PHLEB LEC MIDTERM TRANSES
Module 1: Introduction to Phlebotomy
Phlebotomy
- It was used as a cure for disease
- Bleeding removed “bad” blood
- Bleeding in the form of therapeutic phlebotomy
done today for disease polycythemia vera and
hereditary hemochromatosis.
History of Phlebotomy
Methods of Bleeding:
- Venesection
- Produce scarring
- Cupping
- Produce scarring
- Leeches
- Used to suck blood
George Washington
- First president of the US
- He was first drawn blood for therapeutic
purposes.
- They believed to cure him from his
severe sore throat. However, he died.
- He died on December 14, 1799.
- He bled more than 9 pints or 4 liters of
blood in under 24 hours.
- Soon after his death, the philosophy of
bleeding as the cure to disease began to
change.
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3. Hybrid Phlebotomy
- Blend of centralized and decentralized
phlebotomy
- Either the phlebotomist or
medical professionals can draw
blood from the patient.
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Phlebotomist in Healthcare
Phlebotomist
- Either a nurse or MedTech
- Registered and skilled to draw blood or perform
phlebotomy from patients.
- Multiskilled:
- The
phlebotomist
is
usually
cross-trained in:
- Venipuncture
- Capillary collection
- Patient care
- Receptionist duties
- Sample processing
- Computer work
- Known as laboratory representative.
1. Centralized Laboratory
- Phlebotomist is part of the laboratory
team and dispatched to hospital units to
collect blood samples.
- Common type
- Only a phlebotomist can perform a
phlebotomy on a patient.
- The
laboratory
supervises
phlebotomists, whose primary
responsibilities are to draw
blood and collect specimens.
2. Decentralized Laboratory
- All members of the healthcare team
share responsibility to collect blood
samples
- The nurse, MedTech, or doctors (last
resort) can be phlebotomists as long as
they are registered to do so.
- Medical professionals work
together to draw blood.
Medical professionals can draw
blood and collect specimens
from patients throughout a
hospital.
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Areas of the Hospital
Electroencephalography (EEG)
- Diagnosis
of
neurophysiological
disorders.
Electrocardiography (EKG)
- Monitors patients with cardiovascular
disease.
Pharmacy
- Dispense drugs and advises on drug
usage.
Physical Therapy
- Provides therapy to restore mobility
- Not basic mobility skills
Occupational Therapy
- Provides therapy to help maintain living
skills.
- Restore basic skills; day-to-day
life skills
Laboratory
- Provides testing of patient samples.
Environmental services
- Maintain clean facilities
- Ex: Janitors
Administration
- Keeps the hospital in compliance.
Food service (Dietary)
- Provides diets to patients.
Medical records
- Maintains patient records.
Radiology
Nursing
Ancillary Hospital areas and their purpose
- Gastrointestinal (GI) Laboratory
- Diagnoses gastrointestinal disorders.
Areas of Nursing
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Neonatal
- Newborn care
Obstetrics
- Patients in labor of childbirth
Oncology
- Patients with cancer
Pediatrics
- Toddlers, infants, and children
Intensive Care Unit (ICU)
- Increased care due to the critical needs
of the patient.
Coronary Care Unit (CCU)
- Increased care of the patient due to a
heart condition.
- Just like ICU but centralizes on the
Heart.
Emergency Department
- Emergency treatment of patients.
Nephrology
PHLEB LEC MIDTERM TRANSES
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- Patients on dialysis
- Kidney
Geriatrics
- Elderly patients
Home Health Care
- Follow-up care of a patient at home.
Orthopedic
- Patients with broken bones.
Recovery
- Recovery treatment of patients.
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Patient-Focused Care Concept
Takes the laboratory out of the physical
location.
- Bring the laboratory to the patient.
- Also known as Point of Care Testing
(PCOT)
- Example:
Glucometer
(for
diabetics to check glucose level)
- Home services
Areas or Sections of the Laboratory
Administrative Office
- Admin work
Phlebotomy (Sample Collection)
- Collects samples from patients and
processes samples for testing or
transport.
Chemistry
- Performs biochemical analysis
- Tests performed:
- Comprehensive metabolic panel
- Iron studies
- Renal panel
- Carcinoembryonic antigen (CEA)
- Glucose
- Alanine aminotransferase (ALT)
- Aspartate
aminotransferase
(AST)
- Cholesterol
- Most common body fluids or specimen
for testing: Serum (blood)
- Other specimens: cholesterol,
electrolytes, Fasting blood sugar
(FBS),
vomit,
sodium,
potassium, etc.
Hematology
- Studies the blood in normal and
diseased states.
- Limited to the study of blood
components, such as the WBC, RBC, and
platelets and not the chemistry of the
blood.
- Tests performed:
- Complete Blood Count (CBC)
- Hemoglobin
- Hematocrit
- Platelet count
- Sedimentation rate
- Body fluid cell counts
Coagulation
- Sometimes combined with Hematology
- Study of blood clotting mechanisms
(platelets) as an aid in diagnosis or
monitoring of patient therapy.
Urinalysis
- Urine testing
- Tests performed:
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- Urinalysis
- Reducing substance
- Urine pH
- Urine glucose
Microbiology
- Microbes and Bacteria
- Culture samples to determine if
pathogenic organisms are present in a
sample and determine the organisms’
sensitivity to antibiotics (culture and
sensitivity)
- Test performed:
- Blood cultures (for sepsis)
- Throat cultures
- Anaerobic cultures
- Urine culture
- Parasite identification
- Stool culture
- Mycobacterial
(tuberculosis)
culture [sputum testing for
Acid-Fast Bacillus (AFB)]
- Virus culture
- Fungal cultures
- Genital cultures
- Mycoplasma cultures
- Antibiotic susceptibility testing.
Immunology
- Studies antigens and antibodies to
determine immunity to disease or
presence of disease.
- Tests performed:
- Human immunodeficiency virus
(HIV) testing
- Rubella
- Syphilis (rapid plasma reagin
[RPR])
- Hepatitis Testing
Immunohematology (blood bank)
- Determines compatibility of blood and
blood products that are to be
administered to patients.
- Tests performed:
- Compatibility Testing,
- Antibody screens or ABO
- Rh determination
Cytogenetics
- Study of deficiencies related to genetic
diseases
- Rare because expensive
- Sometimes have their own
laboratory; separated from the
normal laboratory
- Tests performed:
- Chromosome analysis
- Prenatal chromosome screening
Histology
- Tissues
Cytology
- Sometimes
combined
with
Histopathology
- Sometimes have their own laboratory;
separated from the normal laboratory
Molecular Diagnostics
- Sometimes have their own laboratory;
separated from the normal laboratory
- Using polymerase chain reaction (PCR)
technologies to study the presence of
various diseases or infections
PHLEB LEC MIDTERM TRANSES
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Tests performed:
- Methicillin-resistant
Staphylococcus aureus (MRSA)
infections
- HIV
- COVID Testing
Phases of Sample Testing
1. Pre-examination (Preanalytical phase)
- All process from collection the sample
to having it ready for testing
- Before testing of specimen
- Includes:
- Clinician’s request
- Patient
identification
and
information
- Correct sample collection
- Correct use of all equipment
- Sample
preparation
or
centrifugation
- Proper preparation of sample
aliquots
- Maintaining sample integrity
until the examination (analytical
process) can begin.
2. Examination (Analytical Phase)
- All processes done to sample to achieve
results
- Includes:
- Testing the sample
- Quality control of machines,
equipment, etc.
- Maintaining testing equipment
and reagents.
3. Post examination (Post Analytical Phase)
- Releasing the results of the testing and
are communicated to the healthcare
provider.
- It should be timely and reliable.
- Includes:
- Reporting of results
- Ensuring accuracy and reliability
of delivery of results
- Follow-up to repeat testing or
address physician concerns
- Storage of sample after the
examination
Managed Care
Different health sectors coordinate to provide
quality healthcare services to the patient.
Coordinated providing health services and
health benefits.
Health Maintenance Organization (HMO)
- Health insurances
- Least freedom to patients to choose their own
healthcare provider
- Least amount of paperwork compared to other
insurances.
- A primary care doctor to manage your
care and refer you to specialists when
you need one so the care is covered by
the health plan; most HMOs will require
a referral before you can see a
specialist.
- Contracts with physicians and hospitals
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Health insurance plan that provides
health services through a network of
doctors for a monthly or annual fee.
Examples: PhilHealth, Cocolife
Preferred Provider Organization (PPO)
- The patient has more freedom to choose their
healthcare provider compared to HMO.
- You do not have to get a referral from a
primary care doctor to see a specialist.
- Higher out-of-pocket costs if you see
out-of-network doctors vs. in-network providers
- More paperwork than with other plans if you
see out-of-network providers
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Affordable Health Care Act
Implemented by Former President Duterte.
Enacted to help those who could not afford
insurance
Requires all people to have health insurance.
Methods to Treat Patients Faster
1. Point of Care Testing (PCOT)
- Done outside the laboratory and the
bedside of the patient at home.
2. EOCT (??) or basi sa PCOT ni
- Reducing hospital costs to below 1000
dollars per day.
Laboratory Staff
1. Pathologist
2. Medical Laboratory Scientist
3. Medical Laboratory Technician
- Having an average of at least 70% and
lower than 75% in the Board
Examination.
4. Phlebotomy Technician
5. Cytotechnologist
6. Histotechnologist
Effective Healthcare
Requires partnership between patients and
physicians and other health care professionals
Hospitals must provide a foundation for
understanding and respecting the rights and
responsibilities of patients, their families, physicians,
and other caregivers.
Patient Rights
More rights:
Patient has:
- Right to considerate and respectful care
- Must
remain
calm
and
show
consideration and concern for each
patient.
PHLEB LEC MIDTERM TRANSES
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Right to receive understandable information
Right to make decisions about plans of care and
refuse treatment.
- Informed consent.
- Must explain to the patient the
procedures of collecting the specimen.
Right to have an advance directive concerning
treatment or designating a surrogate decision
maker.
Right to and is encourage to obtain from
physicians and other direct caregivers relevant,
current, and understandable information about
diagnosis
- Patient’s primary source of information is
their physician.
- Laboratory staff do not have the right to
directly state the results of the patient
nor give the diagnosis. Refer the patient
to their physicians for the diagnosis.
Right to every consideration of privacy
Right to review his or her medical records
- Refer the patient to their nurse or
physician.
Right to ask and be told of the existence of any
business relationship among the hospital.
Right to consent to or decline to participate in
proposed research studies
Right to expect reasonable continuity of care and
to be informed by physicians and other caregivers
of available and realistic patient care
Right to be informed of hospital policies and
practices that relate to patient care treatment,
and responsibilities.
Right to expect that, within its capacities and
policies, the hospital will make a reasonable
response to the request of a patient for
appropriate and medically indicated care and
services.
- Either the nurse or the physician.
Communication
Showing the customer that there is an attitude of
caring. It is the sending and receiving of messages.
Parts of Communication
● Sender - deliver the message
● Receiver - understand the message
● Medium - way to give the message
● Feedback
Types of Communication
- Verbal
- This message is made up of both verbal
and nonverbal communication.
- Words must have meaning to carry a
message to the receiver.
- Communication must be in the
language that the receiver understands.
- Nonverbal
- Body Language is also known as
Kinesics.
- Postures, gestures, eye contact, and
facial expressions that accompany
verbal communication.
Communication also includes listening.
- Active listening requires the listener to follow
five steps:
- Focus on the customer
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Limit your talking. This allows the
customer to express their feelings.
Do not interrupt
Manage your own thoughts
Listen for feeling, not just words.
Advance Directives
Documents written before incapacitating illness that
give instructions about a person's health care, if in the
future, they cannot speak for themselves.
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Regulatory Agencies
The Joint Commission
CAP (College of American Pathologists)
State Board of Health
CLSI (Clinical and Laboratory Standards
Institute)
CLIA (Clinical Laboratory Improvement
Amendments [of 1988])
OSHA (Occupational Safety and Health
Administration)
NAACLS (National Accrediting Agency for
Clinical Laboratory Science)
Quality Assurance
Quality is phlebotomist’s responsibility
Result of the test sent to physicians depends on
the quality of the sample obtained.
Laboratories must have certain levels of patient
satisfaction to continue receiving payments
from insurance companies.
PHLEB LEC MIDTERM TRANSES
Module 2: Infection Control, Safety, First Aid, and
Personal Wellness
Infection Control
- Maintaining a safe working environment is of
primary concern for all who work in or have
exposure to the healthcare industry.
Types of Infection
1. Nosocomial Infection
- Hospital acquired infection
2. Local Infection
- Localized
- Restricted to one body part
- Ex: Abscesses and
bladder infections
- Infected themselves
Ex: Good bacteria can be a cause of infection to
one’s self.
Portal of Exit and Entry
- Exit
- Pathogen exits from a reservoir
- Entry
- Infectious agents get into the body.
- For a human reservoir, the portal of exit and
entry can include:
- Blood
- Respiratory secretions
- GI tract
- Urinary tract
urinary
3. Systemic Infection
- Affects the entire body
4. Communicable Disease
- This is the organism that causes
infection or diseases that could spread
from one person to another.
Chain of Infection
- Process of how a person could get infected or
get an infection
- Purpose: Guide to stop infection.
1. Infectious Agent
- Cause of infection
- Ex: Bacteria, Virus or Parasites
- The virulence (intensity of an infectious
agent; the more agents, the more
infectious)of these pathogens depends
on:
- their number
- their potency (strength)
- their ability to enter and survive
in the body
- and the susceptibility of the
host (the more susceptible, the
higher the likelihood of
infections).
Reservoirs
- Source of infection
- Person who has an active acute infection or is
carrying the infection without realizing it
- The source and the host can be one and the
same.
Autogenous Infection
- Auto: Own
- Self-infection
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Susceptible Host
- Susceptibility varies greatly with the individual
- Body that the infectious agents can host or
cause infection
- Ex: Humans
- Host’s body defense mechanisms are weakened
by chronic illness, AIDS, or immunosuppressive
agents, the host will not be able to fight many
organisms that normally would not be
infectious.
- Factors affecting susceptibility:
- Age
- Medication
- Disease
- Immunocompromised
individuals
(because of disease)
- Immunosuppressive agents
- Suppress the immune system;
thus, becoming susceptible to
infection
- Usually taken if there are
operations.
Means of Transmission
1. Direct Contact
- Physical
or
transmission.
skin-to-skin
contact
2. Indirect contact
- There is a medium involved.
- No direct skin-to-skin contact to be
infected.
- Ex: Droplets, saliva, coughing
Airborne vs Droplets
Droplets - need close contact. Not long; needs an
immediate host to become infectious or else it dies.
Airborne - infectious agents can stay in the air for hours.
Ex: Tuberculosis
3. Coughing (??)
4. Door knob (??)
5. Vector-borne
- Animals cause infection
- Ex: Dengue, Malaria
Universal Precaution
- “Assumed that all blood and body fluids were
potentially infectious.”
- Any patient has the potential to be
infected with these blood-borne
pathogens.
PHLEB LEC MIDTERM TRANSES
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Developed in 1985 by CDC (Centers for Disease
Control and Prevention) as a response to the
increase in blood-borne diseases such as AIDS
and Hepatitis B.
Also applies to tissue samples:
- Stool
- Urine
- Vomitus
- Oral secretions are not included unless
they contain visible blood
Included a variety of body substances.
For the transmission of HIV and hepatitis:
- Blood
- Semen
- Vaginal secretions
- Cerebrospinal (CSF) fluids
- Synovial fluid
- Pleural fluid
- Peritoneal fluid
- Pericardial fluid
- Amniotic fluid
- Human breast milk
- Wound drainage
Body Substance Isolation (BSI)
- “Assume that the patient has the
potential to transmit disease.”
- The key change was the requirement
that GLOVES should be worn when a
healthcare provider is in contact with
any body substances.
In 1996, the CDC revised the Universal
Precautions and released a new set of
guidelines called “STANDARD PRECAUTION”
that creates a first tier of precautions for all
patients regardless of their diagnosis or
infectious status.
Standard Precaution
- Combines many basic principles of Universal
Precautions with techniques from BSI.
- Maintain that PPE (Personal Protective
Equipment) and barrier controls must be worn
for contact with all body fluids, whether or not
blood is visible.
- Goal: reduce the risk of transmission of
microorganisms from both recognized and
unrecognized source of infection
- Steps:
- Wash hands
- Wear gloves
- Wear protective cover
- Wear a mask and eye protection
- Place intact needle/syringe and sharps
in designated sharps containers.
- Must be puncture-proof
- Do not bend, cut, break the
needles.
Reducing Exposure Risk
1. Engineering Controls
- Physical and mechanical devices that
are available to health care associate to
reduce or eliminate the potential to
transfer infectious diseases.
- All samples and containers should have
a biohazard warning to indicate the
potential infectiousness of the contents.
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Ex: Biosafety cabinets, sharps container,
autoclave (sterilize equipment).
2. Biohazard Symbols
- Created by Charles Baldwin
- USED AS A WARNING so that those
potentially exposed to the substances
will know to take precautions.
- ☣
- Ex: Microorganisms
3. Work Practices Control
- Practices that are incorporated into all
health care associates work habits to
prevent the spread of infection
- HANDWASHING is the single most
important way to prevent the spread of
infection.
- Hands must be washed after
each patient contact or blood
and body fluid exposure, even
when gloves are used.
- After removal of gloves because
of
defects
allowing
contaminants to penetrate the
imperfections of the gloves
- Method of choice for removing
any surface bacteria from the
skin.
- According to DOH, 20 seconds
of handwashing.
- According to WHO, 30 to 60
seconds of handwashing.
Alcohol Based Cleaners
- Chemical solutions that reduce the number of
bacteria on the skin surface.
- Acceptable in place of handwashing
- Handwashing and use of alcohol both reduce
bacteria and viruses but do not totally eliminate
them.
- Simple procedure; people who don’t spend
enough time washing their hands, the hand
cleaner does a more thorough job.
Note:
- Use hand washing technique when hands are
VISIBLY SOILED.
- Use alcohol when hands are NOT VISIBLY
SOILED.
Antiseptic Techniques
- Invented by Joseph Lister
- Used on skin surfaces because the solutions are
safe to human skin.
- Used before skin puncture
- To complete the disinfection process.
- Wait for it to dry
- Example:
- 70% Isopropyl Alcohol
- Why 70%: 70% because it has
more water content. So, the
alcohol
will
not
easily
evaporate; more water, longer
evaporation.
- If alcohol does not
evaporate easily, then it
has more time to
permeate or fight off
infectious agents.
- Povidone Iodine
PHLEB LEC MIDTERM TRANSES
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2% Chlorhexidine gluconate + 70%
isopropyl alcohol
Benzalkonium chloride or benzalkonium
chloride zephrine(??) or
H2O2 or Hydrogen peroxide
Disinfection
- Disinfecting hard surfaces such as countertops is
done using a sterile technique.
- Disinfecting solutions are too harsh on skin, but
they can kill up to 100% of contaminants.
- Not acceptable for total sterilization of human
skin
- Example:
- 10% Hypochlorite Solution
- AKA “10% Household bleach”
- Least expensive and most
effective
- Must be made daily
- 1:10 ratio; 1 is Bleach
and 10 is Water
- Expiration is 24 hours after
preparation
- Must
be
properly
labeled with time and
date the solution was
prepared.
Accidental Needle Prick
- Major source of occupationally acquired HIV
and Hepatitis B and C
- OSHA (The Occupational Safety and Health
Administration) standards contained in the
Needle Safety Act state that all needles must be
covered with a safety device after use and not
recapped.
- Recapping the needle with 1 hand, AKA
Fishing method.
4. Housekeeping
- General rules: Cleaning up spills and
decontaminating
soiled
areas
immediately with a disinfectant after
evacuation of lab personnels or
healthcare associates.
- Responsibility of all health care
associates
- Broken glass should not be picked up
with hands
- Use brush, dustpan, or tongs
5. Hepatitis B virus (HBV) vaccination
- HBV vaccine must be available at no
charge to the phlebotomist
- Effective for 15 or more years in
protecting the phlebotomist from
contracting the disease or becoming a
carrier
- Antigen: Not reactive
- Antibody: Reactive
6. Private rooms
- The use of private rooms reduces the
possibility of transmission of infection
by separating the patient with a disease
from other patients and health care
associates.
- Anteroom is the place where anyone
entering or leaving the patient’s room
can wash their hands or change
protective garments.
7. Personal protective equipment
- Used to protect the phlebotomist from
infectious material contacting street
clothes, skin, or mucous membranes.
- Include:
- Gloves
- Prevent health care
associates
from
transmitting their own
microflora to patient
(Surgery or wound
cleansing)
- Prevent transmission of
microorganisms from
one patient to another.
- Use different gloves for
different patients.
- Goggle or Face Shields
- Needed anytime there
is the potential for
splattering of blood or
body fluids
- The mouth and face
should be protected.
- Gowns
- Necessary when soiling
of clothes is possible
while taking care of
- patients.
- Must be long sleeves
and buttoned
- Only worn inside the
laboratory
- It should be water or
fluid-resistant
- Used only inside the
laboratory or work area
and disposed of on the
appropriate receptacle.
- Removal of the gown
should be from —
- The gown is pulled
down off the —, slide
down the —, and
folded with the inside
out
before
final
removal.
- Mask
- Prevent transmission of
infectious
agents
through the air
- Fluid-proof masks are
available
in
work
conditions
where
spattering body fluids is
likely
- Should never be worn
around the neck then
moved up to cover the
nose and mouth as you
enter another room
- Masks are no longer
effective if moist
- Shoe cover
PHLEB LEC MIDTERM TRANSES
Isolation Techniques
- Isolating the patient occurs to help the health
care team break the chain of infection.
- Limit the amount of contact time a patient has
to spread an infection
- 1877: description of isolation patients to
prevent the spread of disease was first
published.
- Infectious patients are separated from
non-infectious patients.
- This
still
allowed
nosocomial
transmission of disease because aseptic
techniques were not practiced.
- 1910: cubical or cubicle system of isolation was
introduced
- Patients were separated
- Hospital personnel were instructed to
wash hands and disinfect items
contaminated by patients.
- 1960: patients with infectious disease were
placed in single patient isolation rooms
- 1970s: CDC recommended that hospitals use
one of the seven isolation categories
(Category-specific isolation)
- 1983: Establishment of the Disease-specific
isolation to overcome the shortcoming of the
Category specific isolation
- Requirements of the categories were
modified and a new category was
added.
- Category: Blood and body fluid
precaution.
- Protective or Reverse Isolation was
eliminated because studies indicated it
was not efficient.
- Tuberculosis Isolation was updated to
recommend the use of a private room
with negative air pressure (the air inside
the room, stays inside the room) and
HEPA (High-Efficiency Particulate Air)
filter respirator instead of surgical
masks.
- 1996: Revision to work with patients on two
tiers of isolation
- First tier: Standard Precautions
- Second
tier:
Transmission-based
Precautions
- Depends on how an infection or
disease is managed based on
the mode of transmission.
- Old categories were condensed into
three sets of precautions to reduce the
risk of airborne, droplet, and contact
transmission of pathogens.
- Airborne Precautions
- Droplet Precautions
- Contact Precautions
Category Specific Isolation (1970s)
1. Strict Isolation
- Patient with contagious disease placed
in strict isolation
- Ex: Chicken pox, diphtheria, or
pneumonia.
2. Contact Isolation
- Disease contracted by direct contact
with patient
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Ex: Scabies caused by infestation of mite
Sarcoptes scabiei)
3. Respiratory Isolation
- Patient with disease transmitted
through the air
- Ex: Mumps, Pertussis or Rubella
- Wear mask
4. Tuberculosis Isolation
- AFB (Acid-Fast Bacilli ) isolation
- Tuberculosis is an opportunistic disease
- Infects immunocompromised
patients.
5. Drainage or Secretion Precautions
- Wound and skin precautions
- Patients with open wounds
- The dressing that absorbs the fluid
provides potential transmission of
infection.
6. Enteric Precautions
- Patients with severe diarrhea due to
bacteria such as Salmonella, Shigella, or
Vibrio cholerae.
- Transmission is by contact with infected
patient’s feces.
7. Protective or Reverse Isolation
- The first six isolation examples are to
protect the health care worker from the
infected patient.
- However, the Protective or Reverse
Isolation is to protect the patient from
the health care worker.
Transmission-based Isolation Techniques (1996)
Airborne Precautions
- Patients with known or suspected to have illness
transmitted through small particles (5
micrometers or smaller)
Airborne droplets, which may remain
suspended in the air or dust particles containing
infectious agents.
Travel longer distances
Droplet Precautions
- Larger droplets (larger than 5 micrometers)
- Travel short distances (1 meter or less)
- Involves contact with conjunctivae or
the mucous membrane of the nose or
mouth of the susceptible person.
Contact Precautions
- Patients with known or suspected illness that
can be transmitted through the transfer of
microorganisms by direct or indirect contact.
- Direct contact: skin to skin contact
- Indirect contact: via something the
infectious person has contacted.
Examples
of Disease
Airborne
Droplet
Contact
Measles
(rubeola),
Diphtheria,
mycoplasma,
Clostridium
difficile, E. coli,
PHLEB LEC MIDTERM TRANSES
Varicella
(Chicken pox),
TB
pneumonia,
pertussis,
influenza,
rubella, mumps
Shigella
Private
Room
Yes
Yes
Yes
Respiratory
Protection
Yes, TB
No
No
Mask
Persons
susceptible to
measles should
avoid
Yes, if within 3
feet or 1 meter
No
Patient
Transport
Use mask on
patient
Avoid contact
with other
persons or
equipment
Use mask on
patient
Gloves
Follow Standard
Precaution
Yes, if
contacting
contaminated
material
Follow
Standard
Precautions
Gown
No
If you suspect
clothing will be
contaminated
No
-
-
Occupational Safety and Health Administration (OSHA)
- Agency of the federal government that
investigates the possibility of unsafe practices in
the work environment.
- Result of the Occupational Safety and Health
Act of 1970.
- Goal: Promote safety for health care workers
and their environment.
Functions:
1. Develop and promote health and safety
standards for all occupations
2. Develop and issue regulations
3. Determine the level of compliance with
health and safety regulations
4. Level fines for noncompliance with
health and safety regulations
- Notorious for leveling fines against hospitals for
non-compliance with federal regulations
- Often invited by an associate who feels he/she
is working under safe conditions.
- Once they are in the hospital, the inspectors
investigate more than just the area of
complaint: They investigate the safety status of
the entire hospital.
- Includes:
- Investigate of records
- Observation of work
- Performance
- Associate and Management
interviews
Federal Register
- Government publication
- The rules and regulations the health care
institutions must comply with are published.
- December 1991: Revision of the regulations
created strict standards that must be
maintained by all health care institutions.
- July 6, 1992: All rules and regulations had to be
in compliance.
- November 2001: OSHA issued new directives to
its inspectors; gave the inspectors new
enforcement procedures for occupational
exposure to blood-borne pathogens.
The risk of injury exposure from needles
and sharps, catheters, lancets, scalpels,
and suture needles.
- All items that could expose the health
care worker to the risk of infections.
April 2002: CDC developed the most stringent
standards.
- Employees select safer needle devices
- Maintain a log of injuries from sharps.
OSHA Proof of Compliance:
1. Evaluation and implementation of safer needle
devices
2. Documentation of the involvement of non
managerial, frontline employees in choosing
safer devices.
3. Establishment and maintenance of a sharps
injury log for recording injuries from
contaminated sharps.
OSHA Defined Terms:
1. Blood
- Human blood components
- Plasma
- Platelets
- Serosanguineous
(exudate from wounds)
- Medications derived from blood
- Immune globulins
- Albumin
- Factors VIII and IX
fluids
2. Blood-Borne Pathogens
- HBV (Hepatitis B virus) and HIV (Human
Immunodeficiency virus) are identifies
but the term includes any pathogenic
microorganisms that is present in
human blood or other potentially
infectious material (OPIM) which can
infect and cause disease in persons who
are exposed to blood containing the
pathogen.
3. Exposure Incident
- Include:
- Non Intact skin
- Consists of skin with
dermatitis, hangnails,
cuts, abrasions, chafing,
acne.
4. Exposure Control Plan
- Requires the employer to identify those
tasks and procedures in which the
occupational exposure may occur to
identify the positions with duties that
include those tasks and procedures.
5. Engineering Controls
- Isolate
or
remove
blood-borne
pathogens hazards from the workplace.
6. Needleless System
- Device that does not use needles for:
- Collection of bodily fluids or
withdrawal of body fluids after
initial venous or arterial access
is established
PHLEB LEC MIDTERM TRANSES
-
Administration of medication or
fluids.
- Any other procedure involving
the potential occupational
exposure
to
blood-borne
pathogens due to injuries from
contaminated sharps.
7. Occupational Exposure
- Means reasonably anticipated skin, eye,
mucous membrane, or parenteral
contact with blood or other potentially
infectious that may result from the
performance of an employee’s duties.
8. Sharps with Engineered Sharps Injury
Protections (SESIP)
- Non-needle sharp or needle device
used for withdrawing body fluids,
accessing a vein or artery, or
administering medications or other
fluids with built in safety features or
mechanisms that effectively reduces the
risk of an exposure incident.
Interpretation of Standards
Basic Requirements
- An exposure control plane must be developed
- Engineering controls specific to a safer device
must be used when feasible
- Employee input
- There must be recordkeeping of any injuries.
Exposure Control Plan
- Purpose: Eliminate or minimize employee
exposure.
- Required for employers with employees that
have occupational exposure to potentially
infectious materials
- Should be reviewed and updated ANNUALLY to
consider changes in technology that might offer
new devices
- Key provision of the standard because it
requires the employer to identify the individuals
who will receive training, protective equipment,
vaccinations.
Engineering Control Plan
- Employers must implement safer medical
devices that are appropriately commercially
available and effective.
- Equipment should have the following
characteristics:
- Fixed safety feature that provides a
barrier between the hands and needle
after use.
- Safety feature is an integral part of the
device, not an accessory
- Safety feature is in effect before
disassembly and remains in effect after
disposal
- Safety features should be as simple as
possible and require little or training to
be used effectively.
Employee Input
-
One individual or one management group
cannot make the decision.
Should be from the employees who will be
using the device
“Bidding”
All employees do not need to be involved in
testing.
“Survey”
Record Keeping
- Any occupational injury/illness must be
documented in the exposure control plan
- Sharps injuries
- Confidentiality of employees must be
maintained at all times.
- Should contain the following information:
- Type and brand of device involved in
the incident
- Location of the incident
- Description of the incident
Transport
- Blood
- Self-sealing bags, Tupperware-type containers,
paint buckets, or plastic buckets with sealable
lids
- “Mail”
Material Safety Data Sheet (MSDS)
- Information sheets that must be kept on file and
that indicate the hazards of chemicals used in
each section of the laboratory.
- 1987: MSDS were first introduced in the
passage of the Hazard Communication act
- “Right to Know” Law
National Fire Protection Association (NFPA)
Note:
Flash Point (FIre Hazard)
- Temperature at which an object or substance
can start a fire or ignite.
- Low flash point, higher ignition, more
flammable
Fire
PHLEB LEC MIDTERM TRANSES
-
Ability to recognize and react quickly and
skillfully to emergency situations may mean the
difference between life and death for a victim.
External Hemorrhage
- Hemorrhage – can be effectively controlled by
applying firm pressure using cloth or gauze to
the wound until bleeding stops or rescuer
arrives.
- Ineffective and Not Recommended:
- Elevating the affected part above the
level of the heart.
- Using a tourniquet to control bleeding
- Can be harmful
- Last resort to save a life after all
other means to control bleeding
are unsuccessful.
In case of Fire:
RACE
R - Rescue
A - Alarm
C - Confine or Contain Fire
E - Extinguish or Evacuate
How to Use a Fire Extinguisher
PASS
P - Pull the Pin
A - Aim at the base of the Fire
S - Squeeze the Lever
S - Sweep side to side
Disposal of Used Materials
- Requirements:
- Alter the product
- So that no one can remove used
needles or syringes or other
devices for their own personal
use or be injured by an exposed
sharp.
- The waste must be rendered non
infectious
- So the people handling the
waste will not be infected and
the environment will not be
contaminated.
-
Waste to Dispose:
- Incineration
- Chemical treatment
- Autoclave.
First Aid
Shock
- Results when there is insufficient return of
blood flow to the heart, resulting in an
inadequate supply of oxygen to all organs and
tissues of the body.
- Conditions that will lead to some degree of
shock:
- Hemorrhage
- Heart attack
- Drug reaction
- Trauma
- Symptoms of shock:
- Pale, cold, clammy skin
- Rapid, weak pulse
- Increased, shallow breathing rate
- Expressionless face and staring eyes.
- First Aid for Shock:
- Maintain an open airway for the victim
- Call for assistance
- Keep the victim lying down with the
head lower than the rest of the body
- Attempt to control bleeding or other
cause of shock if known
- Keep the victim warm until help arrives.
Personal Wellness
- Requires a holistic approach, or one that meets
the physical, emotional, social, spiritual, and
economic needs.
- It is something almost everyone can have, but
achieving it requires knowledge, self-awareness,
motivation, and effort.
Proper Wellness
1. Personal Hygiene
- Personal wellness starts with good
personal hygiene
- To shower or bathe and use
deodorant on a regular basis
- Brushing teeth and use
mouthwash more than once a
day if possible
- Hair should be clean and neatly
combed
- Fingernails should be clean,
short, and neatly trimmed.
- Good personal hygiene communicates a
strongly favorable impression about an
individual.
PHLEB LEC MIDTERM TRANSES
2. Proper Nutrition
- Act or process of nourishing
- To promote growth and repair and maintain
vital processes.
- Purpose: Keep us alive and provide what the
body needs for energy and day-to-day
functioning.
3. Rest and Exercise
- Personal wellness requires a nutritious
diet, exercise, and getting the right
amount of rest.
- Fatigue brought on by physical causes is
typically relieved by sleep.
- Lack of rest and sleep can lead to
medical problems.
4. Back Protection
- The spin is designed to withstand
everyday movement, including the
demands of exercise.
- Improper lifting and poor posture habits
can cause weaknesses.
5. Stress Management
- Stress is a condition that results when
physical, chemical, or emotional factors
cause mental or bodily tension
- Evidence suggests that “negative stress”
(such as an emergency or argument)
has a damaging effect on personal
wellness.
- The immune system may be weakened
and other symptoms such as
hypertension, ulcers, migraines, and
nervous breakdowns may eventually
result.
PHLEB LEC MIDTERM TRANSES
Module 3: Circulatory System
Circulatory System
- System of closed tubes
- Functions:
- Transports blood containing oxygen and
nutrients through the body.
- Picks up metabolic waste products
- Transports hormones, enzymes, and
clotting factors (coagulation)
Heart
- Functions:
- Carries blood
- Exchanges nutrients, waste, and gases
w/tissues.
- Transports substances
- Helps regulate blood pressure
- Directs blood flow to the tissues.
-
Outer part of the serous
pericardium
Lies
below
the
fibrous
pericardium
-
Pericardial Cavity
- Space that lies between the
parietal
pericardium
and
visceral pericardium
- Filled with pericardial fluid
- Lubricant;
decreases
friction;
-
Visceral
Serous
Pericardium
(Epicardium)
- Innermost layer of the serous
pericardium
- Lines the outer surface of the
heart itself
Layers of the Heart
Epicardium
- AKA Visceral Serous Pericardium
- Thin, serous membrane forming the smooth
outer surface of the heart.
- Tissue: Simple squamous epithelium overlying
loose connective tissue and adipose tissue (fat;
yellow)
- Protects the heart from friction
Parts of the Heart
Pericardium
- Fibrous connective sac that encloses the heart
- Supports and lubricates the heart during
contraction.
- Protects the heart from trauma or infection.
- Parts:
- Fibrous Pericardium
- Outermost
layer
of the
pericardium
- Prevent the
heart from
overstretching
- Anchors the heart to the
mediastinum.
- Hold the heart in place.
-
Serous Pericardium
- Innermost
layer
pericardium
- Reduces friction
Parts of the Serous Pericardium
- Parietal Serous Pericardium
of
Myocardium
- Thick, middle layer of heart composed of
cardiac muscle.
- Tissue: Cardiac muscle cells
- Responsible for contraction of heart
Endocardium
- Smooth, inner layer (similar to epicardium)
- Tissue: Simple squamous epithelium over layer
of connective tissue
- Allows blood to move through the heart easily
- Folds of endocardium form heart valves.
the
Chambers of the Heart
Atrium (Right and Left)
PHLEB LEC MIDTERM TRANSES
-
Blood enters the heart
Ventricles (Right and Left)
- Blood exits the heart
-
Valves of the Heart
Tricuspid Valve
- AKA Right Atrioventricular Valve
- Separates the right ventricle and right atrium
-
Pulmonary Semilunar Valve
- AKA Pulmonic Valve
- Separates the right ventricle and pulmonary
artery
Bicuspid Valve
- AKA Left Atrioventricular Valve OR Mitral Valve
- Separates the left ventricle and left atrium
Aortic Semilunar Valve
- AKA Aortic Valve
- Separates the left ventricle and aorta
-
Veins
-
-
Blood Flow
Tissue to the Heart - Deoxygenated blood
- Will go the the superior and inferior vena cava
Blood Vessels
Arteries
- Oxygenated blood (bright red)
- Pulse (Has force to pump oxygenated blood)
- Carry blood away from the heart
- “Branch” or “diverge” as they form smaller and
smaller divisions
- Thick walls to withstand pressure (reservoir)
produced when the heart pushes blood into the
arteries. Elastic fibers (tunica media) allow the
artery to stretch under pressure.
Aorta: Largest artery
Arteriole: Smallest artery that connects arteries
to capillaries.
Pulmonary circulation: Carry poor oxygen blood
from hearts to the lungs
Systemic circulation: Carry rich oxygen blood
from the heart to the organs and tissues.
Deoxygenated blood (dark red)
Valves: Stop the blood from going in the wrong
direction
Carry blood toward the heart to be oxygenated
“Join” or “merge” into successfully larger vessels
approaching the heart.
Body muscles surround the veins so that when
the muscles contract, the veins are squeezed
and the blood has been pushed along the
vessels.
Thin walls compared to arteries
Vena Cava: Largest veins; SVC (blood from
upper body) and IVC (blood from lower body)
Venules: Smallest veins that connects veins to
capillaries; only tunica intima
Pulmonary circulation: Carry rich oxygen blood
from lungs to the heart
Systemic circulation: Carry poor oxygen blood
from capillaries to the heart to the organs and
tissues.
Capillaries
- Connects the arteries and veins through
arterioles and venules
- Contact tissues cells and directly serve cellular
needs.
- Exchange between blood and tissue cells occurs.
- Drop off oxygen nutrients from heart by
arteries
- Pick up CO2 and other waste products
and send to heart by veins
- Have the thinnest walls among the blood
vessels; one cell thick wall and very narrow
- Internal lining of simple squamous endothelial
cells called endothelium surrounded by delicate
loose connective tissue.
Layers of the Blood Vessels
Tunica Intima
- Innermost layer
- Layers:
- Endothelium
- Basement membrane
- Lamina Propria: Thin
connective tissue
layer
of
PHLEB LEC MIDTERM TRANSES
-
Internal elastic membrane: fenestrated
layer of elastic fibers that separates the
tunica intima from tunica media
Tunica Media
- Middle layer
- Contains variable amounts of elastic and
collagen fibers
- Layers:
- External elastic membrane: Separates
the tunica media from tunica externa
Tunica Adventitia/Externa
- Outermost layer
- Dense connective tissues adjacent to the tunica
media
-
The cardiovascular and lymphatic are both
integral parts of the circulatory system
Cardiovascular moves blood throughout the
body.
Lymphatic is part of the circulatory system,
comprising a network of conduits called
lymphatic vessels.
Blood
- “River of Life”
- Sticky, heavier than water, higher temperature
than the rest of the body, more in males.
- Connective tissue consisting of a liquid matrix
that contains cells and cell fragments.
- Adult (150lb/68 kgs) has approx. 5 liters of
blood
- 45% are formed elements/cells
- 55% fluid (plasma in circulation
w/fibrinogen.
- Functions:
- Transport of gases, nutrients, and waste
- Transport of processed molecules
- Transport of regulatory molecules
- Regulation of pH and osmosis
- Maintenance of Body Temperature
- Protection against foreign substances
- Clot formation (platelets)
Valves in the Veins
Valves
- The veins in the extremities contain structures
to Keep the blood flowing in a one-way
direction.
Lymphatic System
- Subunit of Circulatory system because it is still
composed of vessels.
- Network of lymph vessels and lymph nodes that
transport fluid, fats, proteins, and lymphocytes
to the bloodstream as lymph.
- Functions:
- Returns tissue fluid to the bloodstream
- Protects the body by removing
microorganisms and impurities
- Processes lymphocytes
- Delivers fats absorbed from the small
intestine to the bloodstream
- Lymph vessels extend throughout the entire
body.
- Lymphocytes: type of white blood cell in the
vertebrate immune system
- Lymphatic vessels: thin tube that carries lymph
(lymphatic fluid) and white blood cells through
the lymphatic system.
Lymphatic System and its relation with the Circulatory
System
Fibrinogen - clot formation
Albumin - osmotic pressure
Globulins - immunoglobulins (IGM); antibodies
Blood Plasma vs Blood Serum
Plasma - no coagulations; placed in tubes with
anticoagulants; unclotted whole blood
Serum - have coagulations; plasma - fibrinogen; clotted
whole blood; no anticoagulants
PHLEB LEC MIDTERM TRANSES
-
-
Formed Elements
Red Blood Cells (Erythrocytes)
- 95%
- Biconcave disk-shaped
- Anucleated
- 120 days lifespan; will go to the spleen if dead;
senescent
- Function:
- Transport of oxygen and carbon dioxide
- ⅓ of RBC volume = hemoglobin
- 4 protein chains and 4 heme groups
- GLOBIN - protein
- HEME - red pigmented molecule
- Contains one iron atom (ferrous
state) Fe2+
- Maturation of RBC
Release heparin - prevents formation of
clots.
Eosinophils
- Stain bright red
- 2 lobes nucleus
- Involved in inflammatory responses
- granules-destroy parasites.
WBCs Agranulocytes
- Lymphocytes
- Smallest
- Antibody production (B-cells)
- Regulation of the immune system.
(T-cells)
- B-cells: Produce plasma cells that turn
into antibodies; bone marrow
- T-cells: regulation of the immune
system; thymus
-
Monocytes
- Largest WBCs
- Leave the blood circulation enter tissues
(macrophages)
- Phagocytosis
Platelets (Thrombocytes)
- Minute fragments of cells
- Prevents blood loss; clot formation
White Blood Cells (Leukocytes)
- Spherical cells that lack hemoglobin
- “Buffy coat”
- WBCs and Platelets
- Larger than RBCs and is nucleated
- Protect
the
body
against
invading
microorganisms or pathogens
- Remove dead cells or debris from tissues by
phagocytosis.
WBCs Granulocytes
- Neutrophils
- AKA Polymorphonuclear (PMN) cells
- Most common type
- 2-4 lobes of the nucleus
- 10-12 hours lifespan
- Phagocytosis of foreign substances.
-
Basophils
- Least common; rare
- Large cytoplasmic granules
- Darkly stained
- Deep blue purple
- 2 lobes
- Release
histamine
inflammation)
(promote
Maturation of Platelets
Veins for Blood Collection
For venipuncture:
- Antecubital fossa (usual location)
- Usually M or H shaped pattern on the
arm
- Back of hand
- Wrist
- Ankle or foot
PHLEB LEC MIDTERM TRANSES
Median Cubital vein
- 1st choice
- Stable
- Away from the pulse
- Forms a bridged pathway between the cephalic
and basilic veins
- Easiest to palpate
- Less tendency to roll than other veins
- Anchor (support) the vein
Cephalic Vein
- 2nd choice
- Follows along the thumb side the arm
- Not prone to rolling, but is slightly more
difficult to feel.
- No pulse
- Visible for obese patients
Basilic Vein
- 3rd Choice
- Close to the pulse
- More difficult to feel; has tendency to
roll
- Venipuncture should be approached
with caution.
- Close to the arteries and median nerves
Arteries for Blood Collection
*We do not perform arterial puncture
PHLEB LEC MIDTERM TRANSES
Module 4: Blood Collection, Equipment, Additives, and
Order of Draw
-
Syringes have safety shields to cover the
needles immediately after use.
Syringe
- Syringe and needle method is one of the oldest
methods known that does not destroy the
integrity of the vein
- Similar apparatus has been found in Egyptian
tombs
- The principle and basic construction of the
structure remains the same
- Syringe: Sleeve with a plunger that fits
inside a needle attached to the end.
- The use of needle and syringe is limited by the
capacity of the syringe.
Pink - Safety Shield
Thumb pad - to place the thumb; used to activate the
safety device
- The gauge of the needle is determined by the
diameter of the lumen (opening at the bevel
end of the needle)
- The higher the gauge = the smaller the
diameter/lumen
- Example:
- a 30 gauge needle has a
narrower lumen than a 25
gauge needle.
-
-
Made of either glass or plastic
“Breathing/Aspirate the syringe”
- Pull the plunger twice halfway the
barrel
- To ensure that it moves freely but still
maintains syringe sterility.
The vacuum created by pulling the plunger
while the needle is in the patient’s vein fills the
syringe with blood.
Needle Gauge
Use
27
PPD (Purified Protein Derivative) Skin Tests;
a method used to diagnose silent (latent)
tuberculosis (TB) infection
25
IM (Intermuscular) Injections
23
Butterfly or Syringe Collection
22
21
Needle
- Recommended length: 1 inch to 1 ½ inches.
- Types:
- Multisample (Closed System)
- Butterfly (Winged Infusion; both
system)
- Hypodermic (Open System)
20
Syringe/Evacuated System Collection
PHLEB LEC MIDTERM TRANSES
-
-
-
Antiseptic
- Bacteriostatic: Process where an antiseptic
agent prevents the growth of bacteria (i.e., it
keeps them in the stationary phase of growth)
- Kinds:
- Alcohol pads
- 70% Isopropyl alcohol
- Povidone iodine pads
- Cotton pads w/ alcohol
Tourniquet
- Purpose: Constricts the flow of blood and makes
the vein more prominent.
- It does not cut into the patient’s arm
but distributes the pressure.
- 1
minute
only
to
avoid
hemoconcentration
(increased
concentration of cells and solids in the
blood usually resulting from loss of fluid
to the tissues) because it will cause
falsely elevated results.
- When left too long, blood
becomes stagnant causing
hemoconcentration.
- Increased concentration
of constituents in the
blood
sample
=
disrupting the balance
of fluid in tissue causing
the
release
of
potassium.
- Velcro strips or round rubber tubing are no
longer acceptable.
- Soft, pliable, flat strip approximately 1 inch wide
by 15 to 18 inches long.
- Should be made up of non latex material
- Reuse of the tourniquet is not a safety issue for
the phlebotomist but is a contamination
concern for the patient.
- 2 to 4 inches above the puncture site.
- Applied tight enough to slow the flow of blood
in the veins but not prevent the flow of blood in
the arteries.
- Patient should close their hand or “make fist”
-
Pumping the fist can inadvertently
double the concentration of potassium
in the sample of blood. And when that
happens, the physician gets potassium
results that no longer represent what's
really going on with the patient.
- Potassium: released into the
bloodstream from the tissues
and red blood cells.
Palpating the vein determines the direction,
depth, and size.
- One of the more difficult skills a
phlebotomist learns.
- Phlebotomists use the index or middle
finger to press down on the top of the
vein to feel for a bounce or running the
finger across the arm to locate a vein as
the finger runs over the “speed bump”
of the vein.
Limits:
- Loses ability to stretch or will tear.
- Solid tourniquet must be discarded and
not be cleaned
- Contaminated by blood-discarded in
biohazard containers.
Alternatives:
- Sphygmomanometer (blood pressure
cuff)
- Inflated between the diastolic
and systolic reading
- Used only when the vein is not
prominent with a tourniquet
- For obese, pediatric, or geriatric
patients.
Evacuated Collection Tubes
- Contains a vacuum with a rubber stopper
sealing the tube.
- Range in volume from 2 mL to 15 mL
- Interiors are sterile to prevent contamination of
the sample and the patient.
- Glass or plastic = 65 to 127 mm with external
diameter of 10, 13, or 16 mm.
- The BD Vacutainer is named after Becton
Dickinson “Hemogard”
- Blood collection tubes with Hemogard
™ (BD) closure protect you from blood
which might splatter when the tube is
opened. The rubber stopper is recessed
inside the plastic shield, preventing
exposure to blood present on the
stopper.
Coagulation
- Hemostasis
- Coagulation process causes the
formation of blood clots when an injury
occurs.
- Lysing (lysis) the blood clot when the
injury has been repaired.
PHLEB LEC MIDTERM TRANSES
-
3.
-
Action: Prevents coagulation by binding calcium
in a non-ionized form.
Ratio: 1 part anticoagulant to 9 parts of blood;
1:9.
Tests: Prothrombin time (evaluate blood
clotting), aPTT (Activated Partial Thromboplastin
Clotting Time; measures how long it takes blood
to form a clot), and Fibrinogen assay (measures
the ability of fibrinogen to form fibrin clot after
being exposed to a high concentration of
purified thrombin.)
Sodium Citrate
Citrate may also be used in blood donor bags.
CPDA 1: Citrate-phosphate-dextrose-adenine
Action: Prevents clotting and preserves the
viability of the erythrocytes
Ratio: 1:9 = 63 mL anticoagulant:450 mL blood
4. Sodium Citrate (Yellow)
- ACD: Acid Citrate Dextrose
- Contains trisodium citrate, citric acid,
and dextrose solution
- Uses: Tissue typing in blood banks, DNA testing,
paternity testing, HLA (human leukocyte
antigen) testing, and immunohematology.
Stages of Hemostasis:
- Primary Hemostasis
- Vasoconstriction - limits bleeding from
the injury
- Platelet Aggregation - platelets clump
with each other.
- Platelet Adhesion - platelet clump
adhere to injured area
-
Secondary Hemostasis
- Needed for more serious injuries and
includes the formation of a fibrin clot.
Additives
1. Potassium oxalate/Sodium Fluoride (Gray)
- Oxalate - anticoagulant
- Fluoride - Preservative; Sodium fluoride
preserves glucose in the sample (slows down
glycolysis)
- Without fluoride, glucose is broken
down at a rate of 7% per hour.
- Action: Precipitating out the calcium in the
blood.
- Used if there is a delay in testing.
2. Sodium Citrate 3.2% (Light Blue)
5. Sodium Polyanethol Sulfonate (SPS) (Yellow)
- Action: Inhibits phagocytosis (ingesting) of
bacteria by WBCs, inhibits serum complement,
and inhibits certain antibiotics.
- Main function is to allow bacteria to grow so
they can be cultured.
- Uses: Collection of blood samples for culture
(microbiology).
6. Ethylene diamine tetraacetic acid (EDTA)
(Lavender)
- Action: Binds the calcium
- Uses: CBC (platelet count, rbc count, wbc count,
hemoglobin, hematocrit, etc), differential blood
smear, more stable microHct
- Tripotassium EDTA - glass tubes and liquid form
- Dipotassium EDTA - plastic tubes and
spray-dried powder form
- Anticoagulant of choice by
International
Council for Standardization in Haematology
(ICSH) and Clinical & Laboratory Standards
Institute (CLSI)
7. Ethylene diamine tetraacetic acid (EDTA)
(White or Pearl)
- EDTA + gel = separate plasma from cells
- Uses:
HIV-positive
patients,
molecular
diagnostic tests (PCR) or DNA amplification
techniques.
8. Heparin (Green)
- Naturally occurring anticoagulant
- Produced by liver, lung, gastrointestinal
tract, and other bodily tissues.
- Produces the least stress to RBCs and minimizes
hemolysis
- Prevents clotting by inhibiting thrombin
formation.
- Uses: pH determination, electrolyte studies, and
arterial blood gases
PHLEB LEC MIDTERM TRANSES
-
Lithium heparin, sodium
ammonium heparin.
heparin,
and
9. Trace Element Tubes (Royal Blue)
- Uses: Analysis of trace elements, such as lead,
zinc, copper, or arsenic.
- No anticoagulant produces a clot sample
(serum); Sodium heparin anticoagulant;
Disodium EDTA anticoagulant.
Additive/Anticoagulant
Potassium oxalate
Precipitates calcium
Inhibits glycolysis
Sodium Citrate
Binds calcium
Binds calcium and
allows bacteria to grow
SPS
EDTA
Binds calcium
Lithium, sodium, and
ammonium heparin
Inhibits conversion of
prothrombin
to
thrombin
Stopper
Color
Additive
Inversi
on
Department
Light Blue
Sodium
Citrate
(Plasma)
3-4
Coagulations
Glass None/Plain
(Serum)
Chemistry, blood bank,
serology/immunology
Red
Plastic - Clot
activator
(Serum)
5
Red/Black
(Tiger),
Gold,
Red/Gold
Clot Activator
(SST) and Gel
Separator
(Serum)
5
Chemistry
Green
Heparin
(Sodium,
Ammonium,
Lithium)
(Plasma)
5-10
Chemistry
Pink,
Lavender/Purp
le, Tan, Pearl
EDTA
(Plasma)
8-10
Hematology, Blood Bank
Sodium
fluoride &
Potassium
oxalate
(Plasma)
8-10
Sodium
fluoride &
EDTA
(Plasma)
5-10
Orange
Yellow
Evacuated System (Vacutainer System)
- Principle: Tube with a vacuum already in its
attaches to the needle and the tube’s vacuum is
replaced by blood.
Action
Sodium fluoride
Gray
Phosphate
Dextrose
(CPD) (Plasma)
Chemistry
Thrombin
(Serum)
Sodium
polyanethol
sulfonate
(SPS)
(Plasma)
Acid citrate
dextrose
(ACD) or
Citrate
Chemistry
Microbiology
8
Blood
Bank/Immunohematolog
y
Butterfly Collection Set (Winged Infusion Set)
- 21 or 23 gauge needle
- Needle has a safety device
- 3-12 inch tubing
- At the other end of the tubing is a hub
- Discarded in the sharps container.
PHLEB LEC MIDTERM TRANSES
Additional Notes:
Spx (Sample)
- Whole blood: has RBC, WBC, and Platelets
- Plasma: w/ anticoagulants
- Serum: w/o anticoagulants
Calcium in the blood helps with blood clotting.
PHLEB LEC MIDTERM TRANSES
Module 5: Venipuncture Procedures
Venipuncture
- Process of collecting or drawing blood from a
vein.
Venipuncture Steps:
1. Review & accession test request
- Types:
- Bar-code requisitions
- Manual requisitions (Paper)
-
-
-
-
Identify the patient:
- The
most
important
step
in
venipuncture is the correct patient
identification.
- Because this will compromise
the patient’s health
- Can misdiagnose the patient.
- Verify name and date of birth
- Personal information or px
demographics (name and birth
date)
- Patient Identifiers:
- Patient’s name
- Birthdate
- ID Band (for in-patients)
- Check ID bracelet or band
- Notify nurse of ID discrepancies
- Search for missing IDs
- Wake sleeping patients
- Ask a relative or nurse to identify a
patient who is unconscious, young,
mentally incompetent, or non-English
speaking.
-
Prepare the patient:
- Explain the procedure
- Address patient inquiries
- Handle patient objections
- Address difficult patients
- Address objects in patient’s mouth
Regardless of the difficulties involved, you must
always determine that the patient understands
what is about to take place and obtain
permission before proceeding. This is part of
informed consent.
Computer requisitions
- Phlebotomist
is
typically
required to write the time of
collection and his or her initials
on the label after collecting the
specimen.
Phlebotomist must:
- Check to see that all required info is
present and complete
- Verify tests to be collected and time and
date of collection
- Especially in-patients, there is
timed specimens (where there
is a specific time to collect
specimens from the patient;
present as DUE)
- Identify diet restrictions or other special
circumstances
- FBS test (red tube): fasting 8-10
hours
- Lipid profiling (red tube):
fasting 10-12 or 12-14 hours
- If a patient cannot fast for long
periods, 9 hours will do.
- Accession or record the order received.
2. Approach, introduce, identify, & prepare
patient
- Approach the patient:
- Be organized and prepare with
paperwork
- Look for signs containing info. (e.g., DNR
[do not resuscitate] and DNAR [do not
attempt resuscitation])
Knock lightly on door
Ask visitors to step out
Identify yourself
Obtain consent for procedure
Put patient at ease, using professional
bedside manner
●
3. Verify diet restrictions and latex sensitivity
- If patient has overfasted or under fasted
and there is the need to collect the
specimen:
- 1st option: Ask them to go back
- 2nd option: Write “nonfasting”
on the requisition and specimen
label.
- Always ask for allergies, especially in
latex and alcohol.
4. Sanitize hands
5. Position patient, apply tourniquet, and ask
patient to make a fist
- Positioning the patient:
- Inpatient: lying down in bed
- Outpatient: sitting up in blood-drawing
chair
- Patient prone to fainting: reclining sofa,
chair, or bed
- If the patient fainted: Pull out
the syringe and do not
continue.
PHLEB LEC MIDTERM TRANSES
-
Support hand or arm that is to be the
site of venipuncture.
Tourniquet application & fist clenching:
- Apply tourniquet snugly 3 to 4 inches
above intended site
- Near puncture site: The vein
will collapse
- Far puncture site: Ineffective
since the vein will not be
prominent.
- Never apply over open sore
- Visually inspect arms
- What to look for:
- Scars
- Mastectomy (prone to
infection)
- Tattoos
- Burns
- IV site
IV Site: can get blood; however, must stop the IV fluid
for 5 minutes before collecting blood
- Example: If you draw 5 mL of blood, discard the
first few mL (1-2 mL) of blood because it might
be contaminated with IV fluid.
- Apply over a dry washcloth or gauze if
patient has sensitive skin
- Ask patient to make a fist
- To make the vein prominent.
- A tourniquet has a greater tendency to roll or
twist on the arms of obese patients:
- Bariatric tourniquets are available from
manufacturers.
- However, if bariatric tourniquets are not
available, two tourniquets placed on top
of each other sometimes solves the
problem.
-
-
6. Select vein, release tourniquet, & ask patient
to open fist
- Preferred site is antecubital area of arm
- First choices are median cubital &
median veins
- H and M patterns
- Palpate patient’s dominant arm with
index finger
- Not the thumb because the
thumb has a pulse.
- Roll finger side to side while pressing
against vein to judge size
- Avoid veins that feel hard & cord-like or
lack resilience
- Patients that undergo dialysis
and chemotherapy.
- Release tourniquet & have patient open
fist
- If vein was not found over 1
min, remove the tourniquet and
reapply after 2 minutes.
- Don’t use veins on underside of wrist
7. Clean and air-dry the site
- Clean site using with an antiseptic to avoid
infection or contamination
- Use 70% isopropyl alcohol
- Use circular motion, moving outward in
widening concentric circles
- Clean an area about 2 to 3 in. in diameter
-
Allow area to dry 30 seconds to 1 minute
Don’t dry alcohol with non sterile gauze or fan
or blow on site…let air dry
- Air drying alcohol:
- To
allow
the
complete
bacteriostatic effect of the
antiseptic
- To avoid contamination or
hemolysis, which can result in
hemolysis or contamination in
alcohol testing
- To
avoid
stinging/burning
sensation while the needle is
inserted.
Don’t touch site after cleaning it
- Can touch or palpate the vein above the
puncture site and insert the needle at
an angle that is below where you
touched.
- Leaving an alcohol pad and pointing it
to the direction of the site for markings
- If it is necessary to re-palpate the vein
after the site has been clean, the site
must be cleaned again.
8. Prepare equipment and put on gloves
*It is recommended that you put gloves on
before touching the patient to practice universal
precautions.
- ETS (evacuated tube system) equipment
preparation
- Preparation of a winged infusion set (butterfly)
- Preparation of syringe equipment
- Positioning equipment for use
9. Reapply tourniquet, uncap, and inspect needle
- Reapply tourniquet:
- According to the CLSI, when a
tourniquet has been in place for longer
than 1 minute, it should be released
and reapplied after 2 minutes.
-
Uncapping the needle:
- Uncapping the needle using only 1 hand
because you are prone to needle prick
when using 2 hands.
-
Inspection of needle:
- Look for:
- Needle blunt
- Need end barb
- Bended needle
- Obstructed lumen
10. Ask patient to remake a fist, anchor vein, &
insert needle
- Anchoring
- It stabilizes the vein
- Use nondominant hand to anchor
(secure firmly) the vein
- Place your thumb at least 1 to 2 inches
below & slightly to side of site
- L-hold: Proper hold to anchor
the vein
- C-hold: Not recommended
- Pull skin toward wrist
-
Needle insertion
PHLEB LEC MIDTERM TRANSES
-
Never switch hands!!!!!!
Hold collection device or butterfly
needle in dominant hand
With bevel facing up, position needle
above insertion site
Insert at 30-degree angle or less in
smooth, steady forward motion
11. Establish blood flow, release tourniquet, and
ask patient to open fist
- For ETS:
- Advance collection tube into tube
holder until stopper is completely
penetrated by needle
- Push tube with thumb while index &
middle fingers straddle & grasp flanges
of tube
- holder, pulling back slightly
- Blood will begin to flow into tube
- Because of vacuum
- Release tourniquet as soon as blood
flow is established
- Have patient release fist
-
-
For Open System:
- Release tourniquet after the syringe
barrel has been filled or once the
needed volume is collected.
Maintain needle position, DO NOT lift up tip!
Let tube fill from bottom to prevent reflux
17. Check patient's arm and apply bandage
- Apply bandage after a few minutes after
applying pressure because it will cause
hematoma.
- Label the tubes when the patient is applying
pressure on the puncture site.
- After labeling the tube/s, that is the time to
apply bandage.
18. Dispose of contaminated materials
19. Thank patient, remove gloves, and sanitize
hands
20. Transport specimen to lab
Pediatric Venipuncture
- Children <2 years: limit to superficial veins
- Cannot extract blood below 1 year old,
especially newborns
- Challenges:
- Small, undeveloped veins
- Considerable risk of permanent damage
- Smaller blood volume in body; risk for
anemia or cardiac arrest due to anemia
-
Dealing With Parents or Guardians:
- Earn trust by being warm, friendly, calm,
confident, & caring
- Ask about child’s past experiences with
blood collection
- Allow to stay in room, if desired
-
Dealing With the Child:
- Gain trust; approach slowly &
determine level of anxiety
- Explain procedure in terms a child can
understand
- Emphasize importance of remaining still
- Offer a reward for cooperating (stickers
work great)
- NEVER tell a child it won’t hurt
14. Discard collection unit, syringe needle, or
transfer device
- Theoretically, the tube holder from the ETS
must also be disposed together with the needle
used; disposed as a unit.
-
Pain Interventions:
- Eutectic mixture of local anesthetics
(EMLA)
- Available in a cream & in oral solution
- Takes about 1 hour to anesthetize area
15. Label tubes
- Patient’s first & last names
- Patient’s identification number (if applicable) or
date of birth
- Date & time of collection
- Phlebotomist’s initials
- Pertinent additional information, such as
“fasting”
- Compare information on each labeled tube with
the patient’s wristband and the requisition.
- Do not pre-label the tube
- Because this will confuse the
phlebotomist.
-
Selecting a Method of Restraint:
- Infants: wrap in a blanket
- Toddlers: have parent hold on lap
- Have 2nd person lean over child who is
lying down
-
Equipment Selection:
- 23-gauge butterfly needle attached to
an evacuated tube or syringe
-
Procedures:
- Collect minimum amount of blood
required for testing
- Because of the risk of anemia or
cardiac arrest due to anemia.
12. Fill, remove, & mix tubes in order of draw or fill
syringe
- Manufacturer: created the vacuum in the
vacuum tubes.
- ETS will automatically stop filling because of the
vacuum.
- After filling the tubes, invert it to avoid clotting
the specimen that would lead to erroneous
results.
13. Place gauze, remove needle, activate safety
feature, & apply pressure
- Fishing technique: One-hand recap
16. Observe special handling instructions
- Such as putting on ice, protecting from light etc.
Geriatric Venipuncture
PHLEB LEC MIDTERM TRANSES
-
Challenges:
- Skin changes
- Hearing impairment
- Visual impairment
- Mental impairment
- Effects of disease:
- Arthritis (can’t usually make a
tight fist)
- Diabetes (bad circulation)
- Parkinson’s & stroke (affects
strength and ability to hold
hand/arm still)
- Pulmonary function
-
Safety Issues:
- More space need for wheelchairs &
walkers
- Non-slip & clutter-free floors
-
Patients in Wheelchairs:
- Lock wheels when drawing blood,
assisting from chair
-
Blood-Collection Procedures:
- Patient identification: don’t rely on
nods of agreement; verify patient
information with a relative or attendant.
Equipment
selection:
choose
equipment best suited for patient and
situation; Butterfly, Short draw tubes,
MicroEDTA
- Tourniquet application: loose enough
to not damage skin. Apply over sleeves
when possible.
- Must be removed with only one
hand for convenience in case of
emergencies, such as when a
patient will faint.
- Site selection: avoid bruised areas from
previous venipunctures
- Cleaning the site: don’t rub too
vigorously
- Performing the venipuncture: anchor
vein firmly to avoid rolling
- Holding pressure: bleeding may take
longer to stop
Patients on Dialysis and Those in Other
Settings
- Dialysis Patients
- Most common reason for dialysis is end stage
renal disease (ESRD)
- Do not use the arm with AV fistula for
venipuncture!!
-
Long-Term Care Patients:
- Adult daycare
- Assisted living
- Rehabilitation facilities
- Private homes
-
Home Care Patients:
- Home care phlebotomists must have:
- Exceptional
phlebotomy,
interpersonal, & organizational
skills
- Ability
to
function
independently
-
-
Ability to be comfortable
working in varied & unusual
circumstances
Ability to carry all equipment
with them
-
Hospice Patients:
- Require extra care, kindness, & respect
NAACLS (National Accreditation Agency for
Clinical Laboratory Sciences) Entry Level Competencies
Met in this Chapter:
Additional Notes:
Hospice care focuses on the care, comfort, and
quality of life of a person with a serious illness who is
approaching the end of life.
Test status:
- Timed
- Fasting
- TAT (Turnaround Time)
- The time from sample collection to
releasing of results.
- STAT (Short Turnaround Time)
- A "stat" test is defined as a quick
turnaround time, generally an hour or
less from specimen receipt until test
result reporting; urgent or immediate.
- The time is shortened from sample
collection to releasing of results
- Done when a patient is dying or critical.
Example for STAT and TAT:
- The TAT of CBC is 1 hour and when the doctor
requests STAT CBC, the TAT is shortened because
of urgency. Now, the TAT is shortened into 30
minutes.
Difference of veins, arteries, and tendons
- Arteries have pulse
- Tendons are hard and solid
- If squeezed, it remains in its shape
unlike veins.
- Veins do not have a pulse and are not hard.
PHLEB LEC MIDTERM TRANSES
Module 6: Pre-Analytical Considerations
Pre-Analytical Phase of Testing
- When the test is ordered until the beginning of
testing.
Phlebotomist must:
- Have technical skills to perform blood draw
- Recognize pre-analytical factors and address
them.
Definition of Terms
Reference Range/Intervals
- Consist of range of values with high and low
limits
- High limits: maximum
- Low limits: minimum
- Tests confirm health or screen, diagnose and
monitor disease.
- Test compared with specimens of healthy
people.
- Most often based on healthy, fasting people.
Basal State
- Resting state of the body early in the morning
after fasting 12 hours.
- Basal state specimen
- Ideal for establishing reference range on
in-patients.
- Effects of diet and exercise on test
results are minimized.
- Influenced by:
- Age
- Gender
- Conditions of the body
- Diurnal (Happens daily)
- Circadian (24-hour cycle)
Physiological Variables
Variable
Age
Has effect on
RBC, WBC, Creatinine
clearance
Altitude
RBC
Dehydration
Hemoconcentration, RBC,
Enzymes, Na
Diet
Glucose, lipids, electrolytes
Diurnal
variation
TSH, Cortisol, Fe
Drug
therapy
Enzymes, hormones
Exercise/IM
injection
pH, PCO2, CK, LDH, Glucose
Fever
Hormones, Cortisol
Gender
RBC, Hematocrit, Hemoglobin
Jaundice
Yellow color interferes
Position
Protein, K
Pregnancy
RBC
Smoking
Cholesterol, cortisol, glucose,
GH, TAGS, WBC
Age of the Patient
- Newborns
- Have higher values of WBCs (for
infections and due to delivery) and RBCs
- Elder patients
- Increased creatinine
- Creatinine: Kidney function test
- If creatinine is increased, this
indicates kidney failure.
Diet
-
Food with sugar
- FBS
Lot of fatty foods increase that fat content in
blood
Dehydrated patients.
- Dehydrated: decreased water level,
increased
solutes,
analytes
or
electrolytes.
- Analytes become concentrated because
of the lack of water content in the body.
-
Altitude
- Affect the number of red blood in a patient's
blood.
- High altitude: The body will compensate
for the lack of oxygen, the body will
produce more RBCs since they carry
RBCs.
Drug therapy treatments
- Chemotherapy
- Decrease WBCs
- Steroids or diuretics
- Decreased Na and K
- Increased Ca and glucose.
Exercise
- Produce lactic acid and LDH (Lactate
Dehydrogenase) in the muscle metabolism
- Increased
creatinine (NPN: non-protein
nitrogen) because they are a product of muscle
metabolism
- If a patient is a body-builder, always ask
if they exercised because they should
not exercise.
Fever
-
-
Fever-induced
- Fever-induced hypoglycemia
- Increase glucagon and insulin
levels.
Increases cortisol and may disrupt its normal
diurnal variation.
- Cortisol increases when stressed
- Triggers sugar level to increase.
Gender
- Affects the concentration of a number of blood
components.
- Normal values for males and females.
- Example:
PHLEB LEC MIDTERM TRANSES
-
-
RBC, Hgb, Hct, creatinine normal values
are higher for males than females.
- This is due to hormones and
muscle mass (for creatinine)
Babies have low levels of creatinine
because they have small muscle mass.
Intramuscular IM injection
- Muscle injection
- Increase levels of creatinine kinase (CK), skeletal
muscle fraction of LDH.
Jaundice/Icteric
- Interfere with chemistry tests based on color
reactions, including reagent-strip analysis of
urine.
- Increased bilirubin; thus, yellow skin color
- Normal color of serum: yellowish
- Patient with jaundice/icteric: dark
yellow
Body Position
- Before and during blood collection can influence
specimen composition.
- Shift of cells
Pregnancy
- Increases in body fluid, which are normal during
pregnancy.
- Increased glucose because they may have
gestational diabetes
- A type of diabetes that can develop
during pregnancy in women who don't
already have diabetes.
- Due to hormones that increase glucose
in the body.
- The placenta produces a
hormone called the human
placental lactogen (HPL), also
known as human chorionic
somatomammotropin (HCS)
Smoking
- Patients who smoke prior to specimen
collection may have increased cholesterol,
cortisol, glucose, growth hormone, and
triglyceride levels, and WBC counts.
Emotional Stress
- Increased WBCs
Temperature and humidity
- Acute heat exposure: interstitial fluid will move
to the plasma cell.
- Plasma cell is a blood vessel
- Extensive sweating without fluid replacement
- Decreased water level, increased
electrolytes or analytes.
Extracellular fluid (ECF)
- Extra and outside cellular fluid
- Types:
- Interstitial fluid
- Fluid from tissue spaces
- Intravascular fluid (plasma)
- Fluid inside the vessel
- Specimen to be collected.
Intracellular fluid (ICF)
- Inside the cell fluid
- Fluid inside the RBCs
*from left to right
1. Hemolyzed Serum
- Red serum (hemolyzed)
- Due to RBC rupture
- Due
to
prolonged
tourniquet
2. Lipemic Serum (Lipemia)
- Increased lipids in the serum
- Because patient ate and did not
fast
- Other term for lipemic specimens:
- Chylous
- Lactescent
- Milky specimen
3. Normal Serum
- Yellow to yellowish serum color
4. Icteric Serum
- Dark yellow serum color
- Increased bilirubin
Problem Sites
1. Burns, Scars, and Tattoos
- Burns: Hard to palpate the vein
- Impaired blood circulation
- Cause harm to patient
- Tattoos: contaminated with dyes
- Troubleshoot: find spot without any dye
or burns.
2. Damaged veins
- Sclerosed: Hardened vein
- Thrombosed: Clotted vein
- Cannot collect blood here.
PHLEB LEC MIDTERM TRANSES
-
Troubleshoot: Collect blood away from
the damaged veins; choose distant from
these veins.
3. Edema
- Enlargement due to inflammation due
to fluid inside
- Usually only lipids are collected.
- Troubleshoot: find another arm
4. Hematoma
- Caused by blood leaking into the tissues
during or after venipuncture.
- Release tourniquet, remove needle,
apply pressure, and apply ice.
- Causes:
- Small fragile veins
- Needle too large
- Excessive probing to find the
vein
- Removing needle prior to
releasing the tourniquet
- Needle going all the way
through
- Needle only partially entering
the vein allowing leakage
- Applying
pressure
to
gauze/cotton before the needle
is removed.
- Acetaminophen or ibuprofen can help
to relieve discomfort from a hematoma
- Ice applied in the first 24 hours helps
manage the swelling and discomfort.
- After 24 hours, apply heat or warm
moist compresses to encourage
resorption of accumulated blood.
5. Mastectomy (Surgical breast removal)
- Blood should never be drawn from an
arm on the same side as the
mastectomy without first consulting the
patient’s physician.
- Troubleshoot: Choose the other arm.
- Because the side with the
mastectomy
would
cause
swelling or infection because of
the removal of lymph nodes on
that side.
- Will affect the WBCs
- Lymphostasis
6. Obesity
- Check the antecubital area first.
- Obese patients often have a double
crease in the antecubital area with an
easily palpable median cubital vein
between the two creases.
Vascular Access Sites and Devices (VAD)
- Vascular and access are medical words that
mean “a way t get your blood”
- Vascular = blood; access = a way to get
there.
Vascular Access Devices (VAD)
Arterial Line
- Catheter placed in artery (radial)
- Tests: Blood gas
- No tourniquet in the arterial line.
Arteriovenous Shunt (Fistula)
- Permanent surgical fusion of artery and vein.
- Can be found on patients undergoing kidney
dialysis.
Heparin or Saline Lock (IV Hep-lock)
- A catheter or cannula connected to a
stopcock/cap
- Placed in the lower arm above the vein for up to
24 hours (??).
IV Site
- Can get blood; however, must stop the IV fluid
for 5 minutes before collecting blood. Not lower
than 2-3 minutes.
- The first blood drawn from the IV site is
still contaminated with IV fluid.
- IV Line: a catheter inserted into a vein to
administer fluid
Central Vascular Access Device (CVAD)
- Known as indwelling lines.
- Tube inserted in the main vein or artery.
- For administration of fluid and medicine
- Do not usually draw blood here.
Central Venous Catheter or Line
- Inserted into large vein (subclavian)
- Advanced into superior vena cava
Implanted port
- A small chamber attached to indwelling line
- Surgically implanted under skin (upper chest or
arm)
Peripherally inserted central catheter
- Inserted in veins of extremities and threaded
into central veins.
Patient Complications
Allergies
- Adhesive allergy
- Antiseptic allergy
- If allergic to alcohol, use iodine
- Latex allergy
Excessive Bleeding
- Aspirin cause excessive bleeding
- Does not clot the blood.
Syncope (Fainting)
- Vasovagal: loss of consciousness due to nervous
system response to abrupt pain, stress, or
trauma.
- Patients with a history of fainting, they can be in
a lying position when extracting blood.
Nausea and Vomiting
Pain
-
Digging is never okay
-
Petechiae
- Tiny red spots of bleeding under the skin
- Causes: Prolonged tourniquet
Seizures/Convulsion
PHLEB LEC MIDTERM TRANSES
Procedural Error Risks
1. Hematoma formation
2. Iatrogenic anemia
- Iatrogenic: Condition caused by a
medical procedure.
- Anemia acquired or caused by a
medical procedure
- Excessive blood collection
3. Infection
4. Nerve injury
- Near brachial vein
5. Reflux of anticoagulant
6. Never poke and hope (blindshot)
- Avoid numerous venipunctures in the
same area over time
- Avoid blind probing and improper
technique.
Specimen Quality Concerns
1. Hemoconcentration
- A decrease in a fluid content of blood
- Caused: Stagnant blood
- An increase in nonfilterable large
molecules.
2. Hemolysis
- Damage or RBC destruction or rupture.
3. Specimen Contamination
Needle Position
https://quizlet.com/397166291/phlebotomy-test-2-revi
ew-flash-cards/
Collapsed Vein
- Vein walls draw together temporarily, shutting
off blood flow.
- Caused by:
- Vacuum of tube or plunger pressure is
too strong for vein
- Tourniquet is too tight or too close to
site
- Tourniquet is removed during draw
(esp. Elderly)
Tube Vacuum
- Loss of vacuum due to bevel partially out of
skin.
- Loss of vacuum due to damage to tube
PHLEB LEC MIDTERM TRANSES
Module 7: Capillary Collection
Capillary blood sampling
- Refers to sampling blood from a puncture on
the finger, heel or an earlobe, is increasingly
common in medicine.
- Capillary dermal skin: Puncture site for
capillary sampling
- Prick
- AKA dermal puncture or skin puncture, is the
usual collection procedure for infants. In adults,
it is an alternative collection procedure when
minute amounts of blood are needed for
testing, or for patients for whom venipuncture
is inadvisable or impossible.
- In addition, it is typically used when collecting
blood from infants and point-of-care.
Capillary Puncture Equipment
CAPIJECT - Featuring automatic blade or needle
retraction, CAPIJECT safety lancets enclose the sharp
before and after use for maximum safety.
Tenderlett Devices - creates a small, shallow incision in
the finger which cuts more of the capillary bed without
cutting too deeply.
Laser Lancet
- The Lasette laser lancing device uses a laser,
rather than a sharp instrument, to pierce the
skin, which causes less pain and bruising at the
sample site.
- Cross-contamination between patients
is avoided by disposing of the single-use
lens cover between uses.
- The device is approved for patients 5
years and older
Microcollection tubes (AKA Bullets)
- Hold up to 750 mL of blood. They are made of
plastic and are available with a variety of
anticoagulants and additives
- 1 mL = 1 microliter
Additives
# of
inversion
Laboratory
Used
K2EDTA
10X
Whole blood,
CBC,
Hematology
Lithium
Heparin
10x
Plasma,
Chemistry
Lithium
Heparin
and Gel
for plasma
separation
10x
Plasma,
Chemistry
NaFI/Na2
EDTA
10x
Glucose
Clot
Activator
and Gel
for serum
separation
5x
Serum,
Chemistry
No
additive
0x
Serum,
Chemistry,
Serology,
Blood Banking
Additional Supplies
- Alcohol pads
- Gauze pads
- Sharps disposal container
- Warming devices: increase circulation
- Heel warmers for infants
- Temperature:
should
exceed 42 degrees Celsius
- Applied for 3-5 minutes.
Glass slides
not
Microhematocrit Tubes
- Small tubes, either plastic or glass, with a
volume up to 75 mL. These tubes are used
infrequently and have been largely replaced by
microcollection containers.
PHLEB LEC MIDTERM TRANSES
Capillary Specimens made up of:
a. Arterial blood
b. Venous blood
c. Capillary blood
d. Interstitial fluid (a type of ECF)
e. Intracellular fluid (ICF)
Although potassium values are normally lower
in properly collected skin puncture specimens, levels
may be falsely elevated if there is tissue fluid
contamination or hemolysis of the specimen.
Indications for a Capillary Puncture
Adults and Older children
- Save veins for other procedures.
- Several unsuccessful venipunctures
- The patient has thrombotic or clot-forming
tendencies.
- The patient is apprehensive or has an intense
fear of needles.
- There are no accessible veins
- To obtain blood for POCT (Point-of-care-testing)
Methods of choice for older children and for adults
whose veins are inaccessible
Importance:
- Cancer
- Undergo chemotherapy
- Severely burned
- Patients who are obese and whose veins are not
visible or too deel to locate
- POCT (Point-of-care-testing)
- Bedside of patient; home
- Glucose testing (non-fasting)
- Geriartic patients
-
Patients with poor circulation (Shock)
Patient who is extremely cold - rectified by the
phlebotomist
Warming Devices (to prevent hemolysis/diluted)
1. Warm wet washcloth
2. Dry heat or Heat pack
- Heel warmers for infants
- Cooling effect
- Evaporation
3. Massaging patient's finger
Order of Draw
The CLSI (Clinical and Laboratory Standard Institute)
orders for capillary specimens is as follows:
1. Blood gas specimens (CBGs)
2. EDTA Specimens
3. Other Additives specimens
4. Serum specimens
Specimens for newborn screening tests should be
collected separately.
Capillary Puncture Steps
STEP 1: Review and Accession Test Request
STEP 2: Approach, Identify and Prepare Patient
STEP 3. Verify Diet Restrictions And Latex Sensitivity
STEP 4: Sanitize Hands And Put On Gloves
STEP 5: Position Patient
STEP 6: Select The Puncture/Incision Site
Special Procedures that Require Capillary Blood
- Example: Malarial Test
Infants and Young Children
- Infants have a small blood volume
- Can cause iatrogenic anemia
- Large quantities removed rapidly
- Obtaining blood from infants and children by
venipuncture
- Puncturing deep veins
- An infant or child can be injured
- For newborn screening tests.
Dermal puncture in adults and children is performed on
the third (middle) or fourth (ring) finger, on the palmar
surface (near the fleshy) of the center of the distal or
end segment.
Importance:
Infants
Some tests that cannot be collected for capillary
puncture:
- ESR (Erythrocyte Sedimentation Rate)
- Coagulation studies
- Blood culture
Limitations
- Severely dehydrated patients
Dermal
puncture in infants is performed on the heel, on the
medial and lateral borders only
PHLEB LEC MIDTERM TRANSES
Osteomyelitis is inflammation or swelling that occurs in
the bone.
Osteochondritis is a joint condition in which bone
underneath the cartilage of a joint dies due to lack of
blood flow.
Make Little People Happy - Median Lateral Plantar Heel
Sites for puncture
- Side or tip of the
finger should not be
punctured
- Site must be warm
- Finger must not be
swollen
STEP 7: Preparing the Site
CAUTION: The temperature of the material used to
warm the site must not exceed 42°C (108°F)
If a wet washcloth is used, be sure to remove
any residual water, as residual water will cause
hemolysis and dilution of the specimen.
- Massaging the finger proximal to the puncture
site (closer to the palm) can help increase blood
flow.
- To avoid hemolysis, massage gently, and
do not squeeze.
Step 8: Clean And Air-dry Site
- The CLSI recommended antiseptic for cleaning a
capillary puncture site is 70% isopropanol or
isopropyl alcohol.
- In addition to causing stinging, contamination,
and hemolysis, residual alcohol interferes with
the formation of rounded drops of blood on the
skin surface.
- Use of povidone–iodine is not
recommended for dermal punctures,
because it may elevate test results for
bilirubin, uric acid, phosphorus, and
potassium (BURPP)
Step 9: Prepare Equipment
- Hold the finger or heel firmly.
- This prevents it from moving during the
puncture and reassures the patient.
- Grasp the patient’s finger with its palmar
surface up, holding it between your thumb and
index finger.
- To hold the patient’s heel, place your thumb in
the arch, wrap your hand over the top of the
foot, and place your index finger behind the
heel.
Step 10: Puncture The Site And Discard Lancet
- Puncture the skin slightly lateral to the center of
the finger (that is, slightly toward the pinky
finger), so that the hand can be tilted for easier
blood flow into the container.
- Do not lift the device immediately after the
puncture is complete.
- Count to two before lifting the device to
ensure that the blade has made the
puncture to the full depth and then fully
retracted.
- Scraping of the skin may occur if the blade is not
retracted.
- Dispose of the used blade immediately in an
appropriate collection container.
- Failure to obtain blood: If you are unable to
obtain sufficient blood with the first puncture,
the policy at most institutions is to attempt one
more puncture. You must use a sterile lancet to
make the new puncture. After two unsuccessful
punctures, notify the nursing station and
contact a different phlebotomist to complete
the procedure.
Step 11: Wipe away the first drop of blood with a dry
gauze pad
- Because it may be contaminated with
tissue fluid or debris (sloughing skin)
Step 12: Fill And Mix Tubes/Containers In Order Of
Draw
- No MILKING
- Once blood is flowing freely, position the
container for collection.
- Microcollection tubes should be slanted
downward.
- Lightly touch the scoop of the tube to
the blood drop, and allow the blood to
run into the tube.
- Do not scrape the skin with the container. This
causes hemolysis, activates platelets, and
contaminates the sample with epithelial skin
cells.
- Tap the container lightly to move blood to the
bottom. Close the lid after the sample has been
collected.
- Invert the tube 8 to 10 times after filling if
additives are present.
- Be careful not to overfill the microcollection
tube containing anticoagulant because the ratio
of anticoagulant to blood will be exceeded and
microclots will form.
- The collection will need to be repeated due to
inaccurate test results.
- Order of collection: Platelet counts, complete
blood counts (CBCs) and other hematology tests
are collected first, followed by chemistry tests.
- Be mindful of specimens that require special
handling before transport.
Step 13: Place Gauze And Apply Pressure
- Once bleeding has stopped, you can bandage
the site for older children and adults.
PHLEB LEC MIDTERM TRANSES
Step 14: Label Specimen And Observe Special Handling
Instructions
- When drawing blood from children and infants,
be especially careful that all equipment has
been picked up and bed rails have been placed
back in position.
- Label the microsample container, and place it in
a larger holder for transport to the laboratory
Step 15: Check The Site And Apply Bandage
- Do not use a bandage on children younger than
age 2, as they may remove the bandage and
choke on it.
Step 16: Dispose Of Used And Contaminated
Materials
Step 17: Thank Patient, Remove Gloves, And Sanitize
Hands
Step 18: Transport Specimen To The Lab
Blood Smear
- Drop of blood spread thin on a microscope
slide.
EDTA - Within 1 hr
cause severe mental handicaps or other serious
abnormalities if not detected and treated early.
- Phenylketonuria
- A PKU screening test is a blood
test given to newborns one to
three days after birth. PKU
stands for phenylketonuria. It is
a rare disorder that prevents
the body from breaking down
part of a protein called
phenylalanine (Phe). Phe is in all
foods that contain protein, such
as milk, meats, and nuts. It's
also in an artificial sweetener
called aspartame.
- Hypothyroidism
- Decreased thyroid hormone
production in a newborn. In
very rare cases, no thyroid
hormone is produced. The
condition
is
also
called
congenital
hypothyroidism.
Congenital means present from
birth.
- Galactosemia
- Inherited defect of galactose
metabolism caused by an
enzyme
deficiency
that
prevents proper metabolism
and utilization of galactose, or
milk sugar. The main dietary
source of galactose is lactose,
the principle carbohydrate
found in all forms of milk.
Things to remember
- The capillary tube or micro-container tube
should not touch the puncture site.
- Depth of puncture for adults is approximately
3mm
- One error: puncture not deep enough and not
obtain a good bleed
- If puncture is adequate, 0.5mL of blood can be
collected
- Wipe the first drop of blood
- Blood flow can be enhanced by applying
continuous pressure to surrounding tissues
- Rapid milking does not enhance blood flow
- Excessive pressure may cause hemolysis or
contamination with tissue fluid
Special Capillary Puncture Procedure
1. Capillary Blood Gases
2. Neonatal Bilirubin Collection
3. Newborn/neonatal Screening
- The state mandated testing of newborns for the
presence of certain genetic (inherited),
metabolic (chemical changes within living cells),
hormonal, and functional disorders that can
Capillary Puncture for Babies
- Plantar surface of the heel
- Depth of puncture: 2mm
Precautions
- Excessive crying of the infant can lead to
elevated leukocyte count.
- Hemolysis
- Alcohol not allowed to completely air
dry
- Finger or heel squeezed too vigorously
- Newborns have increased RBC fragility
- Blood was scraped off
PHLEB LEC MIDTERM TRANSES