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PMLS-2 - Prelim to Finals

BS Medical Laboratory Science (Lyceum of the Philippines University)

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INTRODUCTION TO PHLEBOTOMY

PHLEBOTOMY
PHLEBOS Vein
TEMNEIN cut
▪ Venesection
▪ It is the process of collecting blood through vein by using incision or
PHLEBOTOMY puncture methods.
▪ It draws blood for analysis or for therapeutic and diagnostic
measures.

EVOLUTION OF PHLEBOTOMY
STONE AGE ▪ Uses crude tools in to cut vessels and extract blood from the body.
ANCIENT EGYPTANS ▪ “bloodletting” as early as 1400 BC
MIDDLE ▪ Barber-surgeons
AGE ▪ Performed bloodletting during 17th and 18th century
▪ Believed that a person’s health was dependent on the balance of four
humors.
o Earth – blood and brain
HIPPOCRATES o Air – phlegm and lungs
(460-377 BC) o Fire – black bile and spleen
o Water – yellow bile and gall bladder.
▪ Bloodletting or removal of excess humor is performed to keep the
balance in the body.
▪ Helps to ease the pain, inflammation, or other health-related
CUPPING concerns.
▪ Uses special-heated suction cups.
▪ For the incision, it uses lancets and fleams.
▪ Also known as Hirudotherapy.
LEECHING ▪ Uses leeches for bloodletting.
▪ Used for microsurgical replantation.
▪ Leeches produce local vasodilator, anesthetic, and hirudin, an
anticoagulant.

▪ To collect blood samples for laboratory testing or transfusion.

▪ Labels the collected blood sample with necessary and correct data
ROLES OF A to easily identify the patient.
PHLEBOTOMIST ▪ Delivers and transports collected sample within time limits.
▪ Processes collected samples. E.g., centrifuging and aliquoting.
▪ Assist in urine and non-blood collections.

TYPES OF PHLEBOTOMY IN A HOSPITAL SETTING

CENTRALIZED ▪ Phlebotomists are dispatched from the laboratory to either in
PHLEBOTOMY nursing units or outpatient areas to collect blood samples.
DECENTRALIZED ▪ “Patient-focused care”
PHLEBOTOMY ▪ Duties of the hospital staff revolve more than around the patient.
HYBRID PHLEBOTOMY ▪ Blend of centralized and decentralized phlebotomy.

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INTRODUCTION TO PHLEBOTOMY

LABORATORY SECTIONS
ADMINISTRATIVE ▪ Paper works, responds to calls, handles specimen collection
OFFICE requests.
PHLEBOTOMY ▪ Collects sample from patients and processes samples for testing
and transport.
URINALYSIS ▪ Study of urine and other body fluids.
▪ Studies blood in normal and diseased states.
o Complete blood count (CBC)
o Red blood cell count (RBC)
o White blood cell count (WBC)
o Hemoglobin
HEMATOLOGY
o Hematocrit
o Platelet count
o Sedimentation rate
o Body fluid cell counts.
▪ Studies blood clotting mechanisms.
o PT
o aPTT
COAGULATION o D-dimer
o Factor VIII
o Fibrinogen Assay
o Heparin Level
o vWF
▪ performs biochemical analysis of blood and body fluids.
o Metabolic panel
o Hepatic panel
o Renal panel
o Iron studies
CLINICAL CHEMISTRY
o Glucose
o Cholesterol
o Enzymes

MICROBIOLOGY • Culture samples to determine if pathogenic organisms are

present in a sample
• Antibiotic susceptibility
• Studies antigen and antibody to determine immunity or presence
of disease
o HIV Testing
IMMUNOLOGY o Rubella
o RPR
o VDRL
o Hepatitis Testing
• Determines the compatibility of blood and blood products to be
administered to the patient.
BLOOD BANKING o Crossmatching
o ABO blood typing
o Rh typing
o Antibody panel testing
• Study deficiencies related to genetic disease.
CYTOGENETICS o Chromosome Analysis
o Prenatal Chromosome Screening
MOLECULAR • Using PCR technologies to study the presence of various
DIAGNOSIS diseases and infections.
o MRSA infections & HIV Testing

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INTRODUCTION TO PHLEBOTOMY

HISTOPATHOLOGY • Examine tissue and cell smears fir evidence of cancer, infection
or other abnormalities.
STAT REQUEST • Emergency cases
OUTPATIENT • Patients who are not admitted in the hospital.
DEPARTMENT

LABORATORY STAFF
PATHOLOGIST • Reads and interprets results.
• Examines tissue under the microscope.
MEDICAL LABORATORY • Performing wide range of laboratory tests.
SCIENTIST • Confirming and reporting laboratory results.
MEDICAL LABORATORY • Under the supervision of Medical Laboratory Scientists.
TECHNICIAN • Performs general tests.
PHLEBOTOMY • Collect blood samples
TECHINICIAN
HISTOTECHNOLOGIST • Prepares body tissue samples for microscopic evaluation of the
pathologist.

PHASES OF SAMPLE PROCESSING

• Request form
• Patient identification and information
PRE-EXAMINATION/ • Correct sample collection
PRE-ANALYTICAL • Correct use of all equipment
• Sample preparation and centrifugation
• Maintaining sample integrity until processing
EXAMINATION/ • Sample testing
ANALYTICAL • Maintaining testing equipment and reagents
• Reporting of results
POST-EXAMINATION/ • Ensuring accuracy and reliability of delivery of the result
POST-ANALYTICAL • Follow-up if repeat testing is needed or attend to other
needs of the physician
• Storage of sample after processing

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PMLS 2: CHAPTER 2

INFECTION CONTROL RESERVOIR

▪ Prevention of nosocomial or healthcare- ▪ Where the germs lived.
associated infections. ▪ People
▪ Controlling the spread of disease and ▪ Wild animals & pets
minimizing the number of healthcare- ▪ Food
associated infections. ▪ Soil
▪ It is about identifying and controlling the ▪ Water
factors involved with the spread of the
infections whether from patient-to- PORTAL OF EXIT
patient, patient-to-staff, staff-to-patient,
▪ How the germs got out
or among staffs.
▪ Mouth (vomit, saliva)
PREVENTION ▪ Cuts in the skin (blood)
▪ During diapering and toileting stool.
▪ Hand hygiene/ hand washing
▪ Cleaning, disinfection, or sterilization, MODE OF TRANSMISSION
vaccination, or surveillance. ▪ Germs get around.
▪ Contact (hands, toys, sand)
MONITORING, INVESTIGATION, &
▪ Droplets (when speaking, sneezing, or
SURVEILLANCE coughing0.
▪ Monitoring, investigation, and
PORTAL OF ENTRY
surveillance of outbreaks.
▪ How the germs get in
NOSOCOMIAL INFECTION ▪ Mouth
▪ Infections contracted within the hospital. ▪ Cuts in the skin
▪ Those not becoming clinically apparent ▪ Eyes
until the discharge of the patient SUSCEPTIBLE HOST
▪ Infections contracted by the healthcare
professionals as a result of their direct or ▪ Next person who will get sick
indirect contact with the patients. ▪ Babies
▪ The patient contracted the disease ▪ Children
during hospital stay. ▪ Elderly
▪ People with weakened immune system
COMMUNITY ACQUIRED INFECTION ▪ Unimmunized people
▪ Anyone
▪ Infections contracted outside the
hospital.
▪ Patient becomes ill 48 hours before the
admission in the hospital.

COMMUNICABLE DISEASE
▪ Continuous spread of the disease from
one person to another.

CHAIN OF INFECTION

CAUSATIVE AGENT
▪ Bacteria, viruses, parasites.

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PMLS 2: CHAPTER 2

PERSONAL PROTECTIVE EQUIPMENT ▪ Pollen – 80%

(PPE)
ACTIVATED CARBON
▪ It is an equipment worn to minimize
exposure to hazards that cause serious
▪ Stop odor
workplace injuries and illnesses. ▪ Virus – 10%
▪ These injuries and illnesses may result ▪ Bacteria – 50%
from contact with chemical, ▪ Dust – 50%
radiobiological, physical, electrical, ▪ Pollen – 50%
mechanical, or other workplace hazards.
CLOTH MASK
LAB GOWN ▪ DIY
▪ Additional layer of protection for skin. ▪ Virus – 0%
▪ Bacteria – 50%
GLOVES ▪ Dust – 50%
▪ Pollen – 50%
▪ Avoid direct contact to highly infections
agent. SPONGE MASK
MASK ▪ Fashion use
▪ Virus – 0%
▪ Required when drawing blood from
▪ Bacteria – 5%
patients
▪ Dust – 5%
GOGGLES ▪ Pollen – 5%

▪ Protects the eyes from spills and PERSONAL PROTECTIVE EQUIPMENT

splashes. (PPE)
TYPES OF MASKS ▪ Long hair must be tied back.
▪ Long pants that cover the ankle.
▪ Shirts that cover your torso. (Crop tops
are not allowed)
N95
▪ Natural fibers are recommended
▪ Strongest protection. because they are fire resistant.
▪ Virus – 95% ▪ Shoes completely enclose that foot and
▪ Bacteria – 100% can be wiped clean.
▪ Dust – 100%
HAND HYGEINE
▪ Pollen – 100%
▪ It is the most important means of
SURGICAL MASK
preventing the spread of infection.
▪ Medical use. ▪ Hands must be decontaminated
▪ Virus – 95% frequently, including the glove removal,
▪ Bacteria – 80% as gloves can contain defects.
▪ Dust – 80% ▪ CDC and Healthcare Infection Control
▪ Pollen – 80% practices advisory committee (HICPAC)
guidelines that allows the use of alcohol
FFP1 MASK based antiseptic hand cleaners instead
of handwashing if hands are not visibly
▪ Isolate suspended particles. dirty/ soiled.
▪ Virus – 95% ▪ If there is no handwashing facility
▪ Bacteria – 80% available, clean visibly soiled hands with
▪ Dust – 80%

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PMLS 2: CHAPTER 2

detergent wipes followed by alcohol- ▪ Rub hands palm to palm.

based cleaner. ▪ Right palm over left dorsum with
interlaced fingers and vice versa.
BEFORE TOUCHING THE PATIENT ▪ Palm to palm with fingers interlaced.
▪ Clean your hands before touching a ▪ Back of fingers to opposing palms with
patient when approaching him/her. fingers interlocked.
• To protect the patient against ▪ Rotational rubbing of left thumb clasped
harmful germs carried your in right palm and vice versa.
hands. ▪ Rotational rubbing, backwards and
forwards with clasped fingers of right
BEFORE CLEAN/ASEPTIC PROCEDURE hand in left palm and vice versa.

▪ Clean your hands immediately before PROPER HANGWSHING TECHNIQUE

performing a clean/aseptic procedure. (WATER & SOAP)
• To protect the patient against
harmful germs, including the ▪ Wet hands with water.
patient’s own, from entering ▪ Apply enough soap to cover all hand
his/her body. surfaces.
▪ Rub hands palm to palm.
AFTER BODY FLUID EXPOSURE RISK ▪ Right palm over left dorsum with
interlaced fingers and vice versa.
▪ Clean hands immediately after an ▪ Palm to palm with fingers interlaced.
exposure risk to body fluids. ▪ Back of fingers to opposing palms with
• To protect the healthcare fingers interlocked.
provider and its environment ▪ Rotational rubbing of left thumb clasped
from harmful germs from the in right palm and vice versa.
patient. ▪ Rotational rubbing, backwards and
forwards with clasped fingers of right
AFTER PATIENT TOUCHING
hand in left palm and vice versa.
▪ Clean hands after touching the patient ▪ Rinse hand with water (downwards).
and their surroundings, when leaving. ▪ Dry hands thoroughly with a single use
• To protect the healthcare towel or tissue.
provider and its environment ▪ Use towel/tissue to turn off the faucet.
from harmful germs from the
ISOLATION
patient.
▪ Isolation precautions should be used for
AFTER TOUCHING PATIENT
patients who are either known or
SURROUNDINGS suspected to have an infectious disease,
▪ Clean hands after touching any object or are colonized or infected with a multi-
furniture in the patient’s surroundings resistant organism or who are particularly
immediately. susceptible to infection.
• To protect the healthcare ▪ Isolation procedures separate certain
patients from others and limit their
provider and its environment
contact with hospital personnel and
from harmful germs from the
visitors.
patient.

PROPER HAND WASHING TECHNIQUE SOURCE ISOLATION

(ANTISEPTIC/ALCOHOL) ▪ When patients with contagious diseases
are placed into a room to protect other
▪ Apply a palmful of the product in a
people from becoming infected.
cupped hand, covering all surfaces.

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PMLS 2: CHAPTER 2

PROTECTIVE ISOLATION
▪ Protect an immunocompromised patient
who is at risk of acquiring
microorganisms from either the
environment or from other patients, staff
or visitors.

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PMLS 2: CHAPTER 3

CIRCULATORY SYSTEM LEFT ATRIUM

▪ An organ system that permits blood to ▪ Receives newly oxygenated blood from
circulate. the lungs.
▪ Transports nutrients, oxygen, carbon
dioxide, hormones, and blood cells to SYSTEMIC CIRCULATION
and from the cells in the body to provide ▪ It provides the functional blood supply to
nourishment and help in fighting all body tissue.
diseases, stabilize temperature and pH,
▪ It carries oxygen and nutrients to the cells
and maintain homeostasis.
and picks up carbon dioxide and waste
▪ Includes pulmonary and systemic products.
circulation.
▪ Network of veins, arteries, and blood
PULMONARY CIRCULATION vessels that transports blood from heart,
services the body’s cells and then re-
▪ A “loop” from the heart through the lungs enters the heart.
where blood is oxygenated.
▪ It sends oxygen-depleted NOTE:
(deoxygenated) blood away from the
▪ Blood is pumped from the left ventricle of
heart through the pulmonary artery to the
the heart through the AORTA and arterial
lungs and returns oxygenated blood to
branches to the ARTERIOLES and
the heart through the pulmonary veins.
through CAPILLARIES, where it reaches
RIGHT ATRIUM an equilibrium with the TISSUE FLUID,
and then drains through the venules into
▪ The upper chamber of the right side of the VEINS and returns, via SUPERIOR &
the heart. INFERIOR VENA CAVA, to the RIGHT
▪ The blood that is returned to the right ATRIUM OF THE HEART.
atrium is deoxygenated and passed into
the RIGHT VENTRICLE to be pumped VASCULAR SYSTEM
through the PULMONARY ARTERY to
ARTERIES
the lungs for re-oxygenation and removal
of carbon dioxide. ▪ Oxygen-rich blood (bright red)
▪ It has thick walls to withstand the
PULMONARY ARTERY pressure o ventricular contraction, which
creates a pulse that can be felt,
▪ It divides above the heart into two distinguishing them from veins.
branches, to the right and left lungs, ▪ When arterial blood is collected by
where the arteries further subdivide into syringe, the pressure normally causes
smaller and smaller branches until the blood to "pump” or pulse into the syringe
capillaries in the pulmonary ai sacs under its own power.
(alveoli) are reached.
▪ In the capillaries, the blood takes up VEIN
oxygen from the air breathed into the air ▪ Oxygen-poor blood (brick red).
sacs and releases carbon dioxide. It then ▪ It has thinner walls than the same-size
flows into larger and larger vessels until arteries because blood in them is under
the PULMONARY VEINS. less pressure.
▪ They collapse more easily.
PULMONARY VEINS ▪ Blood is kept moving through vein by
skeletal muscle movement and the
▪ It is usually in four in number, each opening and closing o valves that line
serving a whole lobe of the lung. their inner walls.
▪ It opens into the LEFT ATRIUM of the
heart. CAPILLARIES

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PMLS 2: CHAPTER 3

▪ It allows the exchange of gases and other M PATTERN VEINS

substances between the tissues and the
blood. MEDIAN VEIN
▪ It is only one cell thick.
▪ Center-most vein.
▪ The capillary bed in the skin can easily be
▪ First-choice vein – it is well anchored,
punctured with lancet to provide blood
tends to be less painful, and is not as
specimens for testing.
close to major nerves or arteries as the
H PATTERN VEINS others, making it generally safest to
puncture.
MEDIAN CUBITAL VEIN
MEDIAN CEPHALIC VEIN
▪ Near the center of the antecubital fossa.
▪ Preferred vein for venipuncture – it is ▪ Branches from the median vein to the
typically large, close to the surface, and lateral aspect of the arm.
the most stationary, making it the easiest ▪ Second-choice vein -it is accessible,
and least painful to puncture, and least unlikely to roll, less painful, located far
likely to bruise. enough away from major nerves or
arteries, generally safe to puncture.
CEPHALIC VEIN
MEDIAN BASILIC VEIN
▪ Lateral aspect of the antecubital fossa.
▪ Second-choice vein. ▪ Branches from the median vein to the
▪ Often harder to palpate (feel) than the medial aspect of the arm.
median cubital, it is fairly well anchored ▪ Third-choice vein – may appear more
and often the only vein that can be felt in accessible, located near the anterior and
obese patients. posterior branches of the median
cutaneous nerve.
BASILIC VEIN
▪ Medial site of the antecubital fossa.
▪ Last-choice vein
▪ It is 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.
▪ CLSI (Clinical and Laboratory Standards
Institute) recommend against using it
unless no other vein in either arm is more
prominent.

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PHLEBOTOMY EQUIPMENTS ▪ 23 gauge – blue

▪ 24 gauge – purple
SYRINGE ▪ 25 gauge – orange
▪ Syringe and needle method is one of the ▪ 26 gauge – brown
oldest methods known that does not ▪ 27 gauge – dark green
destroy the integrity of vein. ▪ 30 gauge - yellow
▪ Are made of glass or plastic.
NEEDLE GAUGE AND NEEDLE USE
NOTE: ▪ 27: skin tests
How to use: ▪ 25: intramuscular injections (cannot be
• Pull the plunger to create a vacuum used for veni bc RBCs will be destroyed
within the barrel when the blood is pulled thru the bore)

(The plunger on a syringe is often hard to pull. A ▪ 23: butterfly or syringe collection (most
technique called breathing the syringe needs to common for children)
be done before it is used. Pull the plunger midway ▪ 22-20: syringe or ETS collection (21 most
then push it back to make the plunger pull more common for adults)
smoothly)
▪ 18-16: IVs or blood donation
• The vacuum created while pulling the
plunger while a needle is in a patient’s EVACUATED TUBE SYSTEM
vein fills the syringe with blood
▪ Closed systems: prevents exposure to air
(The larger the syringe, the greater blood) from outside contaminants.
▪ Allows multiple tubes to be collected in a
(a too large vacuum has the tendency to pull too single venipuncture.
hard on the vein and collapse it. pull the plunger
slowly) EVACUATED TUBES
(Syringes are used for difficult to draw veins such ▪ Contains a vacuum with a rubber stopper
as fragile, thin and rolly veins) sealing the tube.
▪ Volume varies from 2ml to 15ml.
NEEDLE ▪ It has sterile interiors to prevent
▪ It is used on a syringe consists of a hub, contamination.
cannula (shaft), and a bevel. ▪ Has an expiration date.
▪ Hub is attached to a syringe.
ADDITIVES
▪ Recommended length: 1 to 1 ½ inch.
▪ The gauge of the needle is determined by ▪ Used to improve sample quality and
the diameter of the lumen or opening. accelerate sample processing
▪ Needle gauge is inversely proportional to (anticoagulants, preservatives, r clot
the needle bore. activators).
▪ Bevel must always be facing upward; the
opening of the needle should be visible. ORDER OF DRAW

COLOR OF NEEDLES ▪ Blood culture

▪ Yellow tube 8-10
▪ 16 gauge – gray ▪ Light blue 3 4
-

▪ 18 gauge – pink ▪ Red (glass) O

▪ 19 gauge – beige ▪ Red (plastic) 5

▪ 20 gauge - yellow ▪ SST or gold

▪ 21 gauge – light green ▪ Green
8-10
▪ 22 gauge – black ▪ PST or Light green

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▪ Lavender • 3.8% (0.129)

▪ Pink ▪ Blood anticoagulant ratio – 9:1
▪ Gray ▪ For coagulation studies – PT, aPTT, INK,
percent saturation PT
COLORS OF EVACUATED TUBES
BLACK TOP (whole blood)
RED TOP/GOLD TOP (serum)
▪ Buffered sodium citrate
▪ Blood clots
▪ Chelates calcium
▪ Serum is separated after centrifugation.
▪ Blood to coagulant ratio: 4:1
▪ For chemistry, serology, and Blood bank
▪ For sedimentation rates
(crossmatching) testing.
• FBS, RBS, Enzymes, LAVENDER TOP (whole blood)
Electrolytes
▪ Red top: 30-60mins; Gold Top: 15-30min ▪ Ethylenediamine Tetraacetic Acid EDTA
▪ Chelates calcium
YELLOW TOP (Acid Citrate Dextrose) ▪ Three concentrations:
• Plastic (spray-dried): K2 EDTA
▪ White blood cell preservative.
or dipotassium EDTA (prevents
▪ For Blood bank, HLA phenotyping,
the cell morphology and provides
paternity testing.
stable microhct result)
YELLOW TOP (Sodium Polyanethanol • Glass (liquid): K3 EDTA or
Sulfonate) tripotassium EDTA
(sequestrene)
▪ SPS – allows bacteria to grow so that • NA2 EDTA: disodium EDTA
they can be cultured. (versine)
▪ Aids in bacterial recovery by inhibiting ▪ For hematology, blood banking
complement, phagocytes, and certain (crossmatching)
antibiotics.
▪ 0.025% SPS GRAY TOP
▪ For serum microbiology (blood culture)
▪ Potassium oxalate
GREEN TOP (Plasma) ▪ Contains antiglycolytic agent: sodium
fluoride or iodoacetate.
▪ Sodium or lithium heparin ▪ Inhibits glycolysis by binding to Mg2+
▪ Enhances anti-thrombin III to inhibit needed by enolase in the glycolytic
thrombin formation. pathway.
▪ For chemistry tests. ▪ For glucose testing, lactate testing
LIGHT GREEN TOP (Plasma) PINK TOP (whole blood)
▪ sodium heparin ▪ Spray-dried K2 EDTA
▪ Plasma separator tube ▪ Chelates calcium
▪ Enhances anti-thrombin III to inhibit ▪ For blood banking and molecular
thrombin formation. diagnosis.
▪ For chemistry tests.
WHITE TOP (plasma)
LIGHT BLUE TOP (Plasma)
▪ EDTA or ACD
▪ Sodium citrate ▪ Chelates calcium
▪ Chelates calcium – it binds to calcium ▪ For molecular diagnosis
salts to remove calcium.
▪ Two concentrations ROYAL BLUE TOP (plasma)
• 3.2% (0.105) – preferred ▪ Sodium heparin – inhibits thrombin

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▪ K2 EDTA – chelates calcium ▪ Applied tight enough to slow the flow of

▪ For chemistries toxicology or trace blood in the veins but not prevent the flow
elements. of blood in the arteries
▪ Modern: do not use latex tourniquets as
TAN TOP (plasma) to avoid latex exposure and allergy
▪ Na Heparin (glass) – inhibits thrombin ▪ Patient should close his or her hand to
▪ K2 EDTA (plastic) – chelates calcium make the vein prominent.
▪ For lead testing ▪ Palpating vein (one of the most difficult
skills to learn): using the finger to press
ORANGE TOP (serum) down on top of the vein to feel the
“bounce” or running the finger across the
▪ Thrombin – clot activator arm to feel the “speed bump”
▪ For STAT chemistry ▪ Should not be on the arm for more than 1
min; can cause hemoconcentration:
increased concentration of cellular
BUTTERFLY COLLECTION SYSTEM components in the sample
▪ Blood pressure cuff
▪ Used for small and fragile veins that are (sphygmomanometer) can be used as an
difficult to draw from. alternative (can be used for obese,
• 21- or 23-gauge needle with pediatric, or geriatric px)
attached plastic wings on one
end. MICROCOLLECT EQUIPMENT
• 3 – 12-inch tubing leads from the
▪ Equipment for capillary puncture.
needle.
SAMPLE COLLECTION TRAYS
NOTE:
▪ Alcohol swabs
▪ 3–12-inch tubing leads from the needle to
▪ Gauze squares or cotton balls
a hub that could be attached to either a
▪ Evacuated tube holder
syringe barrel or evacuated tube needle
▪ Evacuated tubes
adapter called luer adapter
▪ Syringes
▪ When disposing in sharps container, hold
▪ Needles
the plastic wing and drop the tubing next
▪ Butterfly infusion set
(to prevent needle stick injury because of
▪ Microcollect equipment
the tubing)
▪ Tourniquet
▪ Since these veins are near the skin
▪ Disposable gloves
surface, the winged needle is inserted at
▪ Sharps and/or waste container
a 5-degree angle instead of the usual 15-
▪ Marking pen
30 in.
CLEASING AGENTS
TOURNIQUET
▪ It constricts the flow of blood in the arm DISINFECTANT
and makes the veins more prominent. ▪ Removes or kills microorganisms on
▪ It is usually 1 inch wide, 15-18 inches surfaces and instruments.
long ▪ 10% sodium hypochlorite – best
▪ Applied 3-4 inches above the puncture
site. ANTISEPTIC
▪ Palpating vein – to determine the
direction, depth, and size. ▪ Prevents microorganisms and their
toxins from infecting the blood
NOTE: ▪ 70% isopropyl alcohol – the most
common and best

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HAND SANITIZER
▪ Alcohol-based rinses, gels, and foams.
▪ Can replace handwashing if hands are
not visibly soiled or dirty.

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VENIPUNCTURE PROCEDURES
I. VENIPUNCTURE
▪ It is the most common procedure a phlebotomist
performs.
▪ The most important step in venipuncture is patient
identification.
- Syringe Method (open system)
ROUTINE VENIPUNCTURE - Evacuated Tube System (closed system)
- Butterfly Method – a type of venipuncture
procedure that is used for delicate / fragile veins.
▪ Venipuncture – collection of blood from the veins.
- Most often method for the purpose of laboratory
testing.

II. STEP BY STEP VENIPUNCTURE PROCEDURES

PREPARE REQUEST FORM OF THE PATIENT.
- Patient’s complete name
- Age
- Date of Birth
- Patient identification number (IN-PATIENT)
- 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
I ▪ Requisition can also be used for the out-patient.
▪ Several tasks need to perform when receiving a requisition:
- Examine them to make sure that each has all the necessary information: full name,
DOB, ordering physician, and patient location.
- Check for duplicates – if there are several requisitions for one patient, gather/ group
them together so that all collections cab ne made with a single puncture.
- Prioritize requisitions – stats, timed collection, routine
- Collect all the equipment you need for the collections you will be performing.
GREET AND IDENTIFY PATIENT.
▪ Conscious patients (out-patient)
- Ask patient to give their full name and spell their last name.
- Compare the information on the request form.
▪ Conscious patients (in-patient)
- Ask patient to give their full name and spell their last name.
- Compare their information on their identification bracelet and request form.
▪ Sleeping patient
- Awaken a sleeping patient before attempting venipuncture.
- If the patient is already awake, do the same steps as conscious patients.
II ▪ Semi-conscious or comatose patient
- Ask the watcher (or nurse) 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) 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, cross-
reference it with the temporary number.
III VERIFY DIET RESTRICTION, LATEX SENSITIVITY, AND OTHER ALLERGIES.
SANITIZE HANDS AND POSITION THE PATIENT
IV - The patient should be comfortable.
- The patient must be seated or in reclined position.
- Arm should be rested on a flat surface.

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- A pillow may be needed to support the patient’s arm or with the use of another fisted
arm.
ASSEMBLE THE EQUIPMENT AND SUPPLIES
V - If patient is allergy to alcohol, phlebotomist may use povidone/ iodine swabs.
APPLY TOURNIQUET
- tourniquet must not be left longer than 1 minute (can cause hemoconcentration)
- 3-4 inches away from the site.
ASK THE PATIENT TO MAKE A FIST WITHOUT HAND PUMPING.
SELECT SUITABLE VEIN FOR VENIPUNCTURE.
SITES TO BE AVOIDED:
▪ Burns, scars, or tattoos
▪ Damaged veins
▪ Edematous
▪ Hematoma
VI ▪ Mastectomy
▪ IV-line, cannula, and fistula
NOTE:
- Draw on the opposite arm.
- If patient is in IV-line, ask first the nurse to turn off the IV for 5mins.
• The first 5ml, discard.
- If the patient feels pain upon tourniquet application, release the tourniquet. Then,
reapply.
• If the fingers experience tingling feeling
• Arm should not turn red.
CONSEQUENCES FOR IMPROPER TOURNIQUET APPLICATION:
▪ Hemoconcentration – increased in ratio of formed elements (caused by too long and too
tight application of tourniquet)
▪ Hemolysis
▪ Production of petechiae (puh-TEE-kee-ee) rashes – small red spots caused by too tight
tourniquet application.
PUT ON GLOVES
VII CLEANSE THE VENIPUNCTURE SITE WITH 70% ISOPROPYL ALCOHOL
ALLOW THE AREA TO DRY
REAPPLY THE TOURNIQUET
VIII ANCHOR THE VEIN FIRMLY.
ENTER THE SKIN WITH NEEDLE AT APPROX 30-DEGREE ANGLE
BEVEL UP.
- If the vein is superficial, then lower the needle angle.
- If the vein is deep, increase the needle angle.
- In puncturing, it must be swift and fast motion. (Not too slow, not too fast)
IF USING A SYRINGE:
▪ Pull back on the barrel with a slow, even tension up to the desired volume of blood.
▪ Use two hands.
IX 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 tube gently.
NOTE:
▪ If the needle is in bevel down or side position, blood will not flow freely from the vein
towards the needle.
ORDER OF DRAW
▪ Blood culture (sterile procedure) (yellow)
▪ Coagulation tubes (light blue)
▪ Serum tubes with or with clot activator or gel serum separator (red/gold)
▪ Heparin tubes with/without gel plasma separator (green)
▪ EDTA tubes (lavender)
▪ Oxalate/fluoride, glycolytic inhibitor tubes (black)
X RELEASE THE TOURNIQUET
NOTE:
▪ Never withdraw the needle without removing the tourniquet.
▪ Blood will leak if tourniquet is not removed before releasing the syringe and may cause
hematoma.
XI PLACE GAUZE, WITHDRAW NEEDLE, & APPLY PRESSURE
XII PROPERLY RECAP THE NEEDLE USING “FISHING OUT” TECHNIQUE

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XIII CHECK CONDITION OF THE PATIENT

XIV DISPOSE CONTAMINATED MATERIAL IN DESIGNATED CONTAINERS USING UNIVERSAL
PRECAUTIONS.
▪ Needle and holder
▪ Syringe
XV LABEL TUBES AT PATIENT’S SIDE

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PROBLEMS ENCOUNTERED IN VENIPUNCTURE

▪ Reposition the needle – patient may indicate that the

venipuncture is painful.
▪ Releasing the tourniquet – it may be pinching the arm and causing
pain rather than the needle.
PAIN ▪ Discontinue venipuncture – if the patient indicates sharp, piercing
pain.
▪ Avoid deep, probing or fishing venipuncture especially in basilic
vein.
▪ It is caused by deep, probing or fishing out venipuncture
especially in basilic vein.
▪ First felt by a tingling or numbing of arm or hand.
▪ May result to legal issues.
▪ Avoid proving venipunctures and puncture only veins that can be
NERVE DAMAGE felt.
▪ Deep punctures can also result in puncturing an artery.
▪ If nerve is only touched, not damaged, it may be gone in a few
hours or days.
▪ If damaged, numbness could be permanent.
▪ Discontinue venipuncture.
▪ Upsetting to some patient that the become nauseated and vomit.
▪ Patient will indicate that he or she feels sick.
▪ Make the patient as comfortable as possible.
NAUSEA ▪ Instruct him/her to breathe slowly.
▪ Apply cold compress if necessary.
▪ Give waste basket or container and have tissues and water ready.
▪ Warning signs: perspiration beads on the forehead,
hyperventilation, loss of color.
▪ Vasovagal syncope – fainting due to abrupt pain or trauma.
SYNCOPE ▪ Discontinue venipuncture.
▪ Lower the head and arms.
▪ Ask the patient if he/she has fainted before, if he/she did, let them
lie down before drawing blood (do not draw while sitting or in a
chair with wheels)
▪ Experience hypoglycemia because they fasted (for too long)
▪ If conscious, let them drink a glass of orange juice or cola will
temporarily help.
▪ If unconscious, call a physician.
DIABETIC SHOCK ▪ Patient’s diabetes needs to regulate their diet and eat specific
times a day. If a patient needs to fast, he/she breaks from their
normal routine.
▪ First signs are cold sweats, pale face, mental confusion and
instant personality change.
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 minutes.
▪ Patient falls into unconsciousness, no pulse or respiration, dilated
eyes, and pale skin.
CARDIAC ARREST ▪ Immediate CPR.
▪ Many individuals who come in to have their blood drawn to have
a health problem; persons with heart problem can go to cardiac
arrest.
▪ 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.
CONTINUOUS BLEEDING ▪ Leave it on for 15mins or until the bleeding stops.
▪ Ask the patient to place a cotton or gauze at the puncture site to
stop bleeding.
▪ Bleeding will stop at approximately 2 minutes.
SKIN ALLERGIES ▪ Some patients are allergic to latex, tape, or iodine.
▪ Use hypoallergenic tape and non-latex elastic wrap.
HEMATOMA ▪ Discontinue venipuncture and apply heave pressure.
▪ Leakage of blood under the skin at the site of venipuncture.
▪ Petechiae – small red dots are indications of small amounts of
bleeding under the skin surface often a result of how low platelet
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)

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PROBLEMS ENCOUNTERED IN VENIPUNCTURE

UNUSUAL BLOOD SPECIMENS

▪ Serum/plasma that contains large amounts of bilirubin.
▪ Patient presents with jaundice.
ICETERIC ▪ Serum/plasma – dark yellow
▪ Bilirubin is the degradation product of RBCs; causes the yellow
color of urine and brown color of stool.
▪ Jaundice – yellowish discoloration of skin and sclera of eyes.
▪ Serum/plasma contains large amounts of fats and lipids.
LIPEMIC ▪ May be due to patient not fasting.
▪ Serum/plasma – milky or white
▪ Serum/plasma contaminated with RBC contents.
- Red or darker red
▪ Hemolysis – breakdown or rupturing of the cell membranes of
RBCs.
CAUSES OF HEMOLYSIS
▪ Drawing from a hematoma
HEMOLYZED ▪ Rupturing of RBCs by using a needle that is too small
▪ Alcohol on the site of venipuncture that entered the blood
sample.
▪ Pulling the plunger too forcibly
▪ Fast drip. Expelling blood vigorously as it is transferred to the
tube.
▪ Redirecting
▪ Mixing tubes vigorously.

▪ Vacuum in tube is not working.

▪ Bevel against the vein wall.
POSSIBLE CAUSES FOR ▪ Bevel inserted too far.
FAILED VENIPUNCTURE ▪ Needle partially inserted.
▪ Needle slipped beside the vein.
▪ Collapsed vein
▪ Undetermined needle position.

▪ Retie the tourniquet.

▪ Use a blood pressure cuff in place of a tourniquet.
▪ Massage the arm or warm the location.
▪ Massage the arm or warm the location.
▪ Lower the patient’s arm.
TECHNIQUES TO ▪ Reseat the tube holder.
ENHANCE VEIN AND ▪ Use a different tube.
RECOVER A FAILED ▪ Place your finger below the venipuncture site and stretch the
VENIPUNCTURE 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 up to 2 tries only. Ask
someone else to do it (endorse to another staff)

▪ Misidentification of patient.
▪ Mislabeling of specimen.
▪ Short draws/ wrong AC/ blood ratio.
MOST COMMON ERRORS ▪ Mixing problems/clots
IN SPECIMEN ▪ Hemolysis/lipemia
COLLECTION ▪ Hemoconcentration from prolonged tourniquet time.
▪ Exposure to light/extreme temperatures.
▪ Improperly timed specimen/delayed delivery to the laboratory.
▪ Processing errors: incomplete centrifugation, improper storage.

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SPECIMEN CONDITIONS

TIME OFSPECIMEN COLLECTION

FASTING ▪ NPO (non-per orem) “nothing by mouth.
▪ Generally, 8-14hrs.
RANDOM ▪ Collected anytime
BASAL STATE ▪ Early morning after waking up.
POST-PRANDIAL ▪ Collected after meals.

CLASSIFICATION OF METHOD AS TO SAMPLE REQUIREMENTS

MACROMETHOD ▪ Installs blood sample 1mL and above.
MICROMETHOD ▪ Installs blood sample from 0.1 to 0.9 mL.
ULTRAMICROMETHOD ▪ Blood sample from 0.01 to 0.09 mL.
NANOLITER METHOD ▪ Blood sample from 0.001 to 0.009 mL.

FACTORS CONTRIBUTING TO VARIATION OF RESULTS

▪ Moderate exercise can increase blood glucose, lactic acid,
EXERCISE serum proteins, muscle enzymes: creatine kinase (CK), LHD,
aldolase.
▪ Did not undergo fasting:
- Elevated blood glucose
- Potassium
- Lipids
▪ Prolonged Fasting
- Elevated serum bilirubin
- TAG
FASTING - Glycerol
- free FA
- Decreased plasma glucose
▪ Abstinence from eating or drinking (except water) for at least 8
hours is required for most fasting specimens.
▪ Some tests require 12-14 hour fast.
▪ Chewing gum is not allowed.
▪ Medications should be continued as normal unless instructed
otherwise.
▪ High protein diet = increased urea, ammonia, urates.
▪ Long time vegetarian = decreased LDL, VLDL,, total lipid,
DIET phospholipid, cholesterol, TAG.
▪ Hyperchylomicronemia = increases turbidity or latescence
(TAG level exceeds 4.6 mmol/L (4.0 g/L)
▪ Preferably supine or upright sitting position.
▪ Changes in posture result to efflux of filterable substances from
POSITION OR POSTURE the intravascular space to the interstitial fluid spaces.
▪ Non-filterable substances increase concentration.
TOURNIQUET ▪ One-minute application
▪ Prolonged application = venous statis or hemoconcentration.
▪ Hemoconcentration = blood pooling at the venipuncture site.
▪ Affects hematological tests such as hemoglobin, hematocrit,
and blood counts.
▪ Acute exposure to cigarette smoking affects hematological
indexes and oxidative stress, biomarkers negatively.
SMOKING ▪ Increased hemoglobin – body requires increased oxygen
carrying capacity, RBC 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.
▪ Increases plasma concentration of lactate, urate, acetate, and
ALCOHOL INGESTION acetaldehyde, GGT concentration.
▪ May affect blood sugar and fat levels.
STRESS (ANXIETY) ▪ Affects hormone secretion results to hyperventilation leading to
a disturbance in acid-base balance in the blood.
DRUGS ▪ May interfere with liver function tests.

APPEARANCE
▪ Image projected portrays a trustworthy professional.
PATIENT INTERACTION COMMUNICATION SKILLS
BEDSIDE MANNER
ATTITUDE

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SPECIMEN CONDITIONS

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
ATTIDUTES OF A ▪ Having a drive to meet a need.
PROFESSIONAL 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.

INFORMED
▪ Voluntary permission
EXPRESSED
▪ May be given verbally or in writing.
IMPLIED
▪ Actions that imply consent.
TYPES OF PATIENT HIV
CONSENT ▪ Laws specify what type of information must be given.
FOR MINORS
▪ Parent or guardian consent is required.
REFUSAL
▪ An individual has a constitutional right to refuse a medical
procedure.

CONFIDENTIALITY
▪ Treat all patient information as private and confidential.
▪ Penalties: disciplinary action, fines and possible jail time.
LEGAL ISSUES BATTERY
▪ Deliberate harmful or offensive touching without consent or
legal justification.
NEGLIGENCE
MALPRACTICE

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CAPILLARY PUNCTURE

CAPILLARY PUNCTURE EQUIPMENTS

LANCET/INCISION DEVICE ▪ Finger puncture (3rd or 4th finger)ring/micehingethe
(AUTOMATED PRICKER) ▪ Heel puncture
▪ Laser lancet
▪ Microcollection containers (lavender – common in Ph)
- Maximum – 0.5 mL
- Minimum – 0.25 mL
COLLECTION DEVICES ▪ Microhematocrit tubes – used for (manual) hematocrit testing
- Red & Green – heparinized
- Blue – plain tube
PLASTIC/CLAY SEALANT
CAPILLARY BLOOD GAS ▪ Collection tubes/caps
COLLECTION EQUIPMENT ▪ Stirrers/magnets
MICROSCOPE SLIDES
WARMING DEVICE

CAPILLARY PUNCTURE PRINCIPLES

▪ Arterial blood Capillary Blook
·

COMPOSITION OF ▪ Venous blood

AVCII
CAPILLARY PUNCTURE ▪ Interstitial fluid
▪ Intracellular fluid
CLOSELY RESEMBLES ARTERIAL BLOOD
▪ Higher in capillary puncture blood
REFERENCE (NORMAL) - Glucose
VALUES FOR CAPILLARY ▪ Lower in capillary puncture blood
PUNCTURE BLOOD - Total protein TP
- Calcium Calt
- potassium R
ADULTS
▪ no accessible veins
▪ to save veins for chemotherapy
▪ clotting tendencies/deficiencies
INDICATIONS FOR ▪ POCT procedures such as glucose monitoring.
PERFORMING CAPILLARY CHILDREN AND INFANTS
PUNCTURE ▪ To prevent anemia
▪ To prevent cardiac arrest from removal of large quantities of
blood.
▪ Venipuncture too difficult.
▪ To prevent injury.
▪ When capillary blood is preferred.

TESTS THAT CANNOT BE ▪ Erythrocyte sedimentation rate (ESR)

PERFORMED BY ▪ Coagulation studies that require plasma
CAPILLARY PUNCTURE ▪ Blood cultures
▪ Tests that require large volumes of serum or plasma.

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CAPILLARY PUNCTURE CELLGRS

Capillary BG, dlta Specimen, Lithium Heparin,""Welotactivator,
Gray, RIG tube,
▪ Slides (smearing) Serum Specimen

ORDER OF DRAW ▪ EDTA Specimens

▪ Other additive specimens (last is red top – serum)
▪ Serum specimens

CAPILLARY PUNCTURE STEPS

STEP 1 ▪ Review 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.
▪ Position patient
STEP 5 - For finger – hand extended, palm up. (massage)
- For heel – supine with foot lower than torso.
▪ Select puncture/incision site
- Should be warm, normal color, and free from scars, cuts, bruises or
STEP 6 rashes.
- Do not choose cold, cyanotic, infected or edematous site.
- Finger for adult/ older child, heel for infant.

NOTE:
▪ Adults and older children (over 1 year old)
- Use the palmar surface of the distal or end segment of the middle or ring finger of the
nondominant hand.
DO NOT:
▪ Use same side as mastectomy
▪ Use finger on child less than 1 year old
▪ Puncture side or tip finger
▪ Puncture thumb, index, or little finger.
▪ Puncture parallel to whorls of fingerprint.

NOTE:
▪ Infants (less than 1 year old)
- Use the medial or lateral plantar surfaces of the heel.
DO NOT:
▪ Puncture earlobes, finger, or big toe.
▪ Puncture deeper than 2.0mm
▪ Puncture posterior curvature of heel (calcaneous bone)
▪ Puncture between imaginary line or on arch.
▪ Puncture in bruised areas.

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CAPILLARY PUNCTURE

CAPILLARY PUNCTURE PROCEDURE

STEP 7 ▪ Warm site if applicable
- Increases blood flow to site making collection easier especially in
infant heel sticks.
- “Arterializes” blood; essential for capillary blood gases.
- Helps with finger puncture collection when patient has cold hands.
STEP 8 ▪ Cleanse and air-dry site
- Do not use iodine; its yellow color interferes with uric acid,
phosphorus, and potassium.
STEP 9 ▪ Prepare equipment.
▪ Puncture the site and discard lancet.
- Finger puncture: fleshy area, slightly off center, perpendicular to
whorls of fingerprint.
- Heel puncture: medial or lateral plantar surface.
STEP 10 ▪ For both finger and heel puncture
- Place lancet firmly against site
- Warn patient
- Depress lancet trigger
▪ Discard lancet in sharps container immediately.
STEP 11 ▪ Wipe away first blood drop.
▪ Fill and mix tubes/containers in order of draw.
- Gentle intermittent pressure, do not milk, position site downward
to enhance flow.
STEP 12 - Slide first, then EDTA, other additives, serum
- Microhematocrit tube: use capillary action
- Microcollection containers – touch blood drop, do not scoop or
touch sitre.
- Mix gently.
STEP 13 ▪ Place gauze and apply pressure.
▪ Label specimen and observe special handling instructions.
- Label with appropriate information.
STEP 14 - Apply label directly to microcollection container.
- Place microhematocrit tubes in nonadditive tube then label that
tube.
- Ice, body temperature, protect from light, etc.
STEP 15 ▪ Check the site and apply bandage.
- Do not bandage children less than 2 years old.
STEP 16 ▪ Dispose of used and contaminated materials.
STEP 17 ▪ Thank the patient, remove gloves, and sanitize hands.
STEP 18 ▪ Transport specimen to lab.

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CAPILLARY PUNCTURE

SPECIAL CAPILLARY PUNCTURE PROCEDURES

CAPILLARY BLOOD ▪ Less desirable than ABG – exposed to air during collection, contains
GASES (CBG) tissue fluid, rarely done on adults.
▪ Desirable for infants and small children to avoid hazards of arterial
puncture.
▪ Warm site for 10-15 mins to maximize arterial flow.
▪ Minimize exposure to air during collection.
NEONATAL BILIRUBIN ▪ Done routinely on jaundiced (yellow) infants.
COLLECTION ▪ Minimize exposure to light during collection and transport.
▪ Avoid hemolysis and exposure to light.
NEWBORN/NEONATAL ▪ Done routinely to detect inborn disorders.
SCREENING ▪ PKU, hypothyroidism, galactosemia.
▪ Blood drops collected on filter paper, fill circles from slide of the
paper, air-dry horizontally.

Skin puncture
in capillary bed in dermal layer skin
of

site,Equipmen
incision
(2mm)
Cancet
tubes
microcollection with ammonium heparin
tube, coated
Microbemascus
blue plain
red/qween-reparinized
Scalant
Clay blood
microscopeslide -
peripheral smear

Warming Device

than blood
arterial blood, higher propertion venous

than
lower result
verpuncture
CBC Platzlet slightly
-

Specimen
Bloodas
esplain last)
Serum Specimen

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