NO MORE FREE NOTES.

READ FURTHER

henlo!

just wanted to get ur attention !

if you are reading this, i just want to thank u for trusting me and my notes with

your studying. it’s been so overwhelming for me to see how much my they’ve have

helped u in ur journey so far in velez. don’t be hesitant to message me if u feel like

there’s something off with it (or to even send me ur own notes bc i’m actually highly

appreciative of ppl who do hehe); my DMs are open anyway "

btw, i highly recommend you cross-refer to the book. please don’t solely rely on my

notes because i don’t even tbh # consider this as more of a really condensed

version of our book lol

happy studying! dungan ta graduate

jeremiah 29:11 / philippians 4:13

@ashumerez | BSMT-1 2019 : PMLS 2

table of contents

MIDTERM COVERAGE
# TOPIC LECTURER PAGES
1 Understanding Phlebotomy Sir Patrick John G. Romero 1-4
2 Infection Control and Safety Sir Mark Harold Abegonia 5-9
3 The Circulatory System Dr. Jenina L. Canoy 10-15
4 Phlebotomy Equipment, Additives, and Order of Draw Mrs. Carmelita A. Atamosa 16-19
5 Venipuncture Procedure Mrs. Rebecca I. Remedio 20-28
6 Pre-examination Variables and Venipuncture Complications Dr. Annabel M. Laranjo 28-33
7 Dermal Puncture and Preparation of Blood Smears Mrs. Pichi Arcilie E. Malintad 34-43
POST-MIDTERM / PRE-FINALS COVERAGE
8 Special Blood Collection Sir Nestor M. Pompa, Jr. 44-48
9 Specimen Handling, Transport, and Processing Mrs. Nida C. Gelig 49-54
10 Waived Testing and Collection of Non-Blood Specimens Mrs. Iluminada Cinco 55-58
11 Arterial Blood Collection Dr. Annabel M. Laranjo 59-65
12 Point-of-Care Testing and Urine Drug Sample Collection Sir Nestor M. Pompa, Jr. 66-74
@ashumerez | BSMT-1G 2019 : PMLS 2 1

Understanding Phlebotomy
LESSON 1
Date of Lecture : 14 January 2019. Sir Patrick Romero, RMT.
Reference : Strasinger, S. K., & Schaub, D. L. (2011). The Phlebotomy Textbook (3rd ed.). Chapters 1-2.

FUN FACTS
• Phlebotomy means "an incision to the vein"
• One of the oldest medical procedures, dating back to the early Egyptians.
• Hippocrates believed that disease was caused by an excess of body fluids and that removal of the excess would cause the body
to return to a healthy state.
• Techniques for bloodletting included application of “leeches” and barber surgery–blood from an incision produced by the barber’s
razor was collected in a bowl. The red and white stripe symbolize red blood and white bandages, respectively, and the pole the
patients held on to during the incision.
• Bloodletting is now called "therapeutic phlebotomy" (i.e. in cases of polycythemia vera).

PRIMARY ROLE
• The primary role of phlebotomy is the collection of blood samples for lab analysis to diagnose and monitor medical conditions.
• The specialization of phlebotomy expanded rapidly and with it take the role of the phlebotomist, who is no longer just someone
who "takes blood" but is recognized as a key player on the healthcare team.
o (Involves three stages — (1) pre-analytical (role of the phlebotomist), (2) analytical (role of the medtech), (3) post-
analytical)
o Anyone can perform phlebotomy as long as there is proper training.

Role of Phlebotomist
1. Correct identification and preparation of the patient before sample collection (ask for complete name, birthdate)
2. Collection of the appropriate amount of blood by venipuncture or dermal puncture for the specified tests
3. Selection of the appropriate sample containers for the specified tests
4. Correct labeling of all samples with the required information
• Important because mislabeling is a crime
5. Appropriate transportation of samples back to the lab in a timely manner
6. Effective interaction with patients and hospital personnel
7. Processing of samples for delivery to the appropriate laboratory departments
8. Performance of computer operations and record-keeping pertaining to phlebotomy
9. Observation of all safety regulations, quality control checks, and preventive maintenance procedures attendance at
continuing education programs.
10. Performing and monitoring point-of-care testing

PROFESSIONAL CHARACTERISTICS FOR PHLEBOTOMISTS

• It is important for phlebotomists to understand that they are the actual face of the laboratory because they are the people who
interact with the patients.
CHARACTERISTICS DEFINITION
Dependable, Usually issues in commitment i.e. overtime
Cooperative, Committed (e.g. if a patient needs a STAT result towards the end of your shift, will you carry on or endorse it?)
Compassionate, A smile (not seductive) and a cheerful tone of voice (not overly) can put a patient more at ease.
Courteous, Respectful Courteous phlebotomists introduce themselves to the patients before they approach them.
A misidentified patient of mislabeled sample can be critical to patient safety
• You can be held responsible for your mistakes in the laboratory).
Patient confidentiality must be protected.
Integrity, Honesty, • (1) Requesting physician, (2) patient, (3) medtech who performed the test, and (4) parent if
Competence patient is a minor — only people who are allowed to know your HIV status
Phlebotomists must demonstrate competence and procedures they are trained to perform.
• e.g. blood extraction of a baby—inform your senior medtech and ask for assistance. Avoid over-
competence or incompetence as well.)
A patient observing a phlebotomist struggling to locate the necessary collection equipment becomes
nervous about the phlebotomist.
Organized, Flexible, Technical Tips
Responsible The few minutes it takes to When organizing requests, be the abbreviation for work that must
organize can save you many sure that you have all of the be done immediately is STAT
minutes of anxiety as well. patient’s requisitions. (Short Turnaround Time) or stat.
Clothing and lab coats must be clean and unwrinkled. Lab coats must be completely buttoned and
Appearance completely cover clothing.
Shoes must be clean, polished, closed toed, and skid-proof.
 @ashumerez | BSMT-1G 2019 : PMLS 2 2

If jewelry is worn, it must be conservative. Dangling jewelry including earrings can be grabbed by a patient
or become tangled in bedside equipment. Many institutions do not permit facial piercings and tattoos; if
present, they must be completely covered. Makeup must also be conservatively applied.
Perfume and cologne are usually not recommended or must be kept to a minimum. Many persons are
allergic to certain fragrances. Remember that the phlebotomist works in close contact with the patient and
the smell of a perfume can be particularly disturbing to a sick person.
Hair (e.g. facial) must be clean, neat, and trimmed. Long hair must be neatly pulled back. Like jewelry, long
hair can become tangled in equipment or pulled by the patient. Long hair hanging near an infectious patient
can transport the infection to your next patient.
Personal hygiene is extremely important because of close patient contact, and careful attention should be
paid to bathing and use of the deodorants and mouthwashes.
Fingernails must be kept clean and short. Based on the Centers for Disease Control and Prevention (CDC)
Handwashing Guidelines, artificial nail extenders are not allowed.
Communication (1) Verbal (2) Listening (3) Nonverbal

COMMUNICATION
Verbal Skills Listening Skills* Nonverbal Skills
Introduce themselves Looking directly and attentively at the patient. If you walk briskly into the room,
…enable
Encouraging the patient to express feelings, smile, and look directly at the patient
phlebotomists Explain the procedures
anxieties, and concerns. while talking, you demonstrate
to:
Allowing the patient time to describe why he positive body language. This makes
Reassure the patient
or she is concerned. patients feel that they are important
ge 20 and that you care about them and
Avoid medical jargons
Providing feedback to the patient through your work.
Use age-appropriate appropriate responses. Allowing patients to maintain their
2057_Ch02_019-036:2057_Ch02_019-036 20/12/10 10:34 AM Page 21
Tips phrases zone of comfort (space) is important
Speak calmly and slowly in phlebotomy even though you
Encouraging patient communication by
Do not appear rushed or must be close to them to collect the
asking questions.
disinterested. sample. CHAPTER 2 ✦ The Clinical Laboratory 21
-Care Field
Laboratory Director
Laboratory Administrator
(Pathologist)

o areas,
Clinical L aboratory
ea is re- Technical Supervisor
Laboratory Information Systems
(LIS)

cimens,
ns, and Technologist

include
Anatomical Clinical Hematology Histology Cytology Phlebotomy
Coagulation
Cytology Hematology Chemistry
Immunology
Histology Coagulation Blood Bank
Microbiology Technologist (HTL) Technologist Phlebotomist
Cytogenetics Chemistry
Blood bank
Serology (Immunology) MLS Technician (HT)

Microbiology
ess and
Urinalysis
ce of ab- Phlebotomy
MLT

icolaou
sts per- FIGURE 2-1 Clinical laboratory organizational chart.
Laboratory Assistant

FIGURE 2-2 Clinical laboratory personnel organizational chart.

*Telephone skills Often the laboratory director has one or more asso- Laboratory Manager (Administrator)
ciate pathologists to assist with the laboratory The laboratory manager is responsible for overall
1. Answer the phone promptly and politely, stating the name of the department and your name.
certain sections, such as hematology, coagulation, responsibilities. The laboratory director may also
be a laboratory specialist who possesses a doctorate
2. Keep writing materials beside the phone to record information.degree.
technical and administrative management of the
laboratory, including personnel and budgets. The

3.chemistry, and urinalysis, may be andcombined

if you cannotin a them,
core transfer them to another person or laboratory manager is usually a medical laboratory
Make every attempt to help callers, help document that can.
4.laboratory for more efficient use of personnel.
Provide accurate and consistent information by keeping current with laboratory policies,
Alert of Changes in Personnel Title Changes
looking up information published in
department manuals or asking a supervisor.
s (HTs) 5. Reporting of critical test results.
In October 2009, the American Society for Clinical Labora-
tory Pathology (ASCP) Board of Registry (BOR) and the
of certain laboratory personnel have changed. These
changes are:

ssue ob- National Accrediting Agency for Clinical Laboratory

Science (NCA) combined to form the ASCP Board of Certi-
1. Clinical laboratory technicians, CLT (NCA), and medical
laboratory technicians, MLT (ASCP), are now both

frozen HEALTH CARE DELIVERY SYSTEM

fication (BOC). Because of this unification the designations MLT(ASCP).

• CLINICAL
Some healthcareLABORATORY
settings where a phlebotomist can be employed in the Philippines— (1) hospital and (2) free-standing lab. Continued
sue. Hospital
•
PERSONNEL
Community hospital • Nonprofit
• Teaching hospitals (university-based) • For-profit hospitals
The laboratory employs a large number of person-
nel, whose qualifications vary with their job descrip-
tions. Most personnel are required to be certified
@ashumerez | BSMT-1G 2019 : PMLS 2 3
• There are hospitals that specialize in a particular type of patient (e.g. children) or illness (e.g. mental health, rehabilitation, and
cancer treatment):
AREA DESCRIPTION
Emergency Department (ED) Care Immediate
Intensive Care Unit (ICU) Critically ill
Cardiac care unit (CCU) Patients with acute heart disorders
Pediatrics Children
Nursery Infants
Neonatal intensive care nursery Newborns experiencing difficulties
Labor and delivery (L&D) Childbirth
Operating room (OR) Surgical procedures
Recovery room Postoperative patients
Psychiatric unit Mentally disturbed patients
Dialysis unit Patients with severe renal disorders
Medical/surgical units General patient care
Oncology center Cancer treatment
Short-stay unit Outpatient surgery

Hospital organizational charts are further broken down into department organization charts. The four traditional hospital services (where
many departments are located within such):
SERVICE COMPONENTS
(largest; contains all the departments that pertain to the patients' needs)
• cardiac care unit (CCU) • hospital patient-care units • nursery
Nursing
• central supply • infection control • operating room (OR)
• emergency department (ED) • intensive care unit (ICU) • social services
• communication systems • housekeeping/environmental services • engineering and maintenance
Support
• food service/dietary • laundry • security
• accounting • credit and collection • planning
Fiscal • admitting • data processing • public relations department (including
• business office • health information management marketing and outreach programs)
• CV testing • rad. ther. • OT • PT
Professional • clinical lab • nuclear med • pharma • RT
• radiology/medical imaging

Admitting Processes patient admissions and discharges

Business Office Performs daily business functions including patient accounts, paying bills, and payroll
Central Supply Sterilizes, stores, and distributes sterile supplies
Dietary/Food Service Prepares and serves food and provides nutrition care and education
Engineering and Maintenance Maintains hospital’s physical plant including communications and clinical equipment
Health Information Management Maintains patient records and hospital legal and regulatory documents
Housekeeping/Environmental Maintains a sanitary and safe hospital (e.g. laundry, cleaning of patient rooms, and disposal of
Services biological waste)
Human Resources Recruits, interviews, and orients new employees. Provides employee benefit and salary information
Marketing/Public Relations Promotes hospital services to the community
Volunteer Services Coordinates activities of hospital volunteers

CLINICAL AREAS OF THE LABORATORY

• Blood bank (immunohematology) • Hematology • Sample processing
• Chemistry • Microbiology • Serology (immunology)
• Coagulation • Phlebotomy • Urinalysis

Many laboratories have a separate section for the Laboratory Information System (LIS). The LIS department is responsible for laboratory
computer operations, maintaining records, and documentation for compliance with accreditation regulations.
CLIN. LAB PERSONNEL DEFINITION
physician who has completed a 4- to 5-year pathology residency
a specialist in the study of disease and works in both clinical pathology and anatomical pathology
Director of the liaison between the medical staff and the laboratory staff
Laboratory • acts as a consultant to physicians regarding a patient’s diagnosis and treatment.
(Pathologist)
responsibilities include:
• working with the laboratory administrator to establish laboratory policies
@ashumerez | BSMT-1G 2019 : PMLS 2 4
• interpret test results
• perform bone marrow biopsies and autopsies
• diagnose disease from tissue specimens or cell preparations
responsible for overall technical and administrative management of the lab (e.g. personnel, budgets)
Laboratory Manager
liaison among the laboratory staff, the administrator of professional services, and the laboratory director.
has training in:
• phlebotomy • quality control and preventive maintenance of instruments
Lab Assistant • sample receiving and • computer data entry and can perform basic "waived" lab
processing testing
aids the MLS or MLT by preparing samples for testing

ANATOMICAL LABORATORY
Cytology process and examine tissue and body fluids for the presence of abnormal cells, (e.g. cancer cells, Pap smear)
histology technicians (HTs) and technologists (HTLs) process and stain tissue obtained from (1) biopsies, (2)
Histology surgery, (3) autopsies, and (4) frozen sections.
• A pathologist then examines the tissue.
chromosome studies are performed to detect genetic disorders, analyzing:
Cytogenetics
• Blood • amniotic fluid • Tissue • BM specimens
CLINICAL LABORATORY
study of the formed (cellular) elements of the blood – (1) RBCs, (2) WBCs, (3) Plts
Hematology Most common sample is whole blood
• Obtained usng tube with anticoagulant (lavender)
can be part of hematology section, but is separate in bigger laboratories
Coagulation Overall process of hemostasis is evaluated – (1) platelets, (2) blood vessels, (3) coagulation factors, (4) fibrinolysis,
(5) inhibitors, and (6) anticoagulant therapy [(a) heparin and (b) Coumadin]
most automated area of the laboratory
computerized and designed to perform single and multiple tests from small amounts of specimen.
1 Electrophoresis Hemoglobin… and protein electrophoresis on (1) serum, (2) urine, and (3) CSF
2 Toxicology therapeutic drug monitoring (TDM) and the identification of drugs of abuse
Uses enzyme immunoassay (EIA) techniques to measure substances such as (1) digoxin,
3 Immunochemistry (2) thyroid hormones, (3) cortisol, (4) vitamin B12, (5) folate, (6) carcinoembryonic antigen,
and (7) creatine kinase (CK) isoenzymes
Chemistry
Primarily on serum in gel barrier tubes (red, green, gray, or royal blue stoppers)
Serum and plasma are obtained by centrifugation, which should be performed within 1-2 hours of collection.
differences in the appearance or color of a specimen may that may adversely affect the test results:
hemolyzed appears red because of the release of hemoglobin from RBCs
icteric yellow because of excess bilirubin
lipemic cloudy because of increased lipids
Samples must be allowed to clot fully before centrifugation to ensure complete separation of the cells and serum
testing procedures involve RBC antigens (Ag) and antibodies (Ab)
• blood from patients and donors is tested for its blood group (ABO) and Rh type
Blood Bank
Patients may come to the blood bank to donate their own blood so that they can receive an autologous transfusion
(Immunohema)
if blood is needed during surgery.
Serum separator tubes containing gel, plain red (serum), lavender, or pink (plasma) stopper tubes
performs tests to evaluate the body’s immune response
Serology • (1) production of antibodies (immunoglobulins) and (2) cellular activation
(Immunology) detect the presence of antibodies to bacteria, fungi, parasites, viruses, and antibodies produced against body
substances (autoimmunity) – red top, SST
responsible for the identification of pathogenic microorganisms and for hospital infection control
divided into (1) bacteriology, (2) mycology, (3) parasitology, and (4) virology
culture and sensitivity
• primary procedure performed
• used to detect and identify microorganisms and to determine the most effective antibiotic therapy.
o Results are available within 2 days for most bacteria; however, cultures for tuberculosis and fungi
Microbiology
may require several weeks for completion.
Identification of bacteria is based on:
• Gram stain reactions • O2 and nutritional requirements • biochemical reactions
Identification of fungi is based on:
• culture growth • microscopic morphology
Specific sterile techniques must be observed in the collection of culture samples to prevent bacterial contamination.
@ashumerez | BSMT-1G 2019 : PMLS 2 5

INFECTION CONTROL AND SAFETY

LESSON 2 2057_Ch04_051-080:2057 06/01/11 12:43 PM Page 53

Date of Lecture : 22 January 2019. Sir Mark Harold Abegonia.

Reference : (1) Strasinger, S. K., & Schaub, D. L. (2011). The Phlebotomy Textbook (3rd ed.). Chapter 4, pages 51-61. CHAPTER 4 Safety and Infection Control 53 ✦

(2) McPherson, R. A., Pincus, M. R., & Henry, J. B. (2017). Henry’s Clinical Diagnosis and Management
4. Means of Transmission
by Laboratory
Airborne: inhalation of dried aerosol nuclei ●

Methods (23rd ed.). St. Louis: Elsevier. Chapter 1, pages 7-9.

Once the infectious agent has left the reservoir
it must have a way to reach a susceptible host.
circulating on air currents or attached to dust
particles

(3) Centers for Disease Control and Prevention. (2016, September 29). Means Infection Control.
of transmission include:
Retrieved
Direct contact: unprotected host touches or
●
January
Vector: parasites 26, 2019,
Vehicle: ingestion of contaminated food or water
such as malaria
●
transmitted
●
by a mosquito bite
from https://www.cdc.gov/infectioncontrol/guidelines/isolation/prevention.html
is touched by the reservoir
Droplet: the host inhales material from the
●
Technical Tip 4-1. For phlebotomists the means of
IMPORTANT : These notes would not have been possible if it were not for the influencereservoirof Elisha Maedroplets
such as aerosol
infected person
Montefolka
from an of Block
transmission can beF. #notforced
an accidental needlestick.

Break the link Break the link

INTRODUCTION • Immunizations
• Patient isolation Infectious agent
• Disinfection
• Hand hygiene

• Healthcare setting • Nursery

precautions
• Healthy lifestyle
• Bacteria
• Fungi

o Contains wide variety of safety hazards à capable of producing

• Parasites
Susceptible • Viruses
host Reservoir

serious injury or life-threatening disease. • Patients

• Elderly
• Humans
• Animals
• Newborns • Insects
• To work safely in this environment, the phlebotomist must: • Immuno-
compromised
• Fomites
• Blood/body

o Learn what hazards exist and the basic safety precautions

• Health-care fluids
workers

associated.
o Finally apply the basic common sense required for everyday Portal of
Portal of exit

safety. entry
• Nose
• Nose
• Mouth
• Mucous

•
• Mouth
Some hazards are unique to the healthcare environment and • Mucous
membranes
membranes
• Specimen
collection
others are encountered uniquely throughout life. One must also keep in • Skin
• Unsterile
equipment
mind that these hazards affect not only the phlebotomist but also the Means of transmission

patient. Therefore, phlebotomists must be prepared to protect themselves • Droplet

• Airborne
Break the link • Contact Break the link
and the patients. • Hand hygiene
• Standard precautions
• Vector
• Vehicle
• Sealed biohazardous
waste containers
• PPE • Sealed specimen
• Sterile equipment containers
• Hand hygiene

infection control Break the link

• Standard precautions

• Hand hygiene
Infection control is a vital concept to consider daily in our workplace. • Standard precautions
• PPE

Working safely in the new healthcare setting requires careful attention to detail, from • Patient isolation

routine hand hygiene to more complex infection prevention measures such as wearing of personal protective equipment (PPE) (e.g. isolation
FIGURE 41 Chain of infection and safety practices related to the biohazard symbol.

gowns, mask, gloves, and goggles) and placing patients in negative pressure isolation rooms. Protecting the safety of patients, colleagues,
and yourself is a key aspect of your career as a phlebotomist.

Most infections can be prevented by hand hygiene and other precautions at the break any of the links in the change of infection.
The chain of infection contains the six factors (links) that must be present for an infection to occur. transmission of an infection any one of
these chains; likewise, if the chain is broken at any of the links, an infection will not develop.

THE CHAIN OF INFECTION

COMPONENT DEFINITION/EXAMPLES BREAKING THE CHAIN
Infectious Early detection and treatment of infectious
1 consist of (1) bacteria, (2) fungi, (3) parasites, and (4) viruses
Agent agents
a place where infectious agent can live and possibly multiply (e.g.
humans and animals)
Equipment and other soiled objects often called fomites will serve
Disinfecting the work area kills the infectious
2 Reservoir as reservoirs particularly if they contain blood or other body fluids.
agent and eliminates the reservoir.
Some microorganisms form spores or become inactive when
conditions are not ideal such as in dried blood. They wait patiently
until a suitable reservoir is available.
Disposing of needles and lancets in sealed
The infectious agent must have a way to exit the reservoir to
sharps containers and other contaminated
continue the chain of infection (e.g. through the nose, mouth, and
materials in biohazard containers and
mucous membranes and in blood or other body fluid when the
keeping tubes and sample containers
reservoir is a human or an animal.)
3 Portal of Exit sealed.
When contaminated materials are in the
appropriate containers, the infectious agent
Phlebotomists provide a portal of exit when they collect blood.
still has a reservoir but no means to exit as
long as the container remains sealed.
Once the infectious agent has left the reservoir it must have a way
to reach a susceptible host. Means of transmission include:
Handwashing, standard precautions and
Means of unprotected host touches or is touched by the
4 Direct Contact transmission-based precautions are covered
Transmission reservoir
later in this chapter.
the host inhales material from the reservoir such
Droplet
as aerosol droplets from an infected person
@ashumerez | BSMT-1G 2019 : PMLS 2 6

inhalation of dried aerosol nuclei circulating on

Airborne
air currents or attached to dust particles
Vehicle ingestion of contaminated food or water
Vector parasites such as malaria transmitted
After the infectious agent has been transmitted to a new reservoir
it must have a means to enter the reservoir.
The portal of entry can be the same as the portal of exit (e.g. nose,
Disinfection and sterilization and strict
mouth, mucous membranes, and open wounds).
Portal of adherence to Standard Precautions and
5
Entry Medical and surgical procedures provide a very convenient portal transmission-based precautions are used to
of entry for infectious agents. This is why all needles used in block the portal of entry.
phlebotomy are packaged individually in sterile containers and a
needle is never used more than once or from a container that has
been opened.
This can be another patient or the health-care provider. Observation of special precautions when
Patients are ideal susceptible hosts because their immune systems working in the nursery and in isolation rooms
that normally provide defense against infection are already designated for protection of susceptible
involved with the patient’s illness. patients.
Patients receiving chemotherapy and immunocompromised
Susceptible patients are very susceptible hosts. The immune system is still Workers must stay current with the required
6
Host developing in newborns and infants and begins to weaken as health-care workers’ immunizations and
people age, making these groups of patients more susceptible to tests (Box 4-1).
infection.
The immune system also is depressed by stress, fatigue, and lack
Maintenance of a healthy lifestyle is very
of proper nutrition. These factors contribute to the susceptibility of
important for the health-care worker.
the health-care provider.

Standard Precautions
• developed by the CDC by combining the recommendations of Universal Precautions and Body Substance Isolation procedures.
o CDC consistently modifies SP as changes occur in the HC environment.
• assumes that every person in the HC setting is potentially infected or colonized by an organism that could be transmitted.
• applies to all blood and body fluids, mucous membranes, and nonintact skin and stresses hand washing (Fig. 4-4).

necessary when microorganisms can remain

• adenovirus • mumps SC, Mask
infective while being carried through the air on the
1 Airborne • chickenpox • shingles (h. zoster) or
dried residue of a droplet or on a dust particle.
• measles • TB respirator
Filtration systems may be required in px’s room.
required for persons infected with microorganisms • diphtheria • parvovirus B19
that can be transmitted on moist particles such as • group A strep. • rhinovirus
2 Droplet those produced during coughing and sneezing. • Haemophilus sp. • scarlet fever SC, Mask
capable of traveling only short distances through • Neisseria meningitides • influenza
the air (less than 3 ft.) • respiratory syncytial virus • pertussis
• antibiotic-rsst. infxns. • impetigo
used when pxs have an infection transmitted by • Clostridium difficile • respi. syncytial SC,
3 Contact direct skin-to-skin contact / by indirect contact by • draining wounds virus gloves,
touching objects in the px’s room. • herpes simplex • Rotavirus gown
• herpes zoster • scabies

hand contact
• Hand contact represents the number one method of infection transmission. Phlebotomists circulate from one patient to another
throughout their working hours, and without the observance of proper precautions, such contact can provide an unlimited for the
transmission of infection.
• Hand hygiene has been cited frequently as the single most important practice to reduce the transmission agents in healthcare
settings and is an essential element of Standard Precautions.
• The term “hand hygiene” includes:
o handwashing with either plain or anti-septic containing soap and water;
o use of alcohol-based products (e.g. gels, rinses, foams) that do not require the use of water.
• In the absence of visible soiling of hands, approved alcohol-based products for hand disinfection are preferred over antimicrobial
or plain soap and water because of:
o superior microbiocidal activity o reduced drying of the skin o convenience
• Improved hand hygiene practices have been associated with the sustained decrease in the incidence of infections due to resistant
microorganisms primarily in the ICU.
@ashumerez | BSMT-1G 2019 : PMLS 2 7

FIVE (5) MOMENTS FOR HANDWASHING

MOMENT WHEN WHY
Clean your hands before touching a patient when To protect the patient against harmful
1 Before Patient Contact
approaching him or her. germs carried on your hands
Clean your hands immediately before any clean or To protect the patient against harmful
Before a Clean/Aseptic
2 septic procedure. germs, including the patient's own, from
Procedure
entering his or her body
After Body Fluid Clean your hands immediately after exposure risk to To protect yourself and the healthcare
3
Exposure Risk body fluids (and after glove removal). environment from harmful patient germs
Clean your hands after touching a patient and his or her To protect yourself and the healthcare
4 After Patient Contact
immediate surroundings when leaving the patient's side. environment from harmful germs
Clean your hands after touching any object or furniture
After Contact with To protect yourself and the healthcare
5 in the patient's immediate surroundings when leaving
Patient Surroundings environment from harmful patient germs
even if the patient has not been touched.

PERSONAL PROTECTIVE EQUIPMENT (PPE)

Personal Protective Equipment (PPE) refers to a variety of barriers and respirators used alone or in combination to protect mucous
membranes, airways, skin, and clothing from contact with infectious agents. The selection of PPE is based on the nature of the patient
interaction and/or the likely mode(s) of transmission. Designated containers for used disposable or reusable PPE should be placed in a
location that is convenient to the site of removal to facilitate disposal and containment of contaminated materials. Hand hygiene is always
the final step after removing and disposing of PPE.

PPE DEFINITION/EXAMPLES/PROPER GUIDELINES

Gloves are used to prevent contamination of healthcare personnel hands when:
• anticipating direct contact with blood or body fluids, mucous membranes, nonintact skin and other potentially
infectious material;
• having direct contact with patients who are colonized or infected with pathogens transmitted by the contact
route (e.g. VRE, MRSA, RSV)
• handling or touching visibly or potentially contaminated patient care equipment and environmental surfaces.
Protects both patients and healthcare personnel from exposure to infectious material that may be carried on hands
may reduce the volume of blood on the external surface of a sharp by 46-86%
Nonsterile disposable medical gloves made of a variety of materials (e.g. (1) latex, (2) vinyl, (3) nitrile) are available
for routine patient care.
The selection of glove type for non-surgical use is based on a number of factors:
• the task that is to be performed; • anticipated contact with chemicals and chemotherapeutic
• latex sensitivity; agents;
• sizing; • facility policies for creating a latex-free environment.
For contact with blood and body fluids during non-surgical patient care, a single pair of gloves generally provides
adequate barrier protection. However, there is considerable variability that influence their barrier effectiveness.
1 Gloves • the task that is to be performed • the type of material
Studies have shown repeatedly that vinyl gloves have higher failure rates than latex or nitrile gloves when tested
under simulated and actual clinical conditions; henceforth, either latex or nitrile gloves are preferable for clinical
procedures that require manual dexterity and/or will involve more than brief patient contact.
During patient care, transmission of infectious organisms can be reduced by adhering to the principles of working
from “clean” to “dirty”, and confining or limiting contamination to surfaces that are directly needed for patient care.
• It may be necessary to change gloves during care of single patient to prevent cross-contamination of body sites.
• It also may be necessary to change gloves if the patient interaction also involves touching portable computer
keyboards or other mobile equipment that is transported from room to room.
Discarding gloves between patients is necessary to prevent transmission of infectious material.
• Gloves must not be washed for subsequent reuse because microorganisms cannot be removed reliably from
glove surfaces and continued glove integrity cannot be ensured.
When gloves are worn in combination with other PPE, they are put on last. Gloves that are removed properly will
prevent hand contamination.
Gloves that fit snugly around the wrist are preferred for use with an isolation gown because they will cover the gown
cuff and provide a more reliable continuous barrier for the arms, wrists, and hands.
Hand hygiene following glove removal further ensures that the hands will not carry potentially infectious material that
might have penetrated through unrecognized tears or that could contaminate the hands during glove removal.
specified by Standard and Transmission-Based Precautions to protect the HCW’s arms and exposed body areas
Isolation and prevent contamination of clothing with (1) blood, (2) body fluids, and (3) other potentially infectious material.
2
Gowns The need for and type of isolation gown selected is based on the nature of the patient interaction, including the
anticipated degree of contact with infectious material and potential for blood and body fluid penetration of the barrier.
@ashumerez | BSMT-1G 2019 : PMLS 2 8

The wearing of isolation gowns and other protective apparel is mandated by the Occupational Safety and Health
Administration (OSHA) Bloodborne Pathogens Standard.
When applying Standard Precautions, an isolation gown is worn only if contact with blood or body fluid is anticipated.
• However, when Contact Precautions are used (i.e., to prevent transmission of an infectious agent that is not
interrupted by Standard Precautions alone and that is associated with environmental contamination), donning
of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated
environmental surfaces.
• The routine donning of isolation gowns upon entry into an intensive care unit or other high-risk area does not
prevent or influence potential colonization or infection of patients in those areas.
Full coverage of the arms and body front, from neck to the mid-thigh or below will ensure that clothing and exposed
upper body areas are protected.
Several gown sizes should be available in a healthcare facility to ensure appropriate coverage for staff members.
Isolation gowns should be removed before leaving the patient care area to prevent possible contamination of the
environment outside the patient’s room.
• Isolation gowns should be removed in a manner that prevents contamination of clothing or skin.
o The outer, “contaminated”, side of the gown is turned inward and rolled into a bundle, and then discarded
into a designated container for waste or linen to contain contamination.
Masks are used for three (3) primary purposes in healthcare settings:
• placed on healthcare personnel to protect them from contact with infectious material from patients (e.g. (1)
respiratory secretions and (2) sprays of blood or body fluids)
• placed on healthcare personnel when engaged in procedures requiring sterile technique to protect patients
from exposure to infectious agents carried in a healthcare worker's mouth or nose, and
• placed on coughing patients to limit potential dissemination of infectious respiratory secretions from the patient
to others (i.e., Respiratory Hygiene/Cough Etiquette).
Masks may be used in combination with goggles to protect the mouth, nose and eyes, or a face shield may be used
instead of a mask and goggles, to provide more complete protection for the face, as discussed below. Masks should
not be confused with particulate respirators that are used to prevent inhalation of small particles that may contain
infectious agents transmitted via the airborne route as described below.
The mucous membranes of the mouth, nose, and eyes are susceptible portals of entry for infectious agents, as can
be other skin surfaces if skin integrity is compromised (e.g., by acne, dermatitis). Therefore, use of PPE to protect
3 Masks these body sites is an important component of Standard Precautions.
• Procedures that generate splashes or sprays of blood, body fluids, secretions, or excretions (e.g. (1)
endotracheal suctioning, (2) bronchoscopy, (3) invasive vascular procedures) require either a face shield
(disposable or reusable) or mask and goggles.
Two mask types are available for use in healthcare settings:
1. Surgical masks that are cleared by the FDA and required to have fluid-resistant properties
2. Procedure or Isolation Masks
Since procedure/isolation masks are not regulated by the FDA, there may be more variability in quality and
performance than with surgical masks.
No studies have been published that compare mask types to determine whether one mask type provides better
protection than another.
Masks come in various (1) shapes (e.g. (1.1) molded and (1.2) non-molded), (2) sizes, (3) filtration efficiency, and (4)
method of attachment (e.g. (4.1) ties, (4.2) elastic, (4.3) ear loops). Healthcare facilities may find that different types of
masks are needed to meet individual healthcare personnel needs.
The eye protection chosen for specific work situations (e.g. goggles or face shield) depends upon circumstances of:
• exposure • other PPE used • personal vision needs
Personal eyeglasses/contact lenses are NOT considered adequate eye protection under National Institute for
Occupational Safety and Health (NIOSH). NIOSH states that eye protection must be:
• comfortable • allow for sufficient peripheral vision • must be adjustable to ensure a secure fit
Indirectly-vented goggles with a manufacturer’s anti-fog coating may provide the most reliable practical eye
protection from splashes, sprays, and respiratory droplets from multiple angles.
Newer styles of goggles may provide better indirect airflow properties to reduce fogging, as well as better peripheral
Goggles or
vision and more size options for fitting goggles to different workers. Many styles of goggles fit adequately over
4 Face
prescription glasses with minimal gaps.
Shields
While effective as eye protection, goggles do not provide splash or spray protection to other parts of the face.
It is important to remind healthcare personnel that protection for the eyes, nose and mouth by using a mask and
goggles, or face shield alone, is necessary when it is likely that there will be a splash or spray of any respiratory
secretions or other body fluids.
Disposable or non-disposable face shields may be used as an alternative to goggles.
• As compared with goggles, a face shield can provide protection to other facial areas in addition to the eyes.
Face shields extending from chin to crown provide better face and eye protection from splashes and sprays;
face shields that wrap around the sides may reduce splashes around the edge of the shield.
@ashumerez | BSMT-1G 2019 : PMLS 2 9

Removal of a face shield, goggles and mask can be performed safely after gloves have been removed, and hand
hygiene performed.
• The ties, ear pieces and/or headband used to secure the equipment to the head are considered “clean”
and therefore safe to touch with bare hands.
• The front of a mask, goggles and face shield are considered contaminated.
The Centers for Disease Control and Prevention (CDC) recommends eye protection for a variety of potential exposure settings
where workers may be at risk of acquiring infectious diseases via ocular exposure.
• Infectious diseases can be transmitted through various mechanisms, among which are infections that can be introduced through
the mucous membranes of the eye (conjunctiva), including viruses and bacteria than can cause (1) conjunctivitis (e.g. (1.1)
adenovirus, (1.2) herpes simplex, (1.3) Staphylococcus aureus) and viruses that can cause (2) systemic infections, including (a)
bloodborne viruses (e.g. (a.1) hepatitis B and C viruses and (a.2) human immunodeficiency virus (HIV)), (b) herpes viruses, and (c)
rhinoviruses.
o Infectious agents are introduced to the eye either directly (e.g. (1) blood splashes, (2) respiratory droplets generated
during coughing or suctioning) or from touching the eyes with contaminated fingers or other objects.

PUTTING ON/DONNING OF PPE

PPE SEQUENCE
The type of PPE used will vary based on the level of precautions required, such as standard and contact, droplet or airborne infection
isolation precautions. The procedure for putting on and removing PPE should be tailored to the specific type of PPE.
Fully cover torso from neck to knees, arms to end of wrist, and wrap around the back
1 Gown
Fasten in back at neck and waist
Secure ties or elastic bands at middle of head and neck
Fit flexible band to nose bridge
2 Mask or Respirator
Fit snug to face and below chin
Fit-check respirator
3 Goggles/Face Shield Place over face and eyes to adjust and fit
4 Gloves Extend to cover wrist of isolation gown
Use safe work practices to protect yourself and limit the spread of contamination:
• Keep hands away from face\ • Change gloves when torn or heavily contaminated
• Limit surfaces touched • Perform hand hygiene

REMOVING OF/DOFFING OF PPE

PPE SEQUENCE
There are a variety of ways to safely remove PPE without contaminating your clothing, skin, or mucous membranes with potentially
infectious materials. Here is one example. Remove all PPE before exiting the patient room except a respirator, if worn. Remove the
respirator after leaving the patient room and closing the door. Remove PPE in the following sequence:
Outside the PPE are contaminated! If your hands get contaminated during PPE removal, immediately wash your hands or use an alcohol-
based hand sanitizer
Using a gloved hand, grasp the palm area of the other gloved hand and peel off first glove
Hold removed glove in gloved hand
1 Gloves
Slide fingers of ungloved hand under remaining glove at wrist and peel off second glove over first glove
Discard gloves in a waste container
Goggles or Remove goggles or face shield from the back by lifting head band or ear pieces.
2
Face Shield If the item is reusable, place in designated receptacle for reprocessing. Otherwise, discard in a waste container.
Unfasten gown ties, taking care that sleeves don’t contact your body when reaching for ties.
Pull gown away from neck and shoulders, touching inside of gown only
3 Gown
Turn gown inside out
Fold or roll into a bundle and discard in a waste container
Mask or Grasp bottom ties or elastics of the mask/respirator, then the ones at the top, and remove without touching the front
4
Respirator Discard in a waste container
5 Wash hands or use an alcohol-based hand sanitizer immediately after removing all PPE.
Perform hand hygiene between steps if hands become contaminated and immediately after removing all PPE.

SUMMARY OF PROPER PROCEDURES

DONNING PPE DOFFING OR REMOVING PPE
1 Gown 1 Gloves
2 Mask 2 Goggles
3 Goggles 3 Gown
4 Gloves 4 Mask
*To prevent skin or clothing contamination
 134 SECTION 2 ✦ Body Systems

The circulatory (cardiovascular) system consists of the

@ashumerez | BSMT-1G 2019 : PMLS 2 heart, blood vessels, and the blood. Blood is circulated 10
Blood Vessel Structure (Fig. 7-1)
The walls of the arteries and veins consist of three
through the blood vessels by the heart to deliver
layers.
The circulatory system
oxygen and nutrients to the cells and transport waste
products to the organs that remove them from the ● Tunica externa: the outer layer composed of
body. connective tissue.
LESSON 3 ● Tunica media: the middle layer composed of
smooth muscle and elastic tissue.
Date of Lecture : 4 February 2019. Dr. Jenina L. Canoy. BLOOD VESSELS ● Tunica intima: the inner layer composed of a
lining of epithelial cells.
Reference : Strasinger, S. K., & Schaub, D. L. (2011). The Phlebotomy Textbook (3rd ed.). Chapters 7 and 9.
The three types of blood vessels that transport blood The space within a blood vessel through which the
IMPORTANT : Aric Jose Hermenico Montecillo of Block H called me “corrupt”
throughoutfor these
the body notes,
are arteries, butcapillaries.
veins, and he alsoblood
asked
flows isme
calledto give him a
a lumen.
shoutout. He really like helped me in life and is one of my best bros. Hi to Glyssa & Abby.
Internal elastic Endothelium (lining)
CIRCULATORY (CARDIOVASCULAR) SYSTEM Tunica
media
lamina
External elastic
• consists of the heart, blood vessels, and the blood. Tunica externa lamina Artery

• Blood Arteriole

Endothelial
o circulated through the blood vessels by the heart to deliver cells
Smooth muscle
oxygen and nutrients to the cells and transport waste products
Precapillary
to the organs that remove them from the body sphincter

• Blood Vessels
o three types of blood vessels that transport blood throughout
Capillary
the body are (1) arteries, (2) veins, and (3) capillaries
Blood flow

blood vessels
Tunica
intima
Venule

BLOOD VESSEL STRUCTURE Tunica

Vein
externa
LAYER LOCATION COMPOSITION Tunica
media
Tunica externa outer connective tissue
Tunica media middle smooth muscle, elastic tissue
Tunica intima inner lining of epithelial cells
Lumen
• space within a blood vessel through which the blood flows

ARTERIES Valve

• FIGURE 71 Comparison of arteries, veins, and capillaries. (From Scanlon, VC, and Sanders, T: Essentials of Anatomy and
large thick-walled blood vessels à propel oxygen-rich blood away fromPhysiology,
the heart to 2007,
ed. 5. FA Davis, thePhiladelphia.)
capillaries
• branch into smaller thinner vessels called arterioles that connect to capillaries.
• The thicker walls aid in the:
o pumping of blood o maintain normal blood pressure (BP)
o give arteries the strength to resist the high pressure caused by the contraction of the heart ventricles.
• The elastic walls expand as the heart pushes blood through the arteries.
o to maintain the pumping pressure to distribute the blood from the artery through the arterioles to the capillaries

ARTERY LOCATION FUNCTION / CHARACTERISTICS

branches into smaller arteries to distribute
1 Aorta largest artery
oxygen-rich blood throughout the body
2 Radial near the thumb side of the wrist the most common site for obtaining a pulse rate
the most accessible site in an emergency, such as cardiac arrest
3 Carotid Near the side of the neck
to check for a pulse rate
4 Brachial in the antecubital space of the elbow the most common site to obtain a BP
5 Femoral located in the groin area may be used for arterial punctures by specially trained personnel
6 Pulmonary The only artery that does not carry oxygenated blood

VEINS
• thinner walls and have less elastic tissue and DIFFERENCES
less connective tissue than arteries because
VEIN ARTERY
the BP in the veins is very low
Color of Blood Dark red Bright red
• carry (1) oxygen-poor blood, (2) carbon
Pulsation Absent Present
dioxide, and (3) other waste products back to
Valves Present Absent
the heart
Location Superficial and deep Deep only; surrounded by muscle
• No gaseous exchange takes place in the
veins, only in the capillaries.
• have one-way valves to keep blood flowing in one direction through the veins by skeletal muscle contraction
• The leg veins have numerous valves to return the blood to the heart against the force of gravity.

VENULES
• small veins that connect capillaries to larger veins; both veins and ventricles have valves

CAPILLARIES
• smallest blood vessels
@ashumerez | BSMT-1G 2019 : PMLS 2 11

• consist of a single layer of epithelial cells to allow exchanges of (1) oxygen, (2) carbon dioxide, (3) nutrients, and (4) waste
products between the blood and tissue cells.
• blood in capillaries is a mixture of arterial and venous blood

heart
STRUCTURE
• hollow muscular organ located in the thoracic cavity between the lungs
o slightly to the left of the body midline that consists of two pumps to circulate blood throughout the circulatory system
2057_Ch07_133-154:2057_Ch07_133-154.qxd 06/01/11 12:44 PM Page 139
• enclosed in a membranous sac called the pericardium

CONTENTS CHAPTER 7 ✦ Circulatory System 139

• heart has four chambers and is divided into right and left halves by a partition called the septum. the aorta. Blood travels throughout the body to the
Aortic arch
UPPER CHAMBER Atrium Collects blood Superior
Right capillaries from arteries that branch
Left off the aorta.
Right PUMPS
vena cava Left pulmonary
Refer to Figures 7-7 and 7-8 to follow the circulation
LOWER CHAMBER Ventricle pumps blood from the heart pulmonary
artery
pulmonary
artery
circulation
of blood thoughoutsystemic
the heart. circulation
Pulmonary As the major player to circulate nourishment to
vein
Aortic the body, the heart has its own vascular system to sus-
semilunar Left tain it (Fig. 7-9). The right and left coronary arteries
• contracts and relaxes to pump oxygen-poor blood through the heart to the lungs valve atrium
Pulmonary
are the first blood vessels branching off the aorta.
Pulmonary They branch into smaller arteries, arterioles, and cap-
• return oxygenated blood to the heart for distribution throughoutvein
the body. semilunar
valve illaries to nourish the heart muscle. The capillaries
Right atrium
• Valves located at the entrance and exit of each ventricle preventTricuspid
a backflow
valve of blood andvalve
keep it flowing in one direction.
Bicuspid
merge to form venules and then veins to return the
blood to the coronary sinus and then back to the
o Heart sounds created by the opening and closing of the Rightvalves are the “lub-dup”Leftsounds heard with a stethoscope.
ventricle
right atrium.
ventricle
Inferior Technical Tip 7-4. When the coronary arteries
vena cava
become obstructed, heart muscle dies because of
FIRST SOUND (“LUB”) SECOND SOUND (“DUP”)
Interventricular septum
lack of oxygen, and a heart attack can occur.
FIGURE 77 Circulation of blood through the heart.
the closure of the entrance valves as the ventricles contract the closure of the exit valves

• A heart murmur is an abnormal heart sound that occurs when the Body tissues
Superior
and inferior
valves close incorrectly. (systemic circulation)
vena cavae

PATHWAY OF BLOOD THROUGH THE HEART Aorta

Coronary
Heart tissue Coronary sinus Right
arteries atrium
vena cavas (superior from upper, inferior from lower parts of the body) –O2-poor bloodà Cardiac veins

RA à tricuspid valve à RV –contractsà pulmonary semilunar valves à pulmonary trunk Aortic

Tricuspid
semilunar
à R&L pulmonary arteries à lungs (pulmonary circulation) à lung capillaries (blood valves valve

releases CO2 and acquires O2) à pulmonary veins à LA à bicuspid valve à LV à aortic
semilunar valve à aorta à throughout the body to the capillaries from arteries (coronary) Left
ventricle
Right
ventricle
that branch off the aorta
• When the coronary arteries become obstructed, heart muscle dies because of Bicuspid
Pulmonary
semilunar
lack of oxygen, and a heart attack can occur. valve
valves

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As the major player to circulate nourishment to the body,2057_Ch07_133-154:2057_Ch07_133-154.qxd
2057_Ch07_133-154:2057_Ch07_133-154.qxd 06/01/11 12:44 PM Page 138
the heart has its own vascular
06/01/11 12:44 PM Page 138
Left
atrium
Pulmonary
trunk

system to sustain it.

aorta à right & left coronary arteries à smaller arteries à arterioles à capillaries (nourish Lung tissue
Pulmonary Pulmonary
the heart muscle) à venules à veins (return the blood to the coronary 138 sinus)
SECTION 2FIGURE à
✦ Body78 RA of the
Diagram
Systems
pathway of blood through the heart.
veins
(pulmonary
CHAPTER arteries
circulation) 7 ✦ Circulatory System 139
138 SECTION 2 ✦ Body Systems

Brachial
Aortic arch
the aorta. Blood travels throughout the body to the
Superior
artery Cephalic vein
capillaries from arteries that branch off the aorta.
Brachial vena cava Left pulmonary
artery
Right Basilic vein
artery
Refer to Figures 7-7 and 7-8 to follow the circulation
Superior
Cephalic vein pulmonary
artery Median ofvena
blood
cava thoughout
Aorta the heart.
Median Pulmonary
Basilic vein antebrachial
Superior
cutaneous cephalic vein As the major player to circulate nourishment to
vein
Aortic nerves
vena cava Aorta Accessory the body, the heart has its own vascular system to sus-
Pulmonary
Median semilunar cephalicLeft
vein Pulmonary vein
antebrachial Median Median tain it (Fig. 7-9).artery The right and left coronary arteries
cephalic vein valve cubital vein atrium
Lateral antebrachial
cutaneous
cutaneous nerve are the first blood vessels Left
branching off the aorta.
nerves
Accessory Pulmonary Pulmonary
Pulmonary
Mitral

cephalic vein Pulmonary semilunar

vein
They branch into smaller atrium arteries,
valve arterioles, and cap-
Median vein Right atrium
cubital vein
artery valve illaries to nourish the heart muscle. The capillaries
Lateral antebrachial Right atrium Aortic
cutaneous nerve mergeTricuspid
to form
valve
venules
Pulmonary valveand then veins to return the
Left Bicuspid
Mitral
Tricuspid valve atrium valve
valve blood to thevalve coronary sinus and then back to the
FIGURE 74 Veins in the arm used for venipuncture.
Right Right atrium right atrium.Right Left
ventricle
ventricle Left ventricle
Aortic
Tricuspid ventricle
Inferior valve Common Veinsvalve
TABLE 72 ●Pulmonary Not Associated With Technical Tip 7-4. When the coronary arteries
valve
Venipuncture
vena cava
Interventricular
FUNCTION Left septum
become
Inferior obstructed, heart muscle dies because of
FIGURE 74 Veins in the arm used for venipuncture. VEIN vena cava
ventricle
Rightcava Carries oxygen-poor blood from FIGURE 76 lack of oxygen, and a heart attack can occur.
Chambers of the heart.
FIGURE 77 Circulation
Superior vena
of blood through the heart.
ventricle the upper body to the heart
COMMON VEINS NOT ASSOCIATED Inferior vena cava WITH
Carries VENIPUNCTURE
oxygen-poor blood from
TABLE 72 Common Veins Not Associated With
●
the lower body to the heart
VEIN Venipuncture Great saphenous FUNCTION
The principal vein in the leg and
Inferior
Superior vena
VEIN cava FUNCTION Carries oxygen-poor
vena cava
Pulmonary
blood from the upper body to the heart
the longest in the body
The only vein carrying Superior
TABLE 73 HeartBody
Valvestissues
Listed in Order of Blood
FIGURE 76 Chambers of the heart. oxygenated blood
●

Inferior vena cava

Superior vena cava Carries oxygen-poor blood from Carries oxygen-poor blood from the lower bodyFlow to Through
the heart the Heart
(systemic circulation)
and inferior
the upper body to the heart NAME LOCATION FUNCTION vena cavae
Great saphenous
Inferior vena cava Carries oxygen-poor blood from The principal vein in the leg and the longest Tricuspid
in the body
Entrance to the Prevents back-
Pulmonary the lower body to the heart The only Right lungvein carrying oxygenated blood
Left lung right ventricle flow into the
Base right atrium
Great saphenous The principal vein in the leg and of heart
Pulmonary Exit of the Allows blood
the longest in the body Coronary Coronary Right
Aorta semilunar Heart tissue
right ventricle flow into the sinus
Pulmonary The only vein carrying arteries Cardiac veins atrium
TABLE 73 ● Heart Valves Listed in Order of Blood pulmonary
oxygenated blood artery
Flow Through the Heart
Mitral/ Entrance to Prevents back-
NAME LOCATION FUNCTION
Aortic bicuspid the left flow into the
Tricuspid Entrance to the semilunar
Prevents back- ventricle left atrium Tricuspid
valves Aortic Exit of the left Allows blood valve
Right lung Left lung right
Diaphragm ventricle flow into the
Apex of heart
semilunar ventricle flow into the
@ashumerez | BSMT-1G 2019 : PMLS 2 12
HEART VALVES LISTED IN ORDER OF BLOOD FLOW THROUGH THE HEART
NAME LOCATION FUNCTION
Small
Tricuspid Entrance to the
Right coronary right ventricle cardiac vein
artery Prevents backflow into the right atrium
and vein
Pulmonary semilunar Exit of the right ventricle Allows blood flow into the pulmonary artery
FIGURE 7 9 Coronary blood vessels.
Mitral / Bicuspid (Adapted from
Entrance toScanlon,
the leftVC, and Sanders, T: Essentials of
ventricle Prevents back- flow into the left atrium
Anatomy and Physiology, ed. 5. FA Davis, 2007, Philadelphia.)
Aortic semilunar Exit of the left ventricle Allows blood flow into the aorta

THE CARDIAC CYCLE

• contraction
Cardiac Cycle phase (systole) and the relaxation phase (diastole) of (ECG)
Electrocardiogram the cardiac muscle that occurs in one heartbeat.
• Cardiac muscle is under involuntary control;
The cardiac cycle is the contraction phase (systole)
therefore, the electrical impulses of the cardiac cycle are essential to produce
The cardiac cycle is measured with an ECG by placing
rhythmic
and contraction
the relaxation and relaxation
phase (diastole) of the heart
of the cardiac muscle.
electrodes connected to a recorder on the patient’s
muscle that occurs in one heartbeat. Cardiac muscle arms, legs, and chest. As shown in Figure 7-11, the
is under involuntary
The following steps incontrol; the therefore,
cardiac the electrical
cycle are
impulses of the cardiac cycle are essential to produce
illustrated in the picture on the right:
rhythmic contraction and relaxation of the heart
1. muscle.
The sinoatrial (SA) node, located in the
upper right atrium,
The following steps inisthe
thecardiac
pacemaker
cycle areofillus-
the
trated
heartinand
Figure 7-10: the heartbeat.
initiates
2. The 1. Theatrioventricular
sinoatrial (SA) node, (AV)located
node inlocated
the upperin
the right
lower atrium, is the pacemaker
interatrial septumofreceives
the heart and
the Left atrium
initiates the heartbeat.
electrical impulse and both the right and
2. The atrioventricular (AV) node located in the Sinoatrial Left
(SA) node ventricle
left lower
atriainteratrial
contract forcing
septum blood
receives to the
the electrical
ventricles
impulse and both the right and left atria con- Atrioventricular
3. Thetract forcingpasses
impulse blood toto thetheventricles.
AV bundle that (AV) node
3. The impulse passes to the AV bundle that sepa- Atrioventricular
separates into right and
rates into right and left bundle branches.
left bundle bundle
branches
4. In the right and left bundle branches the im- Left and right
4. In the pulseright
travels and leftPurkinje
to the bundle branches
fibers the bundle branches
covering the
ventricles,
impulse causing
travels tothemtheto Purkinje
contract, forcing
fibers Purkinje
blood into the aorta and pulmonary artery. fibers
covering the ventricles,
5. The cycle starts again.
causing them to FIGURE 7 10 Conduction pathway of the heart.
contract, forcing blood into the aorta and pulmonary artery.
5. The cycle starts again.
• measured with an ECG by placing electrodes connected to a recorder on the patient’s arms, legs, and chest
• ECG measures the total time of one cardiac cycle and the timing of the atrial and ventricular contractions and relaxations.

HEART RATE / PULSE RATE

• The heart contracts approximately 60 to 80 times per minute, which represents the heart rate or pulse rate.
o arterial pulse (n.) – rhythmic recurring wave that occurs through the arteries during normal pumping action of the heart.
o The pulse is most easily detected by palpation where an artery crosses over a bone or firm tissue.
o Common pulse sites are the (1) temporal, (2) carotid, (3) brachial, and (4) radial arteries.
• In adults and children older than 3 years, the radial artery is usually the easiest to locate.
o Two fingers are pressed against the radius just above the wrist on the thumb side.
o When taking the pulse, the rate (number of beats per minute), the rhythm (pattern of beats or regularity), and strength of
the beat are determined. (The normal count is taken for 30 seconds and multiplied by two.)
o If the patient’s pulse is irregular, it should always be counted for a full 60 seconds.

BLOOD PRESSURE
• the pressure exerted by the blood on the walls of blood vessels during contraction and relaxation of the ventricles.
• MEASUREMENT. A BP cuff called a sphygmomanometer is placed over the upper arm and a stethoscope is placed over the
brachial artery to listen for heart sounds.
o The BP cuff is inflated to restrict the blood flow in the brachial artery and then slowly deflated until loud heart sounds are
heard with the stethoscope.
SYSTOLIC (mm Hg) DIASTOLIC (mm Hg)
higher number; indicates the BP during contraction of the ventricles lower number; the BP when the ventricles are relaxed
first heart sounds heard cuff continues to deflate until sound is no longer heard
Average = 120/80, where systolic = 120 mm Hg; diastolic = 80 mm Hg

blood
• the body’s main fluid for transporting nutrients, waste products, gases, and hormones through the circulatory system.
• An average adult has a blood volume of 5-6L.
• consists of two parts: a liquid portion called plasma, and a cellular portion called the formed elements
 CHAPTER 7 ✦ Circulatory System 143

@ashumerez | BSMT-1G 2019 : PMLS 2 13

PLASMA
• approximately 55% of the total blood volume. Other body tissues and fluids 92% Blood Total body weight

•
8%
clear, straw-colored fluid
o 91% water and 9% dissolved substances.
• transporting medium for the
o plasma proteins o vitamins Blood plasma 52–62% Blood cells 38–48% Blood volume

o nutrients o hormones
o minerals o blood cells
o gases o waste products of metabolism
• The formed elements constitute approximately 45% of the total blood
Water 91.5% Erythrocytes 4.5–6.0 million Blood cells
volume and include the erythrocytes (red blood cells [RBCs]), leukocytes (per microliter)

(white blood cells [WBCs]), and thrombocytes (platelets). Other substances Proteins
Thrombocytes 150,000 – 300,000
Leukocytes 5,000–10,000

o Blood cells are produced in the bone marrow (n.) – the spongy 1.5% 7%

material that fills the inside of the body’s major bones.

o Cells originate from stem cells in the bone marrow, differentiate, Nutrients
Fibrinogen 7%
Basophils 0.5–1.0%
Eosinophils 1–3%

and mature through several stages in the bone marrow and Globulins
Monocytes 3–8%
Hormones
lymphatic tissue until they are released to the circulating blood. 38% Lymphocytes
20–35%
Nitrogenous
wastes

ERYTHROCYTES Respiratory
gases
Albumins
Neutrophils

•
55%
anucleate biconcave disks 55–70%

Electrolytes
• mature through several stages in the bone marrow and enter the circulating
blood as reticulocytes that contain fragments of nuclear material Other substances Proteins Leukocytes
FIGURE 715 Components of blood diagram. (From Scanlon, VC, and Sanders, T: Essentials of Anatomy and Physiology,
• macrophages in the liver and spleen ed. 5. FA Davis, 2007, Philadelphia.)

remove the old erythrocytes from the Diameter 7.2μm

bloodstream and destroy them; the contains hemoglobin Transports O2 and CO2
iron is reused in new cells. (protein) Consists (1) heme (requires iron for synthesis) and (2) globin
• surfaces contain antigens that 4.5 to 6.0M per microliter (μL) of blood
Volume
determine the blood group and type Men > women
of an individual (ABO group and Rh Normal life span 120 days
type).
AGGLUTINOGEN AGGLUTININ
TYPE
BLOOD GROUP AND TYPE 2057_Ch07_133-154:2057_Ch07_133-154.qxd
ANTIGEN 06/01/11 12:44 PM Page 145
ANTIBODIES
• Groups O and A are the most common, and group AB is the least common. A A B
• The plasma of an individual contains naturally occurring antibodies (Abs) for B B A
those antigens not present on the erythrocytes. AB A,B None
• The naturally occurring antibodies react with erythrocytes carrying antigens that O None A,B
are not present on the individual’s own erythrocytes Neutro
• A transfusion reaction may occur when a person receives a different group of blood Type Universal donor Neutro
O protect
because a person’s natural antibodies will destroy the donor RBCs that contain the
Neutro
antigen specific for the antibodies. Patients receive group-specific blood to avoid this clear ce
type of transfusion reaction. numbe
Type Type Type
o Misidentification of patients during phlebotomy is a major cause of transfusion A O B
(Fig. 7-1
reactions. Lymph
o Hemolytic disease of the newborn occurs when incompatibility is present Lymph
between maternal and fetal blood Rh antigens provide
Type Type Type
A AB
B and
B
round
RH TYPE plasm.
• The presence/absence of the RBC antigen called the Rh factor/D antigen determines infectio
whether one is type Rh-positive/Rh-negative. Type Universal recipient
Monoc
AB
o Rh-negative people have no natural antibodies to the Rh factor but will form Monoc
antibodies if they receive Rh-positive blood. FIGURE 717 Compatibility of ABO blood groups. (From act as p
o A second transfusion of Rh-positive blood will cause a transfusion reaction. Scanlon, VC, and Sanders, T: Essentials of Anatomy and Physiology, The cyt
ed. 5. FA Davis, 2007, Philadelphia.) vacuole
monoc
LEUKOCYTES monoc
• provide immunity to certain diseases by producing antibodies and destroying harmful pathogens by phagocytosis tubercu
Leukocytes
• produced in the bone marrow from a stem cell and develop in the thymus and bone marrow Leukocytes, or WBCs, provide immunity to certain
• differentiate and mature through several stages before being released into the bloodstreamdiseases by producing antibodies and destroying
• harmful
circulate in the peripheral blood for several hours and then migrate to the tissues through pathogenswalls
the capillary by phagocytosis. Leukocytes are
produced in the bone marrow from a stem cell and
Leukocytes (4,500-11,000/μL blood) (NLMEB) develop in the thymus and bone marrow. They
Granulocytes differentiate and mature through several stages
provide protection against infection through phagocytosis before being released into the bloodstream. Leuko-
Neutrophils called segmented or polymorphonuclear cells because the nucleus has several
cytes circulate in the peripheral blood for several
hours lobes.
and then migrate to the tissues through the
(40%-60%)
number increases in bacterial infections capillary walls. The normal number of leukocytes
for an adult is 4,500 to 11,000 per µL of blood.
Five types of leukocytes are present in the blood, FIGURE
each with a specific function. They are distinguished Hematolo
by their morphology, as shown later. When stained 2009, Phi
with Wright’s stain, the cells are examined micro-
scopically for granules in the cytoplasm, the shape of
@ashumerez | BSMT-1G 2019 : PMLS 2 14

Eosinophils granules in cytoplasm stain red-orange

Eosinophils nucleus only has two lobes
(1%-3%) detoxify foreign proteins and increase in allergies, skin infections, and parasitic infections
Basophils cytoplasm contains large granules that stain purple-black
(0%-1%) release histamine in the inflammation process and heparin to prevent abnormal blood clotting
Agranulocytes
B Lymphocytes produce antibodies
provide the body with immune
involve in graft rejection and in fighting tumors and
Lymphocytes capability by means of: T Lymphocytes
viruses via direct cell attack
(20%-40%)
has a large round purple nucleus with a rim of sky blue cytoplasm
number of lymphocytes increases in viral infections
largest circulating leukocytes; act as powerful phagocytes to digest foreign material.
Monocytes fine blue-gray appearance with vacuoles and a large, irregular nucleus
(3%-8%) Active phagocytes that become macrophages in the tissues; 1st line of defense
number increases in intracellular infections and tuberculosis
Thrombocytes / small, irregularly shaped disks formed from the cytoplasm of very large cells in the bone marrow – megakaryocytes
Platelets Life span of 9-12 days
(140-440T/μL) play a vital role in blood clotting in all stages of the coagulation mechanism

coagulation / hemostasis
• involves (1) blood vessels, (2) platelets, and (3) the coagulation factors to maintains hemostasis
• the process of forming a blood clot to stop the leakage of blood when injury to a blood vessel occurs and lysing the clot when the
injury has been repaired

STAGE STEPS / CHARACTERISTICS

blood vessels and platelets respond to an injury to a blood vessel
Primary blood vessels constrict to slow the flow of blood to the injured area
1
Hemostasis platelet aggregation (platelets become sticky, clump together)
platelet adhesion (platelets adhere to injured blood vessel wall to form a temporary platelet plug to stop the bleeding)
formation of fibrin clot à coagulation cascade initiates the formation of fibrin stands to strengthen the platelet plug
Secondary
2 I the coagulation cascade, one factor becomes activated, which activates the next factor in a specific sequence.
Hemostasis
two pathways (extrinsic and intrinsic, which come together as the common pathway) to complete the cascade.
last factor in the coagulation cascade (Factor XIII) stabilizes the fibrin clot
3
produces retraction (tightening) of the clot
After the injury to the blood vessel has healed the process of fibrinolysis degrades (breaks down) the fibrin clot into
4
fibrin degradation products (FDPs)

tourniquet
• serves two functions in the venipuncture procedure:
o By impeding venous, but not arterial, blood flow, the tourniquet causes blood to accumulate in the veins making them
more easily located and provides a larger amount of blood for collection.
• Use of a tourniquet can alter some test results by increasing the ratio of cellular elements to plasma (hemoconcentration) and by
causing hemolysis.
o Therefore, the maximum amount of time the tourniquet should remain in place is 1 minute.
o This requires that the tourniquet be applied twice during the venipuncture procedure
§ when vein selection is being made
§ immediately before the puncture is performed
o When the tourniquet is used during vein selection, the CLSI recommends that it should be released for 2 minutes before
being reapplied.
• The tourniquet should be placed on the arm 3-4in above the venipuncture site.
• Application of the commonly used flat vinyl or latex strip requires practice to develop a smooth technique and can be difficult if
properly fitting gloves are not worn.
• To achieve adequate pressure, both sides of the tourniquet must be grasped near the patient’s arm, and while maintaining tension,
the left side is tucked under the right side.
o The loop formed should face downward toward the patient’s antecubital area, and the free end should be away from the
venipuncture area but in a position that allows it to be easily pulled to release the pressure.
o Left-handed persons would reverse this procedure. The tourniquet should be flat around the arm and not rolled/twisted.
• Tourniquets that are folded or applied too tightly are uncomfortable for the patient and may obstruct blood flow to the area.
• The appearance of small, reddish discolorations (petechiae) on the patient’s arm, blanching of the skin around the tourniquet, and
the inability to feel a radial pulse are indications of a tourniquet that is tied too tightly.
• A tourniquet applied too close to the venipuncture site may cause the vein to collapse.
@ashumerez | BSMT-1G 2019 : PMLS 2 15

• The use of disposable one-time use tourniquets is advised, although not required, as part of good infection control practice to
avoid health-care acquired infections (HAIs) for patients.
SITE SELECTION
• The preferred site for venipuncture is the antecubital fossa located anterior and below the bend of the elbow.
o median cubital
"H-shaped" "M-shaped"
o cephalic
cephalic, median cubital, and basilic cephalic, median cephalic,
o basilic
veins in a pattern that looks like a median basilic, and basilic veins.
• Vein patterns vary among individuals—the slanted H.
most often seen arrangement of veins in the
approximately 70% of the population (of
antecubital fossa are referred to as the “H-
the US?)
shaped” and “M-shaped” patterns.
• Notice that the veins continue down the forearm to the wrist area; however, in these areas, they become smaller and less well
anchored, and punctures are more painful to the patient.
o Small prominent veins are also located in the back of the hand.
o When necessary, these veins can be used for venipuncture, but they may require a smaller needle or winged blood
collection set.
• The veins of the lower arm and hand are also the preferred site for administering IV fluids because they allow the patient more
arm flexibility. Frequent venipuncture in these veins could make them unsuitable for IV use.
• Veins on the underside of the wrist must not be used for venipuncture, because of the chance of accidentally puncturing arteries,
nerves, or tendons.

VEINS FOR VENIPUNCTURE

VEIN CHARACTERISTICS
is the vein of choice because it is large and does not tend to move when the needle is inserted
Median
often closer to the surface of the skin, more isolated from underlying structures
Cubital
the least painful to puncture as there are fewer nerve endings in this area
located on the thumb side of the arm is usually more difficult to locate; has more tendencies to move
should be the second choice if the median cubital is inaccessible in both arms
Cephalic
closer to the surface so there is the possibility of a blood spurt when the needle is inserted in to the vein.
• This often is controlled by decreasing the angle of needle insertion to 15 degrees.
located on the inner edge of the antecubital fossa near the median nerve and brachial artery
Least firmly anchored; therefore, it has a tendency to “roll”
• hematoma formation is more likely
Basilic last choice because the (1) median nerve and (2) brachial artery are in close proximity to it
• increasing the risk of permanent injury
Use of the basilic vein is discouraged; however, if necessary, the CLSI standard recommends locating the brachial pulse
before accessing the basilic vein.

PRIME FACTORS TO CONSIDER

• Sustainability of location • Purpose of infusion
• Condition vein • Duration of therapy

Never use an arm with any of the following:

• Fistula • Edema • Shunt (hole or a small passage which
• Decreased sensation • On the side of a mastectomy moves fluids)

Antiseptic used for cleaning should be in contact with skin for at least 30 seconds:
• Iodine tincture (1-2%) • Isopropyl alcohol 70%
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phlebotomy equipment, additives, and order of draw

LESSON 4
Date of Lecture : 11 February 2019. Carmelita A. Atamosa, RMT, MPH.
Reference : Strasinger, S. K., & Schaub, D. L. (2011). The Phlebotomy Textbook (3rd ed.). Chapters 7 and 9.
IMPORTANT : Special thanks to Patrick Yray for helping me encode these notes.

I. Equipment and supplies used in blood collection V. Categories of additives used in blood collection
II. Antiseptics and disinfectants used in venipuncture VI. Color coding used in identifying adjectives
III. Phlebotomy Needles VII. Order of draw followed in multiple tubes collection
IV. Evacuated tube system; syringe system components

equipment and supplies used in blood collection

GENERAL EQUIPMENT & SUPPLIES
EQUIPMENT CHARACTERISTICS
Table for supplies
Special chair for blood collection
Blood Drawing Station
Padded table pediatric patients
Bed or reclining chair
Must have a front guard to prevent patient from falling in case of collapse
Phlebotomy Chairs With adjustable armrest to achieve proper positioning collection
Always ensure patients lock the front guard
Used for in patients
With swivel wheels which glide the car smoothly and quietly down the hospital hallways and in and
Phlebotomy Carts
out of elevators
Equipment
Normally have several shelves to carry adequate supplies
Carriers
Phlebotomy carts/handled carriers/warding trays must contain all necessary materials for extraction
Handheld Carriers Handheld carriers are more convenient than the carts
Phlebotomy carts may not be brought to the rooms for safety reasons

OTHER BASIC EQUIPMENT

EQUIPMENT CHARACTERISTICS
Are substances used to prevent sepsis which is the presence of microorganisms order toxic products
within the bloodstream
Prevent or inhibit the growth development of microorganisms but do not necessarily kill them
Safe to use on human skin
Antiseptics Examples of antiseptics for blood collection
• 70% ethyl and • isopropyl alcohol • Hydrogen peroxide
• Benzalkonium chloride (zephiran chloride) • Povidone-iodine* (0.1-1.0% available iodine)
• Chlorhexidine gluconate • Tincture iodine*
Advisable to use yield sterile packages of antiseptics which remain sterile until seal is broken
* less preferred because some patients are allergic to iodine
chemical substances regulated by the Environmental Protection Agency (EPA) that are used to remove or
kill microorganisms on surfaces and instruments
Stronger more toxic and typically more corrosive the antiseptics
Not safe for human skin
Disinfectants Sodium hypochlorite 5.25% (household bleach)
• biocide chemicals that kill or inhibits the growth of microorganisms
• 1:100 for decontaminating non-porous surfaces after cleaning up blood/body fluid spills
• 1:10 dilution for large amount of at least ten (10) minutes to contact
Freshly made daily
2x2 inch folded and forts to hold pressure over the site
Gauze Pads Effect of cotton balls are used: cotton fibers tend to stick to the site and disrupt the platelet plug forming in
the site which can initiate bleeding
self-adhesive gauze to cover a blood collection site after bleeding stops
Bandages
also used to form pressure bandage following arterial/venous puncture in patients with bleeding problems
must be clearly with a hazard symbol and must be rigid puncture resistant leak-proof and disposable
Needle and sharps
have locking leads to seal the contents when filled to the appropriate volume
disposal containers
must properly disposed as bio hazardous waste
leak proof plastic bags that are commonly used to transport blood and other specimens of the laboratory
Biohazard bags
with biohazard label and outside pocket for requisition and other forms
@ashumerez | BSMT-1G 2019 : PMLS 2 17

MISCELLANEOUS EQUIPMENT Alcohols

1. Slides • Ethyl (70%) Antiseptic for skin
2. Pens • Isopropyl (70%)
3. Watch Chlorine
4. Patient identification equipment
• Chloramine Disinfectant for wounds
a. Barcode readers (n.) – to
identify patients; generate • Hypochlorite solutions Disinfectant
labels for specimen tubes Ethylene oxide Disinfectant (toxic)
5. Gloves Formaldehyde Disinfectant (noxious fumes)
a. Latex and nonpowdered Glutaraldehyde Disinfectant (toxic)
Hydrogen peroxide Antiseptic for skin
Iodine
• Tincture Antiseptic for skin (can be irritiating)
• Iodophors Antiseptic for skin (less stable)
Phenolic compounds
• 1-2% phenols Disinfectant
• Chlorophenol Disinfectant (toxic)
• Chlorohexidine Antiseptic for skin
• Hexylresorcinol Antiseptic for skin
Quaternary ammonium compounds Antiseptic for skin (ingredient in many soaps)

venipuncture equipment
Transillumination device to locate difficult veins using high intensity led or infrared
The hemoglobin in the blood absorbs the light causing the veins to stand out as dark line
Vein finder/locating devices
Examples:
• Venice cope II • AccuVein • neonatal transilluminator
A device that is applied tied around the patient's arm prior to body function to compress the veins and
restrict blood out of the area making them larger easier to find
Tourniquet/Strap
Blood pressure cuff not more than 40mmHg diastolic pressure strap tourniquet
If drop or contaminated with blood or other contaminants it should be discarded
it comes in different sizes and gauge
Hypodermic
G21-23 recommended for blood collection
Needles
• G23 is used for very small veins
(Syringe
bigger needles à post-puncture bleeding; hematoma
Method)
smaller needles à hemolysis; microdots
refers to the diameter of the needle bore
the higher the gauge, the smaller the diameter of the bore and the size of the bore
GAUGE HUB COLOR SIZE DIAMETER
16G White 1.60mm
18G Pink 1 x ½” 1.20mm
19G Cream 1.10mm
Needle Gauge 20G Yellow 0.90mm
21G Green 0.80mm
22G Black 0.70mm
1”, 1 x ¼”, 1 x ½”
23G Blue 0.60mm
Needles 24G Medium Purple
0.55mm
25G Orange
26G Brown ½”, 1 x ½” 0.45mm
Parts of the • Hub • Shaft • Bevel
Needle • Hilt • Lumen • Tip/point
Needles used in the evacuated tube system (ETS)
Facilitated multiple sample collection
Multisample
Color-coded (G21-23)
Needles
Threaded in the middle and have a beveled point at each end:
• Venipuncture • Punctures the rubber stopper of the evacuated tube
• Bevel • Threaded hub • Safety device (eclipse)
Parts of the
Needle • Shaft • Sleeve o flash or backflow confirms
penetration of the vein
Butterfly Consists of a stainless steel beveled needle with attached plastic rain to facilitate needle insertion
Infusion A piece of tubing connects the needle to the adapter that screws into a tube holder making a modified
@ashumerez | BSMT-1G 2019 : PMLS 2 18

Needle evacuated system or a syringe can be attached to collect blood

For micro volume of collection
Lancets Collection depth of the puncture 2.5-3.0mm
For neonates and babies
Come in different volumes (1, 2, 5, 10mL)
May be available in the set with the needle
Syringes
Check the following:
• needle properly attached • check the plunger for defect
Holds the needle and the evacuated tube in the ETS
Made over rigid plastic and may be designed to act as a safety shield for the used needle
May hold the safety device needle pro that consists of a plastic sheet attached by a hinge to the end of
Needle
the evacuated tube holder
Holder /
Holders that retract the needle:
Adapter
Other types uses a one-handed method to retract the needle into the holder and a
ETS Proguard
cover for the end that is open to the stopper puncturing needle
VanishPoint Tube automatically retract the needle by security closing the end cap while the
Holder needle is still in the patient's vein
These are tubes for blood collection which color coded based upon the anticoagulant present in
various sizes (2, 5, 7, and 10 mL).
Evacuated tubes have expiration dates vacuum or ineffective additive.
Contain premeasured amount of vacuum which determine the amount of blood to be collected
Vacutainer
Available in glass or plastic (routinely used for safety reasons)
Tubes
Sterile and are silicone coated to prevent cells adhering to the sides or to prevent activation of cutting
factors and coagulation studies
Evacuated Have thick rubber stoppers with a thinner central area to facilitate needle puncture
Tubes Usually contains anticoagulant proportioned to the blood
Microtainer Color coding corresponds to ETS with markings (minimum and maximum) measured in μL
Tubes / Bullets For pediatric collection
(e.g. plain, heparinized)
the tubes are available (plain or with an anticoagulant, sodium or ammonium heparin) that keep the
Capillary Tubes blood from clotting
all of the tubes have color-coded ends to easily identify the plain and heparin treated tubes
• If collecting anti-coagulated blood from a blood collection tube, use a plain capillary tube.

order of draw
RATIONALE OF THE ORDER OF DRAW (ETS)
ADDITIVE CHARACTERISTICS
Yellow Minimized microbial contamination
Light Blue All other additives affect coagulation
Red Prevents contamination by additive from other tubes
Gold w/ SST Silica pearls activate clotting and affect coagulation tests
Green Causes the least interference in tests other than coagulation tests
Lavender Elevates Na and K; chelates and decreases Ca and Fe; elevates PT and PTT
Gray Abnormal cell morphology and interferes enzyme reaction

ORDER OF DRAW FOR EVACUATED TUBE SYSTEM (ETS)

Yellow Light Blue Red SST PST Green Lavender Gray

ORDER OF DRAW FOR SYRINGE SYSTEM

Sodium Citrate EDTA Heparin Fluoride Plain tube

• Remove the needle first before transferring to tubes
• All tubes with anticoagulants must be filled first
• First tube for coagulation studies - light blue
• Last tube - red top plain tubes
• Rational is to prevent clotting and mixing immediately
@ashumerez | BSMT-1G 2019 : PMLS 2 19

Additives in Vacutainer Tubes

DIFFERENT ACTIONS OF ANTICOAGULANTS
COLOR ANTICOAGULANT ACTION WB P S DEPARTMENT ⟳
Binds Ca and aids in the recovery
Sodium polyanethol sulfonate of microorganisms by inhibiting the
Microbiology (culture) 8
(SPS) actions of complement,
phagocytes, and certain antibiotics
Yellow x
Blood Bank, human
Acid citrate dextrose (ACD) – prevents clotting by binding Ca and leukocyte antigen (HLA)
RBC preservative dextrose preserves RBC phenotyping, and DNA and
paternity testing
Light Blue* 3.2 or 3.8% sodium citrate Binds calcium; prevents coagulation Coagulation
solution of (1) sodium citrate,
minimize in vitro platelet activation x 3-4
(2) theophylline, (3) specialized platelet testing
(Glass CTAD) and the artificial entry of platelet
adenosine, and (4) of citrated plasma
factors into the plasma
dipyridamole
glass None x Chemistry / Serology / BB 0
Red
plastic Clot activator x x Chemistry 5
Pink Spray-coated K2EDTA x x Blood Bank 8
Tan < 0.1μg/mL Pb, K2EDTA Lead determination x
Gold Clot activator and polymer gel Serum Separator Tubes; “stat” x Chemistry (Serum det.) 5
Thrombin-based medical
Orange clotting agent and separation Rapid Serum Tubes (RST) x STAT chemistry 5
gel
STAT and routine
Light Green Li heparin and gel separator Plasma Separator Tubes x 8
chemistry (plasma, K det.)
+
Anticoagulant + Li / Na / NH4 Inhibits prothrombin to thrombin in Chemistry (STAT) / NH3 /
Green x x 8
heparin coagulation cascade; plasma det. ABGs
Binds Ca
Liquid tripotassium EDTA Hematology (CBC),
*K2EDTA maintains cellular integrity
(K3EDTA) immunohematology, blood
Lavender inhibits platelet clumping; doesn’t x x 8
Spray-coated dipotassium donor screening,
interfere routine staining
EDTA (K2EDTA) sedimentation rate
procedures
• NaF + C2K2O4 Lactic acid / glucose
Gray • NaF + EDTA Binds Ca; inhibits microbial growth x tolerance / FBS / blood 8
• NaF alcohol
Hematology / Westergen
Black Buffered sodium citrate Forms Ca salts to remove Ca (4:1) x
sedimentation
Molecular diagnostics; MI
White / Pearl K2EDTA & polymer gel Plasma Preparation Tubes x 8
panels; ammonia level
*Light blue notes:
• 9:1 ratio (9/10 blood, 1/10 sodium citrate)
• he laboratory always rejects incompletely filled light blue stopper tubes.
• Overmixing a light blue stopper tube can activate platelets and cause erroneous coagulation test results.
• Polycythemia, hematocrit > 55% à ¯ citrate coagulant à prevent increase of citrate in the plasma

ADDITIVES IN VACUTAINER TUBES

ADDITIVE CHARACTERISTICS
Anticoagulants Prevents blood from clotting
Antiglycolytic Reagents Prevents Glycolysis (e.g. NaF – gray tube)
Coagulation factors (e.g. thrombin) and subs (e.g. glass (silica) particles, inert clays like diatomite (celite)) that
Clot Activators enhance clotting by providing more space for the platelet activation
• e.g. Red-Gray for stat initiation of clotting to observe sample right away
Inert substances contained in or near the bottom of certain tubes
Thixotropic Gel During centrifugation, the gel lodges between the cell and fluid, forming a barrier à preventing the cells from
Separations metabolizing substances in the serum or plasma
• Examples are PST and SST
@ashumerez | PMLS 2 : BSMT-1G 2019 20

Venipuncture procedure
LESSON 5
Date of Lecture : 18 February 2019. Ma’am Rebecca I. Remedio, RMT.
References : Lotspeich-Stenienger, Clinical Hematology Principles, Procedures, Correlations, Philadelphia J.B. Lippincott Company,
2nd Edition
Rodak, Bernadette et. Al. Hematology, Clinical Principles and Applications, 4th Edition
Warchois, Robin S., Robinson, Richard, Worktex and Procedures Manual, 4th Edition, 2016
Strasinger, Susan King, The Phlebotomy Textbook, 3rd Edition, 2011
Hoeltke, Lynn, The Complete Textbook of Phlebotomy, 4th Edition, 2013

venipuncture Veni Puncture

• The most common procedure a phlebotomist does. vein to get blood from
• A procedure in which a needle is used to collect blood Phlebotomy
• Each phlebotomist develops one’s own style for dealing with patients; performing venipuncture. Greek – “to cut a vein”
• Administrative protocols vary amongst institutions and – of course – every patient is different; however, many basic rules are the
same in all situations. These basic rules must be followed:
o to ensure the safety of the patient and the phlebotomist
o to produce samples that are representative of the patient’s condition
o to create an efficient phlebotomy service for the institution

phlebotomy
• At present, the primary role of phlebotomy is the collection of blood samples for laboratory analysis to diagnose and monitor
medical conditions.
• The specialization of phlebotomy has expanded rapidly and with it the role of the phlebotomist, who is no longer someone who
"takes blood" but is recognized as a key player on the health-care team.
• Because the phlebotomist is often the only personal contact a patient has with the laboratory, he or she can leave a lasting
impression on the quality of the laboratory and the entire healthcare setting.

A PHLEBOTOMIST’S ANATOMY
PART DEFINITION PART DEFINITION
1 Calm Tone of Voice calms anxious parents 5 High Level of Patience Some may require special attention.
deals with the
2 Sharp Mind 6 Strong Feet There is a lot of standing.
challenges of work
controls hand movements during
3 Cheerful smiles at patients 7 Steady Hands
venipuncture procedures
4 Communication Skills now, that’s a classic 8 Compassionate and Kind has a big heart

PROFESSIONALISM AND INTERPERSONAL SKILLS

• Good interpersonal skills are necessary for the phlebotomist (person trained to collect blood)
• Professional attitude (skill, judgement, and polite behavior that is excited from a person who is trained to a job well)
• Neat appearance
• Consideration and care for patient by insuring the patient of safety and confidentiality of results
• Laboratory results and personal information about a patient should not be discussed unless it is relevant to the patient's care
(should not be discussed in public)
o Dependable o Respectful o Responsible
o Cooperative o Integrity o Flexible
o Committed o Honesty o Good communication
o Compassionate o Competence o Clean appearance
o Courteous o Organized
• It's a bloody job but someone has to do it.

SPECIMEN COLLECTION
1. Skin puncture 2. Venipuncture 3. Arterial blood collection*
*not allowed for medtech, only assist the physician

METHODS OF VENOUS BLOOD COLLECTION

METHOD CHARACTERISTICS
Butterfly Infusion usually used for pediatric patients connected to an adapter or syringe
1
(Winged Collection) Set uses butterfly wings with plastic tubing
2 Evacuated Tube System use vacutainer, two-way needle, plastic holder, and evacuated glass tube (vacuum)
barrel and plunger in which needle is attached
3 Syringe Method
phlebotomists can control the vacuum by gently pulling back on the plunger while drawing blood
@ashumerez | PMLS 2 : BSMT-1G 2019 21

for small fragile or damaged veins because they easily collapse under the vacuum pressure of
evacuated tubes
mostly for venipuncture in our laboratory exercises or for beginners

VENOUS BLOOD
ADVANTAGES DISADVANTAGES
Multiple and repeated examinations can be performed on the same specimen Lengthy procedure and requires more preparation
Aliquots of same specimen (plasma, serum) may be frozen for future reference Technically difficult in children, obese, and patients in
No variation in blood valves if specimens are obtained from different veins. shocks
• Ankle veins can be used if arm veins are being used for IV medication
Never draw blood for any laboratory test from the same extremity that is being Hemolyzed blood leads to lowered RBC counts and
used for IV medication (blood transfusion, glucose, etc.) interferes with many chemical tests (enzymes, K)

performance of a venipuncture steps in evacuated tube system

1. Obtain and examine the requisition form.

REQUISITION
All blood collection procedures begin with a request for a test from the treating physician
Outpatient laboratories process the physician's request and generates a requisition à becomes part of the patient's
Definition
medical record and is essential.
Phlebotomists should not collect a sample w/out a requisition form and this form must accompany the sample to the lab.
To provide the phlebotomist with the information needed to correctly identify the patient and the test
Organize the necessary equipment for the collection before you encounter the patient
• Requisition may not indicate any special handling procedures
• Although required to consult laboratory resources to ensure both (1) correct collection and (2) correct handling
Purpose
of the sample
o (e.g. bilirubin test must always be shielded form light after collection even though the requisition does
not state this uses special tube)
collect the appropriate samples; provide legal protection
May be (1) hand-carried by the patient; (2) telephoned or faxed to the central
Outpatient’s
1 processing/accessioning area by health-care provider’s office staff, where the laboratory staff
Requisition
generates a requisition form.
May be (1) delivered to the laboratory; (2) sent by pneumatic tube system; or (3) entered into the
hospital computer at the nursing station and printed out by the laboratory computer.
Forms Phlebotomists should always carefully examine all requisitions for which they are responsible
Inpatient’s before leaving the laboratory.
2
Requisition The requisition should be reviewed to verify the (1) tests to be collected and the (2) time and date
of collection, and to determine whether (3) any special conditions (e.g. fasting, patient preparation
requirements) must be met before the venipuncture. They should check to be sure that all
requisitions for a particular patient are together so that all tests are collected with one venipuncture.
To ensure that the sample drawn and the test results correlate with the appropriate patient, and that they can be correctly
interpreted with regard to any special conditions (e.g. time of collection)
1 First and last names
Identification number
2 • may be hospital-generated number on the patient’s wrist identification band; in all hospital documents
• outpatient setting: laboratory-assigned number
3 Date of birth
4 Location (room number, ER, OPD)
Required 5 Ordering healthcare provider’s name (physician)
Information 6 Tests requested
Requested date and time of sample collection
7
• phlebotomist must write actual date and time on the requisition; the sample label (preferably military time)
8 Status of sample (e.g. STAT, timed, routine)
Other information such as:
• Number and type of collection tubes
9 • Special collection information (e.g. fasting sample, latex sensitivity)
• Special patient information (e.g. areas that should not be used for venipuncture)
• Billing information and ICD-9 codes (Medicare)

2. Greet and reassure the patient and explain the procedure to be performed.
SKILLS IN APPROACHING THE PATIENT
• Social skills are important. Always be polite and friendly with the patient even if they are rude or inconsiderate.
@ashumerez | PMLS 2 : BSMT-1G 2019 22

• patients are always angry about their condition or fearful of the procedure and take out on the first person that they see.
• The phlebotomist could have woken the patient up or could be entering the room right after the doctor gave the patient bad news.
Whatever the patient says, it is inappropriate to counter with unprofessional remarks.
• The easiest way to diffuse an upset patient is to be polite as possible and explain that the doctor’s orders need to be carried out
– here is where your professionalism comes out – as a laboratory representative the reputation of the entire lab rests on the
phlebotomist. The patient’s response on how well the lab performed will not rest on the sophisticated machines alone but on
how skilled, polite and very gentle are the phlebotomist.

3. Identify the patient verbally by having him or her state both first and last names; compare the information on the patient's ID
band with the requisition form.
PATIENT IDENTIFICATION
• The most important step/procedure in phlebotomy is correct identification of the patient.
• The Clinical and Laboratory Standards Institute (CLSI) à two identifiers for patient identification.
• The College of American Pathologists (CAP) and the Joint Commission (JC) à minimum of two patient identifiers when
collecting blood à patient safety goals.
• To ensure that blood is drawn from the right patient, identification is made by comparing information obtained (a) verbally and
from the (b) patient’s wrist ID band with the information on the requisition form.
• Let the patient say his/her full name – ask them to spell it always; wake up the patient who is asleep.

4. Verify if the patient has fasted.

VERIFYING PATIENT’S CONDITION
• Phlebotomists should show both (1) concern for the patient’s comfort; (2) confidence in one’s own ability to perform the procedure.
• Patient should be given a brief explanation of the procedure, including any non-routine techniques will be used (e.g. additional
site preparation performed when collecting blood cultures). They should not be told that the procedure will be painless.
• Patients often question the phlebotomist about what tests are being performed: suggest that they ask their health-care provider
(doctor) these questions.
• Verifying that the appropriate pretest preparation such as fasting or abstaining should be done
• Ask for any allergies to (1) latex or alcohol or (2) iodine

5. Select correct tubes and equipment for the procedure. Have extra tubes available.
ASSEMBLE SUPPLIES AND EQUIPMENT
• T phlebotomist should collect all necessary supplies before actual procedure (e.g. (1) collection equipment, (2) antiseptic pads,
(3) gauze, (4) bandages, and (5) needle disposal system); place them close to the patient.
• The blood collection tray should not be placed on the bed or on the patient’s eating table – placed same side as your free hand
during the collection process.
• Based on the requisition form – check the supplies needed (e.g. tubes – check for expiry)
• Appropriate blood collection system (evacuated tube system, syringe, or winged blood collection set) and the number and type
of collection tubes are selected taking into consideration the age of the patient and the amount of blood to be collected.

6. Wash hands and apply gloves.

7. Position the patient’s arm slightly bent in a downward position so that the tubes fill from the bottom up. Do not allow blood
to touch the stopper puncturing needle. Do not let the patient hyperextend the arm. Ask the patient to make a fist.
POSITION THE PATIENT
• Must be positioned conveniently and safely for the procedure.
• Outpatients are seated and reclined at a drawing station (e.g. phlebotomy chair).
• In some drawing stations, the movable arm serves the dual purposes of providing a solid surface for the patient’s arm and
preventing a patient who faints from falling out of the chair. The patient’s arm should be firmly supported and extended downward
in a straight line.
• A sofa or bed may be used if the patient is anxious or has had previous difficulties during venipuncture.
• A pillow or towel may be placed under the arm for better support.
• Objects such as food, drink, gum, or a thermometer from the patient’s mouth before performance of the venipuncture. Any foreign
object in the mouth could cause choking.

8. Apply the tourniquet 3-4in above the antecubital fossa. Palpate the area in a vertical and horizontal direction to locate a large
vein and to determine the depth, direction and size…
TOURNIQUET APPLICATION
• Should be 3-4in above puncture site
• Proper placement of tourniquet — left over right and insert one end for easy pull out and ends should face up
• Should not be placed for more than a minute to avoid hemoconcentration (leads to hemolysis and petechiae formation)
@ashumerez | PMLS 2 : BSMT-1G 2019 23

LOCATING THE VEIN

can be done by palpation: the ability to see and feel the vein
usually done by using the tip of the index finger (not the thumb) of the non-dominant hand with pushing motion
rather than stroking motion
What to remember done to feel the vein’s width and depth of its exact position
veins feel spongy, bouncy, resilient tube-like structures and firm, but you should be able to differentiate it from
the hard-ridged tendon cords
why thumbs aren’t used to palpate because they have a pulse beat: veins don’t produce pulse, but arteries do
gently massage area to increase circulation
When difficult to
ask patient to make a fist but do not slap the arm in an attempt to raise the vein
locate the vein
gently warm the arm with hot towel or hot pack

VENIPUNCTURE SITE SELECTION

• the most preferred location is in the antecubital fossa on the anterior surface of the arm just distal to the elbows
• although the larger and fuller median cubital and cephalic veins of the arm are used most frequently, the basilic vein on the
dorsum of the arm or dorsal hand veins are also acceptable for venipuncture
VEIN REASON FOR CHOICE / NOT TO CHOOSE
1 Median Cubital large, close to the skin surface and well anchored, so it does not roll away when punctured
2 Cephalic one on line with the thumb; movable and easily collapses but can be seen in obese patients
in line with the pinky finger; least firmly anchored close to the median nerve (or antebrachial nerve) and brachial
3 Basilic
artery which may cause trauma and severe pain if hit

9. Clean the site with 70% isopropyl alcohol in concentric circles moving outward and allow it to air dry.
CLEANING THE SITE
• 70% isopropyl alcohol or a pad with 0.5% chlorhexidine is used to clean the site
• Circular motions starting inward going outwards in widening concentric circles about 2-3 inches
o Repeat this procedure using a new alcohol pad for particularly dirty skin
• For maximum bacteriostatic action, avoid specimen hemolysis and prevent stinging of the patient
o The alcohol should be allowed to dry for 30-60 seconds rather than being wiped off with a gauze pad
• Do not blow, fan or dry area with unsterile gauze the site (reintroduces bacteria)
• If you need to repalpitate the vein, the area must be cleansed again before the puncture

10. Assemble the equipment while the alcohol is drying. Attach the multi-sample needle to the holder.
11. Insert the tube into the holder up to the tube advancement mark.
12. Reapply the tourniquet. Do not touch the puncture site with an unclean finger. Ask the patient to remake a fist. Patient should
be instructed not to “pump” or “continuously clench” the fist to prevent hemoconcentration.
13. Remove the plastic needle cup and examine the needle for defects such as non-pointed or barbed ends.
14. Anchor the vein by placing the thumb of the non-dominant hand 1-2 inches below the site and pulling the skin taut.

15. Grasp the assembled needle and tube holder using your dominant hand with the thumb on the top near the hub and your
other fingers beneath. Smoothly insert the needle into the vein at a 15- to 30-degree angle with the bevel up until you feel a
lessening of resistance. Brace the fingers against the arm to prevent movement of the needle when changing tubes.
NEEDLE INSERTION
ACTION CHARACTERISTICS
Examine the Needle for any defects such as non-pointed or barbed ends, remove the needle cap
Firmly use your thumb to draw the skin taut by placing the thumb 1-2 inches below and slightly to the left of the
Grasp the insertion site with the other fingers at the back of the arm to anchor the vein.
Patient’s Arm The needle should form a 15° to 30° ∠ bevel facing up with the surface of the arm. Swiftly insert the needle
through the skin and into the lumen of the vein. Avoid trauma and excessive probing.

WRONG NEEDLE INSERTION

•
Not all venipuncture result is the immediate appearance of blood, however in many instances this is only a temporary setback that
can be corrected by slight movement of the needle
• Pictures can be found of the last page of the notes.
WRONG NEEDLE POSITION (FAILURE TO OBTAIN BLOOD)
POSITION INSTANCES REMEDY
Angle of insertion is incorrect: rotate the needle a quarter turn to allow blood
Bevel against the Too shallow – needle lays against the upper wall of vein to flow freely into the evacuated tube
1
wall of the vein Too steep – needle lays against lower wall of veins
Failure to insert needle bevel ­ can obstruct blood flow
2 Needle too deep When the angle of insertion is too steep (> 30°)
@ashumerez | PMLS 2 : BSMT-1G 2019 24

While advancing the evacuated tube holder onto the gently pulling the needle back may produce
tube when the holder is not firmly braced against the blood flow
skin, needle may penetrate through the vein into tissue
Blood can leak into the tissues forming hematoma
Using too large an evacuated tube or pulling back on the using a smaller evacuated tube or another
3 Collapsed Vein plunger of the syringe too quickly à suction pressure puncture must be performed using a syringe or
that can cause a vein to collapse and stop blood flow. a winged blood collection set
If the needle angle is too low (< 15°) slowly advancing the needle into the vein to
correct the problem
• if hematoma appears under the skin – stop
Needle may only partially enter the lumen of the vein
4 Needle too shallow venipuncture immediately apply pressure to
causing the blood leak into the tissues forming a
site, causing patient injury and sample
hematoma
collection contains tissue fluid
(contaminated)
Usually happens if vein is not well anchored withdraw the needle up to the bevel just below
Needle Beside
5 needle may slip to the side of the vein without the skin, reanchor the vein, and redirect the
the Vein
penetration (rolling vein) needle into the vein
needle appears to be in the vein and no blood comes out Change your tubes
Faulty
6 Age of tube, cracking or dropping of tube
Evacuated Tube
Loss of vacuum of the tube

16. Using the thumb, advance the tube onto the evacuated tube needle, while the index and the middle fingers grasp the flared
ends of the holder.
FILLING THE TUBES
• Once the vein has been entered, the hand anchoring the vein can be moved and used to push the evacuated tube completely
into the holder.
• Use the thumb to push the tube onto the back of the evacuated tube needle, while the index and middle fingers grasp the flared
ends of the holder.
o Blood should begin to flow into the tube and the fist and tourniquet can be released.
o if the procedure does not last > 1 minute, the tourniquet can be left on until the last tube is filled.
o Some prefer to change hands at this point so that the dominant hand is free for performing the remaining tasks.
• This method of operating is usually better suited for use by experienced phlebotomists because holding the needle steady in
the patient’s vein is often difficult for beginners
• The hand used to hold the needle assembly should remain braced on the patient’s arm.
o This is of particular importance when evacuated tubes are being inserted or removed from the holder, because a certain
amount of resistance is encountered and can cause the needle to be pushed through or pulled out of the vein.
• Tubes should be gently twisted on and off the puncturing needle using the flared ends of the holder as an additional brace.
• Pulling up or pressing down on the needle while it is in the vein can cause pain to the patient or a hematoma formation if blood
leaks from the enlarged hole.
• To prevent any chance of blood refluxing back into the needle, tubes should be held at a downward angle while they are being
filled and have slight pressure applied to them.
o Be sure to follow the prescribed order of draw when multiple tubes are being collected, and allow the tubes to fill
completely before removing them.
• Gentle inversion of the evacuated tubes for 3-8 times, depending on the type of tube, should be done as soon as the tube is
removed before another tube is placed in the assembly.
o The few seconds that this procedure requires does not cause additional discomfort to the patient and ensures that the
sample will be acceptable.
• When the last tube has been filled, it is removed from the assembly and mixed before completing the procedure.
o Failure to remove the evacuated tube before removing the needle causes blood to drip from the end of the needle,
resulting in unnecessary contamination and possible damage to the patient’s clothes.

17. When the blood flows into the tube, release the tourniquet, and ask the patient to open the fist. (lost notes on “Removal of
Tourniquet”)
18. Gently remove the tube when the blood stops flowing into it. Gently invert anticoagulated tubes promptly. Insert the next
tube using the correct order of draw. Fill the tubes completely.
19. Remove the last tube collected from the holder and gently invert.

20. Cover puncture site with clean gauze. Remove the needle smoothly and apply pressure or ask the patient to apply pressure.
NEEDLE REMOVAL
• Remove the last tube before removing the needle, to prevent blood from dripping out of the tube
• Pull the needle assemble straight out from the patient’s arm at the same angle it was inserted and in one swift motion.
• Activate the safety feature/device on the needle (e.g. safety shield/safety glide)
• Apply gauze square folded to the puncture site
@ashumerez | PMLS 2 : BSMT-1G 2019 25

• Patient’s arm should be straight, not bent or raised, outstretched position

• Pressure should be applied at least 2-3 mins (5 mins) until the bleeding has stopped

21. Activate the safety device.

22. Dispose the needle/holder assembly with the safety device activated into the “sharps” container

23. Label the tubes before leaving the patient and verify identification with the patient ID band or verbally with an outpatient.
Observe any special handling procedures. Complete paperwork.
DISPOSAL OF CONTAMINATED MATERIALS
After venipuncture, the used needle collection system (needles, gloves) should be disposed properly in a biohazard waste container.

LABELING OF THE TUBES

• label each tube at the patient’s bedside or in the drawing room in the presence of the patient.
• do not leave the room without labeling the tubes
• use permanent markers – never use a pencil or non-permanent marker
• label must have:
(1) patient’s name (3) date and time of collection
(2) ID number (4) phlebotomist’s initials and ID number

24. Examine the puncture site and apply bandage. Place bandage over folded gauze for additional pressure.

25. Prepare sample and requisition for transportation to the laboratory. Dispose of used supplies.
ATTEND TO THE PATIENT
• Examine the patient’s arm to make sure bleeding has stopped.
• Bleeding should stop within five (5) minutes (unless patient has taken in aspirin or blood thinners or in warfarin therapy).
• Paper tape should be used for patient’s allergic to adhesive bandages.
• Patient is advised to remove bandage after one (1) hour and avoid using the arm to carry heavy objects during that period.

DELIVERING SAMPLE TO THE LABORATORY

• Samples should be delivered as soon as possible to the laboratory
• Blood with anticoagulants should be delivered not more than 45 minutes to 2 hours after collection.

26. Thank the patient, remove gloves, and wash hands.

SUMMARY OF PERFORMANCE OF A VENIPUNCTURE STEPS IN EVACUATED TUBE SYSTEM

STEP NOTABLE ACTIONS
Requisition
1 Obtain and examine the requisition form. • Definition • Forms
• Purpose • Required Information
2 Greet and reassure the patient and explain the procedure to be performed. Skills in Approaching the Patient
Identify the patient verbally by having him or her state both the first and the last
3 Patient Identification
names. Compare the information on the patient’s ID band with the requisition form.
Verify if the patient has fasted, has allergies to latex, or has had previous problems
4 Verifying Patient’s Condition
with venipuncture.
5 Select correct tubes (have extra available) and equipment for procedure. Assemble Supplies and Equipment
6 Wash hands and apply gloves.
Position the patient’s arm slightly bent in a downward position so that the tubes
7 fill from the bottom up. Do not allow blood to touch the stopper puncturing needle. Position the Patient
Do not let the patient hyperextend the arm. Ask the patient to make a fist.
Apply the tourniquet 3-4in above the antecubital fossa. Palpate the area in a
vertical and horizontal direction to locate a large vein and to determine the depth, Tourniquet Application
8 direction and size: Locating the Vein
1. Median cubital 2. cephalic 3. basilic (should be avoided) Venipuncture Site Selection
Remove the tourniquet and have the patient open his or her fist.
Clean the site with 70% isopropyl alcohol in concentric circles moving outward
9 Cleaning the Site
and allow it to air dry.
10 Assemble the equipment while the alcohol is drying. Attach the multi-sample needle to the holder.
11 Insert the tube into the holder up to the tube advancement mark.
ASH | PMLS 2 : BSMT-1G 2019 26

Reapply the tourniquet. Do not touch the puncture site with an unclean finger. Ask the patient to remake a fist. Patient should be
12
instructed not to “pump” or “continuously clench” the fist to prevent hemoconcentration.
13 Remove the plastic needle cup and examine the needle for defects such as non-pointed or barbed ends.
14 Anchor the vein by placing the thumb of the non-dominant hand 1-2 inches below the site and pulling the skin taut.
Grasp the assembled needle and tube holder using your dominant hand with the
Needle Insertion
thumb on the top near the hub and your other fingers beneath. Smoothly insert
Wrong Needle Insertion
15 the needle into the vein at a 15° to 30° ∠ with the bevel up until you feel a lessening
Wrong Needle Position (Failure to Obtain
of resistance. Brace the fingers against the arm to prevent movement of the
Blood)
needle when changing tubes.
Using thumb, advance the tube onto evacuated tube needle, while index and
16 Filling the Tubes
middle fingers grasp the flared ends of the holder.
17 When the blood flows into the tube, release the tourniquet, and ask the patient to open the fist.
Gently remove the tube when the blood stops flowing into it. Gently invert anticoagulated tubes promptly. Insert the next tube
18
using the correct order of draw. Fill the tubes completely.
19 Remove the last tube collected from the holder and gently invert.
Cover the puncture site with clean gauze. Remove the needle smoothly and apply
20 Needle Removal
pressure or ask the patient to apply pressure.
21 Activate the safety device.
22 Dispose the needle/holder assembly with the safety device activated into the “sharps” container
Label the tubes before leaving the patient and verify identification with the patient
Disposal of Contaminated Materials
23 ID band or verbally with an outpatient. Observe any special handling procedures.
Labeling of the Tubes
Complete paperwork.
24 Examine the puncture site and apply bandage. Place bandage over folded gauze for additional pressure.
Prepare sample and requisition for transportation to the laboratory. Dispose of Attend to the Patient
25
used supplies. Delivering Sample to the Laboratory
26 Thank the patient, remove gloves, and wash hands.

Venipuncture using a syringe

MATERIALS NEEDED
• requisition form • Blood transfer device • Sharps container
• gloves tourniquet • Evacuated tubes • Indelible pen
• 70% isopropyl alcohol pad • 2x2 gauze • Bandage biohazard bag
• Syringe needle with safety device
STEP / ACTIONS TAKEN
1 Perform steps 1 to 9 “Venipuncture using an Evacuated Tube System”. Greeting to Positioning the patient.
Assemble the equipment as the alcohol is drying.
2 Attach the hypodermic needle to the syringe.
Pull the plunger back to ensure that it moves freely and then push it forward to remove any air in the syringe.
3 Reapply the tourniquet, remove the needle cap, and inspect the needle.
Ask the patient to remake a fist.
4
Anchor the vein by placing the thumb of the non-dominant hand 1 to 2 in below the site and pulling the skin taut.
Hold the syringe in the dominant hand with the thumb on top near the hub and the other fingers underneath.
Smoothly insert the needle into the vein at a 15° to 30° ∠ with the bevel up until you feel a lessening of resistance. A flash of blood
5
will appear in the hub of the needle when the vein has been entered.
Brace the fingers against the arm to prevent movement of the needle when pulling back on the plunger.
6 Pull back the syringe plunger slowly using the non-dominant hand to collect the appropriate amount of blood.
7 Release the tourniquet and have the patient open the fist.
8 Cover the puncture site with gauze, remove the needle smoothly, activate the safety shield, and apply pressure.
9 Remove the needle from the syringe and discard it in the “sharps” container.
10 Attach a blood transfer device to the syringe.
Holding the syringe vertically with the blood transfer device at the bottom, advance the evacuated tube onto the internal needle
11 in the blood transfer device. Tubes will fill by the vacuum in the tube.
Keep tube in a vertical position to ensure that tubes fill from the bottom up to avoid cross-contamination. Do not push on plunger.
Fill tubes in the correct order.
12
Mix anticoagulant tubes as soon as they are removed from the transfer device.
ASH | PMLS 2 : BSMT-1G 2019 27

13 After the tubes are filled, the entire syringe and blood transfer device are discarded into a “sharps” container.
14 Label the tubes and confirm identification with the patient.
15 Examine the puncture site and apply a bandage.
16 Remove gloves and wash hands.

Venipuncture using a winged blood collection set

MATERIALS NEEDED
• requisition form • Blood transfer device • Sharps container
• gloves tourniquet • Evacuated tubes • Indelible pen
• 70% isopropyl alcohol pad • 2x2 gauze • Bandage biohazard bag
• Butterfly infusion set
STEP / ACTIONS TAKEN
1 Perform steps 1 to 9 “Venipuncture using an Evacuated Tube System”. Greeting to Positioning the patient.
2 Support the hand on the bed or drawing chair armrest and have the patient make a fist.
3 Apply the tourniquet above the wrist bone.
4 Palpate the top of the hand or wrist. Select a vein that is large, straight and that can be easily anchored.
5 Release tourniquet, have the patient relax fist, and clean site with 70% isopropyl alcohol in concentric circles. Allow to airdry.
Assemble equipment as the alcohol is drying. Attach the winged blood collection set to the evacuated tube holder or the syringe.
6 Stretch out the coiled tubing. Pull the plunger back to ensure that it moves freely and then push it forward to remove any air in the
syringe. If using an evacuated tube holder, insert the first tube to the tube advancement mark.
7 Reapply the tourniquet remove the needle cap, and inspect the needle. Lay the syringe and tubing next to the patient’s hand.
Anchor the vein by placing the thumb of the non-dominant hand below the knuckles and pulling the skin taut. Having the patient
8
make a fist may be helpful.
Grasp the needle between the thumb and index finger by holding the back of the needle or by folding the wings together.
Smoothly insert the needle into the vein at a shallow a 10° to 15° ∠ with bevel up.
9
Thread the needle into the lumen of the vein until the bevel is firmly “seated” in the vein. A flash of blood will appear in the tubing
when the needle has entered the vein.
Pull back on the plunger of the syringe slowly and smoothly with the non-dominant hand to collect blood. Do not pull back on the
syringe plunger if a blood plunger does not appear.
10 When using an evacuated tube holder, insert the tubes in the correct order of draw.
Use a discard tube when collecting anticoagulated tubes to prime the tubing and maintain correct blood-to-anticoagulant ratio.
Invert anticoagulated tubes immediately.
11 Release the tourniquet.
Cover the puncture site with gauze, remove the needle smoothly or activate the safety device on needles designed to be retracted
12
while the needle is in the vein.
13 Activate the safety shield for needles designed to be shielded when the needle is out of the vein; apply pressure.
14 Remove the winged blood collection set from the syringe and discard it in the “sharps” container.
15 Attach a blood transfer device to the syringe and fill the evacuated tubes in the correct order.
16 After tubes are filled, the syringe and blood transfer device are discarded into a “sharps” container.
17 Label the tubes and confirm identification with the patient.
18 Examine the puncture site and apply a bandage.
19 Remove gloves and wash hands.

venous blood collection for infants

• Site selection: the veins in the antecubital fossa are the best choice for children older than 2 years.
o Do not use deep veins. Site selection and technique is similar to the used for adults.
• Dorsal hand venipuncture (dorsal hand vein technique) can be used for children younger than 2 years of age.
o This technique can be used to collect samples from superficial hand vein directly into appropriate microscopic containers.
o The advantage of this technique is that more blood can be collected from the vein as compared with a heel stick and
there is less chance of hemolyzing the sample or contaminating the sample with tissue fluid.
o Use of this technique requires additional training and is an institutional decision because saving all veins for IV therapy
may be preferred. Use extreme care when disposing of the contaminated needle.
ASH | PMLS 2 : BSMT-1G 2019 28
CORD BLOOD
• This is obtained at the time of delivery. An admixture of cord jelly (Wharton’s Jelly) must be carefully avoided.
• The placental segment of the cord is either allowed to drain into a test tube, or the
umbilical vein (preferable) is aspirated with needle and syringe.

external jugular vein puncture

• Procedure of choice for obtaining venous blood from infants and small children.
• Infant is wrapped in sheet so that the arms are immobilized alongside the body.
o The child is placed on his back on the examining table so that his head hangs
over the edge of the table as his body is steadied by an assistant.
o His head is supported and turned to one side. When the child cries, the
external jugular stands out distinctly, running the angle of the mandible to the
mid-clavicular area.

preexamination variables and venipuncture complications

LESSON 6
Date of Lecture : 26 February 2019. Dr. Annabel M. Laranjo, MD, FPCP, DPSMID
References : Strasinger, Susan King, The Phlebotomy Textbook, 3rd Edition, 2011

Preexamination variables
VARIABLE CHARACTERISTICS / EXAMPLES
(1) Glucose and (2) triglycerides – most commonly affected
Serum or plasma collected from patients shortly after a meal may appear cloudy or turbid (lipemic) due
Lipemia to the presence of fatty compounds such as meat, cheese, butter, and cream.
will interfere with many test procedures
Certain beverages can also affect laboratory tests:
can cause a transient elevation in glucose levels
Alcohol
chronic à affects tests associated with the liver and increases triglycerides
Consumption
Diet metabolized by the liver à exhaustion
Caffeine Found to affect hormone levels
Hemoglobin levels and electrolyte balance can be altered by drinking too much liquid.
Because of these dietary interferences in laboratory testing, fasting samples are often requested.
• When a fasting sample is requested, it is the responsibility of the phlebotomist to determine whether the patient
has been fasting for the required length of time.
• If the patient has not, this must be reported to a supervisor or the nurse and noted on the requisition form.
• For most tests, the patient is required to fast for 8-12 hours.
Changes in patient posture from a supine à erect position cause variations in some blood constituents:
• cellular elements • high molecular weight substances (e.g. fats,
• plasma proteins cholesterol)
• cpds. bound to plasma proteins o falsely increased à these substances are left behind
The large size of these substances prevents movement between the plasma and tissue fluid when body position
changes.
• Therefore, when a person moves from a supine à erect position and water leaves the plasma, the concentration
of these substances ­ in the plasma.
¯ plasma volume à noticeable ­ in the following tests:
o cell counts o bilirubin o calcium
Posture o protein o cholesterol o enzymes
o albumin o triglycerides
• changing from a supine position to standing à concentration of these analytes ­ 4-15% within 10min.
• » 30 mins. for the analytes to ¯ back to original level after returning from standing to the supine position
Plasma renin, serum aldosterone, and catecholamines can double in 1 hr; therefore,
• patients are required to be lying down for 30 min. before blood collection.
The National Institutes of Health recommends that patients be lying or sitting for 5 min. prior to blood collection for lipid
profiles to minimize the effects caused by posture.
The increase is most noticeable in patients with disorders such as congestive heart failure and liver diseases that cause
increased fluid to remain in the tissue.
Lab results in elderly patients may be more affected by changes in posture.
ASH | PMLS 2 : BSMT-1G 2019 29

Moderate or strenuous exercise affects laboratory test results by increasing the blood levels of:
o Creatinine o hormones o bilirubin
o fatty acids § antidiuretic h. o uric acid
o lactic acid § catecholamines o high-density lipoprotein
o aspartate aminotransferase (AST) § growth hormone (HDL)
o creatine kinase (CK) § cortisol o white blood cell (WBC)
o lactic dehydrogenase (LD) § aldosterone count
o aldolase § renin o ¯ arterial pH and PCO2
§ angiotensin (effect of oxygen ­).
o Allow patients to rest for several hours first because everything is elevated.
The effects of exercise depend on the (1) physical fitness and muscle mass of the patient, (2) the strenuousness and
intensity of the exercise, and (3) the time between the exercise and blood collection.
Vigorous exercise
Exercise
• Temporary activation of coagulation factors and platelet function.
• Light blue test tube (sodium citrate)
• Low results in coagulation factors after vigorous exercise (activation is different from increase)
Transient short-term exercise and prolonged exercise or weight training affect test results differently.
• Muscle contents are released into the blood.
• Anaerobic glycolysis and metabolic changes interfere with laboratory results.
• elevates the enzymes associated with muscles (AST, CK, LD) and the WBC count because WBCs attached to the
venous walls are released into the circulation.
• The values usually return to normal within several hours of relaxation in a healthy person; however, (1) skeletal
muscle enzymes, (2) aldosterone, (3) renin, and (4) angiotensin may be elevated for 24hrs. Prolonged exercise
also ­ the muscle-related waste products (AST, CK, and LD) and hormones; they remain more consistently elevated.
o Well-trained athletes are more resistant to exercise- related changes because of their consistently elevated
level of skeletal muscle enzymes.
Failure to calm a frightened, nervous patient before sample collection may ­ levels of adrenal hormones (cortisol,
catecholamines), ­WBC counts, ¯serum iron, and markedly affect arterial blood gas (ABG) results. (Stress = ­O2, ¯CO2)
It has been shown that WBC counts collected from a violently crying newborn may be markedly elevated.
• This is caused by the release of WBCs attached to the blood vessel walls into the circulation.
• In contrast, WBC counts on early morning samples collected from patients in a basal state will be ¯ until normal
Stress
activity is resumed.
o Newborns can have WBCs as ­ as 20,000 compared to the 5,000-10,000 of adults; vomiting à ­ WBCs.
• Elevated WBC counts return to normal within 1 hour.
• For accurate WBC count, discontinue blood collection from crying child until after child has been calm for ³ 1 hour.
Severe anxiety that results in hyperventilation may cause acid-base imbalances and ­ lactate and fatty acid levels.
The immediate effects of nicotine include increases in (with high risk for hypertension):
o plasma catecholamines o glucose o cholesterol
o cortisol o blood urea nitrogen (BUN) o triglycerides
The extent of the effect depends on the type and the number of cigarettes smoked and the amount of smoke inhaled.
Smoking Glucose and Blood Urea Nitrogen (BUN) can ­ by 10% and triglycerides by 20%.
Increased Decreased
o Hemoglobin o mean corpuscular volume (MCV) Immunoglobulins IgA, IgG, and IgM à lowering the
o RBC counts o immunoglobulin (Ig) E effectiveness of the immune system (prone to infection).
In smoking there is hypoxia à trouble in O2-CO2 exchange à compensatory increase in RBCs
RBC counts and hemoglobin (Hgb) and hematocrit (Hct) levels are ­ in high-altitude areas such as the mountains where
there are ¯ O2 levels.
The body produces increased numbers of RBCs to transport O2 throughout the body.
Normal ranges for RBC parameters must be established for populations living at 5,000-10,000ft above sea level.
Altitude
• It is important to note this information if when speaking with the patient you realize that he or she has just traveled
from another geographical area.
o Na and K will be falsely low because of their extensive sweating especially if they had walked from afar.
o Don’t let them go home right away; let them wait there.
Laboratory results vary between (1) infancy, (2) childhood, (3) adulthood, and the (4) elderly because of the gradual
change in the composition of body fluids.
• As a child, your body is mostly water. As for adults, muscles.
Age and
Hormone levels vary with age and gender.
Gender
RBC, Hgb, and Hct values = males > females.
Normal reference ranges are established for the different patient age and gender groups.
• The age and gender of the patient should be present on the requisition.
Weight gain à plasma volume ­ à hypertension (preeclampsia) à everything ­
Pregnancy
Sugar ­ à diabetes, especially if you have family history.
ASH | PMLS 2 : BSMT-1G 2019 30

Pregnancy-related differences in laboratory test results are caused by the physiological changes in the body including
increases in plasma volume.
• The ­ plasma volume may cause a dilutional effect and cause lower ¯:
o RBC counts (anemic) o alkaline phosphatase o free fatty acids
o Protein o estradiol o iron values
The erythrocyte sedimentation rate and coagulation factors II, V, VII, VIII, IX, and X (2, 5, 7-10) may be increased.
• Mothers don't move à blood clot à stroke/pulmonary embolism
o shock o burns
o malnutrition o trauma
o fever may influence blood and body fluid composition
à Increased à Decreased
Other Malnutrition o ketones o lactate o glucose o thyroid hs. o albumin
Factors
o bilirubin o triglycerides o cholesterol o total protein
Fever à ­ (1) insulin, (2) glucagon, and (3) cortisol (glucocorticoid — stress hormone) levels
Environmental Temperature and humidity
Factors • Acute exposure to heat that causes sweating may cause dehydration and hemoconcentration.
The normal fluctuation in blood levels at different times of the day based on a 24-hour cycle of eating and sleeping.
• The concentration of some blood constituents is affected by the time of day.
Blood analytes are released into the bloodstream intermittently.
Levels highest in the morning:
• cortisol • estradiol • insulin
• aldosterone • thyroid-stimulating hormone (TSH) • potassium
Diurnal • renin • testosterone • RBC count
Variation • luteinizing hormone (LH) • bilirubin • serum iron
• follicle-stimulating hormone (FSH) • hemoglobin
Levels lowest in the morning:
• eosinophil counts • glucose • phosphate
• creatinine • triglyceride
• Cortisol and iron levels can differ by 50% between 8 a.m. to 4 p.m. (special tests)
o It is important to collect samples for analytes that exhibit diurnal variation at the correct scheduled time.
either by changing a metabolic process within the patient or by producing interference with the testing procedure
IV administration of dyes used in diagnostic procedures
• (Get creatinine first before doing the test) radiographic contrast media for kidney disorders and fluorescein used to
evaluate cardiac blood vessels, can interfere with testing procedures.
In general, understanding the effect of medications and diagnostic procedures on laboratory test results is the
responsibility of the healthcare provider, pathologist, or clinical laboratory testing personnel.
• Doctors order, but medtechs execute.
Phlebotomists, however, should be aware of any procedures being performed at the time they are collecting a sample
and note this on the requisition form.
• E.g. samples collected while a patient is receiving a blood transfusion may not represent the patient’s true condition.
A variety of medications, both prescription and over-the-counter, can influence laboratory test results.
Medications that are toxic to the liver à ­ blood liver enzymes (leads to hepatitis) and abnormal coagulation tests.
Elevated BUN levels or imbalanced electrolytes may be noted in patients taking medications that impair renal function.
Patients taking (1) corticosteroids, (2) estrogens, or (3) diuretics.
• can develop pancreatitis and would have ­ (a) serum amylase and (b) lipase levels.
Medications • Chemotherapy drugs cause a decrease in WBC counts and platelets (side effect: infection).
o Patients taking diuretics may have elevated (1) Ca, (2) glucose, and (3) uric acid levels, and ¯ potassium levels.
Oral contraceptives can cause a ¯ in (1) apoprotein, (2) cholesterol, (3) HDL, (4) triglycerides, and (5) iron levels. (See)
Common Medications Affecting Laboratory Tests
MEDICATION AFFECTED TESTS/SYSTEMS
Acetaminophen and certain antibiotics Elevated liver enzymes and bilirubin
Cholesterol-lowering drugs Prolonged PT and APTT
Certain antibiotics Elevated BUN, creatinine, and electrolyte imbalance
Corticosteroids and estrogen diuretics Elevated amylase and lipase
Diuretics ­ calcium, glucose, and uric acid and decreased sodium and potassium
Chemotherapy ¯ RBCs, WBCs, and platelets
Aspirin, salicylates, and herbal supplements Prolonged PT and bleeding time
Radiographic contrast media Routine urinalysis
Fluorescein dye ­ creatinine, cortisol, and digoxin
¯ apoproteins, transcortin, cholesterol, HDL, triglycerides, LH, FSH,
Oral contraceptives
ferritin, and iron
ASH | PMLS 2 : BSMT-1G 2019 31

Aspirin, medications that contain salicylate, and certain herb use can interfere with platelet function (inhibited à bleeding)
or Coumadin anticoagulant therapy and may cause increased risk of bleeding.
Herbs, vitamins, and dietary supplements that have been reported to have effects on coagulation (no researches — that's
why they're coined as "food supplements", not "drugs").
The College of American Pathologists recommends that drugs known to interfere with blood tests should be
discontinued/withheld 4-24 hours before blood tests and 48-72 hours before urine tests.
Herbs, Vitamins, and Dietary Supplements Having Effects on Coagulation and Blood Clotting:
• Garlic • Vitamin E • Bromelain • Feverfew • Horsetail rush
• Ginkgo biloba • Fucus • Cat’s claw • Grape seed • Licorice
• Ginseng • Danshen • Celery • Green tea • Prickly ash
• Anise • St. John’s wort • Coleus • Guarana • Red clover
• Dong Quai • Alfalfa • Cordyceps • Guggu • Reishi
• Omega-3 fatty • Coenzyme Q10 • Evening • Horse chestnut • Sweet clover
acids in fish oil • Bilberry primrose seed • Turmeric
• Ginger • Bladder wach • Fenugreek • Horseradish • White willow
• Patients taking herbs often do not realize the side effect of bleeding that can occur.
• When excessive post venipuncture bleeding occurs, question the patient about herbal medications and document
this on the requisition.

venipuncture complications
COMPLICATION CHARACTERISTICS / EXAMPLES
common; enlisting the help of the nurse who has been caring for the patient may help to calm the person’s fears.
Apprehensive ask for assistance from the nurse to hold the patient’s arm steady during the procedure.
Patients • assistance from a nurse or parent is frequently required when working with children.
• may require assistance when encountering patients in fixed positions (e.g. those in traction or body casts)
spontaneous loss of consciousness caused by insufficient blood flow to the brain.
part of the involuntary nervous system that regulates heart rate and blood pressure malfunctions in response to
a trigger that causes a vasovagal reaction (parasympathetic à activation of vagus nerve)
• The heart rate suddenly drops; blood vessels in the legs dilate causing blood to pool in the legs and ¯BP.
Triggers such as the sight of blood, having blood drawn, fear of bodily injury, standing for long periods of time,
heat expo- sure, and exertion can cause vasovagal syncope.
Other conditions:
• Postural hypotension • heart disease • hypoglycemia
• Dehydration • anemia • neurological disorders
• low blood pressure
Symptoms before fainting or a syncope episode include:
• paleness of the skin • dizziness • feeling of warmth
• hyperventilation • nausea • cold, clammy skin
• lightheadedness
Fainting (Syncope) Must be aware of these symptoms and monitor patient throughout entire venipuncture procedure (ask orally).
Apprehensive patients and fasting patients may be prone to fainting.
The phlebotomist should ask the patient if he or she has had problems with blood collection / tendency to faint.
• Keeping their minds off the procedure through conversation can be helpful.
• If a patient begins to faint during the procedure, immediately remove the tourniquet and needle, and apply
pressure to the venipuncture site.
Inpatient Setting Outpatient Setting
notify the nursing station ASAP make sure patient is supported and that the patient lowers hi/her head
Watch the patient carefully as patients tend to fall forward (can easily slip out of the phlebotomy chair.)
• Ask the patient to take deep breaths.
• If possible, lay the patient flat and loosen tight clothing.
• Cold compresses applied to the fore- head and back of the neck will help to revive the patient.
Outpatients who have been fasting for prolonged periods should be given something sweet to drink (if the blood
has been collected) and required to remain in the area for 15-30 mins.
All incidents of syncope should be documented following institutional policy
Remove Apply Summon
Tourniquet and needle Pressure Help
rare; restrain the patient only to the extent that injury is prevented.
Seizures
Do not attempt to place anything in the patient’s mouth.
• Call doctor if inpatient. If outpatient, you're on your own.
Any very deep puncture caused by sudden movement by the patient should be reported to the physician.
ASH | PMLS 2 : BSMT-1G 2019 32

Document the time the seizure started and stopped according to institutional policy.
Small, nonraised red hemorrhagic spots (petechiae) may have prolonged bleeding following venipuncture.
Petechiae Petechiae can be an indication of a coagulation disorder, such as a ¯ platelet count or abnormal platelet function.
Additional pressure should be applied to the puncture site following needle removal.
Patients are occasionally allergic to alcohol, iodine, latex, or the glue used in adhesive bandages.
Allergies Necessary precautions must be observed by using alternate antiseptics, paper tape or self-adhering wrap
(Coban), and nonlatex products.
A patient may experience nausea or vomiting before, during, or after blood collection.
If patient is nauseated, instruct patient to breathe deeply slowly and apply cold compresses to patient’s forehead.
Vomiting If the patient vomits, stop blood collection and provide the patient with an emesis basin/wastebasket and tissues.
• Give an outpatient water to rinse out his or her mouth and a damp washcloth to wipe the face.
• Notify the patient’s nurse or designated first-aid personnel.
Phlebotomists must be alert for changes in a patient’s condition and notify the nursing station
Additional Patient
• presence of vomitus, urine, or feces; • extreme breathing difficulty;
Observations
• infiltrated or removed IV fluid lines; • and possibly a patient who has expired.
Some patients may refuse to have their blood drawn, and they have the right to do this.
The phlebotomist can stress to the patient that results are needed by the healthcare provider for treatment and
Patient Refusal discuss the problem with the nurse, who may be able to convince the patient to agree to have the test performed.
If the patient continues to refuse, this decision should be written on the requisition form and the form should be
left at the nursing station or the area stated in the institution policy.
Application of the tourniquet for > 1 minute will interfere with some test results, which is why the Clinical and
Laboratory Standards Institute (CLSI) set the limit on tourniquet application time to be 1 minute
• The tourniquet should be released as soon as the vein is accessed.
Prolonged tourniquet time causes hemoconcentration because the plasma portion of the blood passes into the
tissue, which results in an ­ concentration of protein-based analytes in the blood.
• Tests most likely to be affected are those measuring large molecules (e.g. plasma proteins and lipids, RBCs),
and substances bound to protein such as Fe, Ca, Mg, or analytes affected by hemolysis, including K, lactic
acid, and enzymes.
o Tourniquet application/fist clenching aren’t recommended ß drawing samples for LA determinations.
Hemoconcentration Releasing the tourniquet as soon as blood begins to flow into the first tube can sometimes result in the inability
to fill multiple collection tubes.
Phlebotomists may have to decide regarding immediately removing the tourniquet based on the size of the
patients’ veins or the difficulty of the puncture.
• Regardless of the situation, the tourniquet should not remain in place for longer than 1 minute.
Other causes of hemoconcentration are excessive squeezing or probing a site, long-term IV therapy, sclerosed
or occluded veins, and vigorous fist pumping.
Cellular Elements Increased by Hemoconcentration:
• ammonia • calcium • iron • lipids • proteins
• bilirubin • enzymes • lactic acid • potassium • RBCs
Temporary or permanent nerve damage can be caused by incorrect vein selection or improper venipuncture
technique and may result in loss of movement to the arm or hand and the possibility of a lawsuit.
The most critical permanent injury in the venipuncture procedure is damage to the median antebrachial
cutaneous nerve.
The patient may experience a shooting pain, electric-like tingling or numb- ness running up or down the arm or
in the fingers of the arm used for venipuncture.
Errors in technique that can cause injury include:
• blind probing • lateral redirection of the needle
Nerve Injury • selecting high-risk venipuncture sites (underside of • excessive manipulation (jerky
the wrist, basilic vein) movements) of the needle
• employing an excessive ∠ of needle insertion (>30º) • movement by the patient while the
needle is in the vein
The pressure from a hematoma, infiltrations of IV fluid, or a tourniquet that is on for too long or too tight can
cause a nerve compression injury.
Swelling and numbness may occur 24-96 hours later.
• The symptoms of nerve injury are treated with a cold ice pack initially à warm compresses to the area.
Document the incident and direct the patient to medical evaluation if indicated, according to facility policy.

SITE SELECTION
SITE CHARACTERISTICS / REASONS
Areas to Certain areas must be avoided for venipuncture because of the possibility of decreased blood flow, infection, hemolysis,
Be Avoided or sample contamination.
ASH | PMLS 2 : BSMT-1G 2019 33

• Sample contamination affects the integrity of the specimen causing invalid test results.
• The laboratory personnel may not know that contamination has occurred and consequently can report erroneous
test results that adversely affect overall patient care.
• Incorrect blood collection techniques that cause contamination include blood collected from edematous areas,
blood collected from veins with hematomas, blood collected from arms containing an IV, sites contaminated with
alcohol or iodine, or anticoagulant carryover between tubes.
Veins that contain thrombi or have been subjected to numerous venipunctures often feel hard (sclerosed) and should be
avoided as they may be blocked (occluded) and have impaired circulation.
Chemotherapy patients, chronically ill patients, and illegal IV drug users may have hardened veins. Probing or using a
lateral needle direction when redirecting the needle also can cause vein damage.
Damaged
• Areas that appear blue or are cold may also have impaired circulation.
Veins
not recommended à the sample will be contaminated with tissue fluid and yield inaccurate test results.
may be caused by (1) heart failure, (2) renal failure, (3) inflammation, or (4) infection; (5) IV fluid infiltrating into the
surrounding tissue.
Phlebotomists should notify nursing personnel if they encounter this situation.
Often, the cephalic vein is more prominent and easier to palpate.
A blood pressure cuff may work better as a tourniquet when a vinyl or latex tourniquet is too short.
Obesity It is important to not probe to find the vein as that can be painful to the patient and cause hemolysis by destroying RBCs
that can alter test results.
Veins on obese patients are often deep and difficult to palpate. Using a syringe with a 1½-inch needle offers more control.
blood should then be drawn from the other arm because the sample maybe contaminated with IV fluid
If an arm containing an IV must be used for sample collection, the site selected must be below the IV insertion point and
preferably in a different vein.
CLSI recommends having the nurse turn off the IV infusion for 2 minutes, the phlebotomist then may apply the tourniquet
between the IV and the venipuncture site and perform the venipuncture (discard the first 5mL).
Document the location of the venipuncture (right or left arm) and that it was drawn below an infusion site.
• It is preferred, however, that a dermal puncture be performed to collect the sample if possible.
A nurse may choose to collect blood from an IV line that is inserted into the vein.
• If blood is collected from the IV line, the nurse should turn off the IV drip for at least 2 minutes.
IV Therapy
• The first 5 mL of blood drawn must be discarded, because it may be contaminated with IV fluid.
A new syringe is then used for the sample collection.
• If a coagulation test is ordered, an additional 5mL (total of 10mL) of blood should be drawn before collecting the
coagulation test sample because IV lines are frequently flushed with heparin.
o This additional blood can be used for other tests if they have been requested.
Collections from an IV site are usually performed by the nursing staff to ensure proper care of the site.
• Whenever blood is collected from an arm containing an IV line, the type of fluid and location of IV must be noted on
the requisition form.
Avoid collecting blood at the same time dye for a radiological procedure or a unit of blood is being infused.
@ashumerez | BSMT-1G 2019 : PMLS 2 34

Dermal puncture and preparation of blood smear

LESSON 7
Date of Lecture : 4 March 2019. Mrs. Pichi Arcilie E. Malintad, RMT.
Reference : Strasinger, S. K., & Schaub, D. L. (2011). The Phlebotomy Textbook (3rd ed.). Chapter 12.

WHY PERFORM A SKIN PUNCTURE

• Method of choice for collecting samples from infants and children < 2 years old — blood volume in infants is only 150 mL.
o Locating superficial veins that are large enough to accept even a small-gauge needle is difficult in these patients and
available veins may need to be reserved for IV therapy.
o Use of deep veins (e.g. femoral) is not recommended—can be dangerous and may cause complications:
§ cardiac arrest § infection
§ venous thrombosis § reflex arteriospasm (can possibly result in gangrene)
§ hemorrhage § injury caused by restraining the child
§ damage to surrounding tissues & organs
o Drawing excessive amounts of blood from premature and small infants can rapidly cause anemia, because a 2-lb
infant may have a total blood volume of only 150mL.
o Certain tests require capillary blood
§ Newborns screening tests from newborn and infants for neonatal bilirubin
• (physiologic disease, hemolytic disease of the newborn)
§ capillary blood gases (O2 and CO2 levels)

DERMAL PUNCTURE IN ADULTS

• Burned/scarred px • Px with inaccessible veins
• Chemotherapy px • Obese px
o requires frequent tests; whose veins must be • Apprehensive px
reserved for therapy • Px requiring home glucose monitoring
• Patients with thrombotic tendencies • Point-of-care test px
• Geriatric/other patients with very fragile veins

Importance of correct collection

The presence of hemolysis may not be detected in
Hemolysis is more frequently seen in samples collected by dermal
samples containing bilirubin.
puncture than it is in those collected by venipuncture.
• gives false low bilirubin yellow à • It interferes not only with the tests routinely
affected by hemolysis, but also with the frequently
• high bilirubin gives off golden-yellow color in the serum—icteric
requested newborn bilirubin determination.
Hemolysis may occur in dermal puncture for the following reasons:
• Excessive squeezing of the puncture site (“milking”) • Residual alcohol at the site
• Newborns have increased numbers of red blood cells o Always allow site to airdry.
(RBCs) and increased RBC fragility • Vigorous mixing of the microcollection tubes after collection

composition of capillary blood

• Blood collected by dermal puncture comes from the capillaries, arterioles, and venules.
o It is a mixture of arterial and venous blood and may contain small amounts of interstitial and intracellular fluids.
o Because of arterial pressure, the composition of this blood more closely resembles arterial rather than venous blood.
• Warming the site (3-5 mins. at 42°C) before sample collection increases blood flow as much as sevenfold
o Thereby producing a sample that is very close to the composition of arterial blood.
CONCENTRATIONS IN BLOOD Higher Lower
OBTAINED BY DERMAL PUNCTURE glucose potassium, calcium, total protein
o When dermal punctures are performed, this factor should be noted on the requisition form because some of the
analytes will be affected during capillary dermal puncture.
• Alternating between dermal puncture and venipuncture should not be done when results are to be compared.

dermal puncture equipment

• a phlebotomy collection tray or drawing station should contain skin puncture devices, microsample collection containers, glass
slides, and possibly a heel warmer for use in performing dermal punctures

DEVICES
• To prevent contact with bone, the depth of the puncture is critical.
• The Clinical and Laboratory Standards Institute (CLSI) recommends that the incision depth should not exceed 2.0mm in a device
used to perform heelsticks.
o There is concern that even this may be too deep in certain infants, particularly premature infants.
• The (1) length of lancets and the (2) spring release mechanisms control the puncture depth with automatic devices.
@ashumerez | BSMT-1G 2019 : PMLS 2 35

• To produce adequate blood flow, the depth of the puncture is actually much less important than the width of the incision.
o This is because the major vascular area of the skin is located at the dermal subcutaneous junction, which in a newborn
is only 0.35-1.6mm below the skin and can range to 3.0mm in a large adult.
• the number of severed capillaries depends on the incision width.
o Incision widths vary from needle stabs to 2.5mm.
o Sufficient blood flow should be obtained from incision widths <2.5 mm.

BD Microtainer Contact- designed to activate only when the blade or needle is positioned and pressed against the skin
Activated Lancet (Becton
Dickinson) lancets are color-coded to indicate lancet puncture depths
BD Quikheel Lancets color-coded heelstick lancets made specifically for (1) premature infants, (2) newborns, and (3) babies
International Technidyne
Provides a range of color-coded, fully-automated, disposable devices with varying depths
Corporation (Edison, NJ)
designed for heel and finger punctures, respectively
Tenderfoot and
Models are available ranging from the Tenderfoot for preemies to the Tenderlett for (1) toddlers, (2) juniors,
Tenderlett devices
and (3) adults
(Owen Mumford, Inc, Marietta, GA)
available in five versions with varying needle gauges and penetration depths
lancet used depends on the (1) type of skin and (2) amount of blood required for testing
Comfort delicate skin
Unistik 2 safety lancets
Normal normal skin/general use
Extra tougher skin/larger sample
Super multitest situations and optimal blood flow
Neonatal heelsticks on newborns
(Lasette Plus, Cell Robotics International, Inc., Albuquerque, NM)
available for clinical and home use
are approved by the Food and Drug Administration (FDA) for adults and children older than 5 years
lightweight, portable, battery-operated device
Laser lancets eliminates the risks of accidental punctures and the need for sharps containers
laser light penetrates the skin 1-2mm, producing a small hole by vaporizing water in the skin
• creates a smaller wound
• reduces pain and soreness associated with capillary puncture
• allows up to 100μL of blood to be collected

MICROSAMPLE CONTAINERS
• microcollection tubes
o largely replaced the large-bore glass Caraway and Natelson micropipettes
• some containers are designated for a specific test, and others serve multiple purposes
• type of container chosen is usually related to laboratory preference
o because advantages and disadvantages can be associated with each system
frequently referred to as microhematocrit tubes
small tubes used to collect »50-75μL of blood
• primary purpose of performing a microhematocrit test
designed to fit into a hematocrit centrifuge and its corresponding hematocrit reader
available plain or coated with ammonium heparin
RED BLUE
heparinized plain
BANDS
Capillary for hematocrits collected by dermal when the test is being performed on blood from a
1
Tubes puncture lavender stopper (EDTA tube)
clay sealant or a plastic plug
• when sufficient blood has been collected, the end of the capillary tube that has not been used to collect the
sample is closed with this
phlebotomists should use extreme care to prevent breakage when collecting samples and sealing the tubes
tubes protected by plastic sleeves and self-sealing tubes
• available to prevent breakage when collecting samples and sealing the microhematocrit tubes
use of glass capillary tubes is not recommended
plastic collection tubes (e.g. Microtainer [Becton, Dickinson, Franklin Lakes, NJ])
• provide a larger collection volume and present no danger from broken glass
Microcollection variety of anticoagulants and additives, including separator gel, are available
2
Tubes tubes are color coded in the same way as ETS
some tubes supplied with a capillary scoop collector top that is replaced by a color-coded plastic sealer top after
the sample is collected
@ashumerez | BSMT-1G 2019 : PMLS 2 36

microtainer tubes are designed to hold approximately 600 μL of blood

• BD Microtainer tubes with BD Microgard closures
o designed to reduce the risk of blood splatter and blood leakage
o Microgard closure removed by twisting and lifting Tubes have:
• Tubes have:
o integrated blood collection scoop o textured interior o a wider diameter
… to enhance blood flow into the tube and eliminate the need to assemble the equipment.
after completion of the blood collection:
• the cap is placed on the container
• anticoagulated tubes are gently inverted 5-10x to ensure complete mixing
tubes have markings to indicate minimum and maximum collection amounts to prevent underfilling or overfilling
• could cause erroneous results
tube extenders
• available for this system to facilitate labelling and handling
• other capillary blood collection devices have plastic capillary tubes inserted into the collection container
(SAFE-T-FILL capillary blood collection system, RAM Scientific Co., Needham, MA)
after blood has been collected:
• capillary tube is removed • appropriate color-coded cap closes the tube
mixing of anticoagulated samples enhanced by presence of small plastic beads in some collection tube systems
separation of serum or plasma is achieved by centrifugation in specifically designed centrifuge
Microcollection containers are color-coded to match evacuated tube colors and include amber containers for light-
sensitive analyte testing.

ADDITIONAL DERMAL PUNCTURE SUPPLIES

• requirements for the dermal puncture also for the venipuncture
o alcohol pads o gauze o sharps containers
• blood smears
o used for the WBC differential and the examination of RBC morphology
o may be made during the dermal puncture procedure
o require a supply of glass slide
• warming the puncture site increases blood flow to the area and can be accomplished by using:
o commercial heel warmer* o warm washcloths or towels
§ *a packet containing sodium thiosulfate and glycerin that produces heat when the chemicals are mixed
together by gentle squeezing of the packet
§ the packet should be wrapped in a towel and held away from the face during the initial activation

dermal puncture procedure

phlebotomist must have a requisition form containing the same information required for the venipuncture
when a sample is collected, must be noted on the requisition form
• because the concentration of some analytes differs between venous and capillary blood
phlebotomists should carefully examine the information on the requisition form to ensure:
• that they have the appropriate equipment to collect all required samples
• the skin puncture device that corresponds to the age of the patient
Phlebotomist
1 …due to the variety of puncture devices and collection containers available for dermal puncture
Preparation
phlebotomists frequently perform dermal punctures in the nursery
phlebotomists must observe its specified protective isolation procedures:
• wearing of gowns and gloves
• extensive handwashing
• carrying only the necessary equipment to the patient area
equipment should be kept out of patient’s reach at all times
patients (dermal puncture) must be identified using the same procedures as those used for venipuncture:
• requisition form • verbal identification • ID band
in the nursery, an identification band must be present on the infant and not just on the bassinet
pediatric outpatients
• verbal identification may have to be obtained from the parents
Patient ID and • approaching pediatric patients can be difficult
2
Preparation o phlebotomist must present a friendly, confident appearance while explaining the procedure to
the child and the parents
o don’t say the procedure will not hurt and explain the necessity of remaining very still
• parents should be given the choice of staying with the child or leaving the room
o if they choose to stay, may be asked to assist in holding and comforting the child
• very agitated children may need to have their legs and free hand restrained
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o can be accomplished by a parent or co-worker

o by confining the child in a blanket or commercially available papoose-style wrap
o restraint is used à parental consent must be obtained and documented in px’s medical record
Having the parents present can provide emotional support and help enlist the child’s cooperation.
Excessive crying may affect concentration of WBCs’ capillary BGs, which should be noted on the requisition.
patient must be seated or lying down:
3 Patient Position • hand supported on a firm surface • fingers pointed downward (fingersticks)
• palm up • heel in downward position with patient on back (heelstick)
primary danger in dermal puncture is:
• accidental contact with the bone
• followed by infection or inflammation (osteomyelitis or osteochondritis)
can be avoided by selection of puncture sites that provide sufficient distance between the skin and the bone
primary dermal puncture sites are:
• the heel • the distal segments of the 3rd and 4th fingers
the choice of a puncture area is based on: • age • size
areas selected for dermal puncture should not be:
• bruised • earlobes • infected
• callused • edematous, cold, or cyanotic • scarred
punctures should never be made through previous puncture sites
• this practice can easily introduce microorganisms into the puncture and allow them to reach the bone
don’t collect blood from the fingers on the side of a mastectomy without health-care provider’s order
used for dermal punctures on infants younger than 1 year
• it contains more tissue than the fingers
• has not yet become callused from walking
acceptable areas for heel puncture
• are described as the medial and lateral areas of the plantar (bottom)
surface of the heel
• these areas can be determined by drawing imaginary lines
4 Site Selection extending back from the middle of the large toe to the heel and
a Heel
from between the fourth and fifth toes to the heel
• in these areas that the distance between the skin and the calcaneus
(heel bone) is greatest
o notice the short distance between the back (posterior
curvature) of the heel and the calcaneus; this is the reason
why this area is never acceptable for heel puncture
punctures should not be performed in other areas of the foot (e.g. arch)
• cause damage to (1) nerves, (2) tendons, and (3) cartilage
finger punctures are performed on adults and children over 1 year of age
fingers of infants < 1 year old may not contain enough tissue to prevent contact with the bone
fleshy areas located near center of the 3rd and 4th fingers on the palmar side of the
nondominant hand
the tip and sides of the finger contain only about half the tissue mass of the central area
• possibility of bone injury is increased in these areas
b Finger problems associated with use of the other fingers include:
• possible calluses on the thumb
• increased nerve endings in the index finger
• decreased tissue in the fifth finger
a swollen or previously punctured site is unacceptable
• the increased tissue fluid will contaminate the blood sample
patients who routinely perform home glucose monitoring may request a specific finger
the finger or heel from which the sample is to be taken may be warmed for optimal blood flow
• dilates the blood vessels and increases arterial blood flow
• to be effective:
o moisten a towel with warm water (42°C) for not longer than 10 minutes à may alter test results
Warming the
5 o activate a commercial heel warmer and covering the site for 3-5 minutes
Site
primarily required for:
• patients with very cold or cyanotic fingers
• for heelsticks to collect multiple samples
• for the collection of capillary blood gases
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selected site cleansed with 70% isopropyl alcohol (circular motion)

• alcohol should be allowed to dry on the skin for maximum antiseptic action
• residue may be removed with gauze to prevent interference with certain tests and/or rapid hemolysis
• failure to allow the alcohol to dry results to:
o causes a stinging sensation for the patient
Cleansing the
6 o contaminates the sample
Site
o hemolyzes RBCs
o prevents formation of rounded blood drop à blood will mix with alcohol and run down finger
use of povidone-iodine is not recommended for dermal punctures
• sample contamination may elevate some test results:
o bilirubin o phosphorus o uric acid o potassium
the heel or finger should be well supported and held firmly
avoid squeezing the puncture area
massaging the area before the puncture may increase blood flow to the area
heel is held between the thumb and index finger of the nondominant hand
a Heel
index finger held over the heel and the thumb below the heel
finger is held between the nondominant thumb and index finger
b Finger
the palmar surface facing up and the finger pointing downward to increase blood flow
choose a puncture device that corresponds to the size of the patient
remove trigger lock if necessary
Performing the place the puncture device firmly on the puncture site
7
Puncture do not indent the skin when placing the lancet on the puncture site
the blade of the puncture device should be aligned to cut across (perpendicular to) the
Puncture grooves of the fingerprint or heel print
c Device • aids in the formation of a rounded drop
Position o the blood will not tend to run into the grooves
depress the lancet release mechanism and hold for a moment then release
pressure must be maintained
• elasticity of the skin naturally inhibits penetration of the blade
removal of the lancet before the puncture is complete à yield a low blood flow
Failure to place puncture devices firmly on skin: primary cause of insufficient blood flow
Puncture after completing the puncture, the puncture device should be placed in an appropriate sharps container
8
Device Disposal a new puncture device must be used if an additional puncture is required
before beginning the blood collection, the first drop of blood must be wiped away with a clean gauze
• unless testing the first drop of blood is required by the manufacturer of a POC instrument
• prevents contamination of the sample with residual alcohol and tissue fluid released during the puncture
when collecting microsamples, even a minute amount of contamination can severely affect sample quality
• therefore, blood should be freely flowing from the puncture site as a result of firm pressure
o should not be obtained by milking of the surrounding tissue
§ will release tissue fluid
• alternately applying pressure to the area and releasing ß produce the most satisfactory blood flow
• tightly squeezing the area with no relaxation
Sample o cuts off blood flow to the puncture site
9
Collection the collection tip can be lightly touched to the drop of blood à drawn into the container (capillary action)
collection devices should not touch the puncture site and should not be scraped over the skin
• this will produce (1) sample contamination and (2) hemolysis
fingers are positioned slightly downward with the palmar surface facing up during the collection procedure
Applying pressure about ½” away from the puncture site frequently produces better blood flow than pressure
very close to the site.
While the sample is being collected, the patient’s hand does not have to be completely turned over.
• Rotating the hand 90° allows the phlebotomist to clearly see the blood drops without placing himself or
herself in an awkward position and produces adequate blood flow.
Using a scooping motion to collect the blood must be avoided à hemolyze the sample.
are held horizontally while being filled to prevent the introduction of air bubbles
• place the end of the tube into the drop of blood
• maintain the tube in a horizontal position to fill by capillary action during the entire collection
Capillary Tubes
removing the microhematocrit tube from the drop of blood = air bubbles in the sample
10 and
• limits the amount of blood that can be collected per tube
Micropipettes
• will interfere with blood gas determinations
when the tubes are filled, they are sealed with sealant clay or designated plastic caps
recommended tubes are plastic or coated with a puncture-resistant film
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when using a sealant tray, place the end that has not been contaminated with blood into the clay taking care to
not break the tube
• remove the tube with a slight twisting action à firmly plug the microhematocrit tube
tubes are slanted down during the collection
• blood is allowed to run through the capillary collection scoop and down the side of the tube
• the tip of the collection container is placed beneath puncture site and touches the underside of the drop
o first three drops of blood provide the channel to allow blood to freely flow into the container
gently tapping the bottom of the tube is necessary to force blood to the bottom
when a tube is filled, the color-coded top is attached
tubes with anticoagulants should be inverted 5-10x or per manufacturer’s instructions
Microcollection if blood flow is slow, may be necessary to mix the tube while the collection is in progress
11
Tubes • important to work quickly, because blood that takes x > 2 minutes to collect à may form microclots in an
anticoagulated microcollection container
o Clotting is triggered immediately on skin puncture, and it represents the greatest obstacle in
collecting quality samples.
• Fast collection & mixing ensure more accurate test results.
adequate amounts of blood must be collected
overfilled tube may clot
underfilled tube cause morphological changes in cells
the order of draw for collecting multiple samples (dermal puncture)
• important because of the tendency of platelets to accumulate at the site of a wound
blood to be used for tests for the evaluation of platelets must be collected first:
Order of (1) blood smear (2) platelet count (3) CBC
12
Collection (1) blood smear should be made first, followed by (2) lavender EDTA tube
order of collection for multiple tubes:
(1) capillary blood gases (3) EDTA tubes (5) serum tubes
(2) blood smear (4) other anticoagulated tubes
when sufficient blood has been collected:
• the finger or heel is elevated
• pressure is applied to the puncture site with gauze until the bleeding stops
• confirm that bleeding has stopped before removing the pressure
bandages are not used for children younger than 2 years because:
Bandaging the
13 • because the children may remove the bandage
Patient
• place them in their mouth
• possibly aspirate the bandages
adhesive may also:
• cause irritation to skin
• tear sensitive skin (particularly the fragile skin of a newborn or older adult patient)
microsamples must be labeled with the same information required for venipuncture samples
• labels wrapped around microcollection tubes or groups of capillary pipettes
for transport, capillary pipettes are then placed in a large tube
Labelling the
14 • because the outside of the capillary pipettes may be contaminated with blood
Sample
• this procedure also helps to prevent breakage
BD Microtainer tubes have extenders that can be attached to the container
• allows the computer label to be applied vertically
dermal puncture procedure is completed in the same manner as the venipuncture:
• disposing of all used materials in appropriate containers
• removing gloves and washing hands
• thanking the patient and/or the parents for their cooperation
all special handling procedures associated with venipuncture samples also apply to microsamples
observe test collection priorities
to prevent excessive removal of blood from small infants:
Completion of
15 • a log sheet for documenting the amount of blood collected each time a procedure is requested for a
the Procedure
patient must be completed
• phlebotomist should record the amount of blood collected on the log sheet before leaving the area
as with venipuncture, it is recommended that only two punctures be attempted to collect blood
• when a second puncture must be made to collect the sufficient amount of blood:
o the blood should not be added to the previously collected tube
§ cause erroneous results as a result of microclots and hemolysis
§ the puncture also must be performed at a different site using a new puncture device
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special dermal puncture

COLLECTION OF NEWBORN BILIRUBIN
• the most frequently performed tests on newborns measures bilirubin levels
o samples for this determination are often collected at timed intervals over several days
• the decision to perform an exchange transfusion is based on:
o the bilirubin levels o the newborn’s age and condition

a very light-sensitive chemical

Bilirubin
is rapidly destroyed when exposed to light
critical to infant survival and mental health
• the blood-brain barrier is not fully developed in neonates
o condition that allows bilirubin to accumulate in brain and cause permanent or lethal damage
phlebotomy technique is critical to the determination of accurate bilirubin results
turn off the UV light during collection unless newer model is strapped directly to infant
• Bilirubin levels may decrease as much as 50% in a blood sample that has been exposed to light for 2 hours.
amber-colored microcollection tubes are available for collecting bilirubin
Bilirubin Test
• if multiple capillary pipettes are used, the filled tubes should be shielded from light
Results
samples must be collected quickly and protected from excess light during and after the collection
infants who appear jaundiced
• frequently placed under an ultraviolet light (UV) to lower the level of circulating bilirubin
o this light must be turned off during sample collection
hemolysis must be avoided
• it will falsely lower bilirubin results in some procedures and must be corrected for in others
samples must be collected at the specified time so that the rate of bilirubin increase can be determined
increased serum bilirubin in newborns
Hyperbilirubinemia may be caused by the presence of hemolytic disease of the newborn
it may simply occur in particularly premature infants
Particularly
their liver is often not developed enough to process the bilirubin produced from the normal breakdown of RBCs
Premature Infants

NEWBORN SCREENING
• the testing of newborn babies for:
o physical disabilities,
o genetic o hormonal
o metabolic o functional à o mental retardation
o even death (if not detected and treated early)

• screening of newborns for 50 inherited metabolic disorders

o can currently be performed from blood collected by heelstick and placed on specially designed filter paper
• each state has own laws requiring specific test screening of newborns
o however, all states screen newborns for the presence of the most prevalent disorders
§ many of these disorders can be prevented by:
o early changes in the newborn’s diet o early administration of a missing hormone

MANDATORY NEWBORN SCREENING DISORDERS

DISORDER CHARACTERISTICS
caused by the lack of the enzyme needed to metabolize the amino acid phenylalanine to tyrosine
Phenylketonuria • accumulates and causes problems with (1) brain development and (2) mental retardation
1
(PKU) Early detection is crucial damage is irreversible
• can be treated with diet low in phenylalanine and high in tyrosine.
thyroid hormone deficiency present at birth
Congenital
2 Delays in growth and brain development that produce mental retardation
Hypothyroidism
• can be avoided by use of oral doses of thyroid hormone within first few weeks after birth
genetic metabolic disorder caused by the lack of the liver enzyme needed to convert galactose* à glucose
• accumulates in the blood and can cause:
3 Galactosemia o blindness o death o mental retardation
o cataracts o liver disease o renal failure
Treatment: infinite elimination of all milk and dairy products from infant

Blood Collection:
• how newborn screening tests are performed (through dermal puncture) except for the hearing test
• ideal blood à collected between 24 and 72 hours after birth before the baby is released from the hospital
• correct collection of the blood sample is critical for accurate test results
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• recommended that the newborn screening samples should be collected separately:

o after prewarming o puncturing a second site when additional blood tests are requested
• consisting of a patient information form attached to specifically designed filter paper
o has been preprinted with an appropriate number of circles that are part of the requisition
• phlebotomist must be careful not to touch:
o (or contaminate) the area inside the circles with*: o the dried blood spots
§ *alcohol § lotions § urine
§ formula § powder § water

CAUSES FOR INVALID NEWBORN SCREENING SAMPLES

INVALID SAMPLE POSSIBLE CAUSES
Filter paper is removed before blood has completely filled circle or before blood has soaked through to
Quantity insufficient for
other side
testing
Filter paper touches gloves, powder, or lotion
Appears scratched Blood applied with capillary pipette
Not dry before mailing Sample mailed before drying a minimum of 3 hours
Excess blood applied to filter paper using an alternate device
Appears supersaturated
Blood applied to both sides of filter paper
“Milking” area surrounding puncture site
Appears diluted, discolored,
Filter paper contaminated with powder, alcohol, formula, water, lotion
or contaminated
Blood spots exposed to direct heat
Alcohol not dry before puncture
Filter paper contaminated with powder, alcohol, formula, water, lotion
Exhibits serum rings “Milking” the puncture site
Sample dried improperly
Using a capillary pipette to fill the spots
Several drops of blood used to fill the circle
Appears clotted or layered
Blood applied to both sides of filter paper
• the heelstick is performed in the routine manner
o the first drop of blood is wiped away
o large drop of blood is then applied directly onto a filter paper circle
§ do not touch the filter paper to the heel
§ to obtain an even layer of blood, only one large free-
falling drop should be used to fill a circle
o blood is applied to only one side of the filter paper
o there must be enough to soak through the paper and be visible on
the other side
o each circle must be filled for testing
§ if a circle is not evenly or completely filled, a new circle and a larger drop of blood should be used
o layering from multidrop application à uneven or incomplete saturation of filter paper circles à unacceptable sample
• collected sample must be allowed to air dry:
o in a suspended horizontal position o at room temperature o away from direct sunlight
• to prevent cross-contamination, samples should not be hung to dry or stacked during or after the drying process
o when dry, the sample is (1) placed in a special envelope and (2) sent to the appropriate laboratory for testing
o Blood spots must be thoroughly dry before the attached fold-over flap is closed over the spots.
*y’all can find the procedures in the book because my lazyass cannot anymore !"*

• Be sure that all required patient information is filled out on the neonatal screening test form.
• Specific state mandates for newborn screening can be found at the U.S. National Newborn Screening and Genetics Resource
Center website. http://genes-r-us.uthscsa.edu/

CAPILLARY BLOOD GASES

• performing deep ARTERIAL BLOOD CAPILLARY BLOOD
arterial punctures in (1) blood gases (O2 and CO2 content) mixture of venous and arterial blood
newborns and (2) young preferred sample for:
adults’ pH levels • higher conc. of arterial blood
children
o usually not recommended
o unless blood can be obtained from (1) umbilical or (2) scalp arteries, blood gases are performed on capillary blood
• blood is collected from:
o plantar area of the heel or big toe o palmar area of the fingers
• collection site is warmed* à concentration and flow of arterial blood is also increased
o commercial heel warmer o warm, moist washcloth
o 40°C to 42°C for 3 to 5 minutes to increase the flow of arterial blood
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• heparinized blood gas pipettes

o where samples are collected
o designed to correspond with the volume and sampling requirements of the blood gas analyzer being used
ü components:
o plugs or clay sealants
§ needed for both ends of the pipettes
o a magnetic stirrer “flea” and circular magnet
§ used to mix the sample with heparin
v to prevent clotting
• during dermal puncture, pipettes must be:
o completely filled o must not contain air bubbles o should fill in < 30 seconds
o when full, both ends are immediately sealed
§ prevent exposure to room air that could affect the blood gas composition
• the round magnet is slipped over the tube
• the blood is mixed by moving the magnet up and down the tube several times
• the tubes are labeled and placed horizontally in an ice slurry:
o to slow à WBC metabolism
o changes in the (1) pH level and (2) blood gas concentrations
• the sample is immediately transported to the laboratory
• To avoid air bubbles, hold the tube in a horizontal position and be sure that blood flows easily from the puncture site.

PREPARATION OF BLOOD SMEARS

• are needed for the microscopic examination of blood cells that is performed:
o diff. blood cell count o special staining procedures o nonautomated reticulocyte counts
• should be collected before other samples to avoid platelet clumping
• must be considered infectious until they have been fixed with alcohol in the laboratory (wear gloves)
• phlebotomists may make smears when:
o one of these tests is ordered o a dermal puncture is performed
• when collected by venipuncture, the blood smear:
o is usually made in the laboratory from the EDTA tube
§ must be mixed for 2 minutes
o should be made within 1 hour of collection to avoid cell distortion caused by the EDTA anticoagulant
o may be made made (1) manually or by (2) using an automated instrument
• DIFF-SAFE
o a plain capillary pipette or a device
o used to dispense a drop of blood onto the slide
• performing smears at bedside after venipuncture à sometimes necessary to ensure no anticoagulant interference
o dangerous because blood must be forced from the needle onto the slide and the needle cannot be disposed of until
the smear has been made
• carrying numerous smears in a crowded collection tray can cause contamination of (1) equipment and (2) ungloved hands
• properly prepared blood smear
o has a smooth film of blood that covers approximately ½- 2/3 of the slide
o does not contain ridges or holes
o has a lightly feathered edge without streaks
§ area where the microscopic examination is performed
§ the cells here have been spread into a single layer
• an uneven smear indicates that the cells are not evenly distributed
o test results will not be truly representative of the patient’s blood

EFFECTS OF TECHNICAL ERRORS ON BLOOD SMEARS

DISCREPANCY POSSIBLE CAUSES
Increased pressure on the spreader slide
Uneven distribution
Movement of the spreader slide not continuous
of blood (ridges)
Delay in making slide after drop is placed on slide
Dirty slide
Holes in the smear
Contamination with glove powder
No feathered edge Spreader slide not pushed the entire length of the smear slide
Chipped or dirty spreader slide
Streaks in the Spreader slide not placed flush against the smear slide
feathered edge Pulling the spreader slide into the drop of blood so that the blood is pushed instead of pulled
Drop of blood starts to dry out owing to delay in making smear
Smear too Drop of blood is too big
thick and short ∠ of spreader slide is x > 40º
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Drop of blood is too small

Smear too
∠ of spreader slide is <30º
thin and long
Spreader slide pushed too slowly

Blood Smears for Malaria

• Plasmodium species
o the parasites that cause malaria and invade the RBCs
o their presence is detected by microscopic examination of thick and thin blood smears
• patients with malaria exhibit periodic episodes of fever and chills
o related to the multiplication of the parasites within the RBCs
o sample collection is frequently requested on a timed basis similar to that of STAT blood cultures
THIN SMEARS THICK SMEARS
(two or three) made by placing a large drop of blood in the center of a glass slide
prepared in the manner previously described using a wooden applicator stick to spread the blood into a circle (size of a dime)
for parasitic morphology and identification concentrate the sample for detection of parasites
• smear must be allowed to dry for at least 2 hours before staining

BLEEDING TIME
• performed to measure the time required for platelets to form a plug strong enough to stop bleeding from an incision
• its length is increased when:
o the platelet count is low
o platelet disorders affect the ability of the platelets to stick to each other to form a plug
o in persons taking aspirin and certain other medications and herbs
§ Often patients don’t consider aspirin and herbal medication and will not inform unless asked.
§ Never instruct a patient to stop taking prescribed medication.
• The health-care provider must be notified and will make this decision before the BT test is repeated.
• Ingestion the following within the last 7 to 10 days of the test may cause a prolonged BT:
o aspirin o ethanol o streptodornase o various herbs
o dextran o salicylate o streptokinase
• considered a screening test which may be:
o ordered as part of a presurgical workup o evaluation of a bleeding disorder
• Its test results are affected by:
o skin’s vascularity o the type and condition of the patient’s skin
o skin’s temperature o the phlebotomist’s technique
• abnormal results are followed by additional testing
• however, it has essentially been replaced by other platelet function tests which are performed by:
o making an incision on the volar surface of the forearm
o inflating a blood pressure cuff to 40 mmHg to control blood flow to the area
• automated disposable incision devices (e.g. Surgicutt [International Technidyne Corp., Edison, NJ])
o produce standardized incisions of 1 mm in depth and 5 mm in length
• Consideration should be given to documenting that the patient understands the possibility of a scar.

POINT-OF-CARE TESTING
• development of portable hand-held instruments capable of performing a variety of routine laboratory procedures
o increased the efficiency of patient testing
• samples can be:
o collected by dermal puncture
o tested by phlebotomists or other health-care personnel in the patient area
• test results are available quickly
• transportation of samples to the laboratory is avoided
• dermal punctures are performed following routine dermal puncture
o unless modifications are recommended by the instrument manufacturers
• phlebotomists performing point-of-care testing (POCT) should follow all manufacturer recommendations
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Special blood collection

LESSON 8
Date of Lecture : 15 March 2019. Sir Nestor M. Pompa, Jr., RMT, AMT.
References : Strasinger, S. K., & Schaub, D. L. (2011). The Phlebotomy Textbook (3rd ed.). Chapter 11.
Khan, S. & Farooq, F. (2014). Phlebotomy Textbook: Theory and Clinical Approach (3rd ed.).
Ernst, Dennis J. (2005). Applied Phlebotomy.

Definition of terms
1. Aerobic Cultures 3. Aseptic Technique 5. Septicemia
2. Anaerobic Cultures 4. Central Venous Access Device

AEROBIC CULTURES
• for isolation of organism that can survive and grow in oxygenated environments
CULTURE CHARACTERISTICS EXAMPLES
Mycobacterium tuberculosis
1 Obligate Aerobes requires O2 to grow • target organ is the lungs ß highest
concentration of O2
can use O2 if available and have anaerobic methods of
2 Facultative Anaerobes energy production Staph and Strep species
• facultative can survive but not multiply on O2
Helicobacter pylori
require O2 for energy production, but are harmed by
3 Microaerophiles • will feed on your stomach lining
atmospheric concentrations of oxygen (21% O2)
instead of the O2 (20-25%)
4 Aerotolerant Anaerobes do not use O2 but are not harmed by it either Streptococcus mutans

ANAEROBIC CULTURES
• for isolation and preferential growth of anaerobic bacteria
• requires CO2 to survive (capnophilic)
CULTURE CHARACTERISTICS EXAMPLES
Clostridium botulinum
Obligate
1 harmed by the presence of O2 • causes food poisoning in canned goods
Anaerobes
• requires CO2 and N2 to survive
Aerotolerant cannot use O2 for growth, but Lactobacillus
2
Organisms can tolerate its presence • overpopulation causes diarrhea
Facultative can grow without O2 but uses Salmonella spp.
3
Anaerobes it if it is present • even if the egg is sealed, salmonella will still survive

ASEPTIC TECHNIQUE
• utilizes sterile technique
• collection is free from bacteria or other living organisms, including:
o use of PPE o cleaning of work areas
o waste disposal o adherence to Standard Precautions

CENTRAL VENOUS ACCESS DEVICE

• provides access to the central venous system via the superior vena cava (SVC) or
the inferior vena cava (IVC)
• allows ¯amount of venipuncture for patients requiring frequent bloodwork
• used for patients having dialysis
o mostly located on the left side
o If it takes more than a minute to extract blood through a shunt for more
than a (1) minute, it might cause him/her a heart attack.
• used for people with unlocatable or damaged veins
• RMTs need a special phlebotomist license/additional training
o Still usually the doctors who perform this procedure

SEPTICEMIA
• serious bloodstream infection (also known as blood poisoning)
o because bacteria, fungi, and parasite lodge into your tissues most of the time à go into your circulation
• occurs when a bacterial infection elsewhere in the body (e.g. lungs, skin) enters the blood stream:
o urinary tract infections (UTI) o kidney infections
o lung infections (e.g. pneumonia) o abdominal infections
@ashumerez | PMLS 2 : BSMT-1G 2019 45

Collection priorities
1. Routine 2. STAT 3. ASAP

ROUTINE SAMPLES
• for tests order by the physician to diagnose and monitor a patient’s condition (i.e. check-up)
• can be processed any time in the lab and don’t need any special time
• (1) liver profile, (2) kidney profile, (3) hypertension profile, (4) CBC (note what are tested in CBC because Sir kept repeating it in
his lectures), (5) ESR
o (1), (2), (3) require serum ß red (strictly for serologic orders) & gold (has proteins present that can interfere with red) taps

STAT SAMPLES
Sudden/Short Turnaround Time
• Latin word: "statum" – immediately/without delay
• sample is to be collected, analyzed, and have results reported immediately
• have the highest priority
o usually ordered form the ER/ICU to manage critically ill patient whose treatment is based on the lab results
o always prioritize the STAT request of the ER à release results in 1-2 hours

ASAP Samples
As Soon As Possible
• The response time for the collection of this test sample is determined by each hospital or clinic and may vary by laboratory tests.
• just get blood as soon as possible, doesn't even have to be right there and then
o you don’t have to release results right away
• (1) blood culture, (2) hormones, (3) drug testing

TYPES OF SAMPLES
TYPE CHARACTERISTICS
collected from patient who has been fasting
patient refrained from eating and drinking (NPO) for 12 hours
refrained from exercise
1 Fasting
phlebotomist should take note of the time of the last meal before collection
When it comes to water, consult the SOP because it varies between institutions.
• FBS • cholesterol • lipid profile
blood must be drawn at a specific time
Specimen collection cannot go 30 minutes past the physician’s order(s).
Finish blood collection within two (2) minutes.
phlebotomist should arrange their schedule and record the actual time of collection
Reasons for timed samples:
2 Timed • to measure the body’s ability to metabolize a particular substance
• monitoring changes in a patient’s condition
• determining blood levels of medications
• measuring substances that exhibit diurnal variation
• measurement of cardiac markers following acute MI
• monitoring anticoagulant therapy

Special laboratory tests

1. Glucose Tolerance Test (GTT) 2. Lactose Tolerance Test (LTT)
a. 2-Hour Postprandial Glucose Test (2HPP) 3. Diurnal Variation
b. Oral Glucose Tolerance Test (OGTT) 4. Therapeutic Drug Monitoring
c. Oral Glucose Challenge Test (OGCT) 5. Blood Culture

(1) GLUCOSE TOLERANCE TEST (GTT)

• used for the diagnosis of diabetes mellitus and gestational diabetes
o diabetes in pregnant women à children can be obese or mentally retarded
Patient Preparation
• Instruct the patient to eat a balanced diet that includes 150g of carbohydrates per day for 3 days and to fast for 12-16 hours.
o Avoid coffee and unsweetened tea (not water).
o If the patient did eat, consult the attending physician.
• Avoid the following before and during the test à may cause inaccurate results:
o alcohol o smoking o vigorous exercise
o chewing tobacco o sugarless gum
@ashumerez | PMLS 2 : BSMT-1G 2019 46

• Medications that patients must stop intake 3-5 days before the test:
o alcohol o birth control pills o diuretics
o anticonvulsants o BP medications o estrogen-replacement pills
o aspirin o corticosteroids

Procedure
1. Identify the patient.
2. Confirm fasting state: ask the time of his/her last meal or flavored drink intake.
3. Extract blood for FBS
4. Ask patient to drink glucose solution within 5 minutes
PATIENT Adults Small adults and children
a. 75g for screening
GLUCOSE SOLUTION 75 or 100g 1g/kg body weight
b. 100g for those with history of diabetes
5. Timing for the remaining collection begins when the patient finishes the glucose solution. Patients should be given a copy of
the schedule and instructed to continue fasting (drink water only and remain in extraction area.
• finish within 5 minutes à if unable, extend for another 5 à if unable, terminate procedure and let them return the next day
• inability to take in the glucose load --> call the attending physician
• get blood again after an hour (utilize both arms of the patient) ß one shot per arm
6. Collect remaining samples of the scheduled times.
7. Label the tubes properly with the time of extraction.
8. If vomiting occurs, take note of vomiting and discontinue the test.

A. 2-Hour Postprandial Glucose Test (2HPP)

• compares glucose level 2 hours after a meal with high carbohydrate content (no FBS in the procedure)
Patient Preparation
• Fast for 12 hours before the test à eat a meal x ³ 75g of carbs
o After the meal, do not eat anything else before the test.
• Result: x ³ 200mg/dL = indicative of d. mellitus

B. Oral Glucose Tolerance Test (OGTT)

• measures blood glucose levels five (5) times over a period of three (3) hours
Patient Preparation
• Fasting overnight (8-16 hours) and participating normally in activities of daily living
• individual should eat and drink as they normally do prior to the test
o should not consume caffeine or smoke in the morning of testing day
Procedure
PROCEDURE TYPE II DIABETES GESTATIONAL DIABETES
blood for glucose level
1 Extract specimen for serum fasting glucose • in fasting state for min. 8hrs.
• ask patient to wait in lab while test completion is ongoing
Glucose Intake 8 oz (237mL) *Type II à syrupy solution
2 3.5 oz (100g) within 5 minutes
Sugar Content 2.6 oz (75g)
• start timing upon full consumption of drink
Two (2) hours after One (1), two (2), and three (3) hours after
3 Next Blood Extraction
Median cubital, other median cubital, cephalic in the other arm (in that order or as long as not same vein)
Some institutions require urine sample together with the blood for
* Notes
glucose test.

Expected Results for Type II Diabetes

VALUES
AFTER INTERPRETATION
mg/dL mmol/L
Fasting 95 5.3
<140 <7.8 normal
Two (2) hours 140-199 7.8-11 impaired glucose tolerance (prediabetes)
>200 >11 may indicate diabetes

C. Oral Glucose Challenge Test (OGCT)

Procedure
1. Ask the patient to drink » 5oz (» 148mL) of syrupy glucose solution with 1.8oz (50g) of sugar within 5 minutes.
2. Start timing for 1 hour.
3. Instruct patient to remain in health care provider’s office or lab while waiting for extraction
4. Blood sample is taken an hour later and is used to measure blood sugar level.
@ashumerez | PMLS 2 : BSMT-1G 2019 47

(2) LACTOSE TOLERANCE TEST (LTT)

• Disaccharide à fructose + galactose
• used to evaluate patient’s ability to digest lactose (lactose intolerance) which may result in gastrointestinal discomfort or diarrhea

Procedure
1. Identify the patient.
2. Confirm fasting state: ask the time of his/her last meal or flavored drink intake.
3. Extract blood for FBS
4. Ask patient to drink lactose solution within 5 minutes
PATIENT Adults Small adults and children
a. 75g for screening
LACTOSE SOLUTION 75 or 100g 1g/kg body weight
b. 100g for those with history of diabetes
5. Start timing and collect blood samples after 2 hours. Label the tubes properly with the time of extraction. Determine the
glucose level.
Expected Result
Lactose intolerant: glucose levels will raise <20mg/dL from the fasting result.

(3) DIURNAL VARIATION Plasma cortisol level 8-10am, (2x at 4pm)

• fluctuation of values that occurs during each day Serum iron 8-10am, 4pm
• values are dependent in the time of collection Hormones Morning collection
o usually taken corresponding to the peak of diurnal level WBC (until 11am)

(4) THERAPUTIC DRUG MONITORING

o Digoxin o Tobramycin o Valproic acid
o Phenobarbital o Vancomycin o Theophylline
o Lithium o Dilantin o Methotrexate
o Gentamicin o Amikacin o Various antibiotics
• Frequently monitored therapeutic drugs:

TIME OF COLLECTION
Trough Level before the next dosage is given
shortly after medication was given
Intravenous (IV) 30 minutes
Peak Level
Intramuscular (IM) 1 hour
Oral dosage 1-2 hours

(5) BLOOD CULTURE

• requested in patients with fever and chills or signs of septicemia
• done to identify and isolate these bacteria, viruses, and parasites
• determine fever of unknown origin (FUO)
• Timing: sets of 2 (in different sites), drawn 30 or 60 minutes apart (before spike of fever)

MATERIALS/EQUIPMENT NEEDED
•Blood culture bottles • Syringe or ETS o povidone-iodine
with/without ARD • Winged blood collection set o multiple isopropyl alcohol preps
• Blood culture bottle with FAN* • Antiseptics: o chlorhexidine gluconate
• Yellow stopper tubes with SPS o 2% iodine tincture
*Fastidious organisms – easily grow/do not require special nutrients/environment in order to grow

PROCEDURE
1 Vigorous scrubbing of the site for 1 minute using isopropyl alcohol.
The alcohol is followed by scrubbing the site with 2% iodine tincture or povidone-iodine for 1 minute starting in the center of the
2
venipuncture site and progressing outward 3-4in. in concentric circles. (chlorhexidine à back and forth)
3 Allow the iodine to dry on the site for at least 30 seconds.
4 Iodine is removed with alcohol after the procedure.
5 The tops of the blood culture bottles also must be cleaned before inoculating them with blood.
The alcohol pad remains on the bottles until inoculation (do remove)
6 • Iodine should not be used on the stoppers because it can enter the culture during sample inoculation and may cause
deterioration of some stoppers during incubation.

SAMPLE COLLECTION
Two (2) Bottles per Collection Anaerobic and Aerobic
Order of Draw Syringe Anaerobic à Aerobic
@ashumerez | PMLS 2 : BSMT-1G 2019 48

Winged Collection Aerobic à Anaerobic

1:10 (culture bottle usually has 80-100mL content à 8-10mL of blood)
Blood to Media Ratio Adult 8 to 10mL blood
Pedia 1 to 3mL blood
*Label the tubes with the site of collection.

PROCEDURE (continuation)
7 Reapply the tourniquet and perform the venipuncture.
(13) • Do not repalpate the site without cleansing the palpating finger in the same manner as the puncture site.
8 Release the tourniquet. Place gauze over the puncture site, remove the needle, and apply pressure.
9 Activate the safety device or remove the syringe needle with a Point-Lok device.
10 Attach safety transfer device.
First If syringe
11 Inoculate the anaerobic blood culture bottle
Second If winged blood collection set
Dispense the correct amount of blood into bottles.
12
• Some institutions require documenting the amount of blood dispensed.
13 Mix the blood culture bottles by gentle inversion eight (8) times.
14 Fill other collection tubes after the blood culture tubes.
15 Clean the iodine off the arm with alcohol if necessary.
16 Label the samples appropriately and include the site of collection. Verify identification with the patient.
17 Dispose of used equipment and supplies in a biohazard container.
18 Check the venipuncture site for bleeding and bandage the patient’s arm.
19 Thank the patient, remove gloves, and wash hands.

Special handling procedures

SAMPLE CHARACTERISTICS
Cold
1
Agglutinins It wasn’t in the pictures so you can refer to my Lecture 9 notes or just read page 267 of Strasinger

Analytes that may require chilling:

• Ammonia • Gastrin • Catecholamines
Chilled • Lactic acid • ACTH • Homocysteine
2
Samples • Acetone • Parathyroid hormone (PTH) • Some coagulation studies
• Free fatty acids • Renin • Arterial blood gases (if
• Pyruvate • Angiotensin-converting indicated)
• Glucagons enzyme (ACE)
exposure to artificial light/sunlight for any length of time may decrease the concentration
Samples wrap the tube in aluminum foil or using an amber container
3 Sensitive to Specimens sensitive to light:
Light • Bilirubin • Vitamin A • Vitamin B12 • Porphyrins
• Beta-carotene • Vitamin B6 • Folate
used in legal proceedings
must follow chain of custody
Forensic from patient (1) ID, (2) processing, (3) reporting, and (4) storing
4
Samples proper documentation, special containers with seals are important
Documentation
• date and time • ID of handlers • Patient ID • Site of collection
for determination of blood alcohols for medical, legal, or screening purposes
Blood
follows chain of custody protocols
5 Alcohol
site must be cleansed with soap and water or any non-alcoholic antiseptic solution (Benzalkonium chloride)
Samples
Use gray stopper tube (sodium fluoride)
for DNA/RNA testing
for (1) viral loads, (2) therapy management, (3) protein sequencing, and (4) parental testing
Molecular
6 Yellow stopper (ACD) paternity testing
Diagnostics
EDTA special hematology procedures
Citrate coagulation studies
@ashumerez | PMLS 2 : BSMT-1G 2019 49

specimen handling, transport, and processing

LESSON 9
Date of Lecture : 25 March 2019. Ma’am Nida C. Gelig, RMT.
References : Warekois, R.S., Robinson, R., Primrose, P. B. (2016). Phlebotomy: Worktext and Procedures Manual (4th ed.). Chapter 16.
Booth, K. A., Mundt, L.. Phlebotomy: A Competence Based Approach.
McCall, R. E., Tankersley, C. M.. Phlebotomy Essentials (5th ed.).

lecture coverage
1. The ways in which the specimens will reach the testing laboratory 4. Aliquoting
2. The handling of specimens requiring special conditions during transport 5. Causes for specimen rejection
3. The processing of specimens using centrifugation

general guidelines for specimen transport

1. Tubes with additives should be inverted gently and completely 5-10x immediately after being drawn.
o Gentle inversion minimizes hemolysis
o Do not mix together blood from different containers.
2. Specimens must be correctly labeled.
o Barcode labels are becoming the standard in most hospitals.
3. Tubes should remain upright during transport:
o It promotes complete clot formation when there is no additive present.
o It prevents sample contamination due to prolonged contact with stopper.
o It reduces aerosol formation during uncapping as there is no residual blood clinging to the stopper.
4. Time constraints
o The quality of test results depends on the time between collection of samples and its analysis—the longer the interval,
the more likely the results will be inaccurate.
o As a general rule, blood sample should be delivered to the laboratory within 45 minutes of being drawn and centrifuged
within 1 hour.
§ CLSI Standards recommend < 2 hours between collection and separation of serum/plasma by centrifugation.
§ Ongoing glycolysis within the specimen is a primary cause of inaccurate test results.
• Many tests can be affected by glycolysis (false: glucose ¯, potassium and lactate dehydrogenase ­).
o STAT requisitions
§ should be delivered to the laboratory immediately after being drawn and must be performed ASAP
§ Results are expected within 1 hour after they are ordered.
5. Time Limit Exceptions
SAMPLE TEST TIME HELD (hrs.) TEMP (°C) REMARKS
24 RT
Glucose (Gray-top) Centrifugation can be delayed.
48 2-8
CBC 24 Stable; invert 2 mins.
Whole 5 RT Not centrifuged because well-
Platelet count Satisfactory
Blood 24 4 mixed whole blood sample is
(EDTA) Done within an EDTA eventually distorts used.
Blood Smears
hour cell morphology.

Transporting samples to the laboratory

WITHIN THE FACILITY
• Hand-carried by phlebotomist from ward
• Outpatient phlebotomy area (in most laboratories) is within the lab, so transporting may require a simple walk to the next room.
• However, in some facilities, the phlebotomy area is in a different part of the building. To expedite the transport of specimens to
the laboratory, they use:
o Pneumatic tube system (PTS)
§ Not always appropriate for transporting blood sample à may agitate à hemolysis
§ Modified PTS is designed without sharp turns, using padded canisters and provides soft landing.
§ samples must be placed inside a sealed plastic biohazard bag with the request form in the outer pocket (not
with the sample) placed in the canister equipped with shock-absorbent lining materials.
§ Phlebotomist should wear PPE as required by OSHA if the specimen container may have broken in transit.
§ To not transport in the PTS:
• Cerebrospinal fluid (CSF) samples
VOL DEPARTMENT TESTS
1 1mL Chemistry (1) Glucose, (2) total protein
(1) Acid-fast staining, (2) gram staining, (3) India ink preparation (for
2 2mL Microbiology
C. neoformans), (4) inoculation of plated media (isolation of bacteria)
3 1mL Hematology (1) total cell count, (2) differential count
@ashumerez | PMLS 2 : BSMT-1G 2019 50

• Specimens for cytology (immersed in alcohol) or histology (immersed in formalin)

• Blood culture bottles
o A dumb-waiter (small elevator)
o Automated tracks (robotics)

TO OTHER FACILITIES
• For some tests not offered in the lab, the specimen must be sent to another facility or to a reference laboratory.
• Depending on the location of the reference lab, it may need a local courier service or specimens may have to be shipped to the
lab. (e.g. for HIV testing)
TEST Kind Laboratory Performed
Screening EIA (enzyme linked immunization) VSMMC
Confirmatory Western Blot Test NRL-SACCL-SLH (National Reference Lab STD AIDS
(shipped to Nucleic Acid Amplification Test (NAAT) à RNA Cooperative Central Laboratory of San Lazaro Hospital)
MNL) Indirect Immunofluorescent Antibody Assay (IFA) RITM (Research institute for Tropical Medicine, Q.C.)
• Specimens sent in the mail or through express delivery services must comply with the guidelines in special packaging and
biohazard identification.
• In general, clinical specimens for transport must be packed by Triple Packaging:
PART EXAMPLE
1 leak-proof primary receptacle A blood tube or a plastic screw-cap transfer tube
2 leak-proof secondary package biohazard sealable plastic bag, plastic canister, or Styrofoam
3 sturdy outer package cardboard box, mailing tube, wooden box, or cooler
1. The primary container must be labeled the same as the original specimen 2057_Ch16_397-424 20/12/10 3:24 PM Page 418

2. Then wrapped with the absorbent material and placed in a secondary container.
§ Any accompanying paper (e.g. requisition form) is enclosed in the418 outer source (pouch) and must include the SECTION 4 ✦ Additional Techniques

specimen identification and a biohazard label attached. Infectious substance

Absorbent packing

§ A coolant (ice packs or dry ice) may be required in the Primary receptacle
leakproof or siftproof
material (for liquids)

Cross section of closed package

secondary container for refrigerated specimens.
§ Secured with cushioning material (e.g. bubble wrap) Secondary packing
leakproof or siftproof
(e.g., sealed plastic bag)
Primary receptacle
leakproof or siftproof

3. Placed in the outer package (3rd) for shipping which must display Secondary packing

appropriate biohazard labels, sender’s and receiver’s adresses and

leakproof or siftproof
(e.g., sealed plastic bag
Biolo
Subs gical or other intermediate
Cate tance

orientation label (sample contains 50+mL of sample to ensure upright

gory
B Rigid outer packaging)
Rigid outer packaging packaging
UN33
Absorbent material
position)
73
Cushioning
Package mark material

o When done, package should be able to withstands a drop from about Name and telephone number of a

4ft (1.2m) (put padding) person responsible. (This information

may instead be provided on a written
document such as an air waybill.)
FIGURE 16 9 Packing and labeling of Category B infectious substances. (From Pipeline and Hazardous Materials Safety
Administration, US Department of Transportation.)

special specimen handling

• applies to specimens that are to be kept warm, cool, or protected from light duringthan
transit
may
a familiar school or home model, although it
be connected to a higher-powered mainframe
laboratory. LISs may be used only by the laboratory
or may be integrated into a hospital-wide computer
computer for transfer and storage of data. Phle- system. Companies that provide LISs work closely with
botomists may use hand-held computers or personal the laboratory staff to adapt the system to correspond
digital assistants (PDAs) for patient identification, test with particular laboratory operations. LIS clinical
REQUIRES WARMTH DURING TRANSIT requests, and label printing at the patient’s bedside.
Point-of-care patient test results from portable hand-
applications include the following:
Generate laboratory orders
• Must be maintained at 37°C during transport and handling include (1) cold agglutinins, (2) cryoglobulins, andPrint cryofibrinogen
held instruments are directly transmitted to patient’s ●

labels for sample collection

charts. Data can be transferred among the laboratory ●

Monitor sample status in the laboratory

sections or other hospital departments and by com- ●

o (2) and (3) are abnormal proteins that precipitate/thicken during exposure to cold temperature Interface with laboratory analyzers for direct
puter telephone cable, fiber optics, and wireless ra-
reporting of results and autoverification
diowave connections to outside agencies such as
●

Archive past patient results

o (2) can be obtained from whole blood and plasma; (3) can only be obtained from plasma health-care providers’ offices. In many laboratories, ●

Provide billing of laboratory services

employees are assigned computer mailboxes through ●

Provide a mode for result viewing

which they can receive intralaboratory communica- ●

• the tubes for these specimens should be pre-warmed using a heel-warmer packet before collection, and should be transported
Monitor quality control and compliance
tions, that is, notification of meetings, telephone mes-
sages, and procedural changes.
Phlebotomists first encounter an LIS through the
●

wrapped in a heel-warmer packet as well. Laboratory Information Systems (LISs)

receipt of computer-generated requisitions and sam-
ple labels (Fig. 16-10). They must learn to recognize

o Heel warmers are effective up to thirty (30) minutes. Many application programs for laboratory use are cur-
rently available, and the decision to use a particular
the information provided, to be sure that it corre-
sponds with the required information discussed in
program is determined by the requirements of the Chapter 9, and to compare this information with the
• In the lab, the blood sample is allowed to clot inside the incubator (at 37°C) and centrifuged in a pre-warmed centrifuge cup. Serum
is transferred to another test tube.
o Failure to keep the sample warm will result in erroneous laboratory results.

COLD AGGLUTININS
• Autoantibodies produced in patients with Primary Atypical Pneumonia (PAP) caused by
Mycoplasma pneumoniae
• Commonly known as walking pneumonia
o Not bedridden; body malaise; cough; fever
§ Symptoms are more of viral, but it’s actually bacterial.
• Can cause agglutination of patient’s own RBCs on exposure to cold, blockage of small
blood vessels à hemolytic anemia
o Manifests as cyanosis of (a) fingers, (b) toes, (c) ears, and (d) earlobes
o Reversible by rewarming exposed parts
• EDTA tube for a CBC must be pre-warmed and kept warm; clumps of RBCs can cause
problems in automated instruments.
@ashumerez | PMLS 2 : BSMT-1G 2019 51
Testing for Cold Agglutinin Titer (CAT):
1. Do serial dilution of the serum.
2. Add the antigen (2% Group O RBC or patient’s own RBC – no A and B antigens)
3. Incubate the overnight inside the refrigerator (4°C)
4. Read the titer of the cold agglutinin.
a. Reciprocal of the highest dilution showing hemagglutination.
• Significant titer = 32 or higher
• Confirmatory test: incubate (+) at 37°C water bath à 30 minutes à dispersion
of agglutinates à cold agglutinins are eluted

REQUIRING COOLING DURING TRANSIT

• Slows down the metabolic process, keeping analyte levels as close as possible to those found in the blood stream
• Tests that require chilling:
o Arterial blood gases o ammonia o pyruvate o lactic acid
• To chill, place it in a slurry of chipped/shaven ice and water ß promotes complete contact between sample an ice bath
• Avoid large ice cubes à causes part of sample to freeze à hemolysis
• Specimens may even require collection in a pre-chilled evacuated tube.

LIGHT-SENSITIVE SPECIMENS
• There are some specimens that break down when exposed to light
• Light-sensitive specimens can be collected in any of the following:
o Covered in foil o Placed in a brown biohazard bag o Special amber colored plastic tube
• Substances that require protection from light:
o Bilirubin o Vitamin B12 o Urine Porphyrins
o Carotene o Folate

Neonatal Bilirubin
• Commonly performed on newborn infants with jaundiced skin and eyes
o Remedied by placing the infant under ultraviolet light ß must be turned off while collecting blood à turn it back on after
collecting specimen and safely remove it from under lamp

processing of blood samples

SAFETY
• OSHA requires PPE to be worn during sample processing:
o Gloves o Protective face gear (e.g. goggle
o Full-length lab coat (buttoned or snapped) with closed cuffs and mask, chin-length face shield)

CENTRAL PROCESSING / RECEIVING AREA

• The first to handle specimens entering the lab; devoted to receiving and sorting samples as they arrive.
• Date and time of arrival are recorded, often with a time-and-date stamping machine
o Samples are labeled with bar codes that are read by an electronic reader (also records the time sample is received)
o Log Book ß (1) date and time of arrival in lab, (2) patient’s ID, (3) samples, (4) tests, (5) physician
• Samples are then sorted by sample type and distributed within the lab.
o responsible for centrifuging samples and preparing aliquots for distribution to different departments in larger labs

CLOTTING
• Serum specimens à completely clotted before centrifugation
• Complete clotting ß 30-45 mins. @ RT
• Samples from patients on (1) anticoagulants (e.g. heparin, Coumadin (dicumarol)) have longer clotting times as do (2) chilled
specimens and those from patients with (3) high WBC counts.
• Samples with clot activators (including serum separator tubes) clot within 30 minutes.
o If thrombin is used, complete clotting may occur within 5 minutes.
• Plasma specimens can be centrifuged immediately because they have anticoagulants to prevent clotting.

USING THE CENTRIFUGE

• Centrifuges come in many different styles: (1) refrigerated, (2) floor models, and (3) tabletop models.
• The speed of rotation (revolutions per minute, or rpm) and the radius (mm) of the rotor head determine the relative centrifugal
force (RCF) of a centrifuge.
o RCF is expressed as gravity (g)
1.12 x r x (RPM)2
RCF = 1.12 x 10-5 x r x (RPM)2 or RCF =
(1000)
• Most laboratory specimens are centrifuges at 1000-3000 rpm for 15 minutes
• Loosening clots form the side of the tube (rimming) before centrifugation is not recommended à may cause hemolysis.
@ashumerez | PMLS 2 : BSMT-1G 2019 52

• Blood tubes must remain closed before, during, and after centrifugation to avoid contamination with dust, accidental spills,
aerosols, and evaporation of specimen
• Specimen pH increases when the cap is removed à may cause erroneous pH, ionizied calcium and acid phosphatase results.
o Only open the tubes during the aliquoting.
Never start a centrifuge without balancing the tubes within it; every sample must be balanced by another of equal weight.
• not an even number of blood tubes to spin à balance the centrifuge with a similar tube filled with water or saline
• unbalanced centrifuge à vibrate (jump around), will make unusual noises, may damage the specimens or injure phlebotomists.
• The lid of the centrifuge must be closed and secured during operation, and it must stay closed until the rotor stops.
• Never try to stop the centrifuge prematurely by touching the rotor ß dangerous and can disrupt the sample.
• Repeated centrifugation of a specimen is not recommended à may ↑hemolysis of the sample and deterioration of analytes.
• If a tube is broken, the cup must be completely emptied into the sharps container and disinfected.

REMOVING A STOPPER
• The major risk of stopper removal is aerosol (n. a microscopic mist of blood that forms from droplets inside the tube) formation.
o Can contain viruses and endanger a person if enhaled
• Aerosols are especially likely if the tube or rim has been contaminated by residual blood during collection or transport.
• Careful stopper removal reduces the risk of aerosol formation.
• To remove a stopper, place a 4x4-inch piece of gauze over the top to catch blood drops or aerosol. Pull the stopper straight up,
twist if necessary.
o Do not rock it from side to side or “pop” it off.
o The Hemogard top is a plastic top that fits over the stopper to reduce aerosol formation and spattering.
• When removing a top from a tube, always use a safety shield to prevent blood from accidentally spattering on you and to reduce
the risk from aerosols. There are two types of safety shields:
Personal Face Shield Workstation Shield
With clear plastic visor you pull down over your face Glass that acts as a barrier between the phlebotomist and the aerosol

PREPARING ALIQUOTS
• the process of transferring a portion of a specimen into one or more transfer tubes
• Before you begin to aliquot a sample, make sure the transfer tube is properly labeled by comparing it to the label on the specimen
tube that was used for collection.
• A Pasteur Pipet (pipet with a suction bulb) is used to transfer the serum or plasma to the transfer tube.
o Press the suction bulb first before inserting the Pasteur Piper into the tube. Release the bulb gently to suction the
sample and transfer to a transfer tube.
• Be sure to check the specimen requirements before selecting an appropriate transfer tube.
• Specimens must be capped properly prior to and during delivery to the laboratory section or reference laboratory.

SPECIMEN STORAGE

• Serum can be stored on the gel in gel separator tubes for 48³ hours at 4°C. expected stored at
o Confirm gel integrity to be
2-8°C
delayed
• Samples for electrolytes must not be stored at 2-8°C before serum or
centrifugation and testing. plasma @ RT (8
• Specimens can only be thawed once. Repeated freezing and hrs.)
not tested
thawing of the specimen can destroy analytes for testing. frozen at
within 48
³-20°C
hrs.
processing of microbiology specimens
• Microbiology samples must be transported to the laboratory immediately to ­likelihood of recovering pathogenic organisms.
• Most specimens are collected in transport media and are plated immediately on culture media ß the phlebotomist is trained to
perform this task:
o rectal swab o ear discharges
o throat swab o urethral discharges (for Neisseria gonorhoeae, Intraurethral Swab is used)

BLOOD CULTURES
• Brain Heart Infusion Broth (BHIB) and Thioglycolate Broth à incubated at 37°C for 24 hours à checked for evidence of growth:
1 Uniform turbidity in plasma/ broth mixture Gram-negative rods
2 Cotton ball colonies on the sedimented RBC; supernatant may be clear Streptococci (alpha haemolytic, S. pneumoniae)
Beta-hemolytic organisms (S. pyrogenes,
3 Heavy hemolysis of blood
Pseudomonas aeruginosa)
4 Large jelly-like coagulum Staphylococcus aureus
5 Hemolysis and thick pellicle on the surface of the broth suspect Bacillus subtilis (contaminant)
6 Production of small amount of gas and a foul odor in THIO only Bacteroides fragilis (mousy odor)
@ashumerez | PMLS 2 : BSMT-1G 2019 53

BHIB THIO
subculture on blood agar plate and: / O2 chocolate agar plate / aerobic Thio sc (5mL broth) / anaerobic
• Blind Subculture = 24 hours, 48 hours, and 1 week of incubation (Haemophilus influenzae)

Specimen Rejection
All specimen received by the laboratory must be evaluated for acceptability before further processing. Criteria for rejection include:
1. Hemolysis 6. Hemoconcentration or Contamination
2. Clotted Anticoagulated Specimens 7. Icterus and Lipemia
3. Insufficient Volume for Testing [Quantity Not Sufficient (QNS)] 8. Special Requirements Not Followed
4. Incorrect Tube Collected 9. Documentation Errors/Inadequate Identification
5. Incorrect Order of Draw 10. Contaminated Specimen

(1) HEMOLYSIS
destruction of RBCs
Definition • hemoglobin released into the plasma or serum gives it a reddish color à may interfere with some
laboratory tests
• Potassium (K) • Aspartate aminotransferase (AST)
Seriously Affected
• Lactic Dehydrogenase (LD) • Complete blood count (CBC)
1 Rimming clots
Factors in processing, 2 Prolonged contact of serum/ plasma with cells
handling the samples 3 Centrifuging at a higher than recommended speed
also can result in 4 Elevated or decreased temperatures of blood
hemolyzed samples 5 Using pneumatic tube systems with unpadded canisters, excessive agitation
6 Freezing and thawing specimens in transit
FACTOR EXAMPLES
liver disease, sickle cell anemia, autoimmune hemolytic anemia, blood
Physiological factors 1 Metabolic Disorders
transfusion reactions
that can cause
2 Chemical Agents lead, sulfonamides, antimalarial drugs, analgesics
hemolysis:
3 Physical Agents mechanical heart valve, third degree burns
4 Infectious Agents parasites, bacteria

(2) CLOTTED ANTICOAGULATED SPECIMENS

• specimen in an anticoagulated tube clots à specimen must be recollected
• If clots are not discovered by testing personnel, the results will be erroneous à if reported, can jeopardize patient safety
Common causes for specimen clotting in anticoagulated tubes:
• Incorrect order of draw (clot activator tubes drawn before light blue-topped tube)
• Failure to mix each tube as it is removed from the holder
• Failure to tap a micro-collection container between each drop
• Delay in transferring specimens from a syringe to an evacuated tube
• Difficult blood draws in which the blood flows very slowly into the tube
• Use of an expired tube

(3) INSUFFICIENT VOLUME FOR TESTING [QUANTITY NOT SUFFICIENT (QNS)]

• produces improper additive-to-blood ratio (the balance between the amount of additive or anticoagulant and the amount of blood)
• This imbalance will produce erroneous results:
o abnormal chemistry values o coagulation test results o blood counts
The following can cause incomplete collection:
• Loss of vacuum during venipuncture
• Failure to purge air out of the butterfly needle tubing using a discard tube
• Use of expired tubes
• Removal of the tubes before its fill level is reached
• Veins collapsing during venipuncture
• Dermal puncture site that becomes clotted before enough specimen is obtained

(4) INCORRECT TUBE COLLECTED FOR THE TEST ORDERED

• e.g. EDTA for a chemistry test
• Specimens collected must be appropriate for the laboratory tests to be performed.
• Specimen is collected using the incorrect type of tube à the specimen will be rejected à will need to be recollected

(5) INCORRECT ORDER OF DRAW

• The order of draw is designed to prevent specimens from being contaminated with additives that may cause erroneous results.
• Correct tube placement is important for coagulation testing.
@ashumerez | PMLS 2 : BSMT-1G 2019 54
(6) HEMOCONCENTRATION OR CONTAMINATION
• The effects of hemoconcentration (prolonged tourniquet application) and contamination by intravenous (IV) fluids (collecting
blood from a site above an IV) are not easily detected.
• Laboratory personnel may question phlebotomists about collection procedures when they obtain results that do not make sense
or do not pass delta check.
o A delta check is a quality control toll that involves the comparison of questionable test results with previous results of
the same patient; it can be programmed into the laboratory’s computer system to detect an error.
• If laboratory personnel suspect hemoconcentration or contamination, the specimen will need to be recollected.

(7) ICTERUS AND LIPEMIA

• Two interfering substances over which the phlebotomist has no control are icterus and lipemia (in the plasma and serum)
ICTERIC LIPEMIC
Appearance dark-yellow to greenish yellow cloudy
Reason increased amount of bilirubin Abnormal amount of fats
Tests Affected some chemistry tests (e.g. creatinine) hemoglobin levels

(8) SPECIAL REQUIREMENTS NOT FOLLOWED

• e.g. cold agglutinins not kept warm
• The following are special handling requirements:
o The specimen must be protected from light
o The specimen must be kept at the appropriate temperature
o The specimen must be centrifuged and separated within the required timeframe.

(9) DOCUMENTATION ERRORS OR INADEQUATE IDENTIFICATION

Reasons for specimen rejection due to documentation include the following:
• An unlabeled specimen
• A mislabeled specimen (labeled with another patient’s ID)
• A specimen with two labels containing different patient information

(10) CONTAMINATED SPECIMEN

e.g. urine for culture and sensitivity testing collected in non-sterile container

I SEE IT
I LIKE IT
I WANT IT
I GOT IT
!"
@ashumerez | PMLS 2 : BSMT-1G 2019 55

Waived testing and collection of non-blood specimens

LESSON 10
Date of Lecture : 5 April 2019. Ma’am Iluminada Cinco, RMT.
References : Booth, K. A., Mundt, L.. Phlebotomy: A Competence Based Approach (4th ed.). Chapter 13;
https://www.youtube.com/watch?v=T4uQJ05SIe0; Ezrah Toring’s side notes. !

urine
• convenient body fluid to collect
• can be used for many types of laboratory analysis:
o glucose screening o drugs o alcohol o general well-being
• measures total amount of substances excreted in a 24-hour period (e.g. urinary protein)
• can be used to assess the urinary system’s status
• screening for metabolic diseases:
o diabetes mellitus o amino acid overflow o proteinuria

NORMAL OUTPUT pH LEVEL ANURIA POLYURIA

1.2-1.5L/day 4.5-8 500mL/day 2L/day

TYPE CHARACTERISTICS OBTAINING

Best specimen to use for:
(1) general health assessment
(2) hormone levels (e.g. hCG testing) Best urine specimen for routine testing since it is the
1 First morning void
(3) other chemicals (e.g. glucose, protein) most concentrated
Most concentrated (pH: 5-6) à formed elements
are better (crystals, urinary casts, RBC, WBC)
Specimen of convenience
2 Random void Urine specimen that is collected at any time of the day
Acceptable for routine assessment
special instructions for collection must be explained
to patient à to obtain quality specimen
Clean-catch • genitals must be cleansed with mild antiseptic
3 Urine culture
midstream special sterile kit is used
contaminated by normal flora (bacteria) à may
produce false results
Measures...
• protein • sodium • hormones
…excreted over a 24-hour period
Phlebotomists may need to prepare specimen
4 for quantitation of proteins and other substances
a 24-hour collection collection containers and instruct patients in the
(e.g. glucose)
correct method of collecting them for these tests:
• aldosterone
• potassium • sodium
• cortisol
• protein • ureab N
• creatinine b
Drug screening to be used in court of law (not all
5 Legal specimens
RMTs can do this)
6 Catheterization For patients who are unable to void
Needle is inserted into the full bladder à urine is
Physicians directly collect urine from the bladder
7 Suprapubic puncture aspirated (e.g. when culture is hard to get/is
(MT will only assist the doctor)
anaerobic, for infants)
a
Not all 24-hour urine collections require preservatives. For those that do, care must be taken when
adding preservatives to containers.
b
Best way to identify urine: concentrations for urea and creatinine.

• Use chemical fume hood and wear appropriate PPE [(1) gloves; (2) goggles/face shield; (3)
rubber apron]
• Preservatives may have acids or chloroform.
o In dilution, ACID TO WATER.
§ Urine is originally acidic but microorganisms act on urea à ammonia à urine
becomes basic.
o Container must contain lids that close tightly, labeled with caution information.
• May require refrigeration or need to be placed on ice during time of collection.
• That’s a picture of a container for 24-hour urine collection, which may require the addition of a preservative. "#
@ashumerez | PMLS 2 : BSMT-1G 2019 56

ACTION TIME RESULT

not tested Within 1 hour of collection to be refrigerated
kept at RT > 1 hour can alter test results of chemical & microscopic contents* (ammoniacal odor at first sense)

*Urine contents:
• changes in urine color and clarity • ¯several substances if initially present:
• bacterial growth o bilirubin o ketones
• ↑pH and nitrites (NO2-) o glucose o urobilinogen
• Decomposition of casts and cellular elements

FEMALE CLEAN-CATCH URINE SPECIMEN COLLECTION

1. Instruct the patient to follow these steps to clean the perineum.
a. Separate the skin folds (labia) and keep them separated throughout the cleaning and collection process. With one
antiseptic towelette, wipe from front to back (pubic to anal) down one side of the skin folds; then discard the towelette.
b. With a second towelette, wipe down the other side of the skin folds from front to back; discard towelette.
c. With a third towelette, wipe down the middle of the labia front to back and discard the towelette while keeping the skin
folds open with the other hand.
2. Instruct the patient to follow these steps to obtain the specimen.
a. Keeping the skin folds spread apart to avoid contamination, start to urinate into the toilet.
b. Place the cup under the flow of urine after it has begun and remove the cup before it has finished. Do not collect the first
or last part of the stream of urine. Instead, collect the urine at midstream; this is why the phrase “clean-catch midstream”
is used.
3. Once the patient is finished, place the lid on the cup. Ideally, the cup should be about three-fourths full.
4. Label the specimen (name, date of collection).
a. Remember, your facility might require other identification on the specimen, so check with your supervisor.

MALE CLEAN-CATCH URINE SPECIMEN COLLECTION

1. Wash hands carefully with soap and water
2. Using one antiseptic wipe, clean the glans (tip) of the penis.
3. Wipe from the urethral opening (orifice), wiping from the opening in a circular motion. If not circumcised, this is done while holding
the foreskin back. Clean the area around the opening completely. Discard the wipe.
a. Repeat the procedure with a second antiseptic wipe.
4. Following the 1st cleaning, wipe thoroughly using the 2nd antiseptic wipe, while maintaining the foreskin in a retracted position.
Discard the wipe.
5. Void a small amount of urine in the toilet bowl.
6. Continue to void and collect urine in the cup. Do not touch the sample cup on the inside or touch your body or clothing to it.
7. Place the lid carefully into the sample container. Screw the lid on tightly to prevent any leakage.
8. Give the urine to the laboratory associate.

24-HOUR URINE COLLECTION STEPS

• Plan the 24 hour urine collection to start in the morning two (2) days before your next scheduled study visit
o Every single drop of urine has to be collected. Total counts require the entire 24-hour collection of urine.
• Start the urine collection in the morning after you wake up.
o Flush the first morning urine because you need to start your urine collection with an empty bladder.
• Collect your first morning urine on the following morning and it should happen within 10 minutes of the time you started your urine
collection the previous day, finishing the 24 hour urine collection.

1. Wash your hands thoroughly with soap and water.

2. Prepare for urine collection
a. Place the jug on a flat surface and place the lid aside with the top side facing down.
b. Clean the urine collection jug thoroughly with sterile wipes.
c. Important: Write the exact date and time when you start the urine collection on the green part of the label on the
collection jug.
i. There is no need to record each time you urinate, only the start and end times.
3. Pee into the jug unless female:
a. Females receive a special supporting decide called a commode to assist them in urine collection.
i. Insert the commode under the toilet seat towards the front of the bowl every time urinating.
ii. Urinate into the commode
b. Once done, remove the commode and pour the urine into the collection jug while making sure all the urine is transferred.
Post Collection:
4. Clean the rim of the collection jug with a second sterile wipe.
a. Place the screw cap back on the collection jug and close it tightly.
@ashumerez | PMLS 2 : BSMT-1G 2019 57
b. Clean urine outside the jug with a different sterile wipe.
c. Females: Rinse the commode out with tap water and dry with paper towels.
d. Important: Do not overfill the collection jug if you expect to exceed the
volume of the container. Collect the rest of your urine in a clean glass or plastic
container instead.
e. Important: Try not to include feces in the urine sample if you have loose
bowel movement. If feces does get mixed, do not try to remove them; instead,
just notify the study team about in your next visit.
5. Wash your hands thoroughly with soap and water and dry.
a. Important: Record exact date and time you finish the urine collection on the red part of the label on the collection jug.
6. Urine should be stored between 2-8°C (36-46°F) away from food items ß never freeze
a. If 24-hour urine collection is done, store the urine collection jug and any other additional containers in the refrigerator
until your next study visit.
7. Place urine collection jug in a cooler bag with the frozen cooling packs when going to the study center to deposit urine sample.

INFANT SPECIMENS
• Uses special equipment (e.g. sterile plastic bag with a hole to fit around genitalia and is secured with an adhesive backing)
o Diaper is then placed over this bag during urine collection.
o Once collected, urine may then be transferred to urine collection cup/tube.
§ If for urine culture, better to leave it in the bag and transport to lab immediately (depending on facility’s SOP).

Throat Swabs
• sample taken from back of throat
o placed in transport medium before delivery to laboratory to keep organism viable
§ Amies medium and Stuart medium to keep organisms alive for culture
• used for (1) Group A Streptococcus screening (microorganism that causes strep throat)
• …for (2) growing cultures of throat microorganisms (e.g. (a) Haemophilus influenzae and (b) Neisseria gonorrhoeae)
• Sterile swabs with sponge-like tips + tongue depressors made of Dacron or calcium alginate: used for throat culture specimens.
o Do not use cotton-tipped swabs for throat cultures. The cotton may inhibit bacterial growth.
o Most culture swabs have an ampule of growth medium located at the bottom of the swab container.
§ Keeping the swab in contact with the medium ensures any microorganisms present remain viable.
• Gag Reflex
o To help prevent gagging, instruct patients to breathe through the nose.
§ This will help minimize movement of the uvula and make it easier for you to collect the specimen quickly.

PPE
• Always wear gloves when performing procedures on patients. Wear a mask and eye protection since the patient may cough.
o Wearing all appropriate PPE is especially important to prevent the spread of pathogens.
• Often, two (2) throat swabs must be collected
1. Strep screen test 2. To the microbiology lab for throat culture
o Some throat swabs come in pairs and should be used together to collect the specimen.
§ If swabs are separate, it’s still better to use two simultaneously to avoid doing the same procedure twice.

sputum
• mucus that collects in the air passages of the respiratory system SALIVA SPUTUM
o usually TB in the $; gathers overnight thick and produced from the lungs
thin and
• specimens are used in: dull white or dull green
nearly clear
o diagnosing various disorders of the respiratory tract red or brown (bloody)
o sputum culture to identify pathogenic microorganisms

COLLECTION
1. Rinse mouth with water à minimizes contamination by bacteria in the mouth
2. Ask patient to expectorate (v. – generate a cough from deep within the lungs and bronchi) sputum and spit into sterile container.
3. Label specimen with patient and collection information and deliver to microbiology laboratory for testing.
o Laboratory will examine sample for squamous epithelial cells (SECs) (respiratory) and white blood cells (WBCs)
(infection) to determine specimen acceptability.
• Other institutions: collect directly [no (1) toothbrushing, (2) mouth washing, (3) smoking, (4) gargling, etc.]
• Refrigerated; not frozen.
@ashumerez | PMLS 2 : BSMT-1G 2019 58

stool
• For various disorders of the digestive tract
• Tests include:
o stool culture o fecal hemoglobin screening
o fecal fat analysis o ova and parasite identification
• The phlebotomist should give clear, practical instructions for collection of the stool specimen:
o Follow special diet (if prescribed)
o Do not contaminate specimen with urine or water
• When getting, try to get from three (3) different areas. You may need to collect from area with mucus.
• May require clean, dry, sealable, leakproof container
• Container type and size depend on the ordered tests
o If the specimen is for the detection of occult blood or certain other tests, the phlebotomist
may also need to instruct the patient on how to transfer a specimen to another container.

{ Fecal Occult Blood } { Ova and Parasites }

waived testing
• With appropriate training, phlebotomists may perform waived testing in states the do not restrict them.
• Phlebotomist should be aware of the level of testing that they may be asked to perform tests that are waived.
• Waived testing procedures can be performed using kits that are available from a number of manufacturers.
o These kits include easy-to-follow instructions and most come with built-in controls.

Cerebrospinal fluid
• clear, colorless liquid that surrounds the brain and spinal cord
• contains many of the same constituents as blood plasma
• Specimens are obtained by a physician, most often through lumbar puncture (spinal tap)
o Main reason is to diagnose meningitis; and also (1) brain abscess, (2) CNS cancer, (3) multiple sclerosis
• Generally collected in three (3) special sterile containers numbered in order of collection
1. Chemistry and Immunology 2. Microbiology studies 3. Cell counts (Hematology)
o Dictated by laboratory protocols unless physician states otherwise
• Samples should be kept at room temperature
o kept at RT o delivered to the laboratory STAT o analyzed immediately
• Routine tests:
o cell counts o chloride o glucose o total protein
@ashumerez | PMLS 2 : BSMT-1G 2019 59

Arterial blood collection

LESSON 11
Date of Lecture : 08 April 2019. Annabel M. Laranjo, MD, FPCP, DPSMID
Reference : Strasinger, S. K., & Schaub, D. L. (2011). The Phlebotomy Textbook (3rd ed.). Chapters 14;
https://en.wikipedia.org/wiki/Allen%27s_test; mga yaw-yaw.

some stuff she was saying that i can’t find in the book
• pregnancy can also affect arterial blood determination (the gases) because uterus comes out into abdomen à pushes into
diaphragm à rapid breathing (more O2, less CO2)
o you can also perform lactose and ammonia
• exercise takes up O2 à cell metabolism à decreased acid in the blood à increased O2 in the blood
• prolonged smoking à destructs alveoli structure à impaired gas exchange à lungs full of H2CO3’s à ¯O2 (respiratory acidosis)
• pneumonia affects between blood and lungs; TB
introduction
Arterial Blood Venous Blood
uniform throughout the body varies because it receives waste products
primarily requested for the evaluation of blood gases (O2 and CO2) from different parts of the body1
may be requested for the measurement of lactic acid (associated with mortality) and NH3
in certain metabolic conditions. where normal values for most laboratory
blood collection is more uncomfortable and dangerous for the patient and is more tests are based on
difficult to perform (more complications)
1
(liver is metabolic organ à increased waste products, so its blood is the same so different blood from different parts of the body)
• Performing arterial punctures is not a routine duty for phlebotomists.
• The Clinical Laboratory Standards Institute (CLSI) recommends that all institutions require personnel performing arterial punctures
to complete specialized training before performing the procedure.
• This training should include instruction on:
1. Complications associated with arterial punctures a. most errors are in the sample getting and
2. Precautions taken to ensure a safe procedure processing
3. Sample handling procedures to prevent alteration of 4. Correct puncture technique
test results 5. Supervised puncture performance
• Personnel trained to perform arterial punctures include:
o physicians o medical laboratory scientists o emergency medical personnel
o nurses o respiratory therapists o senior phlebotomists
o In some institutions, collecting and testing of ABGs has become the responsibility of the respiratory therapy department.
o In institutions where the laboratory performs the testing, phlebotomists may be required to perform the puncture or to
assist the person performing the puncture and delivering the sample to the laboratory following special procedures
§ Results must be out within minutes because life-saving procedure; patients are usually critically ill.

arterial blood gases

IMPORTANCE
• measures the ability of the lungs to provide oxygen (O2) to the blood
• to remove carbon dioxide (CO2) from the blood and exhale it.

CONDITIONS REQUIRING ABG

CONDITION SIDE NOTES (I GUESS !)
chronic bronchitis (sputum is being produced for 3 months) and
1 Chronic Obstructive Pulmonary Disease (COPD)
pulmonary emphysema
2 Cardiac and Respiratory Failures revive arrested patient in < 5 minutes
3 Severe Shock no blood supply à no O2 à acidosis
4 Lung Cancer
5 Diabetic Coma metabolic acidosis à decreased CO2, increased O2
(Na, K, NH3, Lactate measured every minute/depending on the
6 Open Heart Surgery
physician because electrolyte abnormalities can cause arrhythmia)
7 Respiratory Distress Syndrome (RDS) in Premature Infants difficulty in breathing ß lack of surfactant

SPECIALIZED ABG INSTRUMENTATION

TEST FUNCTION NORMAL VALUES1
Measures the acidity or alkalinity of the blood.
Acidity (pH) 7.35-7.45
Indicates acidosis or alkalosis.
MEASURED 2
Partial Pressure of O2 Measures the pressure of O2 dissolved in the blood.
75–100 mm Hg
(PO2) Tells how well O2 moves from the lungs into the blood.
 CH
@ashumerez | PMLS 2 : BSMT-1G 2019 60
TABLE 141 ● Arterial Blood Tests
2 Measures the pressure of CO2 dissolved in the blood.
Partial Pressure of ARTERIAL BLOOD TEST35–45 mm Hg
DESCRIPTION/FUNCTION
CO2 (PCO2) Tells how well CO2 moves out of the lungs. Partial pressure of Measures the pressure of O2 dissolved
Bicarbonate (HCO3) Buffers the blood to prevent acidosis or alkalosis oxygen (PO2) 20–29 mEq/L
blood. Tells how well O2 moves from
Oxygen Content (ctO2) Measures the amount of O2 in the blood. 15–22 mL/100 mL lungs
ofinto the blood.
blood
DERIVED Partial pressure of carbon Measures the pressure of CO2 dissolve
Oxygen Saturation Measures how much of the hemoglobin in the red blood
cells is carrying O2.
dioxide (PCO2) 95-100%
blood. Tells how well CO2 moves out
(O2Sat) lungs.
1
partial because not all O2 is dissolved by blood, some are in gas form; 2derived values dependpHon the machine used Measures the acidity or alkalinity of th
Indicates acidosis or alkalosis.
Bicarbonate (HCO3) Buffers the blood to prevent acidosis or
arterial puncture equipment Oxygen content (ctO2) Measures the amount of O2 in the blo
• Arterial blood is collected and transported in specially prepared syringes. Oxygen saturation (O2Sat) Measures how much of the hemoglob
• Specimens are introduced directly into blood gas analyzers from the collection syringe (from bedside directly intoredmachine).
blood cells is carrying O2.

o This is necessary to protect the specimen from contact with room air (has many gases that can affect the results).
to 25 gauge
ARTERIAL BLOOD COLLECTION KITS syringe sho
• contains pre-anticoagulated syringes with hypodermic needles containing a safety When usin
slowly pull
shield and a tightly fitting cap for the Luer tip of the syringe after the needle has
been removed
Techn
• machine in Figure 14-1 measures (1) lactate, (2) NH3, (3) electrolytes syring
enter
SYRINGES AND NEEDLES
• Syringes for arterial punctures are plastic with freely moving plungers and contain Heparin
an appropriate anticoagulant (CLSI). and must b
is collected
• Based on the requirements of the testing instrument and the number of tests FIGURE 141 Technologist performing arterial blood gas fere with an
requested, they may range in size from 1-5mL. determination. sample.
o They should be no larger than the volume of sample required.
o Acceptable needle sizes range from 20-25G and are 5/8 - 1½” long Techn
(based on size and depth of artery). would
reque
• Ideally, the syringe should self-fill from the arterial pressure.
o When using 25G needles, it may be necessary to slowly pull the plunger.
Glass syr
§ Excessive pulling on the syringe plunger can cause air or ples cannot
capillary blood to enter the sample. lubricated
FIGURE 142 Arterial blood collection kit.
• Heparin is the anticoagulant of choice for ABGs and must be present in the syringe parin can b
use. The pr
when the sample is collected. an appropriate anticoagulant. Based on the require- a glass syrin
o The type of heparin used must not interfere with any additional tests being performed on the
ments of the testing sample.
instrument and the number of tests A tightly
§ use lyophilized Li heparin when determining electrolytes/ionized requested
calciumthey may range in sizebecause
determination from 1 to 5 sodium
mL. They is the Luer tip
should be no larger than the volume of sample required. has been re
also an electrolyte Based on the size and depth of the artery selected sample, cap
• Glass syringes must be available for use when samples cannot be tested within 30 minutes. for puncture, acceptable needle sizes range from 20 the safety n
o They must be (1) lubricated and (2) heparinized prior to use.
o Liquid heparin can be used to prepare a glass syringe just before use.
o A tightly fitting cap must be available to place on the Luer tip of the collection syringe after the needle has been removed.
§ To prevent air from entering the sample, capping must be performed immediately after the safety needle has
been removed from the syringe. (Mix with anticoagulant right away.)
• Capping devices are available that remove air bubbles already present in the syringe in addition to
preventing the entry of air into the sample.
• Also available is the Point-Lok device (Sims Portex, Inc, Keene, NH), into which the needle can be inserted before removal.

ADDITIONAL SUPPLIES
SUPPLY FUNCTIONS / EXAMPLES
A container of crushed ice / required for maintaining sample integrity if the sample cannot be tested within 30 minutes.
1
ice and water The container must be large enough to cover the entire blood sample with the ice and water.
Materials used for sample
2 labeling must be waterproof if
sample is placed in ice bath.
1 povidone-iodine or chlorhexidine cleansing the site
2 alcohol pads remove iodine after procedure is complete
3 gauze pads apply pressure to the site
4 Bandages
Materials for care of the Self-adhesive pressure dressing
3 5 (e.g. Coban) à used for additional pressure.
puncture site bandages
6 puncture-resistant needle disposal container
local anesthetic before performing arterial punctures
7 • requires a 1-mL hypodermic syringe with a 25G/26G needle containing 0.5 mL of
an anesthetic (e.g. lidocaine) (some are allergic)
@ashumerez | PMLS 2 : BSMT-1G 2019 61

arterial puncture procedure

1. Requisition containing appropriate information is required.
o Patients must be properly identified, and samples must be labeled with required information.
2. The phlebotomist must collect all the required equipment, and if necessary, heparinize the collection syringe and prepare the
syringe to administer the local anesthetic.
o All equipment must be conveniently accessible when the puncture is being performed.
3. Additional patient information concerning the conditions under which the sample was obtained should be provided on either
the requisition form or a designated ABG form. This information includes the following:
o Time of collection (b) the rate of flow per minute shown on the
o Patient’s temperature oxygen monitor in liters per minute (L/M)
o Patient’s respiration rate i. face mask can provide up to 10L
o Method of ventilation (room air or mechanical o Patient activity (e.g. comatose, agitated, or
including the type of ventilation device in use) anesthetized)
o amount of O2 the patient is receiving reported as o Collection site and method (arterial puncture
either the (a) fraction of inspired oxygen (FIO2) or or cannula, capillary puncture)

STEADY STATE
• The patient should have been (1) receiving the specified amount of O2 and (2) have refrained from exercise for at least 20-30
minutes before obtaining the sample.
• Patients are often apprehensive about arterial punctures, and considerable time and care must be taken to reassure them because
an agitated patient will not be in a steady state.
o Telling the patient that a local anesthetic will be administered after the site has been selected may aid in relaxing an
apprehensive patient.
o The patient should be in a relaxed state with normal breathing (14-20 bpm) for ≥5 minutes.

SITE SELECTION
• Arterial punctures can be hazardous–a situation that limits the number
of acceptable sites. To be acceptable, an artery must be:
1. Large enough to accept at least a 25G needle
2. Located near the skin surface so that deep puncture is not
required
3. In an area where injury to surrounding tissues will not be critical
4. Located in an area where other arteries are present to supply
blood (collateral circulation) in case the punctured artery is
damaged, sites used are radial and brachial arteries
• Physicians and specially trained personnel must collect samples from
sites such as:
o Femoral artery o Foot artery
o Umbilical and scalp veins
o These are also the only personnel authorized to insert and
collect samples from arterial cannulas.
§ However, phlebotomists may be asked to assist in
the collection of samples from cannulas.
• The radial artery is the arterial puncture site of choice because:
1. The ulnar artery can provide collateral circulation to the hand.
2. It lies close to the surface of the wrist and is easily accessible.
3. It can be easily compressed against the wrist ligaments, so that pressure can be applied more effectively on the puncture
site after removal of the needle and there is less chance of a hematoma.
• In spite of its large size and the presence of adequate collateral circulation, the brachial artery is not routinely used due to:
o depth o lies in soft tissue (fossa)
o location near the basilic vein and median nerve § does not provide adequate support
for post-puncture pressure

MODIFIED ALLEN TEST

§ was named for Edgar Van Nuys Allen, who described the original version of the test in 1929.
§ An altered test, first suggested by Irving S. Wright (1952), has almost universally replaced the original method in contemporary
medical practice. The alternative method is often referred to as the modified Allen's test or modified Allen test.
§ Before performing a radial artery puncture, the Modified Allen Test is performed to determine if the ulnar artery is capable of
providing collateral circulation to the hand.
o Lack of available circulation could result in loss of the hand or its function, and another site should be chosen.

Original Test
1. The patient is asked to clench both fists tightly for 1 minute at the same time.
2. Pressure is applied over both radial arteries simultaneously so as to occlude them.
@ashumerez | PMLS 2 : BSMT-1G 2019 62
3. The patient then opens the fingers of both hands rapidly, and the examiner compares the color of both.
o The initial pallor should be replaced quickly by rubor.
4. The test may be repeated, this time occluding the ulnar arteries.

§ Allen's test looks for abnormal circulation.

o If color returns quickly as described above, Allen's test is considered to demonstrate normal circulation.
o If the pallor persists for some time after the patient opens their fingers, this suggests a degree of occlusion of the
uncompressed artery.

Modified Allen’s Test

1. One hand is examined at a time.
2. The hand is elevated and the patient is asked to clench his/her fist for about 30 seconds.
3. Pressure is applied over the ulnar and the radial arteries so as to occlude both of them.
4. Still elevated, the hand is then opened.
o It should appear blanched (pallor may be observed at the finger nails).
5. Ulnar pressure is released while radial pressure is maintained, and the color should return within 5-15 secs.
o If color returns as described, Allen's test is considered to be normal.
o If color fails to return, the test is considered abnormal; it suggests that the ulnar artery supply to the hand is insufficient.
§ This indicates that it may not be safe to cannulate or needle the radial artery.

Procedure in page 353

1. Extend the patient’s wrist over a rolled towel and ask the patient to form a tight fist.
2. Locate the pulses of the radial and ulnar arteries on the palmar surface of the wrist by palpating with the second and third
fingers (not the thumb, which has a pulse).
3. Compress both arteries.
4. Have the patient open the fist and observe that the palm has become pale (blanched).
5. Release pressure on the ulnar artery only and watch to see that color returns to the palm.
o This should occur within 5 seconds if the ulnar artery is functioning.
6. If color does not appear (negative modified Allen test), the radial artery must not be used.
o If modified Allen test is (+), proceed by palpating the radial artery to determine its (1) depth, (2) direction, and (3) size.

PREPARING THE SITE

• The risk of infection à arterial punctures > venipunctures.
o Therefore, the puncture site is cleansed with povidone-iodine or chlorhexidine and the area is allowed to air dry.
o The gloved palpating fingers are cleansed in the same manner.
• A local anesthetic may be administered at this time.
o Done by injecting a small amount of anesthetic just under the skin, or into the surrounding tissue if the artery is deep.
o Before injecting the anesthetic, gently pull back on the plunger and check for the appearance of blood, which would
indicate that a blood vessel—rather than tissue— has been entered.
§ Should this happen, a new anesthetic syringe must be prepared and a slightly different site must be chosen.
o Allow 2 minutes for the anesthetic to take effect; if the patient is apprehensive, allow him or her to relax for 5 minutes.
o The anesthesia begins to wear off in 15-20 minutes.
o Be sure to document that the patient does not have an allergy to local anesthesia.

PERFORMING THE PUNCTURE

• Just before performing the puncture, the artery is relocated with the cleansed finger of the nondominant hand.
1. The finger is placed directly over the area where the needle should enter the artery—not where the needle enters the skin.
2. The heparinized syringe is held like a dart in the dominant hand and the needle is inserted about 5 to 10mm below the palpating
finger at a 30º-45º ∠ with the bevel up.
3. The needle is slowly advanced into the artery until blood appears in the needle hub (backflow).
a. At this time, arterial pressure should cause blood to pump into the syringe.
4. The plunger may have to be very carefully pulled back when a plastic syringe and a small needle are used.
a. If blood does not appear, the needle may be slightly redirected (swim?!?!!) but must remain under the skin.
• Blood that does not pulse into the syringe and appears dark rather than bright red may be venous blood and should not be used.

NEEDLE REMOVAL
1. When enough blood has been collected, remove the needle and apply firm pressure to the site with a gauze pad.
a. Arterial punctures are often performed on patients receiving anticoagulant therapy (Coumadin or heparin) or
thrombolytic therapy (tissue plasminogen activator [tPA], streptokinase, or urokinase).
i. Application of pressure for longer than 5 minutes may be necessary for patients receiving this type of therapy.
2. With the hand holding the syringe, immediately expel any air that has entered the sample.
3. Activate the needle protection shield, remove the needle, and apply the Luer cap or insert the needle into a Point-Lok device.
a. If a Point-Lok device is used, insert the needle into the device and apply the Luer cap when both hands are free.
4. Immediately rotate the syringe to mix the anticoagulant with the entire sample. (presence of microthrombi can affect results)
a. This can be done by rolling the syringe on a firm surface with the hand that has been holding the syringe.
@ashumerez | PMLS 2 : BSMT-1G 2019 63
5. After 3-5 minutes, check the puncture site à bleeding has stopped à discontinue the pressure.
a. The phlebotomist, not the patient, must add the pressure for 3-5 minutes.
b. Bleeding has not stopped à reapply pressure for an additional 2 minutes. Repeat this procedure until the bleeding has
stopped. Notify patient care personnel if the bleeding does not stop.

COMPLETION OF THE PROCEDURE

1. When both hands are free, the needle is discarded in an appropriate container and the Luer cap (Filter-Pro device) is applied to
the hub of the syringe.
2. The sample is labeled and, if using a glass syringe, placed in an ice-water bath.
3. After pressure has been removed for 2 minutes, the patient’s arm is rechecked to be sure that a hematoma is not forming, in which
case additional pressure is required.
4. The radial artery is checked for a pulse below the puncture site, and the nurse is notified if a pulse cannot be located.
a. This would indicate a possible arteriospasm.
5. A pressure bandage is applied if no complications are discovered.
6. In the same manner as discussed with previous phlebotomy procedures, before leaving the room, the phlebotomist disposes of
used materials in appropriate containers, removes gloves, washes hands, and thanks the patient.

MATERIALS NEEDED
• Requisition form • Needle with safety device • Ice slurry, if necessary
• Gloves • Luer cap • Indelible pen
• Antiseptic (iodine or chlorhexidine) • Gauze pads • Sharps container
• Alcohol pads • Self-adhesive pressure bandage • Biohazard bag
• Heparinized syringe
STEP / ACTIONS TAKEN
1 Obtain a requisition form and check for completeness.
2 Greet and identify the patient.
3 Explain the procedure and reassure the patient.
4 Obtain O2 therapy information and ensure a steady state.
5 Wash hands and put on gloves.
6 Organize equipment.
7 Heparinize a glass syringe and prepare the local anesthesia syringe if necessary.
8 Support and hyperextend the patient’s wrist.
9 Perform the Modified Allen Test.
10 Locate and palpate the radial artery.
11 Cleanse the site and the palpating finger.
12 Administer anesthetic if necessary.
13 Place a clean, gloved finger over the arterial puncture site.
14 Insert needle, bevel up at a 30º-45º ∠, 10-15mm below the palpating finger.
15 Allow syringe to fill.
16 Remove needle and apply pressure.
17 Activate safety shield, maintaining pressure.
18 Remove needle while retaining pressure.
19 Apply Luer device and mix syringe while retaining pressure.
20 Check puncture site for bleeding after 3-5 minutes. Maintain pressure if bleeding has not stopped.
21 Label sample after bleeding has stopped.
22 Reexamine puncture site.
23 Check for radial pulse.
24 Apply pressure bandage.
25 Remove gloves, wash hands.
26 Thank patient.
27 Immediately deliver sample to the laboratory.

sample integrity
• ABG test results can be noticeably affected by improper sample collection and handling.
• Maintaining the sample under strict anaerobic conditions is of primary importance.
• Sample integrity also is compromised by:
o improper amount of anticoagulant, o collection of venous rather than arterial blood
o failure to analyze the sample in a timely manner

EFFECT OF TECHNICAL ERRORS ON ARTERIAL BLOOD GAS RESULTS

TECHNICAL ERROR EFFECT
Air bubbles present Atmospheric O2 enters the sample, and CO2 from the sample enters the air bubbles
Too much heparin pH is lowered
@ashumerez | PMLS 2 : BSMT-1G 2019 64

Too little heparin/inadequate mixing The presence of clots that will interfere with the analyzer
Delayed analysis WBCs and platelets in the sample continue their metabolism, utilizing O2 and producing CO2
Venous rather than arterial sample Falsely decreased PO2 and increased PCO2

procedural errors
1. Introduction of air into the sample as a result of failure to firmly seat the plunger into the syringe
a. failure to immediately expel any bubbles from the syringe, or failure to seal the syringe or needle after collection
2. Excessive pulling of the syringe plunger resulting in increased suction
a. may cause the aspiration of capillary blood into the sample
3. The presence of excess heparin in the syringe falsely lowers the blood pH
a. When preparing heparinized syringes, all excess heparin must be expelled from the syringe.
4. An inadequate amount of heparin à clotted sample

• Current CLSI recommendations state that samples that will be analyzed within 30 minutes ß (1) collected in plastic syringes,
(2) not placed in an ice bath.
o Samples that will also have electrolytes performed cannot be placed on ice.
o Exception: lactate (lactic acid) tests have been ordered with the ABG ß iced immediately.
• Earlier recommendations: place all samples immediately in ice ß prevent use of O2 by leukocytes and platelets present in sample
o ­amended because samples collected in plastic syringes and analyzed within 30 mins à not affected
• Samples that cannot be analyzed within 30 minutes are still collected in (1) glass syringes and (2) placed in ice and water.
• Every precaution should be taken to avoid the need to recollect an arterial sample because of improper handling.

arterial puncture complications

COMPLICATION CHARACTERISTICS
more common after arterial puncture because the ­pressure forces blood into the surrounding tissue
Failure to maintain pressure for at least 3-5 minutes and to check the site
1 Hematoma
Causes use of arteries located in soft tissues where pressure is difficult to apply
decrease in elasticity in the arteries of older persons
a spontaneous, usually temporary, constriction of an artery in response to a sensation (e.g. pain)
Closure of the artery prohibits (1) collection of the sample and (2) prevents O2 from reaching the tissues so that
2 Arteriospasm
(a) tissue destruction and (b) possible gangrene may result.
• This is why the presence of collateral circulation is essential when performing arterial punctures.
Experienced by apprehensive patients resulting in a sudden loss of consciousness
Vasovagal Stimulation of the vagus nerve as a result of sudden stress or pain produces vascular dilation and a rapid drop in
3
Reaction BP (hypotension).
• Medical assistance should be summoned.
Formation of a clot (thrombus) on the inside wall of an artery or vein in response to a puncture hole can produce
Thrombus occlusion of the vessel, particularly if the thrombus continues to grow.
4
Formation Most frequently caused by irritation from the continued presence of a cannula.
• Collateral circulation again becomes important.
Patients with (1) coagulation disorders or (2) receiving anticoagulant or thrombolytic therapy have an ­risk of
5 Hemorrhage bleeding after arterial puncture.
Puncture of large artery (e.g. femoral artery) using a large-gauge needle can produce considerable hemorrhaging.
Failure to cleanse the arterial puncture site adequately à the introduction of microorganisms into the arterial
circulation ß more likely to cause infection > microorganisms are introduced into the venous circulation.
6 Infection
In the arterial circulation, the organisms are easily carried into many areas of the body without coming in contact
with the protective capabilities of the lymphatic system, which runs in close proximity to the venous circulation.
Its possibility is greater with arterial puncture because of the need to puncture more deeply into the tissue to reach
Nerve
7 the artery, thereby increasing the possibility of encountering a nerve.
Damage
• the brachial artery is located very near the median nerve

COMPLICATION CAUSE PREVENTION

1 Hematoma Arterial blood entering the tissue Phlebotomist applies pressure until bleeding stops
Tissue Destruction /
2 Arteriospasm Evaluate collateral circulation
Gangrene
3 Vasovagal Reaction Apprehension/pain Calming the patient, local anesthetic
5 Hemorrhage Coagulation disorders and thrombolytic therapy Increased pressure, smaller-gauge needles
6 Infection Failure to adequately cleanse the site Proper cleansing, sterile technique
7 Nerve Damage Deep punctures Avoiding deep sites or additional training for deep sites
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• Considering these possible complications, it is easy to understand why phlebotomists should perform arterial punctures only after
receiving specialized training and when the requisition form indicates an arterial puncture.
• Phlebotomists should never perform an arterial puncture just because they have been unsuccessful with the venipuncture.

accidental arterial puncture

• Considering that the brachial artery is located near the basilic vein, a phlebotomist may puncture this artery accidentally.
• Phlebotomists should be alert for the appearance of bright red blood that pulsates into the syringe.
o If an arterial puncture is suspected, the phlebotomist must apply pressure in the manner previously described.
o The sample is submitted to the laboratory and the collection of arterial blood noted on the requisition form.
o Never hesitate to report anything unusual observed while performing an arterial puncture.

study questions answers

page 360

1. To perform arterial punctures, a health-care worker must be:

c. trained in arterial punctures
2. The ABG test that measures the patient’s ability to exhale is the:
b. PCO2
3. The primary anticoagulant used for ABGs is:
a. lithium heparin
4. ABG samples that cannot be tested within 30 minutes:
d. both and c (are collected in glass syringes; are placed in an ice slurry after collection)
5. Which of the following patient information is NOT included on an ABG requisition form?
b. pulse rate
6. The preferred site for arterial puncture is the:
d. radial artery
7. A negative Modified Allen Test indicates:
c. the radial artery cannot be punctured
8. When performing an arterial puncture:
a. the artery is entered below the palpating finger
9. All of the following are technical errors that affect the quality of an ABG sample EXCEPT:
c. removing air bubbles from the syringe
10. A complication of arterial puncture that can lead to tissue destruction is:
d. both a and b (an arteriospasm and a lack of collateral circulation)

hi crush if ure reading this pls chat hehe "#

@ashumerez | PMLS 2 : BSMT-1G 2019 66

Point-of-care testing and urine drug sample collection

LESSON 12
Date of Lecture : 22 April 2019. Nestor M. Pompa, Jr., RMT, AMT.
Reference : Powerpoint; Strasinger, S. K., & Schaub, D. L. (2011). The Phlebotomy Textbook (3rd ed.). Chapter 15
IMPORTANT : Thank you, Manolo Jan Momongan for typing!

definition of poct
• Point-of-Care testing
o Alternate site testing o Decentralized o Near patient
o Ancillary o Extra-laboratory o Physician’s office
o Bed-side
• Laboratory testing at or near the patient bedside often by nonlaboratory personnel.
• Tests can be:
o waived o moderate o high complexity classification

LOCATION WHERE POCT CAN BE PERFORMED

• Specialized areas of the hospital
o ER o CCL o Wards
o OR o ICU o Private rooms
• Home health care • Health fairs
• Physician’s offices • Out-patient clinics

advantages and disadvantages

ADVANTAGES DISADVANTAGES
Decreased TAT
Decreased sample volume Large number of operators causing diluted competency
Elimination of sample transport
Ease of use
Capturing documentation of QC and Patient Results
Improves clinical outcomes by decreasing patient’s discomfort.
Increased interpersonal interaction between patient and HC personnel
Mobility Charging and billing mechanisms
Reduced medical cost

SAMPLES USED IN POCT

• Anticoagulated samples • Noninvasive transcutaneous and transdermal methods • Urine
• Direct swabs from infected areas • Saliva • Whole blood

COMMON POCT ASSOCIATED WITH LAB DEPARTMENT

DEPARTMENT TESTS
1 Hematology • Hgb • Hct • Erythrocyte • sedimentation rate (ESR)
• ABG • Cardiac Markers • Electrolytes • hCG
Clinical
2 • Bilirubin • Comprehensive Metabolic Profile • Glucose • Lipid Panels
Chemistry
• Blood Urea N • Creatinine • Hemoglobin A1c • Liver Function
3 Serology • HIV • Mononucleosis • Helicobacter Pylori
4 UBF • Body Fluid pH • Reagent Strip UA • Occult Blood • Gastroccult
Urine • Amphetamines • Benzodiazepines • Ethanol
5
Toxicology • Barbiturates • Cocaine • Marijuana !
• Bacteria vaginosis • Group A Strep
6 Microbio • Respiratory syncytial Virus
• Influenza A/B • Detection of biowarfare agents
7 Coagulation • PT w/ INR • APTT • ACT

regulation of poct
• CLIA ’88
• Applies to anyone who performs testing of human specimens for the ________ of disease or health problems
o diagnosis o prevention o treatment
• Everyone from physicians performing the most basic tests (e.g. dipstick urinalysis) to the technicians working in POLs.
• Commission on Laboratory Assessment (COLA) that is popular with physician office laboratories, The Joint Commission (JC),
College of American Pathologists (CAP) – accrediting bodies that uses CLIA’88 standard.
o Implementing Body: CMS and CDC
• Expected Facilities to CLIA’88:
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• Facilities that perform testing for forensic purposes.

• Research laboratories that do not report patient results.
• Facilities that are certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) to perform urine
drug testing only.

COMPLEXITY CATEGORIES OF LAB TESTS BY THE FDA

CATEGORY CHARACTERISTICS / EXAMPLES
Simple procedures that are cleared by the FDA for home us.
Employ methodologies that are easy to perform and the likelihood of erroneous results is negligible.
Pose no reasonable risk of harm to the patient if the test is performed incorrectly.
Simple to perform and interpret.
Require no special training or educational background.
Waived Require only minimum QC.
1
Complexity To perform waived testing, the organization must obtain a Certificate of Waiver from the CMS and follow
manufacturers’ directions for the testing process.
Original CLIA’88 Waived Tests:
• Blood Glucose • Hgb by CuSO4 (nonautomated) • Reagent Strip / Tablet Reagent
• ESR (nonautomated) • Ovulation test Urinalysis
• Fecal Occult Blood • Spun Hct • Urine pregnancy tests
Are more difficult to perform than are waived tests.
Require documentation of training in testing principles, instrument calibration and QC.
Moderate Personnel must have a minimum of a high school diploma or equivalent.
Complexity Facilities performing moderate complexity tests are subject to proficiency testing and on-site
Non-waived inspections with CAP, JC.
2
complexity Persons performing POCT are required to demonstrate testing competency on a periodic basis.
Tests requiring sophisticated instrumentation and high degree of interpretation by testing personnel.
High Personnel performing high complexity tests must have formal education with a degree in LS.
Complexity Most tests performed in in this category:
• microbiology • immunology • immunohematology • cytology
Procedures that can be performed in conjunction with any waived test.
Includes clinical microscopy procedures only.
Can be performed only by the following during a patient’s examination:
Provider- • physicians • midwives • dentists
performed • physician’s assistants • nurse practitioners
3 microscopy Laboratories performing these tests must meet the moderate complexity requirements for proficiency testing, patient
procedures test management, QC and QA as required by the accreditation agency.
(PPM) • Fecal Leukocyte Examination • Pinworm examination • Qualitative semen analysis
• Fern Test • Postcoital direct, qualitative • Urine sediment examination
• KOH preparation examinations of vaginal or • Wet mounts (vaginal cervical
• Nasal Smear for eosinophils cervical mucous skin or prostatic

quality assessment and control in poct

QUALITY ASSESSMENT
INCLUSIONS CHARACTERISTICS / EXAMPLES
• accurate result reporting • sample identification • sample processing
Patient Test • methods of patient preparation • sample preservation • sample transportation
1 Management • proper sample collection
Assessment Testing site must have and follow written procedures for these methods so that (1) specimen integrity and (2)
identification are maintained from the pretesting through the post testing process.
• records of the date • testing personnel • expiration dates for reagents
• results • lot numbers and controls
QC
2 • must be retained for 2 years.
Assessment
recommended that records be reviewed daily, as well as monthly, in order to detect either of the following:
• operator difficulties • unstable test systems • shifts • trends
Moderate or high complexity testing must enroll in an approved proficiency testing program that involves three (3)
Proficiency
events per year, with five (5) challenges per analyte in the survey material.
3 Testing
All survey specimens are tested in the same manner as patient specimens.
Assessment
No communication with other laboratories is permitted.
Personnel Includes education and training, continuing education, competency assessment, and performance appraisals.
4
Assessment Each new employee must have documentation of training during orientation to the laboratory.
@ashumerez | PMLS 2 : BSMT-1G 2019 68

This is a checklist of procedures and must include date and initials of the person doing the training and of the
employee being trained.
CLIA mandates continuing education, although no minimum hours are given.
• A record of all applicable continuing education sessions should be maintained.
Personnel file must include a certificate of the education level of each employee performing laboratory testing.
required by CLIA regulations for all POCT personnel performing moderate and high complexity testing at 6 months
and 1 year after initial training.
After the first year, competency must be assessed and validated annually.
Methods for assessing competency include:
Competency
5 • direct observation • blind testing of specimen with known values
Assessment
• review of QC records of proficiency testing records • written assessments
Performance appraisals are done according to institution protocol and include standards of performance linked to
the job description.
The standards may include evaluation of organization and communication skills and attitude.
The laboratory must maintain:
• patient test records 2 yrs. • BB 5 yrs. • pathology/ cytology 10 yrs.
Quality Other records that must be kept include:
6 Assessment • communications, inspection files, and certification records
Records • competency assessment • education and training • QC
• complaints • equipment maintenance • reagent logs
• documentation of problems • proficiency testing • service calls

QUALITY CONTROL
• To provide overall quality patient care.
• Performed to ensure that acceptable standards for accuracy and precision are standards for accuracy and precision are being
met during the process of specimen testing to provide reliable results.
• To verify that instrumentation is functioning properly and has been accurately calibrated, that reagents are stable and are
reacting appropriately, and that testing is being performed correctly.
1. External Control 2. Internal Control 3. Electronic Control

COMMON POCT ERRORS

ANALYTE PERFORMED ERROR
Hemoglobin Failure to adequately fill the cuvette bubbles in the cuvette.
Use of compromised or expired reagent strips.
adequately cleanse and dry the capillary puncture site.
Glucose
Failure to… adequately or correctly apple sample to testing area.
run controls and document as required.
comply with room temperature expiration dates
identify the patient correctly in the something.
Failure to…
observe cartridge warm-up time.
upload meter for timely data transfer.
I-Stat Profiles
Returning RT cartridges to refrigerated storage.
Underfilled or overfilled cartridges.
Moving the device while analyzing a specimen.
Squeezing the cartridge when closing.
Use of compromised or expired reagent strips
Urinalysis Incorrect reaction timing
Leaving reagent strips in the sample too long
(Guaiac Slide Method)
allow the sample to dry on the testing area prior to adding reagent
apply the correct amount of specimen on the slide
Occult Blood Failure to…
wait specified time after sample is applied to add the developer reagent
use the correct sample type for the test
Patients not given pre-collection instructions
Use of incorrectly stored or expired kits
Toxicology Profile
Misinterpretation of patient and control results
Using cotton or calcium alginate collection swabs
Use of compromised or expired reagent kits
Group A Streptococcus
Failure to observe the internal control
Incorrect collection or timing
@ashumerez | PMLS 2 : BSMT-1G 2019 69

Failure to test a first morning sample

Urine Pregnancy Test Addition of reagents in the wrong order
Misinterpretation of test and control results
follow the step-by-step instructions
Failure to…
observe and document internal control results
Immunoassay Kits reagents from different kits
Use of…
incorrectly stored or expired kits
Misinterpretation of test and control results
adequately cleanse and dry the capillary puncture site
Failure to… follow manufacturer’s instructions for sample collection
Coagulation Tests identify the patient correctly in the meter
Inadequate application of specimen
Prematurely performing capillary puncture before test strip/test cartridge is ready to accept the specimen
(analyzers with data management)
application of sample to test strip/test cartridge
POC Meters follow correct timing for…
Failure to… placing test strip/test cartridge in the meter
upload meter for timely data transfer

PREVENTION OF COMMON ERRORS

• Correct patient identification • Sample application and test performance
• Proper sample collection • Proper storage of testing supplies
• Always perform and document QC as required and confirm that QC results are within the expected range before any patient
testing is performed
• Refer to the test procedure for:
o correct interpretation of test results
o confirmatory testing that may be required
o guidance for identification and communication of critical results
• Results must be recorded in the permanent medical record, legible, and easily retrieved

PHASES OF LAB TESTING USING POCT

PHASE CHARACTERISTICS
Encompasses the test ordering process.
Patient identification and patient preparation.
Pre-examination
Sample collection and handling, reagent storage.
Preparing materials, equipment, and the test area.
When the actual test is performed and includes QC testing.
Examination
Includes result interpretation.
Involves recording and reading results
Post-examination Addressing critical values when indicated
Following through for confirmatory testing and disposing of biohazard waste

Procedure Manual & Package Insert:

• Sample collection and handling • Acceptable control ranges
• Safety precautions regarding biological, chemical, • Specimen requirements
electrical, and mechanical hazards • Procedural steps
• Instrument maintenance and calibration • Interpretation of results and normal values and sources of errors
• Reagent storage requirements • Troubleshooting assistance

examples of poct
EXAMPLE USES PRINCIPLE
To monitor person with diabetes mellitus. Photometric (Lifescan Surestep)
To determine whether diet and insulin dosage are Electrochemical (Roche Comfort Curve)
maintaining an acceptable level of Glucose in the Reflectance – use different rgts. in the test strip
body. • The SureStep (LifeScan, Inc., Milpitas, CA)
• Normal values for blood glucose vary slightly • Accucheck II (Boehringer Mannheim Diagnostics,
Glucose among testing procedures and are higher Indianapolis, IN)
1
(Glucometer) when serum or plasma instead of whole blood, • ONE TOUCH II (Life Scan, Inc., Milpitas, CA)
is tested in the clinical laboratory. Employs dry reagent technology using a special reagent
o POCT must be performed on WB; test strip.
however, most new bedside glucose • A glucose oxidase reaction occurs between the
meters report plasma equivalent. blood and reagents in the test strip resulting in the
Normal Values (FBC) 60-115 mg/dL
@ashumerez | PMLS 2 : BSMT-1G 2019 70

Hypoglycemic <60 mg/dL formation of a blue color.

Hyperglycemic increased levels • The intensity of the blue color formed correlates
with the concentration of glucose in the sample.
Directs white light into skin of newborn and measures the
intensity of the specific wavelength that is returned
• Measures the intensity of more than 100
wavelengths of reflected light
To detect and monitor increased levels of bilirubin The intensity of the reflected light is converted to
(hyperbilirubinemia) absorbance units/optical density for analysis.
• Interfering components in the skin are subtracted
from the known spectral properties of the normal
skin by the instrument before displaying the bilirubin
concentration
Transcutaneous When the disposable tip is placed on the Bilicheck meter,
2
Bilirubin the instrument initiates a self-test for integrity and an
electronic check
After a successful calibration, the protective covering and
calibration material are removed from the tip.
Screening for hemolytic disease of the newborn
• The unit is activated and the tip is pressed flat
(HDN) and premature birth, a variety of other risk
against the infant’s forehead.
factors for hyperbilirubinemia) exist
o The indicator light will change from amber to
green when proper pressure is applied.
• On completion of five measurements, a tone sounds
and the test results are displayed with the current
time and date.
primary function: transport O2 to all cells in the body Hemocue – Hgb measurement is determined
¯RBCs/cells’ Hgb (anemia) à ¯O2 reaching cells photometrically using a dry reagent system.
Hgb NORMAL VALUES IN ADULTS The reagents in the microcuvette lyse the RBCs to release
Men 14-17g/dL Hgb
• Hgb is converted to N3- methemoglobin by NaNO3
3 Hemoglobin Female 12-15g/dL and NaN3 to produce a color rxn.
Measurement of Hgb is one of the most frequently
A dual-wavelength photometer reads the absorbance of
performed screening tests in all health-care settings
the reaction and corrects the hemoglobin value for
and also provides a means to monitor patients
lipemia and leukocytosis.
known to have anemia.
Firm plastic strips to which are affixed several separate
4 Urinalysis *separate table below this one*
reagent areas.

5 Occult Blood

6 Pregnancy Test

Prothrombin Time (PT) is the time (sec) for fibrin clot to form.
Measures function of the tissue factor (extrinsic) and common pathways.
Some anticoagulants
7 Coagulation Decreased synsthesis of some clotting factors à chrocnic liver
High
disease, Vit. K defeciency
INR
Increased consumption of clotting factors à Sepsis / DIC
@ashumerez | PMLS 2 : BSMT-1G 2019 71
ANALYTE BASIS COLOR
a double sequential enzyme reaction, one enzyme, A second enzyme, peroxidase, catalyzes the reaction of H2O2
Glucose glucose oxidase, catalyzes the formation of gluconic with a K+ chromogen to oxidize the chromogen to colors ranging
acid and H2O2 from the oxidation of glucose. from green to brown.
The coupling of bilirubin with diazotized
Bilirubin The color ranges through various shades of tan.
dichloraniline in a strongly acid medium.
the development of colors ranging from buff-pink, for a negative reading to purple when acetoacetic acid reacts with
Ketone
nitroprusside.
In the presence of an indicator, colors range from deep blue-
Specific apparent pKa change of certain pretreated
green in urine of low ionic concentration through green and
Gravity polyelectrolytes in relation to ionic concentration
yellow-green in urines of increasing ionic concentrations.
the peroxidase – like activity of hemoglobin which The result color ranges from orange through green; very high
Blood catalyzes the reaction of diisopropylbenzene levels of blood may cause the color development to continue to
dihydroperoxide and 3,3’,5,5’-tetramethylbenzidine. blue.
double indicator principle that give a broad range of
pH orange through yellow and green to blue.
colors covering the entire urinary pH range
depends upon the conversion of nitrate (derived from At the acid pH of the reagent area, nitrite in the urine reacts with
Nitrite the diet) to nitrite by the action of Gram-negative p-arsinilic acid to form diazonium compound in turn couples with
bacteria in urine. 1,2,3,4-tetrahydrobenzo(h)quinolin-3-ol to produce a pink color
granulocytic leukocytes contain esters that catalyze
This pyrrole then reacts with dianozium salt to produce a purple
Leukocytes the hydrolysis of the derivatized pyrrole amino acid
product.
ester to liberate 3-hydroxy-5-phenyl pyrrole.

urine drug sample collection

REPUBLIC ACT OF 9165: Comprehensive Dangerous Drugs Act of 2002
• Safeguard the state and its citizens from dangerous drugs.
• Enhance the efficiency of the law against dangerous drugs and the campaign against trafficking and use of dangerous drugs.
• Re-integrate drug users back into the society.
• Drug-free country by 2011.
o Updates are found in RA 10586 “Anti-Drunk and Drugged Driving Act of 2013”

MANDATORY DRUG TESTING

• Applicants for the following:
o driver’s license o Firearms license o Permit to carry firearms outside of residence
• Officers and members of the (1) military, (2) police and (3) other law enforcement agencies.
• All persons who by nature of their profession carry firearms.
• Any person arrested for violations of RA 9165.
• All candidates for public office whether appointed or elected.

DRUG TEST RESULT

• Valid for 1 year from the date of issue.
§ May be used for other purposes, but strictly confidential
• Positive screening lab test must be confirmed for it may be valid in court.
o Shall be signed by the analyst and head of the lab.
o For (+) results; original shall be given to the client immediately
§ copies shall be given to Bureau of Health Facilities Services (BHFS: DOH) and requesting agency.
§ Drug Test Laboratory (DTL) shall retain a copy.
§ Only government agencies shall be provided with a copy upon written request.

LEGAL ASPECTS OF DRUG TESTING

Drug Test Kit Validation
• Responsibility of the DOH • Registered through FDA • Validated by NRL

Components of Drug Testing Laboratory (DTL)

COMPONENT CHARACTERISTICS / EXAMPLES
Purpose of the existence of the laboratory.
1 Task
Produces goods and services as an output.
• Head of the Laboratory (HOL) • Authorized specimen collector (ASC) • Analyst
2 People Others:
• clerk • lab aid • other admin personnel • secretary
3 Structure basic arrangement of people in the organization (organogram)
4 Technology Intellectual and mechanical processes used by an organization to transform inputs into products or services.
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Performed by the ASC
Prepares collection site
Specimen
Proper specimen collection
Collection
Maintains specimen (1) integrity and (2) security
Proper specimen (1) handling, (2) storage and (3) transport.
Can be permanent or remote site.
Must have clean surface for handling specimen and completing paper works.
Secured temporary capability to maintain a specimen until tested.
Collection
Able to provide donor privacy appropriate to the specimen being collected.
Site
Controlled and secured area for supplies and records.
Poster or information bulletin with detailed description of the proper specimen collection process.
Source of water of handwashing external to toilet facility (waterless urinals) and coloring agent for urine collection.

TEMPORARY / REMOTE COLLECTION FACILITY

• Crime Scene and Post Accident • Jail/Prison • School
• Critically ill/disable • Reasonable / Suspicious Cause • Workplace
• Follow-up • Rehabilitation Center for Random

COLLECTION SUPPLIES
• Coloring/Bluing agent • Labels, water proof pens • Specimen Containers
• Documents (e.g. CCF, MFR Logbooks) • Leak-resistant plastic bags (zip-locked) • Tamper evident seals
• Gloves • Shipping Containers (Ice Chest) • Thermometer / temperature strips

TYPE OF SPECIMEN AND REASON FOR TEST

URINE SALIVA BLOOD, TISSUE, NAILS HAIR SWEAT
Pre-Employment X X X
Random X X X
Reasonable/Suspicion/Cause X X X
Mandatory X X
Return to Duty X X
Follow-Up X X

MINIMUM REQUIRED QUANTITY OF SPECIMEN METHODS OF URINE COLLECTION

Single 60 mL in single container METHOD CHARACTERISTICS
30 mL each of 2 separate containers for split Done in the presence of ASC
Urine
Split specimen: for (1) confirmatory and (2) Donor is physically unable to go to
validity testing Conditions the laboratory or designated
Saliva 2 mL = 1.5 (the primary) + 0.5 (challenge) Observed para pwede collection site.
Blood ≥ 5mL siya ma Involved in crime scene.
Hair 100mg hair/equivalent of strands or 1cm above scalp Unobserved Involved in post-accident.
Sweat 1 patch worn for 7 to 14 days Critically ill.
In the absence of ASC
DRUG SCREENING WORKFLOW Unobserved Submitted samples
1. Begin 5. Seal Specimen Subject to validity tests
2. Verify Donor’s ID 6. Complete CCF
3. Fill up the DT forms 7. Ready for Analysis
4. Collect urine 8. END

STEPS IN URINE COLLECTION

1. Prepare and Secure Collection site and Supplies.
2. Verify Donor’s ID
3. Explain the Basic Collection Procedure.
4. Fill up Step 1 of CCF
5. Either give or allow the donor to select container.
6. Label Container legibly.
7. Body Search: Instruct the donor to remove all unnecessary outer garments from his/her pockets.
8. Instruct donor to wash hands thoroughly.
9. Pay close attention to collection.
10. Measure the temperature and volume of the sample.
11. Inspect for adulteration and substitution of the sample
12. Close and apply seal over the lid bottle in front of the donor.
13. Sign over the seal and indicate collection date and time.
14. Ask donor to fill up and sign step 5.
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WAYS OF TAMPERING URINE SPECIMEN TYPES OF SPECIMEN

• Dilution • Adulteration • Substitution SPECIMEN CHARACTERISTICS
Least expensive, most popular
ACCESSIONING Easy to do.
• Unique accession # upon entry of the specimen to the lab Standardized procedures
1 Urine
• oratory. Detects use within the week.
o Must be the same in the specimen bottle and the Abstaining can produce negative reaction.
CCF Established specimen validity tests.
• Laboratory must assign (1) specimen ID # or donor’s Uncommon method.
code and (2) Lab Accession number. Easy to administer.
o Specimen ID # should be by first come, first 2 Saliva Short detection time.
serve basis. No reference standards.
o Lab Accession # format: year-birthdate- NO confirmatory testing available.
specimen ID Expensive and tedious
Twice more sensitive than urine test
Bottle Labeling Do not detect recent use
• Donor’s name Detects chronic substance abuse.
• Donor’s Code 3 Hair
Require 1.52cm hair clump or 80-120 hair strands.
• Date of Collection Not affected by drug abstinence.
• Time of Collection Can determine temporal pattern.
• Initial of the ASC Longest detection and retention time for 1 year.
• Bottle cap with Donor’s signature, Date and Time of Most expensive method.
Collection. Most accurate method.
o Must overlap between the seal and top of the 4 Blood Least common method.
cap.
Short detection time.
o Must provide a broken Tamper-evident Seal.
Procedure not established and standardized.
o Confirmatory: Must be placed in a zip-lock plastic
bag with the signature of the HOL and Analyst. 5 Tissue
Requires wearing of patch 1-2 weeks
SPECIMEN HANDLING AND STORAGE Uncommon method.
SPECIMEN HANDLING 6 Sweat No reference standards developed yet.
1 Urine Prolonged storage at -20°C stored initially between Surface contamination can cause false positive.
2-6°C for not more than 1 day. Can detect use for extended period of time.
2 Saliva Deep-frozen at least -8°C to -10°C
3 Blood Separate serum then immediately freeze the
specimen. SPECIMEN ID AND LABEL ACCESSION NUMBER
4 Hair Stored at cool and dry place. TYPE OF LAB DONOR’S CODE LAB ACCESSION #
5 Tissue Macerated and Frozen. Free Standing Code indicated in same as donor’s code
Institution the specimen bottle May be different.
Based and CCF.

SPECIMEN TRANSPORT
• Minimize the number of personnel handling the specimen.
• Document the date and purpose on CCF each time a specimen is handled or transferred.
• May be mailed or delivered to the confirmatory lab.
o When courier services are utilized, the time of receipt from the collection site and time of delivery to the lab must be
documented on the CCF.
• Place specimen in heat-sealed transparent plastic bag and sealed with Tamper-evident seal.
• CCF accompanies the appropriate specimen transport container.

chain of custody
• Tracking from point of specimen collection to its final disposition
• From accessioning or receiving, aliquoting, initial and confirmatory testing and INFORMATION INCLUDED
disposition of specimens. STEP COMPONENT
1, 2, 3 Collection site
CUSTODY AND CONTROL FORMS 4 Lab entry (ASC/Lab)
• Used to document security of the specimen, all steps of collection, person who 5 Donor’s signature (collection site)
handled the specimen. 6 Screening Laboratory Report
• Status and integrity of specimen and other pertinent info. 7 Confirmatory Test Report
• “Information included” in the table on the side " 8 Report at NRL Level
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MEMORANDUM FOR RECORD (MFR) CCF FORMS TO BE FILLED UP BY THE DONOR

• Record to document the recovery, FORM PURPOSE
corrective and remedial measures to DT-002A Copy for the donor
administrative errors. DT-002B Copy for the collection Site
• Accomplished by the ASC and other DT-002C Copy for the laboratory
lab personnel. DT-002D to be filled up by the DTL for confirmatory laboratory (for positive sample)
• Recovery of errors not documented
by an MFR ß rejected or canceled.
o Document must include the reason of rejection and corrective measures done.

mechanism of drug testing

CLASSIFICATION OF DRUGS ACCORDING THE FOLLOWING:
(1) Origin
NATURAL SYNTHETIC
1 Marijuana 1 Methamphetamine
2 Coca Bush
2 Barbiturates
3 Raw Opium

(2) Controlled Substances

SCHEDULE DESCRIPTION EXAMPLES
Schedule 1 Illegal drugs, high potential for dependence and abuse Heroine, marijuana
Schedule 2 Highly addictive but medically important cocaine, morphine
Schedule 3 potential for abuse and dependence, needs prescription to acquire the drugs aspirin, codeine
Schedule 4 less likely to produce dependence or abused, require prescription Diazepam, Phenobarbital
Schedule 5 contain small amount of narcotics, least likely to be abused Cough and antidiarrheal medicine

(3) Pharmcological
CLASSIFICATION FUNCTION EXAMPLES
1 Stimulants Increases alertness • Amphetamine • Caffeine • Cocaine • Shabu
2 Hallucinogens Affects sensation and emotion • ecstasy • marijuana • LSD • PCP
3 Narcotics Relieves pain and Induce sleep • codeine • heroin • morphine
4 Sedatives Reduces anxiety and excitement • alcohol • barbiturates
Volatile • furniture • moth
5 Inhalants, solvents, aerosol bases • air freshener • insecticides
Substances polish balls

(4) Legal
CLASSIFICATION CHARACTERISTICS
• create drowning • produces sleep or stupor • relieves pain
1 Narcotics
• depress CNS • reduce physical activity
Psychotropic Any substances, under controlled category, pertaining to any drug or agent having a psychological effect on the
2
Substances individual.
Designer Substances related to, but slightly different from, controlled substances designed by clandestine chemist to
3
Drugs produce “the high” or euphoria of parent drugs to avoid the penalties of trafficking the controlled substance.

METHODS FOR SCREENING METHODS FOR CONFIRMATORY TESTING MOST COMMON DRUGS TESTED
Immunoassay Chromatography 1. Amphetamine 4. Opiates
RIA, EIA, FIA, GC-MS – Gold Standard 2. Cocaine 5. PCP
TLC, HPLC, GC
CIA, LAI 3. Marijuana

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Ily 3 (grado)