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Prelim- Midterms Lessons PMLS 2 Lecture
Medical Laboratory Science (Davao Doctors College)
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LESSON
1:
PHLEBOTOMY
UNDERSTANDING
WHAT IS PHLEBOTOMY?
➢ The process of collecting blood.
➢ Phleb - vein
➢ Tomia (Greek) - cutting
➢ Temnien (Greek) - to cut
➢ Vena (Latin) - vein
➢ Sectio (Latin) - cutting
MIDDLE AGE
➢ Dates back to early Egyptians: it was once thought
that the practice would rid the body of diseases and
provide a cure for almost all ailments.
For thousands of years, medical practitioners clung to the
belief that sickness was merely the result of a little “bad
blood.” With this in mind, patients with a fever or other
ailment were often diagnosed with an overabundance of
blood. To restore bodily harmony, their doctor would simply
cut open a vein and drain the blood.
Picture a Roman gladiator bleeding from battle and would
receive a treatment of further bleeding. The unfortunate
result of the practice became one reason why it did not last
very long.
➢ 12th century: blood letting was practiced by
barbers (because of their skill with sharp
instruments). Barbering was known as a barbersurgeon for 1000 years. They used to perform
blood letting, surgery, extracting teeth and herb
administration. Thus, the red and white poles.
➢ Dec 1799: George Washington, the first pres of US,
had a severe throat infection. The cure that was
used as an intervention was massive bleeding. He
bled more than 9 pints of blood in less than 24
hours and died on Dec 14. after his death, the
philosophy of bleeding as a cure to diseases
changed.
➢ Mid 19th century: blood letting was no longer
considered a cure of illness (man in picture right
most is anton van leeuwenhoek)
➢ The discovery of microorganisms as the causative
agent for many diseases started to change the way
they treat diseases. Blood began to be examined
for diagnostic purposes.
➢ Venesection - most common; a sharp lancet-like
instrumtion that pulled blood to the capillaries under
the cup. Then a spring-loaded box containing
multiple blades cut the area to produce massive
bleeding. Both methods produced much scarring
➢ Leeching (Hirudotherapy) - more modern method
was to use leeches
Ex. When a person’s finger is reattached after accidental
amputation, the arteries and veins do not return to normal
blood flow immediately. The blood tends to pool at the end of
the finger, thereby causing pain and pressure. The leech is
placed on the end of the finger to remove excess blood and
relieve the symptoms. The only problem is that leeches get
full fast so you need to change it after several hours.
Bleeding of individuals to reduce the amt of blood does
occur today to treat diseases like polycythemia vera and
hereditary hemochromatosis. It is called “therapeutic
phlebotomy”.
Blood is still removed to cure the person, but it is primarily
done to FIND a cure, not as the cure itself.
Blood as changed from being therapeutic to being
diagnostic. Thousands of different types of diagnostic tests
are available.
➢ Fleams - are used to puncture vessels and then
allow excess blood to drain out of the body.
➢ Bloodletting - medicine’s oldest practice.
➢ Over abundance of blood or plethora is known as
the cause of illness.
Centralized Phlebotomy (85% of hospitals)
The phlebotomist is part of the laboratory team is dispatched
to hospital units to be collected blood samples. Sample
collection wherein the phlebo is part of the lab team and is
dispatched to hospital units to collect blood samples rounds
per hour then process samples.
Decentralized Phlebotomy (15% of hospitals)
Patient-focused care. The duties of the hospital revolve more
than around the patient. it is easier to use the people who
are already working. The nurse needs to learn phlebo and
the phlebo needs to learn nursing duties; called “patientfocused care”, the duties of the hospital staff revolve more
than around the patient; job is not restricted to one duty;
“patient care technician”.
Hybrid Phlebotomy
Blend of centralized and decentralized. send lab-based
phlebo to nursing units for blood collection and keep some
phlebo available to help patient care technicians for diff draw.
ANCILLARY HOSPITAL AREAS
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Administration - keeps the hospital in compliance
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Electrocardiography - monitors patients with
cardiovascular disease
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Electroencephalography
diagnosis
of
neurophysical disorders
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Environmental services - maintains a clean facility
Food services - provides diets to patients
GI lab - diagnosing gastrointestinal disorders
Laboratory - provides testing of patient samples
Medical records - maintains patient records
Nursing - provides direct patient care
Occupational Therapy - provides therapy to help
maintain livings skills
Pharmacy - dispenses drugs and advises drug
usage
Physical Therapy - provides therapy to restore
mobility
Radiology - uses imaging for diagnosis and
treatment
Respiratory Therapy - provides therapy to
evaluate the lungs
Speech therapy - provides therapy to retore speech
AREAS OF NURSING CARE
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Coronary Heart Unit - increased care of patient
due to heart condition
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Emergency department - emergency treatment
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Geriatric - elderly patients
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Intensive Care Unit - increased care due to critical
needs of the patient
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Neonatal - newborn care
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Nephropathy - patients on dialysis
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Obstetrics - patients in labor of childbirth
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Oncology - patients with cancer
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Orthopedic - patients with broken bones
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Pediatrics - infants and children
➢ Recovery - recovery treatment of patientsent
pierced the veins and made them bleed
➢ Cupping - heated glass cup was placed on a
person’s back. As the cup cooled, it created a suc
LABORATORY SECTIONS
1. Administrative Office. Does the paper works, responds
to calls, handles specimen collection requests.
2. Phlebotomy. Collect sample from patients and processes
samples for testing and transport
3. Urinalysis. Study of urine and other body fluids. Performs
quali and quanti chemical and microscopic exam of urine to
detect UTI, diabetes, kidney or liver diseases.
4. Hematology. Studies blood in normal and diseased
states. Usually limited to the study of cellular components
and not the chemistry of blood. Studies blood cells and
performs qualitative and quantitative analysis along w/
microscopic evaluations.
Ex. CBC, RBC count, WBC count, Hemoglobin, Hematocrit,
Platelet count, Sedimentation rate, Body fluid cells counts
5. Coagulation. Study of blood clotting mechanisms. Or
hemostasis Usually the same area as hematology Study of
the clotting of blood.
Ex. PT, aPTT, factor VIII, Fibrinogen assay, Heparin level,
vWF
6. Clinical Chemistry. Performs biochemical analysis of
blood and body fluids. Works with the fluid portion of the
blood (Serum/Plasma) or other body fluids. Performs
biochemical analysis. In most procedures: Sample is added
to various chemicals and a color or chemical change occurs.
Ex. Metabollic panel, Hepatic panel, Renal panel, Iron
studies, Glucose, Cholesterol, Enzymes, The intensity of
color produced means the more glucose is in the blood
7. Microbiology. Cultures samples to determine if
pathogenic organisms are present in a sample. Determines
organism’s antibiotic susceptibility.
8. Immunology. Studies antigen and antibody to determine
immunity or presence of disease. Antigens- substances that
are foreign to the body Antibodies- proteins made by the
body to combat antigens.
Ex. HIV testing, Rubella, RPR, VDRL, Hepatitis testing
9. Blood Banking. Determines compatability of blood and
blood products to be administered to the patient.
Ex. Crossmatching, ABO blood typing, Rh typing, antibody
panel testing
10. Cytogenetics. Study of deficiencies related to genetic
diseases
Ex. Chromosome analysis, prenatal chromosome screening
11. Molecular Diagnosis. Using PCR technologies to study
the presence of various diseases and infections.
Ex. MRSA infections, HIV testing
12. Histopathology. Examines tissues and cell smears for
evidence of cancer, infection or other abnormalities.
13. STAT Requests. Emergency cases. Tested individually,
not wait for batch processing.
14. Out Patient Department. Patients who are not admitted
in the hospital. Lab aims to achieve the least turn around
time.
LABORATORY STAFF
1. Pathologist. Reads and interprets result. Examines
tissues under microscope. Requires 5 years of training after
graduating from medschool to be eligible to be a certified
pathologist.
2. Medical Laboratory Scientist. Performing wide range of
laboratory tests. Confirming and reporting laboratory tests.
Holds a minimum of baccalaureate degree in MLS.
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varying job description from one health care facility
to the other
cross trained for: venipuncture, capillary collection,
patient care, receptionist duties, sample processing
and computer work
traditional role of phlebotomist is only one job: TO
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COLLECT BLOOD SAMPLES
3. Medical Laboratory technician. Under the supervision of
Med Lab Sci. Performs general tests. Cannot release result.
Depends on board rating. Need special training aside from
hs diploma.
4. Phlebotomy technician. Collect blood samples
5. Histotechnologist. Prepares body tissue samples for
microscopic evaluation of pathologist.
PHASES OF SAMPLE PROCESSING
Pre-examination
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Request form
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Patient identification and information
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Correct sample collection
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Correct use of all equipment
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Sample preparation and centrifugation
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Maintaining sample integrity until processing
Examination
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Sample testing
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Maintaining testing equipment and reagents
Post-examination
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Reporting of results
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Ensuring accuracy and reliablity of the delivery of
the result
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Follow-up if repeat testing is needed or attend to
other needs of the physician
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Storage of sample after processing
LESSON 2: INFECTION CONTROL
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WHAT IS INFECTION CONTROL?
➢ Prevention of nosocomial or health care associated
infections. Controlling the spread of disease and
minimizing the number of healthcare-associated
infections.
➢ Infection control is the discipline concerned with
preventing nosocomial or healthcare-associated
infections. It is about identifying and controlling the
factors involved with the spread of these infections,
whether from patient-to-patient, from patients to
staff, from staff to patients, or among-staff.
FACTORS
● Prevention
● Monitoring/Investigation
● Surveillance, Investigation and Management
(Hand Hygiene, Contact Tracing, Asset Management,
Medical Scope Management, Enviornmental Monitoring,
Surgical Sterile Processing)
NOSOCOMIAL VS. COMMUNITY ACQUIRED INFECTION
Nosocomial Infection
➢ Infections contracted within hospital or those
becoming clinically apparent til the discharge of the
patient or infections contracted by the healthcare
professionals as a result of their direct or indirect
contact with the patients.
➢ The patient contracts the disease during the
hospital stay.
Community Acquired Infection
➢ Infections that are contracted outside the hospital or
those who become clinically apparent within 48
hours from the hospital admission are community
acquired infections.
➢ The disease is contracted by the patient before
getting admitted to the hospital.
CHAIN OF INFECTION
● Agent
● Reservoir
● Portal of Exit
● Mode of Transmission
● Portal of Entry
● Susceptible Host
PERSONAL PROTECTIVE EQUIPMENT
● Lab Gown - Adds an additional layer of protection
for skin.
● Gloves - Avoid direct contact to highly infectious
agents.
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Mask - Required when drawing blood from patients
with transmissible diseases.
Goggles - Protects eyes from spills and splashes.
Long hair must be tied back.
Long pants that cover ankle.
Shirts that cover your torso are required. Crop tops
are not allowed.
Natural fibers are recommended because they are
fire resistant.
Shoes completely enclose the foot and can be
wiped clean.
DIFFERENT TYPES OF MASKS
● N95 (Strongest protection)
● Surgical Mask (Medical use)
● FFP1 Mask (Filtere suspended particles)
● Activate Carbon (Stops odor)
● Cloth Mask (DIY)
● Sponge Mask (Fashion use)
HAND HYGIENE
1. Before touching a patient
2. Before clean/aseptic procedure
3. After body fluid exposure risk
4. After touching a patient
5. After touching patient sorroundings
ISOLATION
Isolation precautions should be used for patients who
are either known or suspected to have an infectious disease,
are colonised or infected with a multi-resistant organism or
who are particularly susceptible to infection. isolation
procedures separate certain patients from others and limit
tHeir contact with hospital personnel and visitors. It is
important that standard precautions are implemented at all
times and all patients must be assessed on admission to
ensure that they are placed in appropriate isolation if
necessary.
1. Source Isolation - when patients with contagious
disease are placed into a room to protect other
people from becoming infected. Isolation rooms are
usually under negative pressure to prvent room air
from entering the hallway. Air evacuated from the
room passes through a HEPA filter.
2. Protective
isolation
protect
an
immunocompromised patient who is at high risk of
acquiring microorganisms from either the
environment or from other patients, staff or visitors.
Positive room air pressure relative to corridors,
along HEPA filtration of incoming air at >12 air
changes per hour. Also recommended for
allogeneic hematopoietic stem cell transplant
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patients.
STANDARD PRECAUTIONS
Are used in the care of all hospitalized persons
regardless of their diagnosis or possible infection status.
Tthey apply to blood, all body fluids, secretions and
excretions, except sweat (whether or not blood is present or
visible), broken skin, and mucous membranes. Designed to
reduce the risk of transmission of microorganisms from
recognized and unrecognized sources.
TRANSMISSION-BASED PRECAUTIONS
● AIRBORNE PRECAUTIONS - designed to reduce
the risk of infection that can be spread through the
air transmission occurs when tiny droplets or dust
containing the infected agent are suspended in the
air for long periods. The agent can float in the air
currents of the facility and can be inhaled by or
deposited on a susceptible person.
● DROPLET PRECAUTIONS - designed to reduce
the risk of infection that can be spread when the
infected droplet contacts the eyes, nose or mouth of
a susceptible person. These are large droplets and
only travel a short distance before falling to the
ground, usually about 3 feet.
- the mask used for droplet precautions is
for one time use and to be disposed of in
the patient room. Do not reuse.
● CONTACT PRECAUTIONS - designed to
reducethe transmission risk of epidemiologically
important micro-organisms by direct or indirect
contact.
- contact involves dry or moist substances
and physical transfer of microorganism
from an inanimate object to a susceptible
person.
- when patient is in contact precautions:
keep door closed, upon entering room don
gloves and gown if you might have contact
with patient or environment.
- place in regular room to reduce the risk of
infection that can be spread when the
infected droplet contacts the eyes, nose or
mouth of a susceptible person. These are
large droplets and only travel a short
distance before falling to the ground,
usually about 3 feet.
- The mask used for droplet precautions is
for one time use and to be disposed of in
the patient room. Do not reuse.
LESSON 3: CIRCULATORY SYSTEM
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WHAT IS A CIRCULATORY SYSTEM?
➢ An organ system that permits blood to circulate and
transports nutrient, oxygen, carbon dioxide,
hormones, and blood cells to and from the cells in
the body to provide nourishment and help in fighting
diseases, stabilize temperature and pH, and
maintain homeostasis.
➢ It includes the Pulmonary Circulation and Systemic
Circulation.
➢ The circulatory system is centered on the HEART, a
muscular organ that rhythmically pumps BLOOD
around a complex network of BLOOD VESSELS
extending to every part of the body.
➢ Blood carries the oxygen and nutrients needed to
fuel the activities of the body’s tissues and organs,
and it plays a vital role in removing the body’s
waste products. An average-sized adult carries
about 5 litres (9 pints) of blood.
PULMONARY CIRCULATION
A "loop" from the heart through the lungs where blood is
oxygenated. Sends oxygen-depleted (deoxygenated) blood
away from the heart through the pulmonary artery to the
lungs and returns oxygenated blood to the heart through the
pulmonary veins.
RIGHT ATRIUM - the upper chamber of the right side of
the heart. The blood that is returned to the right atrium is
deoxygenated (poor in oxygen) and passed into the RIGHT
VENTRICLE to be pumped through the PULMONARY
ARTERY to the lungs for re-oxygenation and removal of
carbon dioxide. PULMONARY ARTERY - this artery divides
above the heart into two branches, to the right and left lungs,
where the further subdivide into smaller and smaller
branches until the capillaries in the pulmonary air sacs
(alveoli) are reached. In the capillaries the blood takes up
oxygen from the air breathed into the air sacs and releases
carbon dioxide. It then flows into larger and larger vessels
until the PULMONARY VEINS. PULMONARY VEINS usually
four in number, each serving a whole lobe of the lung. The
pulmonary veins open into the LEFT ATRIUM of the heart.
LEFT ATRIUM - receives newly oxygenated blood from the
lungs
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Right Atrium
Right Ventricle
Pulmonary Artery
Pulmonary Arterioles
Pulmonary Capillaries
Pulmonary Ventricles
Pulmonary Veins
Left Atrium
SYSTEMIC CIRCULATION
Provides the functional blood supply to all body tissue. It
carries oxygen and nutrients to the cells and picks up carbon
dioxide and waste products.
- network of veins, arteries and blood vessels that
transports blood from heart, services the body's
cells and then re-enters the heart. Blood is pumped
from the LEFT VENTRICLE of the heart through
the AORTA and arterial branches to the
ARTERIOLES and through CAPILLARIES, where
it reaches an equilibrium with the TISSUE FLUID,
and then drains through the venules into the VEINS
and returns, via the SUPERIOR AND INFERIOR
VENAE CAVAE, to the RIGHT ATRIUM of the
heart.
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Left Ventricle
Aorta
Arteries
Tissues
Veins
Superior and Inferior Vena Cava
Right Atrium
VASCULAR SYSTEM
➢ Arteries. Oxygen-rich blood (bright red). have thick
walls to withstand the pressure of ventricular
contraction, which creates a pulse that can be felt,
distinguishing them from veins. When arterial blood
is collected by syringe, the pressure normally
causes blood to “pump” or pulse into the syringe
under its own power.
➢ Veins. Oxygen-poor blood (brick red). have thinner
walls than the same-size arteries because blood in
them is under less pressure. Consequently, they
collapse more easily. Blood is kept moving through
veins by skeletal muscle movement and the
opening and closing of valves that line their inner
walls.
➢ Capillaries. Allow the exchange of gases and other
substances between the tissues and the blood.only
one cell thick. The capillary bed in the skin can
easily be punctured with a lancet to provide blood
specimens for testing.
PHLEBOTOMY-RELATED VASCULAR ANATOMY
The major veins for venipuncture are in the antecubital
fossa, the area of the arm in front of the elbow. Here, several
large veins lie near the surface, making them easier to locate
and draw blood from. Although exact locations vary slightly
from person to person, two basic patterns in which the veins
from the shape of either an H or an M are seen most often.
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H PATTERN (displayed approximately 70% of the
population)
● Medican Cubital Vein
- preferred vein for venipuncture in the H pattern
because it is typically large, closer to the surface,
and the most stationary, making it the easiest and
least painful to puncture and the least likely to
bruise.
- Near the center of the antecubital fossa.
- Preferred vein for venicpuncture.
● Cephalic Vein
- second-choice vein
- although often harder to palpate(feel) than the
median cubital, it is fairly well anchored and often
the only vein that can be felt in obese patients
- Laspect of the antecubutal fossa.
● Basilic Vein
- last choice vein
- although normally large and easy to feel, it is not
well anchored and rolls easily, increasing risk of
puncturing a median cutaneous nerve branch or the
brachial artery that is nearby
- Medial site of the antecubital fossa.
venipuncture. Veins on the underside of the wrist, however,
should NEVER be used for venipuncture. Leg, ankle, and
foot veins are sometimes used but not without permission of
the patient’s physician, due to a potential for significant
medical condition.
M PATTERN
● Median Vein
- Center-most vein.
- it is the first-choice vein in the M pattern
because it is well anchored, tends to be
less painful, and is not as close to major
nerves or arteries as the others, making it
generally safest to puncture.
● Median Cephalic vein
- Branches from the medin vein to the
lateral aspect of the arm.
- it is the second choice M-pattern vein
because it is accessible, unlikely to roll,
less painful, located far enough away from
major nerves or arteries, and generally
safe to puncture.
● Median Basilic vein
- Branches fromt the median to the medial
aspect of the arm.
- it is the 3rd choice in the M pattern
because, although it may appear more
accessible, it is located near the anterior
and posterior branches of the median
cutaneous nerve
Although antecubital veins are used most frequently, veins
on the back of the hand and wrist may also be used for
LESSON
4:
REQUIREMENTS
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PHLEBOTOMY
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EQUIPMENTS
All methods of venipuncture require an invasive procedure of
entering a vein to obtain a blood sample. The syringe and
needle method is one of the oldest methods known that does
not destroy the integrity of the vein. Syringes are made of
glass or plastic (mostly plastic).
How to use:
1. Pull the plunger to create a vacuum within the barrel (The
plunger on a syringe is often hard to pull. A technique called
breathing the syringe needs to be done before it is used. Pull
the plunger midway then push it back to make the plunger
pull smoothly).
2. The vacuum created while pulling the plunger while a
needle is in a patient’s vein fills the syringe with blood (the
larger the syringe, the greater blood). A too large vacuum
has the tendency to pull too hard on the vein and collapse it.
pull the plunger slowly. Syringes are used for difficult to draw
veins such as fragile, thin and rolly veins.
Needle gauge and needle use:
27: skin tests
25: intramuscular injections (cannot be used for veni bc
RBCs will be destroyed when the blood is pulled thru the
bore)
23: butterfly or syringe collection (most common for children)
22-20: syringe or ETS collection (21 most common for
adults)
18-16: IVs or blood donation
A tube with a vacuum already in it attaches to the needle and
the tube’s vacuum is replaced by blood.
Needle used on a syringe consists of a hub, cannula (shaft)
and a bevel. Hub: attached to a syringe (screw the hub)
Recommended length of a needle: 1- 1 ½ inch. The gauge of
the needle is determined by the diameter of the lumen or
opening. Needle gauge is inversely proportional to the
needle bore. The bevel must always be facing upward, the
opening of the needle should be visible.
Parts:
1. Double pointed needle
➢ The needle is a straight hollow type with double
points and a screw hub near the center
➢ The needle outside the holder punctures the skin
while the needle inside the holder pierces the
➢ rubber stopper of an evacuated tube
➢ The bevel must always be facing upward, the
opening of the needle should be visible
➢ The bevel is cut at an angle so as to ensure
maximum blood flow thru the needle
➢ Needle should be inserted at 15-30 degree angle
➢ The deeper the vein, the greater angle you will use
(superficial vein: 15° deep vein: 30°)
2. Adapter (holder)
➢ Where the phlebo holds
3. Vacuum tubes
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SPS: allows bacteria to grow so that they can be cultured
SERUM: liquid portion of coagulated or clotted blood;
fibrinogen and other clotting factors are not present since it
is being used up during clotting.
PLASMA: liquid portion of anticoagulated blood; fibrinogen
and other clotting factors are present since it is not used up
because of the presence of an anticoagulant.
The liquid portion contains water, proteins (including
enzymes and some hormones) and others.
RED TOP (plastic): no anticoag but contains silica particles
as clot activator
RED TOP (glass): no anticoag and additive bc the glass
itself serves as a clot activator
GOLD TOP: aka serum separator tube; no
anticoag but contains a separator gel
(thixotropic
gel)→
principle:
upon
centrifugation, the di昀昀erent speci昀椀c gravity
will separate the components topmost:
serum then gel then formed elements
GREEN TOP: heparin is the anticoagulant naturally found in
the body, thus, it has the least effect on chemistry tests.
Preferred anticoagulant for CC; best for blood gas studies,
electrolyte studies. 3 forms of heparin: lithium, sodium and
ammonium heparin
LIGHT GREEN TOP: aka plasma separator tube
LIGHT BLUE TOP: 2 concentrations: 3.2% (0.105M)
(preferred) and 3.8% (0.129M). Chelates calcium means that
it binds to calcium or forms calcium salts to remove calcium
Tube must strictly be filled 100%; blood to anticoagulant ratio
is 9:1, if the ratio is not achieved, the results will be invalid.
BLACK TOP: blood to anticoagulant ratio is 4:1.
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LAVENDER TOP: has 3 concentrations
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Plastic (spray-dried): K2 EDTA or dipotassium
EDTA (recommended bc it preserves the cell
morphology and provides stable microhct result)
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Glass (liquid): K3 EDTA or tripotassium EDTA
(commercial name: sequestrene)
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NA2 EDTA or disodium EDTA (commercial name:
versene)
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GRAY TOP: also contains an antiglycolytic agent:
Sodium fluoride (if not available, iodoacetate can be
used as an alternative antiglyco agent)
veins are near the skin surface, the winged needle is
inserted at a 5 degree angle instead of the usual 15-30 in.
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Other uncommon tubes
WHITE TOP OR PEARL TOP: helpful in HIV testing
ORANGE TOP: thrombin is the most potent clot activator;
used in STAT chemistries bc the optimum clotting time is 510 min.
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Applied tight enough to slow the flow of blood in the
veins but not prevent the flow of blood in the
arteries
Modern: do not use latex tourniquets as to avoid
latex exposure and allergy
Patient should close his or her hand to make the
vein prominent (dili mangusog dapat)
Palpating vein (one of the most difficult skills to
learn): using the finger to press down on top of the
vein to feel the “bounce” or running the finger
across the arm to feel the “speed bump”
Should not be on the arm for more than 1 min; can
cause hemoconcentration: increased concentration
of cellular compponents in the sample
Blood pressure cuff (sphygmomanometer) can be
used as an alternative (can be used for obese,
pediatric or geriatric px)
BUTTERFLY or winged infusion set COLLECTION SYSTEM
Holding the plastic wings provide easy access into small
surface veins on the back of the hand, the arm or foot. 3-12
inch tubing leads from the needle to a hub that could be
attached to either a syringe barrel or evacuated tube needle
adapter called luer adapter. When disposing in sharps
container, hold the plastic wing and drop the tubing next (so
as to prevent needle stick injury bc of the tubing) Since these
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Cleansing Agents
● Disinfectant - removes or kills micoorganisms and
instruments
- 10% sodium hypochlorite (best)
● Antiseptic - prevents microorganisms and their
toxins from infecting the blood
- 70% isopropyl alcohol (most common and
best)
● Hand Sanitizer - Alcohol-based rinses, gels and
foams
- Can replace handwashing if hands are not
visibly soiled
Microcollect equipment
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Non-spring loaded lancets
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Spring loaded lancets
LESSON
1:
PROCEDURES
VENIPUNCTURE
STEPS IN BLOOD COLLECTION:
STEP 1: Preparation request form the patient.
● Patient’s complete name
● Age
● Date of birth
● Patient identification number
● Type of test to be collected
● Date and time the sample is to be obtained
● Department or location of the patient
● Clinical impression/diagnosis
● Physician’s name
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STEP 2: Greet and identify the patient.
● Conscious Patients (out-patient)
● Ask patient to give their full name and spell
their last name
● Compare the information on the request
form
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Conscious patients (in-patient)
● Ask patient to give their full name and spell
their last name
● Compare the information on their
identification bracelet and request form
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Sleeping patient
● Awaken a sleeping patient before
attempting venipuncture
● If the patient is already awake, do the
same steps as conscious patients.
●
Semi-conscious or comatose patients
● Ask the watcher or nurse, if no nurse is
around to identify the patient
● Compare the information on the
identification bracelet and request form
● Too young, mentally incompetent or do not
speak the language of a phlebotomist
● Ask the watcher or nurse, if no nurse is
around to identify the patient
● Compare the information on the
identification bracelet and request form
●
Unidentified Emergency patient.
● Upon admission, a temporary identification
number will be assigned to the patient.
Use this ID number on all tests.
● When a permanent number or when the
patient has already been identified crossreference it with the temporary number.
STEP 3: Verify diet restriction, latex sensitivity, and other
allergies.
STEP 4: Sanitize hands and position the patient properly.
STEP 5: Assemble equipment and supplies.
STEP 6: Apply tourniquet. Ask the patient to make a fist
without vigorous hand pumping. Select a suitable vein for
puncture.
Burns, scars or tattoos
Damaged veins - springy feel when vein is
palpated/touched.
Edema
Hematoma - causes hemolysis.
Mastectomy - breast cancer (prone to infection and
swelling)
IV line, Cannula, Fistula
Tourniquet: should be 3-4 inches above the site.
Vigorous hand pumping will have effects in some tests
Burns, scars or tattoos: impaired circulation, hard to
palpate and draw from
Damaged veins: Sclerosed (hardened), thrombosed
(clotted)
Edema (swelling/high tissue fluid): veins are not prominent
and hard to locate; tourniquet will be ineffective due to
swelling
Hematoma (leakage of blood in surrounding tissues): painful
and erroneous test results
Mastectomy (lymph node removal): susceptible to swelling
and infection
IV line, cannula, fistula: draw on the opposite arm.
Cannula: a thin tube inserted into a vein or body cavity to
administer medicine, drain off fluid, or insert a surgical
instrument
IV line: If both arms have IV lines and no other vein is
available, ask the nurse to turn off the IV fluid for 5 minutes,
discard the first 5ml of blood then collect the desired sample.
Ask the nurse to turn the IV fluid back on.
STEP 7: Put on gloves. Cleanse the venipuncture site with
70% isopropyl alcohol. Allow the area to air dry.
STEP 8: Anchor the vein firmly.
STEP 9: Enter the skin with a needle at approximately 30degree angle, bevel up.
● If using a syringe, pull back on the barrel with a
slow, even tension up to the desired volume of
blood.
● If using ETS, as soon as the needle is in the vein,
ease the tube forward as far as it will go.
- When the tube is filled, remove and invert
the tube gently.
ORDER OF DRAW:
● Blood culture bottles (sterile procedure)
● Coagulation tubes
● Serum tubes with or without clot activator or gel
serum separator
● EDTA tubes
● Oxalate/fluoride, glycolytic inhibitor tubes
SITES TO BE AVOIDED:
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STEP 10: Release the tourniquet. Never withdraw the
needle without removing the tourniquet.
STEP 11: Place gauze, withdraw needle, and apply
pressure.
STEP 12: Properly recap the needle using “fishing out”
technique.
STEP 13: Check the condition of the patient.
STEP 14: Dispose contaminated material (needle and
holder, and syringe) in designated containers using
universal precautions
STEP 15: Label tubes at patient’s side.
● Place label directly under the cap
● Name at the top
● Barcode straight
● Collector’s user id
● Leave visible window to be seen
● Patient first and last name, date and time of
collection, identification number, and initials of
phlebotomist
LESSON
2:
PROBLEMS
ENCOUNTERED IN VENIPUNCTURE
PAIN
Most common patient reaction. Px may indicate that the
venipuncture is painful. Releasing the tourniquet (it may be
pinching the arm and causing pain rather than the needle)
Discontinue the venipuncture if the px idicates sharp,
piercing pain. Avoid deep, probing or fishing venipuncture
esp in the area of basilic vein.
● Reposition the needle
● Release the tourniquet
● Discontinue venipuncture
● Avoid deep, probing venipunctures
NERVE DAMAGE
Caused by deep, probing or fishing out veni esp in the area
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of basilic vein. First felt by a tingling or numbing of arm or
hand may result in legal issues. Avoid probing venipunctures
and puncture only veins that can be felt. Deep punctures can
also result in puncturing an artery.
● If the nerve is only touched, not damaged, it may be
gone in a few hours or days.
● If damaged, numbness could be permanent
● Discontinue venipuncture
NAUSEA
● Make the patient as comfy as possible
● Instruct him/her to breathe slowly
● Apply cold compress if necessary
● Give waste basket or container and have tissues
and water ready
SYNCOPE
● Warning signs: perspiration beads on the forehead,
hyperventilation, loss of color
● Vasovagal syncope - fainting due to abrupt pain or
trauma
● Discontinue venipuncture
● Lower the head and arms
DIABETIC SHOCK
● Experience hypoglycemia because they fasted
● If conscious, let them drink a glass of orange juice
or cola will temporary help
● If unconscious, call a physician
CONVULSIONS
● Patient become unconscious and exhibit mild to
violent uncontrollable movements
● Do not restrain the patient
● Move objects out of the way; protect the head
● Patient will usually recover after a few minute
CARDIAC ARREST
● Patient will fall into unconsciousness, no pulse or
respiration, dilated eyes and pale skin
● Immediate CPR
CONTINUOUS BLEEDING
● Some patients take more than 5 minutes for the site
to stop bleeding
● Continue to wrap an elastic gauze around the arm
with a pad
● Leave it on for 15 minutes or until the bleeding
stops
SKIN ALLERGIES
● Some patient are allergic to latex, tape or iodine
● Use hypoallergenic tape and non-latex wrap
HEMATOMA
● Discontinue venipuncture and apply heavy pressure
on the site of puncture.
● Leakage of blood under the skin at the site of
venipunctureat the first sign of hematoma,
Discontinue venipuncture and apply heavy pressure
● Petechiae: small red dots that are indications of
small amounts of bleeding under the skin surface
often a result of low plt count or coagulation
problems
● The puncture should not be too deep to pass
through the top and bottom walls of the vein
(“through and through”)
UNUSUAL BLOOD SAMPLES:
● Icteric sample - serum/plasma that contains large
amounts of bilirubin.
- Patient presents with jaundice
● Lipemic sample - milky and cloudy, serum/plasma
contains large amounts of fats and lipids.
- May be due to patient not fasting
● Hemolyzed sample - serum/plasma contaminated
with RBC contents.
CAUSES OF HEMOLYSIS:
a. Drawing from a hematoma
b. Rupturing of RBCs by using a needle that is too
small
c. Alcohol on the site of venipuncture that entered the
blood sample
d. Pulling the plunger too forcibly
e. Fast drip/expelling blood vigorously as it is
transferred to the tube
f. Redirecting
g. Mixing tubes vigorously
POSSIBLE CAUSES FOR FAILED VENIPUNCTURE:
● Vacuum in tube is not working
● Bevel against the vein wall
● Bevel inserted too far
● Needle partially inserted
● Needle slipped beside the vein
● Collapsed vein
● Undetermined needle position
TECHNIQUES TO ENHANCE VEIN AND RECOVER A
FAILED VENIPUNCTURE:
● Retie the tourniquet
● Use a blood pressure cuff in place of a tourniquet
● Massage the arm or warm the location
● Lower patient’s arm
● Reseat the tube holder
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Use a different tube
Place your finger below the venipuncture site and
stretch the vein slightly
Pull back or advance the needle slightly
Rotate the needle one quarter to one half turn.
Make sure to pull a little backward before
redirecting
Venipuncture attempts should be upto 2 tries only.
Ask someone else to do it (endorse to another staff)
COMMON ERRORS IN SPECIMEN COLLECTION:
● Misidentification of patient
● Mislabeling of the patient
● Short draws/wrong AC/blood ratio
● Mixing problems/clots
● Hemolysis/lipemia
● Hemoconcentration from prolonged tourniquet time
● Exposure to light/extreme temperatures
● Improperly tied specimen/delayed delivery to the
laboratory
● Processing errors: incomplete centrifugation,
improper storage
SPECIMEN CONSIDERATIONS ADDITIONAL:
Position or posture
- changes in posture result to efflux of filterable substances
from the intravascular space to the interstitial fluid spaces
- non filterable substances increases in concentration
Tourniquet application
● Hemoconcentration: blood pooling at the
venipuncture site.
If the phlebotomist takes longer than one minute to assess
and locate vein of choice for venipuncture, it is best practice
to release the tourniquet, assemble supplies and reapply
tourniquet immediately before needle insertion.
Smoking
● Acute exposure to cigarette smoking affects
hematological indexes and oxidative stress
biomarkers negatively.
● Increase in hemoglobin because your body requires
increased oxygen-carrying capacity because you
smoke. red blood cell production naturally increases
to compensate for the lower oxygen supply.
● Wbc count increases due to inflammation on
respiratory tree due to the irritant effect of cigarette
smoke
Drugs
First pass: All drugs pass thru the liver
PATIENT INTERACTION
● Appearance
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●
- image projected
professional
Communication skills
Bedside Manner
Attitude
portrays
a
trustworthy
Attitude
● Integrity or honest – doing what is right regardless
of the circumstances
● Compassion – a deep awareness of the distress of
others and a desire to alleviate it
● Motivation – having a drive to meet a need
● Dependability and work ethic – able to be relied
upon.
● Diplomacy – skill on handling situation without
hostility
● Ethical behavior – conforming to a standard of right
and wrong
IMPLIED CONSENT: example px holds put an arm after
being told to draw blood
FOR MINORS: if health care prof did not get a parent or
guardian consent, may be liable for
assault or battery
LESSON 1: CAPILLARY PUNCTURE
CAPILLARY/SKIN/DERMAL PUNCTURE
Severely Burned - blood with tissue fluid
Cancer patients - veins are inaccessible or very fragile
POCT - in healthcare facility
Test on themselves - Ex. Home glucose monitoring
Special procedure - Ex. Malarial Smears
DEHYDRATED - cannot produce adequate capillary
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puncture blood sample (poor circulation)
COLD - not produce adequate blood flow
- situation can be rectified by the phlebotomist, px’s hand
needs to be warmed before puncture. The best way to warm
is with a WARM WET WASHCLOTH (ideal temp 42 degree
Celsius) for only 3-5 min. Warming of the puncture site can
increase the blood flow sevenfold
Finger-stick - most common, can be automatic or manual
Lacer lancet - children >5 y.o, advanced type
Heel-stick lancet - special depth to prevent injury, for
newborn
MICRO-COLLECTION CONTAINERS - the same
action/additive with big tubes
RING/GREAT FINGER - palmar surface of the distal
phalanx, for children over 6 months and adults
- side or tip should not be punctured because tissue
is about half as thick as the tissue in the center of
the finger
*When you puncture the finger always CUT ACROSS the
finger line. It delivers the best possible blood flow and
facilities the formation of drops of blood. Any blood that does
flow follows the lines of the fingerprint, resulting to no droplet
formation.
The blood from the capillary puncture is from the capillary
area of the circulatory system. This blood in the capillary bed
is predominantly arterial. The test result from the
predominantly capillary blood is generally acceptable as a
substitute for venous blood.
Interstitial fluid - fluid in the tissue spaces between cells
Intracellular fluid - fluid within cells from surrounding tissue
Gas tubes - for arterial blood gas, without anticoagulant
- must warm the site before collecting the specimen
Slides - smear Ex. Malaria
HEEL PUNCTURES - (plantar surface-medial or lateral)- are
performed on infants less than 6 months of age, or on older
premature infants who are the approximate size of a full-term
6 month old.
EARLOBE - not recommended except for extreme cases
such as severely burned patient, when no other location
available.
*The puncture site must be warm and not be swollen
(edematous-build up of tissue fluid)
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*If all fingers are cold, warm the hand 3 min with a warm
washcloth or heel warmer
*Clean the finger with 70% Isopropyl alcohol.
- then allow the area to air dry thoroughly before any
puncture
- the patient will feel a sting from the puncture if there is wet
alcohol on the skin
- if not dry---contaminate blood sample and the sample will
become hemolyzed
- even after the betadine ha been allowed to dry, it can cause
elevated POTASSIUM, PHOSPHORUS or URIC ACID
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Rapid milking of the finger does not enhance the
blood flow. Excess pressure may cause hemolysis
or contamination of the sample with tissue fluid.
Scraping of the blood from the surface of the skin
does not allow the blood to flow into the
microcollection device and HEMOLYZES the cells.
The blood will spread the blood over the surface of
the skin resulting to clot formation.
Rotate the tube so the blood entering the tube
contacts the anticoagulant coating the sides.
Anticoagulant samples should be mixed by inverting
8-10 times once they are capped
The phlebotomist must choose the correct device for the age
of the patient and quantity of the sample needed. Puncture
quick and deep enough to achieve the full depth of the blade
and to obtain the sample needed.
AREA OF CHOICE: Bones, arteries, and nerves are not
near these areas
SITES TO AVOID: possible damage to the posterior tibial
artery
First drop of blood- contains interstitial fluid that may
interfere in the lab results.
--0.5 mL of blood can be collected from a single puncture.
*the puncture should not be done at a previous puncture site
because of the possibility of infection.
DO NOT PUNCTURE IN THE CENTRAL ARCH AREA OF
THE FOOT - puncture in this area may result in damage to
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nerves, tendons, and cartilage.
The same procedure with fingerstick capillary puncture.
DOES NOT INJURE THE BONE OR NERVES OF THE
HEEL The infants finger does not produce an adequate
blood sample.
● Excessive crying - can result in elevated
leukocyte count. The WBC count does not
return to normal for up to 60 min.
● Hemolysis is the greatest concern with
microcollection samples. Increase potassium
● Elevated Bilirubin- yellow color of serum may
mask hemolysis
● Concentration-glucose, potassium, total protein
and calcium have been reported to be different
● Sequential sample- when collecting sequential
samples of glucose, potassium, total protein, or
calcium, the phlebotomist should use the same
collection method throughout the consecutive
collections.
LESSON 2: SPECIMEN HANDLING AND
PROCESSING
The goal of a phlebotomist is to provide acceptable samples
for laboratory testing as required by the physician. Certain
general criteria must be followed for a sample to be
acceptable. If the criteria are not followed, the sample must
be rejected and re-collected.
LABEL OF THE TEST TO BE PERFORMED- especially for
body fluids( CSF, PERITONEAL, PLEURAL)
POTASSIUM- increased with presence of hemolysis or
excess tissue fluid.
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-
for unusual results of patient, further study
EXPOSED TO LIGHT
- bilirubin, Vitamin C,E, K.
- wrap the tube with aluminum foil or use AMBER tubes.
Never freeze whole blood
STORAGE: maintain sample integrity, before disposal
Room temperature is specified as between 15 and 30°C
Refrigeration temperature is between 2 and 10°C
CSF - if it is blood-stained in anyway this invalidates the test.
We do not accept CSF sample with a RCC of greater than
150.
PERITONEAL volume - If possible, > 500 mL or entire
volume collected should be submitted.
CONTAINER - different container per lab section plus extra
container for additional tests.
LABEL: patient’s name, type of specimen, test
CENTRIFUGATION: except Bacteriology and Hematology
tests
CLOT- more than 30 mins, sample is not acceptable
CENTRIFUGE - do not centrifuge the sample
immediately, allow the sample to clot first
- sample is not acceptable if na re-centrifuge
SEPARATE - for Send-out/outside testing by other
laboratory
- if the test is not available in your lab
STORAGE- store only plasma/serum, do not include
rbcs
FROZEN TEMPERATURE is at or below 20°C.
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VOLUME: more than half of the container
CONTAINER: label must be on the body, not on the lid
PROCESSING: accumulation of bacteria
COLLECTION: refrain from having sex or masturbation for
2-5 days before sample collection. Delivering it to the
laboratory within 60 minutes.
PROCESSING: within 2 hours to observe the movement of
parasite present. Stool specimen collected from the diaper is
not allowed. Specimen should NOT contain urine, oil, tissue
or other contaminants.
COLLECTION: early morning collection, have the patiemt
rinse the mouth with water and then expectorate deep cough
sputum directly.
VOLUME: 3 containers with 1 hour interval each
- rinse your mouth out with water prior to collection and to
avoid food for 1-2 hours before the sample is collected.
The specimens are listed in order of priority; those listed are
those most useful for testing for the greatest number of
different pathogens with a single clinical specimen.
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