrained in this is a moral
when the lowest serum philosophy of how a
concentration is expected, phlebotomist treats a patient
which is usually 30 minutes HHS U.S. Department of Health and
before administering the next Human Services
dose
Wheal A whitish raised bump produced HIPAA U.S. Health Insurance Portability
by the fluid from an intradermal and Accountability Act
injection ICD-10 International Statistical
Classification of Diseases and
Chapter 10: Sample Preparation and Handling Related Health Problems list of
diagnosis codes of illness.
Circadian Cyclical changes throughout the
Published by the American
day
Medical Association
Circannual Seasonal changes over the
course of a year Malpractice Failure of a professional person
Cyclical Occurring in cycles to offer a standard of care,
Diurnal Daily variation in blood levels at resulting in injury or harm to the
a particular time of day patient
Etiologic Agent Viable microorganism or its Medical Necessity Service that is reasonable and
toxin that causes or may cause necessary for the treatment of
human disease the patient’s illness

“If you don’t love it, you’re going to fail.”

Steve Jobs
 Principles of Medical Laboratory Science Practice 2 (LEC) 45

OIG U.S. Office of the Inspector

General
PHI Protected Health Information

Chapter 13: Competency

Competency Ability to correctly perform a
task according to a standard
procedure

“If you don’t love it, you’re going to fail.”

Steve Jobs