Phlebotomy worktext and procedure manual

Infections

***Although these microorganisms can live and multiply on and within the body without causing disease, the correct conditions, such as a break in the skin, can allow these organisms to enter the body and cause an infection. ***An infection is an invasion and growth of a microorganism in the human body that causes disease. Infectious organisms, also called pathogens, can be viruses, bacteria, fungi, protists (single-celled organisms), helminths (worm-like animals), or prions (molecules of infectious proteins). ---these organisms then cause even more serious disease, requiring more aggressive treatment, usually in a hospital. Infections contracted by patients during a hospital stay are termed healthcare-associated infections (also called nosocomial infections). Healthcare-associated infections (HAIs) may be caused by direct contact with other patients, but they are most often caused by failure of hospital personnel to follow in- infection control practices, such as hand hygiene.

Modified Allen Test

- Extend the patient's wrist over a towel, and have the patient make a fist - Locate pulses of both the ulnar and radial arteries, and compress both arteries -Have the patient open and close fist repeatedly -Release the pressure from the ulnar artery -Interpret the results

Problems Associated with Cleaning the Site

--> Alcohol cannot be used for site cleaning when drawing a blood alcohol test -> It is also not a strong enough antiseptic for drawing blood cultures, blood gases, or blood donations -> In these cases, povidone-iodine is used instead --> Hemoconcentration A tourniquet should not remain in place for more than 1 minute at a time This is to prevent hemoconcentration or alteration in the ratio of elements in the blood Prolonged tourniquet application can also alter potassium and lactic acid levels by a different mechanism --> Formation of petechiae Petechiae are small, nonraised red spots that appear on the skin when the tourniquet is applied to a patient with a capillary wall or platelet disorder --> Tourniquet applied too tightly If there is no arterial pulse or the patient complains of pinching or numbing of the arm, the tourniquet is too tight --> Latex allergy Latex allergy is becoming increasingly common, and all patients must be asked whether they have a latex allergy ****Latex bandages should also be avoided for these patients.**** Nonlatex tourniquets and gloves are available and in wide use in hospitals, clinics, and nursing homes. Always check with the nurse on duty before you comply with any request. *****Failure to apply adequate pressure, particularly with patients on excessive doses of warfarin (Coumadin) or with a coagulation disorder, can cause compartment syndrome*****.

Difficulty in Finding a Vein

--> Check the other arm -> Enhance vein prominence -Massage gently upward from the wrist to the elbow -Dangle the arm in a downward position to increase blood in the arm -Apply heat -Rotate the wrist to increase the prominence of the cephalic vein Use a sphygmomanometer/blood pressure cuff The blood pressure cuff should be placed 3 to 4 inches above the venipuncture site and inflated to a pressure above the diastolic but below the systolic reading Use an alternative site The leg and foot are more susceptible to infections and clots, and they are not recommended sites for patients with diabetes or those on anticoagulant therapy (heparin or warfarin)

Factors That Affect Sample Integrity

--> Hemolysis Hemolysis is the destruction of blood cells, resulting in the release of hemoglobin and cellular contents into the plasma The serum or plasma is pinkish or red in a hemolyzed sample due to rupture of red blood cells

Chapter 11 Venipuncture Complications Factors That Prevent Access to the Patient Barriers to Communicating with the Patient (Cont.)

--> Locating the patient If the patient is not in his or her room, make every effort to locate the patient by checking with the nursing station If the patient is in another department and the test is a short turnaround (stat) or timed request, proceed to that area and draw the blood there --> identifying the patient Several situations can make ID difficult, including the following: Emergency requisitions Emergency room (ER) collections Orders telephoned into the laboratory Requisitions picked up at the site Despite the difficulties these situations may present, the information on the requisition must match exactly the information on the patient's ID band. --> Sleeping or unconscious patients If you encounter a sleeping patient, you should make one or two attempts to gently wake the patient, and give them time to become oriented, before you begin the draw There are times when you must draw from a patient who is unconscious and cannot be awakened Unconscious patients are most commonly encountered in the intensive care units (ICU), emergency departments, and nursing homes. --> Presence of physicians or clergy If a physician or clergy member is in the room, return at another time for the procedure unless it is a stat or timed collection In that case, you should respectfully interrupt and explain the reason for the interruption If the physician enters while you are preparing to draw, leave the room until he or she is finished with the patient. --> Presence of visitors When you enter a room with visitors, greet them as you would the patient Explain the purpose of your visit to the patient, and ask the visitors if they would mind stepping outside Most visitors will exit to leave you to work without distraction --> Apprehensive patients Many patients have some apprehension about being stuck with a needle or having their blood drawn Most patients can be easily calmed by engaging them in a little distracting conversation on neutral topics, such as the weather, traffic, or local news --> Language problems When the patient cannot understand you, he or she cannot give informed consent In this situation, you may need a translator Alternatively, if you can effectively communicate with the patient by showing him or her what you will do, you may be able to obtain consent without a translator --> Patient refusal The patient always retains the right to refuse a blood collection Find the nurse and explain that the patient has refused the procedure The nurse may ask you to return with him or her to the room If the patient again refuses, document this on the request, along with the nurse's name, and notify the health care provider

Problems in Site Selection

--> Occluded and sclerosed veins Veins that are occluded (blocked) or sclerosed (hardened) feel hard or cordlike and lack resiliency Occlusion and sclerosis can be caused by inflammation, disease, chemotherapy, prolonged IV therapy, or repeated venipuncture Such veins are susceptible to infection, and because the blood flow is impaired, the sample may produce erroneous test results --> Hematomas Hematomas may be caused by the needle going through the vein, by having the bevel opening only partially in the vein, or by failing to apply enough pressure after withdrawal Blood from a hematoma is no longer fresh from the vein, and the hematoma can obstruct the vein, slowing blood flow --> Edematous tissue The arm may appear swollen because of the accumulation of tissue fluid Burns, scars, and tattoos Areas with burns, scars, or tattoos have impaired circulation, are susceptible to infection, and maybe painful or difficult to penetrate --> Mastectomies The removal of lymph tissue on the side of the mastectomy causes lymphostasis, or lack of lymph fluid movement The collection also may be painful to the patient, and the risk of infection may be increased IV sites Blood should not be drawn from an arm if there is an IV device in place Use the other arm instead, or an alternative site --> Any condition resulting in disruption of skin integrity means that the site should be avoided Open or weeping lesions, skin rashes, recent tattoos, or incompletely healed stitches are examples of sites that should be avoided because of the increased risk of infection.

Arterial Puncture Complications

-> Arteriospasm, the spontaneous constriction of an artery in response to pain -> Embolism, or blood vessel obstruction, due to an air bubble or dislodged clot in the artery -> Hematoma, resulting from inadequate pressure on the site -Hemorrhage -Infection, from skin contaminants -Lightheadedness, nausea, or fainting. -Nerve damage, caused by inadvertent contact with a nerve -Severe pain -Thrombosis, or clot formation, within the artery

Identification of Newborns

-> On their identification (ID) bracelets, newborns may be identified only by their last names, such as "Baby Boy (or Girl) Smith" (ask the nurse and confirm.) -As always, use the hospital ID number, not the name, as the ultimate proof of ID

Coagulation/ chemistry: other categories

-> With recent advances in POCT instrumentation, physicians now have a choice of tests for monitoring heparin therapy -> CLIA-waived PT testing instruments are frequently used in physicians' offices and clinics Chemistry: Glucose -Bedside glucose monitoring is the most common chemistry test done by POCT -Glucose is determined with dermal puncture and reagent strips Chemistry: Ancillary Blood Glucose Test -The ancillary blood glucose test is performed at the bedside, most often for patients with diabetes mellitus -Because different manufacturers have somewhat different procedures for their machines and test strips, be sure to read and understand the directions for the one you are using -Control solutions must also be run using the same procedure as for the patient's test Chemistry: Hemoglobin A1c -Hemoglobin A1c can be analyzed as a CLIA-waived test, using a handheld portable testing monitor -It can be used at the bedside or other POC, providing immediate results -The test monitors the long-term effectiveness of diabetes therapy by providing a reading of A1c, a protein related to the average blood glucose level over a period of 4 to 6 weeks Chemistry: Cardiac Troponin T -> Cardiac troponin T (cardiac TnT) is part of a protein complex in cardiac muscle that aids the interaction of actin and myosin Chemistry: Lipids -Cholesterol levels may be determined as part of a routine examination or to monitor therapy with cholesterol-lowering drugs -Blood is applied to a card, and a color determination is made after the reaction takes place -Other cholesterol POCT methods use instrumentation Chemistry: Blood Gases and Electrolytes -Several instruments are available that can analyze arterial blood gases (the concentrations of oxygen and carbon dioxide and the pH) and common electrolytes (sodium, potassium, calcium, chloride, and bicarbonate) -Because of their complexity, all these instruments require careful calibration and more training than do simpler instruments such as hemoglobin analyzers Chemistry: B-Type Natriuretic Peptide -B-type natriuretic peptide (BNP), also known as brain natriuretic peptide, is a hormone made by the heart in response to the expansion of ventricular volume and pressure overload -The measurement of BNP at the bedside allows the practitioner to quickly differentiate between chronic obstructive pulmonary disease (COPD) and CHD, which may have similar symptoms.

Midstream Clean Catch

->Clean the genitalia -For women, use sterile soap to cleanse the area surrounding the urethra. -For men, use towelettes with benzalkonium and alcohol; for uncircumcised men, retract the foreskin for cleaning. ->Collect the sample -Specific procedures for sample collection may differ between institutions. ->Finish the collection -Cap the container. Refrigerate or add preservatives if necessary. Label the specimen with the patient's name and the date and time of collection.

Catheter Collection

-A catheterized urine sample is collected by a physician, nurse, or medical assistant -A catheter (narrow plastic tube) is inserted through the urethra into the bladder -This technique may be used for a culture and sensitivity (C&S) test when a urinary tract infection is suspected and obtaining a normal clean-catch specimen is not possible Suprapubic Aspiration -A suprapubic aspiration sample is collected by a physician -A needle is inserted through the abdominal wall into the bladder for the collection of a sample -The specimen is used for bacterial culture of anaerobes (bacteria that do not grow in the presence of oxygen) and for cytologic (cell) examination in cases of suspected bladder cancer Urine Samples for Drug Testing -Urinalysis can reveal the presence of many types of drugs and metabolites in the bloodstream -Drug testing is becoming increasingly common in outpatient settings, driven by the concern for a drug-free workplace -Collection and handling procedures must follow COC guidelines because the sample may be used in a legal proceeding or in decision making regarding employment or athletic participation

Centrifuging

-A centrifuge spins the sample at a very high speed, separating components based on density -Cellular elements, which are denser, move to the bottom; the less dense plasma or serum is pushed to the top

Chilled Specimens

-A number of tests require that the specimen be chilled immediately after collection -Chilling is used to prevent chemical changes that would alter test results -The sample should be placed in crushed ice or in an ice and water mixture and immediately delivered to the laboratory

Arterial Blood Gas Testing (Cont.)

-ABGs measure the gas-exchange ability of the lungs and the buffering capacity of the blood -A lower-than-normal Po2 and a higher-than-normal Pco2 indicate that gas exchange in the lungs is impaired -Abnormal values mean that the body's tissues are not getting adequate oxygen, a serious and potentially life-threatening situation

Preparing Aliquots

-All tubes into which aliquots are placed should be labeled before filling and then capped before delivery to the appropriate department -Aliquots are not poured off because this may cause splashing and aerosol formation -Instead, an aliquot is removed with any one of several types of disposable pipetting systems

Amniotic Fluid Specimens

-Amniotic fluid is the fluid within the amniotic sac, developed within the uterus, that bathes and cushions the developing fetus -It is formed by the metabolism of fetal cells, by the transfer of water across the placental membrane, and in the third trimester by fetal urine -Amniotic fluid is collected by a physician in a procedure known as amniocentesis

Autologous Donation

-An autologous donation is blood donated by a patient for his or her own use later -Patients planning surgery often make autologous donations before the procedure -Because multiple units might be needed during surgery, patients may need to donate several times -A patient can donate as often as every 72 hours, assuming that his or her health is good

Types of Vascular Access Devices (Cont.)

-An implanted port is a chamber located under the skin and connected to an indwelling line -A peripherally inserted central catheter (PICC) is threaded into a central vein after insertion into a peripheral (noncentral) vein, usually, the basilic or cephalic, accessed from the antecubital area -An arterial line is placed in an artery for continuous monitoring of blood pressure or frequent collection of samples for blood gas testing -A heparin lock or saline lock is a tube temporarily placed in a peripheral vein to administer medicine or draw blood -An arteriovenous (AV) shunt is an artificial connection between an artery and a vein -An external AV shunt consists of a cannula with a rubber septum through which a needle may be inserted for drawing blood -Never use a syringe larger than 20 mL, because pulling on the plunger can create enough vacuum to collapse the line -VADs are often periodically flushed with heparin to keep the line open -The order of draw should be blood cultures, anticoagulated tubes, and then clotted tubes

Equipment for Arterial Puncture

-Arterial blood is collected in a syringe that has been pretreated with heparin to prevent coagulation -Syringes must be either glass or gas-impermeable plastic -The volume of blood required determines the syringe size; available syringe volumes range from 1 to 5 mL -The typical collection needle is usually 21 or 22 gauge, and 1 to 1½ inches long -The risk of serious infection is greater with arterial puncture than with venipuncture -For this reason, both alcohol and povidone-iodine or chlorhexidine are used to clean the site -To lessen pain, 0.5 mL of lidocaine, a local anesthetic, may be injected subcutaneously, using a 25- to 26-gauge needle on a 1-mL syringe -Arterial blood is under pressure and may spray out of the puncture -You need a fluid-resistant gown, face protection, and gloves -You also need a puncture-resistant container for sharps -The Luer tip covers the syringe top after you have removed the needle Other equipment needed for arterial puncture includes the following: Crushed ice Ice and water Gauze pads Pressure bandages Thermometer (to take the patient's temperature) Transport container

Geriatric Patients

-As with infants, collection from geriatric patients presents both physical and psychological challenges -Working with geriatric patients also can bring considerable rewards for phlebotomists who take the time to get to know their patients as people -Geriatric patients are also the most likely clients in adult daycare settings and home care -Patients in LTC facilities are often coping with the special challenges that have led to the need for institutionalization -These challenges may include chronic illness, loss of mobility, or cognitive impairment, or dementia

Special Considerations for Blood Collection

-Be especially careful with patient ID -Be aware of the frequency of blood draws because the risk for anemia is higher in geriatric patients -Be especially gentle when applying pressure to the finger to avoid bruising -If you are performing venipuncture, you can apply the tourniquet over clothing to limit bruising -To improve access and comfort, place the arm on a pillow and have the patient grip a washcloth while the arm is supported on either side by rolled towels -Anchor the vein firmly, as veins have a tendency to roll more easily in geriatric patients -Use a smaller needle or a butterfly and smaller tubes for more fragile veins

Neonatal Bilirubin

-Bilirubin is a substance produced by the normal breakdown of RBCs -The liver is responsible for further processing of bilirubin so that it does not reach excessive levels in the blood -Buildup of bilirubin causes jaundice, or yellowing of the skin, and can lead to brain damage if untreated, a condition called kernicterus

Collection Precautions

-Bilirubin is light-sensitive -Hemolysis of the specimen falsely lowers the results, so precautions against hemolysis must be taken -Collection times must be recorded exactly to track the rate of bilirubin increase

Blood Donor Collection

-Blood donation is a vital link in the health care system, and the phlebotomist plays a central role in the collection of donated blood -Blood banks collect and store donated blood for use in both emergency and scheduled transfusions -Potential donors must be screened to ensure that the donation is not harmful to the donor or the recipient -Screening involves the following: -Registration -Interview and medical history -Physical examination

Specimen Collection

-Blood for neonatal screening is collected by capillary heel stick on special filter paper -Recent studies have shown that the levels of phenylalanine are significantly different between capillary and venous samples -The filter paper is supplied in a kit provided by the state agency responsible for screening tests -To collect a sample for neonatal screening, first perform a routine heel stick -Wipe away the first drop of blood, and then apply one large drop of blood directly to the circle -Do not touch the paper against the puncture site, and do not apply successive drops onto a single circle -Use of expired specimen collection card -Collection date missing -QNS (quality not sufficient) blood submitted -Blood not completely soaked through the filter paper -Contaminated or discolored specimen -Blood is caked, clotted, or layered on the filter paper circles -Patient demographic information is missing -Form number does not match that of the blood circles -Specimen is too old on receipt (received 14 or more days after collection) -Requisition form received but no blood sample -Specimen submitted on the improper collection form -Improper drying or collection resulting in serum separation -Specimen torn or damaged during transit -Laboratory accident

Collection Procedure

-Blood is collected by the unit, whose volume is 400 to 500 mL, or approximately 0.5 liter -It is collected directly into a sterile plastic bag, which hangs below the collection site and fills with gravity The weight of the filled bag triggers a clamp that stops the collection A 16- to 18-gauge needle is used for the collection

Blood Smears

-Blood smears are made to allow microscopic examination of the blood cells -The blood smear is used for determining the proportion of the various blood cell types, called a differential count; counting reticulocytes; and performing special staining procedures Blood Smear Preparation -Prepare the site -Place one drop of blood on a clean slide, ½ to 1 inch from the end, centered between the two sides -Place the edge of a second slide, the "spreader," onto the first slide in front of the blood at a 25- to 30-degree angle, and draw it back to just contact the drop -Move the spreader slide forward, away from the drop, in one continuous movement to the end of the slide -Examine the smears -An acceptable smear must have a feathered edge, meaning that the cells appear to thin out farther from the original drop -At the far end, you should see a very thin transparent layer Malaria Smears -Malaria is caused by blood-borne protozoa of the genus Plasmodium -A patient with malaria has cycles of fever and chills that coincide with the life cycle of the parasite in the bloodstream -Malaria is diagnosed with a blood smear, drawn as a stat or timed collection just before the onset of fever or chills -> To make the thick smear, use a larger drop of blood, and spread it out to only about the size of a dime

Legal and Forensic Specimens

-Blood specimens may be collected for use as evidence in legal proceedings, including alcohol and drug testing, deoxyribonucleic acid (DNA) analysis, or paternity or parentage testing -The most important concept in handling forensic specimens is the chain of custody (COC), a protocol that ensures that the sample is always in the custody of a person legally entrusted to be in control of it -The purpose and procedure of the test must be explained to the patient -The patient must present picture identification -The specimen must be labeled appropriately to establish a COC -The specimen must be sealed in such a way that any tampering can be identified -The specimen must be placed in a locked container before transport to the testing site

Special Physiologic Considerations

-Children have a lower total blood volume than adults do -The younger (and smaller) the child, the lower the volume that can be safely withdrawn -Infants and children should not have more than 5% of their blood volume removed within a 24-hour period unless medically necessary -Removal of 3% or less is the preferred maximum -Dermal puncture requires a very small amount of blood and is the most common pediatric collection procedure -However, it cannot be used when a larger volume of blood is required, such as for blood culture or cross-match testing or for coagulation testing -For blood culture in infants and small children, a sample of 1 to 5 mL is required -Children differ in their levels of understanding, ability to cooperate, and anxiety about medical procedures -For many children, needles represent pain, and their fear of pain often makes the collection procedure challenging for the phlebotomist -As a phlebotomist, your goal is to make the collection as calm, comfortable, and painless as possible for the child -Prepare your equipment ahead of time, before you encounter the child -If possible, perform the procedure in a room that is not the child's hospital room such as a procedure room -Be friendly, cheerful, and empathetic -Explain what you will be doing in terms that are appropriate for the child's age -Do not say that it will not hurt -Give the child choices whenever possible to increase his or her feeling of control -Use the shortest possible needle for the procedure, and keep it out of sight for as long as possible -Distract the child just before the actual stick so that he or she is looking away -During the draw, tell the child how much longer it will be ("just one more tube" or "a few more seconds") -Afterward, praise the child (even if he or she did not cooperate as well as you had hoped) and offer him or her a small reward, such as a sticker (for younger children) or a pencil (for older children).

Cold Agglutinin

-Cold agglutinins are antibodies often formed in response to infection with Mycoplasma pneumoniae, a cause of atypical pneumonia -The antibodies created by the immune system during the infection may also react with RBCs at temperatures below body temperature, causing them to stick together, hence cold agglutinins (agglutination is the process of sticking together)

Therapeutic Drug Monitoring (Cont.)

-Collection is usually timed to coincide with either the trough or the peak serum level -The trough level is the lowest serum level and occurs immediately before the next dose of medicine is given -The peak level, or highest serum level, occurs sometime after the dose is given; exactly when depends on the characteristics of the drug, the patient's own metabolism, and the method of administration Blood Cultures -A blood culture (BC) is ordered to test for the presence of microorganisms in the blood, a potentially life-threatening situation -Such microorganisms include bacteria, fungi, and protozoa -Bacteremia refers specifically to the presence of bacteria in the blood Types of Collection Containers There are three basic types of containers for collecting BCs -A long-necked bottle, which accepts a BD Vacutainer needle and tube holder -A shorter bottle, which accepts a winged infusion device, such as a BD Bactec, using a special adapter -A standard evacuated tube with sodium polyanethole sulfonate (SPS) anticoagulant

Fasting Specimens and the Basal State

-Diurnal variation refers to the normal daily fluctuations in body chemistry related to hormonal cycles, sleep-wake cycles, and other regular patterns of change -To minimize the variations introduced by normal fluctuations in blood composition, reference ranges for blood tests are based on healthy patients in what is known as the basal state -The basal state is defined as the body's state after 8 to 12 hours of fasting and abstention from strenuous exercise -If a fasting specimen is requested, the phlebotomist must ask the patient if he or she has had anything to eat or drink other than water, or has had any caffeine or nicotine, within the past 12 hours -It is better to ask the question in this form than to ask, "Have you been fasting for 12 hours?" because some patients may not consider an evening snack or morning juice to be a violation of their fast

electrocardiography

-Electrocardiography is a method for recording the electrical activity of the heart -The output of the electrocardiograph is a tracing, called an electrocardiogram (ECG or EKG) -The ECG is used to diagnose heart diseases such as ischemia, myocardial infarction, or fibrillation The Cardiac Cycle -As you learned in Chapter 7, each heartbeat cycle includes a contraction and relaxation of each of the four chambers of the heart -This contraction is triggered and coordinated by electrical impulses from the heart's pacemaker, called the sinoatrial node, located in the upper wall of the right atrium -The electrical activity occurring during this cycle is recorded on the ECG -The normal ECG consists of tracing with five prominent points where the graph changes direction -These are arbitrarily known as P, Q, R, S, and T.

Protecting Specimens from Light

-Exposure to light can break down light-sensitive analytes -Bilirubin is the most common light-sensitive analyte; others include vitamin B12, carotene, folate, and urine porphyrin -To prevent light exposure, samples are collected in amber-colored microtubes, wrapped in aluminum foil, or an amber/brown biohazard bag, and placed inside a brown envelope or heavy paper bag

Light-Sensitive Specimens

-Exposure to light can break down or alter certain blood constituents -Specimens to be tested for these constituents must be protected from light after collection -This is done by wrapping the tube in aluminum foil immediately after collection

Mental Impairment

-Forgetfulness, confusion, and dementia are more common among geriatric patients -These patients may have difficulty communicating and complying with requests and may also be combative -Use the wristband, not the patient's response, to confirm patient ID -Some patients may be in restraints to prevent them from hurting themselves or others

Patients Requiring Blood Draws for Extended Periods (Cont.)

-Frequent blood drawing in these patients often causes the most commonly used sites to become damaged from overuse -The veins may become hardened and difficult to penetrate with the needle, and the skin may develop scar tissue -In some diseases, the trauma to the skin from frequent needle puncture may cause it to become delicate and easily torn -Patients in the ICU or ER are likely to have some type of vascular access device (VAD) or indwelling line in place that may affect your collection -A VAD is a tube that is inserted into either a vein or an artery and is used to administer fluids or medications, monitor blood pressure, or draw blood

Working with Intravenous Lines

-Have the nurse turn off the IV drip before the draw for the appropriate amount of time for the IV to clear of medications -Apply a tourniquet distal to the IV insertion site Select a vein distal to the IV insertion site and different from the vein with the IV line -Discard the first 5 mL of blood, because it will be contaminated with the IV fluid

Common Disorders

-Hearing loss is common among geriatric patients -Begin your encounter with a patient by speaking slowly and deliberately to be sure the patient understands -Visual impairment is common and may impair the patient's ability to comply quickly or easily with your requests -A number of conditions, including Parkinson's disease and stroke, can lead to unclear speech -Arthritis affects a large percentage of geriatric patients -Arthritis may prevent your patient from fully straightening his or her arm or fingers -Many patients may be on anticoagulant therapy for previous heart attacks or strokes -These patients have an increased risk of hematoma -Tremor is common in advanced old age and may make it difficult for the patient to hold his or her arm steady during the blood collection process

Immobilization of Infants and Children

-Immobilizing pediatric patients may be necessary to ensure their safety during the draw -Wrapping newborns or very young infants in a receiving blanket is usually sufficient, as they are not strong enough to work themselves loose during the procedure -Older babies, toddlers, and young children need to be restrained -Pediatric draws are done with the patient either seated in the lap of a parent or other assistant or lying down, with the parent or assistant leaning over the child -For a seated child, the parent hugs the child's body, crosses his or her legs around the child's legs to prevent kicking, and holds the arm not being used in the draw -For a child lying down, the parent or assistant leans over the child, holding the unused arm securely

Legal Alcohol Collection

-Important features of alcohol testing include the following: -The site must not be cleaned with alcohol, as this would falsely elevate the result -Tubes must be filled as full as the vacuum allows to minimize the escape of alcohol from the specimen into the space above -Note on the requisition form that the site was cleansed with soap and water or another a nonalcoholic solution

Specimen Rejection

-Improper or inadequate identification -Hemolysis -Incorrect tube for the test ordered -Tubes past their expiration date -Inadequate ratio of blood to additive -Insufficient volume for testing -Drawing a specimen at the wrong time -Contaminated specimen -Improper handling -Bringing a sample to the laboratory outside the appropriate time frame

Settlement and Judgment

-In an out-of-court settlement, the two parties reach an agreement without the intervention of a jury -When the parties cannot reach an agreement, the case goes to court for trial and judgment -A judgment against the defendant in a civil case usually results in a fine, which may be only compensatory or punitive Professional Liability Liable means that you are legally responsible for an action and can be held accountable for its consequences -You must perform only those procedures that you have been properly trained to perform and that fall within --your scope of practice -Judgments regarding medical liability revolve around the concept of the accepted standard of care, which represents the consensus of medical opinion on patient care in a particular situation Medical Malpractice -Malpractice is the delivery of substandard care that results in harm to the patient -A malpractice suit usually names one or more professionals involved as well as the institution as defendants -The suit alleges professional negligence as the cause of specific harms, which may include both physical and emotional distress, as well as lost income or potential income, as the result of specific actions Four Elements of Negligence Duty: Plaintiff must prove that the defendant owed a certain level of care Dereliction of duty: Revolves around the accepted standard of care and the action or inaction of the plaintiff Injury: There must be proof that a legally recognizable injury occurred to the patient Direct cause: There must be proof that the injury was a direct result of the defendant's action or inactions Defense Against Malpractice -Show that the standard of care was followed -All parties should carefully document exactly what happened -Each institution has a set of protocols for reporting such incidents, which usually involve prompt and complete documentation of the circumstances of the incident in an event report

Transporting Specimens to the Laboratory

-In many institutions, samples are hand-carried by the phlebotomist or another member of the laboratory team -Samples may be dropped off at designated areas within the hospital for transportation and delivery by the laboratory staff -Minimum information should include the patient's name, hospital number and room number, specimen type, date and time of delivery to the drop-off area, and name of the person depositing it -Some institutions use a pneumatic tube system, in which samples are carried in sealed plastic carriers that travel within a network of tubes -Shock-absorbing foam inserts are placed in carriers to reduce the shaking and agitation of the sample during transport -Special containers are used to protect the sample and prevent contamination of other material during transport

Transport and Processing of Non-blood Specimens

-Microbiology samples must be transported to the laboratory immediately to increase the likelihood of recovering pathogenic organisms -Most specimens are collected in transport media and do not require additional processing after collection -Most samples are plated immediately on culture media; often the phlebotomist is trained to perform this task

Aliquot Handling and Labeling

-Multiple aliquots prepared from a single specimen allow different departments to share a single sample for multiple tests -Each aliquot must be properly labeled as to the source and additives present Analytical Variables -An analytical variable is any variable that affects the testing process -Although most samples are tested by MLS, MT, and MLT laboratory personnel, the phlebotomist may be trained to perform CLIA-waived testing -If pipetting of reagents is required for a test, the improper pipetting technique may yield results that fall outside the expected range or falsely fall inside the expected range Postanalytical Variables -A post-analytical variable is any variable in the reporting and follow-up of test results -The phlebotomist may be responsible for reporting --POCT results that he or she performed -The method of delivery is determined by the facility and may include telephone, fax, computer, or hand delivery.

Neonatal Screening

-Neonatal screening tests are required as a part of mandatory, state-based public health programs -The tests are used to detect inherited metabolic disorders that cause severe brain damage or other impairments, and allow for implementation of early intervention treatments

Venipuncture in Newborns

-No tourniquet is needed -Using a 23-gauge needle, gently insert the needle 3 to 5 mm distal to the vein, slowly advancing until you see blood in the hub of the needle -Once blood begins to flow, you can release your hold on the needle and use your free hand to pull gently on the syringe -After withdrawing the needle, apply firm pressure with sterile gauze until the bleeding stops -Follow the procedure for using a blood transfer device to fill required tubes and dispose of used devices -Record volume of blood collected per your facility's protocol

Involvement of Parents and Siblings

-Parents who are present during the procedure can help in several ways -Ask the parent whether the child has had blood drawn previously and, if so, what techniques helped ease the child's anxiety -Some parents may prefer not to remain with the child during the procedure because they are reluctant to see the child in pain or become queasy at the sight of blood

Defense Against Malpractice (Cont.)

-Patient communication is also an important aspect of preventing malpractice claims -Always obtain positive informed consent before performing a procedure -Procedures must be explained in a way that the patient can understand, and the patient must give positive consent -The only time nonverbal consent is acceptable is in cases in which immediate action must be taken to save a patient's life Health Insurance Portability and Accountability Act -HIPAA defines a set of standards and procedures for the protection of privacy of health information -Under HIPAA, patients have the right to control their protected health information (PHI), and disclosing PHI without the patient's consent is illegal -Never discuss a patient's condition in a public place, such as a hallway, elevator, or eating area -Never discuss information concerning a patient with someone not involved in that patient's care -Never release medical information concerning a patient to anyone not specifically authorized to acquire it -Never leave patient records out where patients or visitors can glance at them -Always log off computers when tasks are completed

Putting on PPE

-Perform hand hygiene before donning PPE -Put on a gown and tie behind your back -Put on the mask, respirator, goggles, or face shield -Put on the gloves and make sure they go over the cuff of the gown

Site Selection

-Phlebotomists collect only from the radial or brachial arteries; other collections require a physician or other specially trained professional -Other arteries that can be used include the femoral and dorsalis pedis -The artery used for collection must be located near the skin surface and be large enough to accept at least a 23-gauge needle -In addition, the region distal to the collection site should have collateral circulation, meaning that it receives blood from more than one artery -The radial artery, supplying the hand, is the artery of choice -Although it is smaller than either the brachial or the femoral artery, it has good collateral circulation and is easily accessible along the thumb side of the wrist Its small size is a disadvantage in patients with low cardiac output because it is hard to locate -The brachial artery is large; therefore, it is easy to palpate and puncture -It is located in the antecubital fossa, below the basilic vein and near the insertion of the biceps muscle -It has adequate collateral circulation, although not as much as the radial artery -The femoral artery is the largest artery used It is located in the groin area above the thigh, lateral to the pubic bone -The femoral is used when the previously mentioned sites are not available for puncture -Its large size and high volume make it useful when cardiac output is low -However, it has poor collateral circulation -Alternative sites in adults include the dorsalis pedis artery in the foot -When puncturing the dorsalis pedis, the posterior tibial must be checked for an adequate pulse -In newborns who have difficulty breathing, blood may be collected from both the umbilical artery and the umbilical vein

Radial Artery Puncture

-Prepare the patient, and examine and complete the requisition form -Take the patient's temperature and respiration rate and record them on the requisition form if required by your facility's protocol -The patient should be in a respiratory steady-state, meaning that he or she has received the specified amount of oxygen and has refrained from exercise for at least 30 minutes -Choose and prepare the site -Perform the modified Allen test to assess collateral circulation in the hand -If the result is positive, proceed -Fully extend the arm, with the anterior surface facing upward - Palpate for the artery with either the middle of the index finger to locate the greatest maximum pulsation -Perform the puncture -Cleanse the fingers of your non-dominant hand and place them over the area where the needle should enter the artery, using the index finger and middle finger of your non-dominant hand to stabilize the artery -Hold the syringe like a dart with your dominant hand, with the needle tip pointed bevel up toward the upper arm -As the needle is inserted into the artery, blood should appear in the hub Withdraw the needle, apply pressure, and ice the syringe -Withdraw the needle with your dominant hand -With your non-dominant hand, apply direct pressure to the site with a folded gauze square -Hold it for at least 5 minutes -Meanwhile, with the hand holding the syringe, depress the plunger slightly, if necessary, to expel any air that may have entered the needle -Examine the puncture site -After 5 minutes (or 15 minutes for patients on anticoagulant therapy), check the site to ensure that the bleeding has stopped -A number of medications increase bleeding times, including anticoagulants (e.g., heparin and warfarin) and thrombolytics (e.g., tissue plasminogen activator, streptokinase, and urokinase) -> thromcytes (platelets) -Label and ice the specimen -Dispose of the needle in the sharps container -Label the specimen with a waterproof pen, and return the syringe to the ice -Deliver the specimen to the laboratory immediately

Quality Assurance (QA) and Quality Control (QC)**

-QA guarantees quality patient care through a specific program, including both technical and nontechnical procedures -QA programs use written documentation to set standards for the performance of procedures, monitor compliance with written procedures, and track patient outcomes with scheduled evaluations of all laboratory activities -QC is part of QA -QC requires documenting equipment inspections, calibrating instruments, and monitoring the protocols used in each step of phlebotomy, from patient preparation and identification, through collection procedures and equipment, to transportation of specimens and distribution in the laboratory. Procedure Manual -The procedure manual is present in the department at all times -It contains protocols and other information about all the tests performed in the laboratory, including the principle behind the test, the purpose of performing it, the specimen type the test requires, the collection method, and the equipment and supplies required Directory of Services -The directory of services contains a variety of information pertinent to the smooth coordination of nursing staff and laboratory personnel -It includes laboratory test schedules, early morning collection schedules, and written notification of any changes, plus information on patient preparation, specimen types and handling, and normal values Monitoring of Variables Variable: Any factor that can be measured or counted that affects the outcome of test results and therefore patient care Preanalytic variables: Occur before analysis of the specimen Analytic variables: Occur during specimen analysis; can be affected by preanalytic variables, such as collection time or transport conditions Postanalytic variables: Delays in reporting results or improper entry of results in the data bank; also may be part of the phlebotomist's responsibilities

OSHA Bloodborne Pathogen Standard (BBP)

-Regulation approved in 1992 to protect health care workers from infection -The bloodborne pathogen rule was revised in 2001 to clarify issues related to sharps safety

Clotting

-Serum specimens must be completely clotted before centrifugation -Complete clotting may take 30 to 45 minutes at room temperature -Samples with clot activators (including serum separator tubes) clot within 30 minutes -If thrombin is used, complete clotting may occur within 5 minutes

Specimen Collection par 1

-Site selection: Sites that cause specimen contamination include hematomas or areas with edema and the side of the body that has undergone mastectomy or is currently receiving IV fluids -Tourniquet application: Tourniquets should be left on no longer than 1 minute to reduce hemoconcentration -Site cleansing: Proper cleansing reduces the risk of infection. Blood culture collections require special care to prevent contamination of the sample with skin flora. -Specimen collection: Specimens must be collected in the right tube for the test ordered and in the right order. -Labeling: Incorrect or incomplete labeling makes a specimen useless and requires redrawing the specimen at a later date. Patient's Perception -The patient's perception of the level of care he or she receives is directly affected by the skill, professionalism, and care you show as a phlebotomist -This perception reflects not only on you but on the entire laboratory as well -Break the chain of infection by performing hand hygiene upon entering and leaving the room, and by wearing gloves during the procedure Accidental Puncture -Accidental puncture with a used needle must be reported immediately to a supervisor -QA procedures include monitoring the number of accidental punctures and instituting additional training or equipment modifications in the event of frequent accidents Transportation -Specimen transportation variables include the method of delivery, the treatment of the sample during transportation, and the timing of delivery -Samples requiring either cold or warm temperatures during transport must be placed in the appropriate container and must be handled so that the appropriate temperature is maintained throughout the transport process Separation Times -No more than 2 hours should elapse between the time a specimen is collected and the time serum or plasma is separated from formed elements -After this time, the sample will begin to show falsely lowered glucose and falsely elevated potassium and lactate dehydrogenase Centrifuge Maintenance -Centrifuges must be calibrated every 3 months with a tachometer to ensure that they are running at the reported speed -Variation may indicate the need to replace worn parts Evaporation and Contamination -Evaporation of liquid, especially from small samples, can affect ABGs, alcohol, and ammonia, among other tests -Contamination may occur while the sample is uncovered, arising from airborne dust or talc from gloves -Contamination may also occur from incomplete separation, such as when RBCs are left in the sample after incomplete centrifugation Refrigerators and Freezers -Temperatures of refrigerators and freezers must be monitored daily, with temperatures recorded either automatically or manually at specified times of day -Temperature readings that are too high or low indicate that the unit needs maintenance or replacement

Physical Changes

-Skin changes are among the most important -The amount of collagen in the skin is reduced, so the skin becomes less elastic, and the layers of skin become thinner -Bruising is more likely, and it takes longer to replace cells, so longer healing times are needed -Veins also are often closer to the skin; therefore, the penetration angle of the needle needs to be reduced

Central Processing

-Specimens entering the lab are usually first handled by central processing, an area devoted to accessioning and sorting samples as they arrive -The date and time of arrival are recorded, often with a time- and date-stamping machine -Each sample is marked with an accession number, a unique identifying number used for cataloging the sample in the lab -Central processing is also usually responsible for centrifuging samples, to separate plasma or serum from cellular elements, and for preparing aliquots, which are small portions of the specimen transferred into separate containers for distribution to a variety of lab departments -Before centrifuging, the stopper should remain on the sample to prevent its contamination or alteration

Why Collect a Sweat Electrolyte/Chloride Specimen?

-Sweat electrolytes (SEs) are the salts, including chloride, present in normal sweat -The sweat electrolyte/chloride test is performed as part of the diagnosis for cystic fibrosis -Sweat electrolyte/chloride specimens are subjected to the iontophoretic pilocarpine test, which requires special training -Sweating is induced by applying a weak electrical current (known as iontophoresis) and the drug pilocarpine to the test area Cerebrospinal Fluid Specimens -Cerebrospinal fluid (CSF) circulates in the brain and spinal cord, where it provides nourishment and removes wastes from the central nervous system -It is most commonly collected by lumbar puncture (spinal tap), in which a needle is inserted between the vertebrae at the base of the spine -Three to four tubes are collected in sterile plastic containers and numbered in the order of collection

2-Hour Postprandial Test

-The 2-hour postprandial test is used to test for diabetes mellitus -It compares the fasting glucose level with the level 2 hours after consuming glucose, either by eating a meal or by ingesting a measured amount of glucose (postprandial means "after a meal") -After the phlebotomist has obtained a fasting specimen, the patient is instructed to eat a full meal and then return to the lab 2 hours after eating for collection of the second specimen

Special Considerations

-The ID band must be present on the infant -Keep your equipment out of the patient's reach -Warm the heel for 3 to 5 minutes, using a heelwarmer packet -Avoid using adhesive bandages -Document the collection in the nursery log sheet

Electrocardiogram Equipment

-The electrical activity of the heart is recorded with 10 numbered electrodes that are placed in defined locations on the patient's chest, arms, and legs -A wire is attached to each electrode -The wires pass to the ECG machine through a cable -The tracing is made on heat- and pressure-sensitive paper by a stylus Performing an Electrocardiogram -The patient should be wearing a gown that opens in the front, and the lower legs must be exposed -The patient should be lying down and must remain still during the ECG Other CLIA-Waived Tests The number of CLIA-waived tests is growing because of both advances in bioanalytic chemistry and recognition that such tests allow more flexible delivery of care by a wider range of staff Occult Blood The stool specimen is placed on the card (two windows) or slide, and the reagent or developer solution (stabilized peroxide reagent) is added to the test area Urinalysis -Many commonly requested urine tests can be performed using a dipstick, a plastic strip with reagents embedded in it -Tests may include pH, protein, glucose, ketones, bilirubin, urobilinogen, blood, leukocyte esterase, nitrite, and specific gravity -The color change on the strip is compared with the reference color chart on the bottle at the appropriate time Pregnancy A pregnancy test detects the presence of human chorionic gonadotropin (hCG), a hormone produced by the placenta after implantation of a fertilized egg Rapid Group A Streptococcus -This test detects group A Streptococcus (Streptococcus pyogenes) from a throat swab -The procedure usually requires extracting the sample to isolate bacterial carbohydrates, followed by the addition of reagents and the development of a color change Influenza A and B -Influenza (flu) is a viral disease of the respiratory system -The test is performed on a specimen collected by a nasal swab, nasopharyngeal swab, nasal wash, or nasopharyngeal aspirate (in which fluid is withdrawn under suction from the rear of the nasal cavity) -A single sample can be used to run both the test for A and B types

Other Tolerance Tests

-The epinephrine tolerance test determines the patient's ability to mobilize glycogen from the liver -The glucagon tolerance test is identical in purpose and procedure, except that the hormone glucagon is injected instead of epinephrine -The lactose tolerance test (LTT) determines whether the lactose-digesting enzyme lactase is present in the gut Diurnal Variation -Many substances in the blood (especially hormones) show diurnal variation, or regular changes throughout the day -Cortisol, for instance, is usually twice as high in the morning as in the late afternoon -The time for the draw is usually scheduled for the diurnal peak or trough

Glucose Tolerance Test

-The glucose tolerance test (GTT), also called the oral glucose tolerance test (OGTT), tests for both diabetes mellitus and other disorders of carbohydrate metabolism -Hyperglycemia, or abnormally elevated blood sugar, is most commonly caused by diabetes -Hypoglycemia, or abnormally lowered blood sugar, maybe due to one of several endocrine disorders or other metabolic disruptions -Glucose tolerance testing is still widely used in pregnant women to diagnose gestational diabetes -Gestational diabetes is insulin-resistant diabetes that develops in almost 20% of women late in pregnancy -Patients will be instructed by their physicians regarding pretest preparation, which includes eating high-carbohydrate meals for several days and then fasting for 12 hours immediately before the test -The blood and urine specimens should be tested before the GTT proceeds. -In the event that the glucose level is severely elevated, the physician may decide not to proceed with the test -The patient then drinks a standardized amount of glucose solution within 5 minutes -Timing for the rest of the procedure begins after the drink is finished -The phlebotomist makes a collection schedule -All collections should be made on time and using the same collection method (i.e., venipuncture or dermal puncture) and anticoagulant for each sample

Removing a Stopper

-The major risk of stopper removal is the formation of an aerosol, a microscopic mist of blood that forms from droplets inside the tube -Aerosols are especially likely if the tube or rim has been contaminated by the blood during collection or transport -Many automated instruments allow for testing without stopper removal

Sampling Errors

-The most significant source of error is failure to deliver the sample to the laboratory immediately or to properly store the sample on ice if delivery will be delayed -Blood cells continue to respire after collection, and this may cause considerable changes in the analyze values, including Po2, Pco2, and pH -Samples collected in a plastic syringe are not iced and must be analyzed within 30 minutes of collection Specimen Rejection -Air bubbles in the specimen -Clotting -Failure to ice the specimen -Improper or absent labeling -Inadequate volume of specimen for the test -Too long a delay in delivering the specimen to the laboratory -Use of the wrong syringe Capillary Blood Gas Testing -Capillary blood gas (CBG) testing is an alternative -ABG testing when the arterial collection is not possible or is not recommended -Capillary blood is not as desirable a specimen for blood gas testing because it is a mixture of blood from the capillaries, venules, and arterioles and is mixed with tissue fluid -Clean the site with the appropriate antiseptic swab, using the antiseptic required by your institution -Collect the sample in a heparinized glass pipet -Fill the tube completely with blood so that no air bubbles remain -Mix well using the magnet and flea, and transport the specimen to the laboratory on ice

Types of Vascular Access Devices

-The name of the VAD is based on the location of the tubing in the vascular system -A central venous catheter (CVC), also called a central venous line, is the most common type of VAD -Central refers to the large veins emptying into the heart, into which the CVC is inserted

Timing

-The number of organisms in the bloodstream is often highest just before a spike in the patient's temperature -By frequently recording the temperature, these spikes can often be predicted and collection scheduled accordingly Multiple Sites -Contamination of the sample by skin bacteria is a frequent complication of BC collection -However, distinguishing contaminants from true pathogens can be difficult because some contaminants can grow on indwelling devices, causing infection in the patient -To reduce errors caused by this contamination, a known skin contaminant must be cultured from at least two different sites to be considered a blood pathogen Blood Culture Collection Procedure -> Prepare the site -After identifying the site, scrub it vigorously with alcohol to clean 1½ to 2 inches beyond the intended puncture site -Scrub vigorously with 2% iodine or a povidone-iodine swab stick -Avoid touching the site once it has been cleaned -Prepare your collection equipment -Collect the sample -Reapply the tourniquet, and perform the venipuncture -Attend to the patient -After collection, remove the iodine from the patient's arm with alcohol -Check the puncture site to be sure bleeding has stopped -Apply a bandage, using a fresh adhesive bandage or placing adhesive tape over the gauze square

Collection Procedure for Semen Specimens

-The patient should be instructed to avoid ejaculation for 3 days before the collection -The sample should be ejaculated into a sterile plastic container -The time of the collection should be recorded because sperm die quickly, and viability analysis is based on the time elapsed since collection -For fertility testing, the volume of semen is also important, so the patient should report whether the sample collected is complete or partial Why Collect a Throat Specimen? -A throat culture sample (throat swab) is used to diagnose a throat infection -In particular, the sample is used to determine whether the infection is caused by group A Streptococcus bacteria, for which antibiotics are an effective treatment Why Collect a Nasopharyngeal Specimen? A nasopharyngeal (NP) culture is used to diagnose whooping cough, croup, pneumonia, respiratory syncytial virus (RSV), and other upper respiratory tract infections -> The sample is collected using cotton- or Dacron-tipped sterile wire <-

Pediatric Dermal Puncture

-The procedures for dermal puncture were discussed in Chapter 10 -As you learned in that chapter, heel puncture is preferred for children younger than 1 year, because the tissue overlying the finger bones is not thick enough for safe collection there

Therapeutic Phlebotomy

-Therapeutic phlebotomy is the removal of blood from a patient's system as part of the treatment for a disorder -The principal disorders treated by therapeutic phlebotomy are polycythemia, a disease characterized by excessive production of red blood cells (RBCs), and hemochromatosis, an excess of iron in the blood -In both cases, periodic removal of a unit of blood may be part of the treatment program

Timed Specimens

-Timed specimens are most often used to monitor: -Medication levels -Changes in the patient's condition -Normal diurnal variation in blood levels at different times of the day -Cardiac enzymes, used to diagnose or rule out myocardial infarction (heart attack); these are tested at admission and then twice more at 8-hour intervals

Anesthetics

-Topical anesthetic cream may be useful for venipuncture procedures in pediatric patients -The most commonly used agent is EMLA (eutectic mixture of local anesthetics), a mixture of lidocaine and prilocaine (for infants) -Anesthetic is not recommended for phenylketonuria (PKU) testing (described later)

Requisition Handling

-Variables to be controlled include duplicate or missing requisitions, tests left off the requisition, missing patient number, missing doctor name, or priority not indicated -QA procedures for these variables include recording and counting the numbers of each type of requisition error Equipment Tubes should be checked for lot number and expiration date Stoppers should be checked for cracks or improper seating Tubes may lose vacuum without any visible sign of defect Needles should always be checked for defects Syringe plungers must move freely in the barrel Patient Identification -It cannot be emphasized too strongly that proper patient identification is the most important procedure in phlebotomy -Improper identification can lead to injury or death -A delta check is a QA procedure that helps spot identification errors Patient Preparation Posture: A sample collected from an erect patient has a higher concentration of large molecules such as enzymes and albumin, as well as white blood cells (WBCs) and red blood cells (RBCs), compared with a sample collected from a supine patient (laying down facing up) Short-term exercise: Exercise increases levels of muscle enzymes such as creatine kinase, as well as WBCs, creatinine, and fatty acids Long-term exercise: A prolonged exercise regimen increases sex hormones, as well as many of the values increased by short-term exercise. Medications/treatments: Certain medications affect test results directly. Aspirin is the most common one, prolonging bleeding times. Alcohol consumption: Although moderate amounts of alcohol do not affect test results (except, of course, for the alcohol test), glucose is slightly elevated, and chronic consumption can lead to increase values on liver function tests, as well as platelet aggregation studies Smoking: Smoking increases catecholamines, cortisol, WBCs, mean corpuscular volume, and hemoglobin, and it decreases eosinophils Stress: Anxiety, crying, or hyperventilation may affect test results, including the stress hormones produced by the adrenal cortex. Diurnal variation: Certain specimens must be collected at specific times of day because of significant changes throughout the day. Fasting: Prolonged fasting increases bilirubin and fatty acids. A fasting specimen should be taken 8 to 12 hours after the last intake of food. Age: Many laboratory values vary with age. For instance, because organ function declines with advancing age, values affected by kidney or liver function are different for the elderly than for younger patients. Altitude: Patients living at higher altitudes have less oxygen available to breathe, so the body compensates by producing a higher RBC mass. Dehydration: Prolonged diarrhea or vomiting causes loss of fluid from the intravascular circulation. Sex: The normal ranges of some analytes differ for males and females. Pregnancy: The changes that occur in pregnancy affect laboratory values. The presence of the fetus and increased water retention causes a dilution effect that is reflected in falsely lower hemoglobin and RBC counts, as well as other analytes.

Cryofibrinogen and Cryoglobulin

-Warm collection and storage are required for two other types of samples: cryofibrinogen (an abnormal type of fibrinogen) and cryoglobulin (an abnormal serum protein) -These samples should be collected and handled in the same manner as a cold agglutinin sample

Supplies

-When performing venipuncture, use shorter needles, if possible, and use the smallest gauge consistent with the requirements of the tests -Butterfly needles and smaller, partial-fill tubes should be used for pediatric draws -Take along a selection of rewards, such as stickers or small toys

plurals

-a -ae Axilla/axillae -is -es Naris/nares -on -oa Spermatozoon/spermatozoa -um -a Ovum/ova -us-iNucleus/nuclei

Suffixes

-emia Blood condition Anemia -itis Inflammation Arthritis -oma Tumor, growth Hematoma -stasis Stopping, control Hemostasis -stomy Opening Colostomy -tomy Cut Phlebotomy

phlebotomy

-phlebo-= means veins -tomy= to make an incision is the practice of drawing blood. Greek word

Order of draw

1. Blood culture tubes (which are sterile) are drawn first. This prevents the transfer of unsterilized material from other tubes into the sterile tube. 2.Light blue-topped tubes (for coagulation tests) are next. These tubes are always drawn before tubes containing other kinds of anticoagulants or clot activators because other additives could contaminate this tube and interfere with coagulation testing. If coagulation tests are the only tests ordered, you only need a light blue-topped tube. Your institution may have you draw a plain red-topped tube first and discard it (this may help prevent contamination by tissue fluids). The discard tube may be a plain red glass tube or a specially manufactured plastic tube without any additive. Also, if you are drawing with a butterfly, you must draw a discard tube to draw out the air in the tubing and prevent a short draw. 3.Glass red-topped tubes or plastic red-topped tubes may be drawn now. 4. Red-gray (gold BD Hemogard) tubes and plastic gold-topped tubes are next. These contain clot activators, which would interfere with many other samples if passed into other tubes. 5.Green tubes are drawn next. The heparin from the green tube is less likely to interfere with EDTA-containing tubes than vice versa. 6. Lavender-topped tubes are next. EDTA binds many metals, in addition to calcium, so it can cause problems with many test results, including giving falsely low calcium and falsely high potassium readings. For this reason, lavender tubes are drawn near the end. 7. The gray-topped tube is last. This tube contains potassium oxalate. The potassium would elevate the potassium levels measured in electrolyte anal- ysis, and oxalate can damage cell membranes. Also, another additive, sodium fluoride, elevates sodium levels and inhibits many enzymes. Other color tubes are typically drawn after these six, but you should check the instructions on the manufacturer's package insert and your laboratory's procedures manual for specific information. The glass red-topped tube (but not the plastic red-topped tube) may be drawn after the sterile tube if your institution allows it.

11 things you will need

1. Requisition 2. gloves 3.tourniquet 4. alcohol 5. needle 6. tube holoder 7. tubes 8. gauze 9. sharps container d 10. labels 11. bandage

Bleeding Time Test

A bleeding time (BT) test measures the length of time required for bleeding to stop after an incision is made. In the past, this test was used before surgery to help assess the overall integrity of primary hemostasis. Inconsistencies in the test have led to its replacement by the platelet function assay (PFA) or other tests. These are performed not on dermal puncture samples but on venous blood.

DIFFERENCES BETWEEN VENOUS AND CAPILLARY BLOOD

A capillary puncture collects blood from capillaries. Because capillaries are the bridges between arteries and veins, blood collected by capillary puncture is a mixture of venous blood and arterial blood. The arterial proportion in the sample is increased when the collection site is warmed, as may be done to help increase blood flow before collection. Small amounts of tissue fluid from the puncture site may also be in the sample, especially in the first drop.

Requsition

A form requesting the purchase of merchandise

continuation arteries

A myocardial infarction (MI, or heart attack) occurs when the heart receives inadequate blood supply through the coronary arteries. This often occurs when the arteries become clogged with built- up atherosclerotic plaques. The resulting lack of oxygen, termed ischemia, causes damage to the muscle.

Anticoagulant

A plasma sample is collected in a tube containing an anticoagulant, a chemical that keeps blood from clotting. The sample is spun at high speed in a can centrifuge, which separates the plasma from the cells. The plasma is the straw-to-yellow color fluid that floats on top of the cells in the sample.

certification

A process in which a person, an institution, or a program is evaluated and recognized as meeting certain predetermined standards to provide safe and ethical care.

incident report

A report documenting an incident and the response to the incident; also known as an occurrence report or event report.

Hematology

A simple, fast method of anemia testing uses a handheld hemoglobin analyzer

Cardiopulmonary Resuscitation

A victim of cardiac arrest will be unresponsive and will not be breathing normally. Quick intervention may save the person's life. Guidelines issued by the American Heart Association in 2010 emphasize that continual chest compressions should be the initial CPR action for all victims, regardless of their age, and that breathing aid is less important than continual compression, especially in adults. If you are not trained in rescue breathing or cannot provide rescue breathing, you should perform compression-only ("hands-only CPR") after determining the victim is not responsive and not breathing normally. 1. Determine whether the victim is conscious by asking loudly, "Are you okay?" If there is no response, alert emergency medical personnel (either within the hospital or by calling 911). Determine whether the victim is breathing normally. If the victim is unresponsive and is not breathing or is only gasping, begin chest compressions immediately. (If there is an automated external defibrillator [AED] device nearby, use that instead.) To perform chest compressions, push down on the chest, right between the nipples, compressing the chest between 11⁄2 and 2 inches. Compressions should be at the rate of 100 per minute, so each compression should take less than 1 second. Continue compressions until professional help arrives.

informed consent

A written agreement to participate in a study made by an adult who has been informed of all the risks that participation may entail.

Common Health Care Abbreviations

A/C Accommodations AC/ac Before meals AMA Against medical advice AMI Acute myocardial infarction ASAP As soon as possible BID/bid Twice a day BIN/bin Twice a night BP Blood pressure CA/Ca Cancer CDC Centers for Disease Control and Prevention CHF Congestive heart failure cm Centimeter CPR Cardiopulmonary resuscitation Dx Diagnosis DOB Date of birth ECG/EKG Electrocardiogram ER Emergency room FDA Food and Drug Administration GI Gastrointestinal HIV Human immunodeficiency virus IV Intravenous L Liter

chapter 17 point- of care testing (PCOT)

Advantages of Point-of-Care Testing -Point-of-care testing (POCT) refers to the performance of analytic tests immediately after obtaining a sample, often in the same room that the patient in seen in (the "point of care") -By "bringing the laboratory to the patient," the turnaround time for obtaining test results is shortened, allowing more prompt medical attention, faster diagnosis and treatment, and potentially decreased recovery time -Most tests performed as POCT are tests waived by the -Clinical Laboratory Improvement Act of 1988 (CLIA) An essential feature of a CLIA-waived test is that the testing equipment and procedure are so simple and accurate that erroneous results are unlikely -In general, POCT instruments are easy to use, the required training is simple, and they can be used by a variety of medical professionals, including phlebotomists, nurses, nurse assistants, and physicians -Quality assurance and controls are still essential for the use of POCT instruments, just as they are with laboratory-based instrumentation -Finally, proper and adequate training for all personnel performing these procedures is critical to implement POCT successfully

Certification

After completing an accredited or approved pro- gram, you are eligible to take a certifying examina- tion. Certification is evidence that an individual has demonstrated proficiency in a particular area of practice. As shown in Table 1-1, the organizations and companies that offer certification are American Allied Health, the American Certification Agency for Healthcare Professionals (ACA), the AMT, the American Society for Clinical Pathology (ASCP), the ASPT, the National Healthcareer Association (NHA), and the NPA. Once you pass the examina- tion, you may use the title shown in Table 1-1 as part of your professional name.

PROTECTING THE PUNCTURE SITE

After drawing blood, you need to stop the bleeding by applying pressure to the puncture site. This is done with a 2- 3 2-inch gauze pad, folded into quarters.

Platelet Phase

Aggregating platelets become activated, releasing factors that promote fibrin accumulation in the next phase The combination of the vascular phase and the platelet phase is called primary hemostasis

Airborne Transmission

Airborne transmission involves either airborne droplet nuclei or dust particles that contain the in- infectious microorganism. Droplet nuclei are particles smaller than 5 mm that can remain suspended in the air for long periods. These droplet nuclei can be transported long distances by air currents and can cause disease when inhaled. Droplet nuclei can be formed by sneezing or coughing or simply by singing or talking. They may also form during aerosol-producing procedures, such as suctioning or bronchoscopy. Examples of microbes spread in this manner are Mycobacterium tuberculosis, rubella virus (measles), and varicella-zoster virus (chickenpox). Special ventilation and air-handling equipment designed to prevent airborne transmission in- include high-efficiency particulate air (HEPA) filters

Confidentiality

All information regarding a patient's condition, in- cluding the types of tests ordered or the results of those tests, is confidential medical information. For the phlebotomist, this means that information regard- ing a patient should never be discussed with a coworker who is not involved in that patient's treat- ment.

ACA

American Certification Agency for Healthcare Professionals

AMT

American Medical Technologists

ASCLS

American Society for Clinical Laboratory Science

ASCP

American Society for Clinical Pathology

ASPT

American Society of Phlebotomy Technicians

test for digestive disease

Amylase or lipase Carotene Complete blood count (CBC) Liver tests (PANEL) • Alkaline phosphatase (ALP)• Alanine aminotransferase (ALT)• Aspartate aminotransferase (AST) • g-Glutamyltransferase (GGT) • Bilirubin • Hepatitis B surface antigen (HBsAG) • Hepatitis C antibody • Hepatitis C virus (HCV) by polymerase chain reaction (PCR) • Ammonia GastrinOccult bloodOva and parasites (O&P) Stool culture disorders Pancreatitis Steatorrhea (malabsorption syndrome causing fatty stools) Appendicitis Liver disease Gastric malignancy Gastrointestinal bleeding Parasitic infection Stool pathogens

Pathogen

An organism that causes disease

Anticoagulants

Anticoagulants prevent blood from clotting. Sodium or potassium ethylenediaminetetraacetic acid (EDTA) binds calcium, thereby inhibiting the coagulation cascade. Other additives that bind calcium include sodium citrate, potassium oxalate, and sodium polyanetholesulfonate (SPS) AND Sodium fluoride inhibits glycolysis and can be used for glucose determination.

CLEANING THE PUNCTURE SITE

Antiseptics and disinfectants are used to reduce the risk of infection. By convention, antiseptic refers to an agent used to clean living tissue. Disinfectant refers to an agent used to clean a surface other than living tissue. AND The most commonly used antiseptic is 70% isopropyl alcohol (rubbing alcohol). Isopropyl alcohol is bacteriostatic, meaning that it inhibits the growth or reproduction of bacteria but does not kill them.

Protected Health Information (PHI)

Any information about health status, provision of health care, or payment for health care that can be linked to an individual.

Professional Appearance

Appearance has a significant effect on how the phle- botomist is thought of by patients and treated by coworkers, including superiors. First impressions are often lasting ones. Cleanliness and scrupulous grooming is critical, with conservative clothing, hair, and makeup the general rule.

(locating veins) tourniquet

Applying a tourniquet is the most common way to do this. A tourniquet prevents venous blood flow out of the arm, causing the veins to bulge.

Arteries

Arteries branch into smaller vessels called arterioles, which ultimately branch to form capillaries.

Personal Characteristics

As a phlebotomist, you will often be the first medical professional a patient meets. You therefore represent not only yourself or the laboratory but the entire health care facility. This public relations aspect of your work is important because it sets the tone for the patient's stay in the health care facility and the patient's satisfaction with the service the facility provides.

PHLEBOTOMY EQUIPMENT

As a phlebotomist, your primary duty is to collect blood and prepare it properly for delivery to the laboratory.

Additional Supplies

As in venipuncture, alcohol pads are used to prepare the site, and gauze pads are used to help stop the bleeding. A sharps disposal container is needed for the lancet.

Hand Collection Using a Winged Infusion Set

Assemble your equipment Remove the WIS from the package Insert the first tube Position the patient's hand, and apply the tourniquet Place the hand in an accessible position --> Insert the needle Choose the largest and straightest vein, and clean the site in the usual manner Anchor the vein firmly with your non-dominant hand Grasp the needle between the thumb and the index finger by folding the wings together in the middle Insert the needle into the vein, bevel side up, and lined up in the direction of the vein. --> Collect the sample If you are using evacuated tubes, push the collection tube into the adapter If you are using a syringe, pull the plunger back slowly, only matching the rate at which the blood is flowing into the syringe --> Finish the collection When the tube is completely filled, release the tourniquet and remove the needle --> Attend to the patient Apply pressure to the site, as you would for routine venipuncture --> Dispose of the WIS Special safety precautions must be observed when disposing of the WIS The entire system should be gathered up in one hand If using a syringe, discard the tubing and needle as for a WIS.

Immune System Disorder

Autoimmunity is an attack by the immune system on the body's own tissues Allergy is an inappropriately severe immune reaction to an otherwise harmless substance Severe combined immune deficiency (SCID) is an inherited disorder marked by an almost total lack of T and B cells

Physical Hazards

Avoiding physical hazards in the workplace is mostly a matter of common sense, plus learning some important habits: Avoid running. This is not only a safety rule but also a consideration for patients, who may become concerned or agitated. Watch for wet floors. Your facility should use cones or other types of signs to warn when a floor is wet and should have cleanup equipment for spills

Different type of kinds of Aids

Bleeding Aid Apply direct pressure to a bleeding wound; first place a clean cloth, if available, against the wound. Elevate the limb unless you suspect a fracture. Maintain pressure until medical assistance is available. First Aid for Shock Recognize the early signs of shock: pale, cold, or clammy skin; rapid pulse; shallow breathing; weakness; and possible nausea or vomiting. In the event of possible shock, perform the following actions: • Call for professional assistance.• Keep the victim lying down.• Elevate the injured person's legs, unless you suspect a fracture.

Blood (important information)

Blood An average adult has 5 to 6 L of blood. Blood is composed of plasma—the fluid portion—and cellular components called the formed elements

FUNCTIONS OF THE CLINICAL PATHOLOGY LABORATORY DEPARTMENTS

Blood Bank or Immunohematology The blood bank or immunohematology department deals with blood used for transfusions. Blood is tested there to identify the blood type of both patient and donor blood to determine their compatibility. Compatibility testing is performed to ensure that the patient's immune system does not reject the donor blood.

chapter 12

Blood Collection in Special Populations -> Pediatric Patients -Collecting blood from pediatric patients presents both technical and psychological challenges - Because greater technical expertise is required to perform phlebotomy on children than on adults, you should master your collection methods on adult patients first

Clinical Pathology Area

Blood and other body fluids can be analyzed in a number of ways, and the divisions within the clini- cal pathology area reflect these differences. The number of sections in this area depends on the size of the hospital. In some laboratories, some func- tions may be combined. The clinical departments in a typical laboratory are as follows: • Blood banking or immunohematology • Chemistry• Specimen processing• Coagulation and hemostasis • Hematology• Flow cytometry• Microbiology• Molecular diagnostics• Serology or immunology• Urinalysis and clinical microscopy • Phlebotomy• Referrals

SITE SELECTION General Considerations

Bone puncture can lead to osteochondritis, a painful inflammation of the bone or cartilage, or osteomyelitis, a potentially serious, sometimes fatal, bone infection. Puncture depth and width To minimize the risk of inflammation and infection, the lancet should never penetrate more than 3.0 mm For a heel puncture, the maximum depth is 2.0 mm, because the calcaneus, or heel bone, can lie very close to the surface Puncture width should not exceed 2.4 mm (lateral side) NOT the middle of the finger

cardiopulmonary resuscitation

Call for medical assistance (call 911), start cardiopulmonary resuscitation (CPR) if indicated, and keep the victim warm (CPR is discussed later in this chapter).

EQUIPMENT FOR CAPILLARY COLLECTION

Capillary collection equipment allows the phlebotomist to puncture the skin safely and collect the sample quickly and efficiently, with a minimum of discomfort for the patient.

CELLs

Cells Cells are the smallest living units in the body. Cells are much like small factories, using raw materials to produce products for internal use or export. For cells, the raw materials include oxygen from the air and food molecules such as sugars and amino acids; the products are often more complex molecules, such as hormones or proteins.

Continuing Education

Certification programs usually require phlebotomists to participate in continuing education programs and earn a certain number of continuing education units (CEUs) to remain certified. These programs provide updates on new information, regulations, and techniques and help phlebotomists refresh skills that are used less frequently.

CPT

Certified Phlebotomy Technician

Specimen Processing

Chemistry tests are performed on either serum or plasma. Serum is collected in a tube without antico- agulants (a plain red-top tube) or in a serum sepa- rator tube (SST). Plain red-top tubes need 45 to 60 minutes for full clot activation, and an SST needs a minimum of 30 minutes. When results are needed quickly (a stat, or short turnaround time requisi- tion), blood can be collected in a tube with clot ac- tivators. After clotting, serum is separated out by centrifugation. A centrifuge spins the sample at high speeds to separate components based on den- sity

Clot Activators

Clot activators promote coagulation. Clotting in plain serum tubes takes about 60 minutes, while clotting in serum tubes with clot activators takes only 30 minutes. Thrombin directly increases clotting and is used for stat serum chemistry determinations or if the patient is on anticoagulants

Coagulation Phase

Coagulation is a cascade of enzymes and factors ultimately resulting in a blood clot Coagulation is initiated by release of tissue factor (extrinsic pathway); other plasma coagulation factors contact the materials exposed when the blood vessel is damaged (intrinsic pathway)

combing vowela

Combining vowels are added to make the pronunciation easier Example: Leuk means "white"; cyte means "cell" Word: "o" added to make leukocyte Not usually used when the suffix begins with a vowel Example: leuk (root) and emia (suffix) = leukemia

Common Vehicle Transmission & Vector Transmission

Common vehicle transmission involves a common source that causes multiple cases of the disease. This type of transmission is caused by contaminated items such as food, water, medications, devices, and equipment. An example of this is a foodborne illness, such as salmonellosis or listeriosis, which can occur by ingesting food (e.g., chicken or hot dogs) contaminated with the bacteria Salmonella or Listeria. Although some infectious agents are inactivated in the gastrointestinal tract, many others are not. Vector Transmission Some infectious agents are carried by agents such as arthropods (e.g., insects and ticks) that are not harmed by their presence. Such organisms are called vectors. Mosquitoes, for instance, may carry malaria and yellow fever, and ticks may carry Lyme disease and Rocky Mountain spotted fever.

chapter 13 Arterial Blood Collection

Composition of Arterial Blood -Arterial blood is rich in both oxygen and electrolytes; this is different from venous blood, in which the levels of these substances vary, depending on the metabolic activities of surrounding tissues -Arterial collection is most often used for testing arterial blood gases (ABGs), ammonia, and lactic acid Arterial Blood Gas Testing -The absolute amount of oxygen is expressed as the partial pressure of oxygen (Po2) -Similarly, the carbon dioxide level is expressed as the partial pressure of carbon dioxide (Pco2)

patient identification

Correctly and unambiguously identifying the patient is the most important step in any phlebotomy procedure. When blood is drawn from the wrong patient, the test results for that blood will be attributed to the wrong person. This could have profound consequences—the patient may receive the incorrect diagnosis or the wrong treatment, resulting in injury or even death. Even if no harm comes to the patient, drawing blood from the wrong patient may result in dismissal of the phlebotomist and the potential for a lawsuit.

Test skin disease

Culture and sensitivity (C&S) Bacterial or fungal infection Potassium hydroxide (KOH) prep Fungal infection Skin biopsy Malignancy

Circulation Through the Heart

Deoxygenated blood from the systemic circulation collects in the superior and inferior venae cavae (singular: vena cava), which empty into the right atrium (Figure 7-2). Contraction of the right atrium forces blood through the tricuspid valve into the right ventricle. Contraction of the right ventricle forces blood out through the pulmonary semilunar valve, through the pulmonary trunk, and into the left and right pulmonary arteries. Blood then travels to the lungs, picking up oxygen and releasing carbon dioxide in the capillaries surrounding the alveoli. Returning to the heart via the left and right pulmonary veins, oxygenated blood enters the left atrium.

CLEANING UP A SPILL

Despite careful technique, spills do occur. Careful and thorough cleanup protects you and your co-workers from exposure to infectious agents and potential infection. Although each laboratory has its own detailed procedures, general guidelines include the following: • Wear gloves.• Use 10% bleach as a disinfectant. Bleach solutions must be made fresh once a week from concentrated bleach. When you make a fresh solution, label the container as "10% bleach" and indicate the date it was made. • Clean up the visible blood first, then disinfect the entire area of potential contamination. • Allow the bleach to remain in contact with the contaminated area for 20 to 30 minutes to ensure complete disinfection. Kits that contain powder or gels for absorption are available in all laboratories and work well for large spills.

TYPES OF SAFETY HAZARDS

Despite their goal of promoting health, health care facilities can be dangerous places for people who are not aware of the potential risks. Types of hazards include the following: •*** Biological: Infectious agents, including airborne or bloodborne organisms such as bacteria and viruses • ***Physical: Wet floors, heavy lifting (e.g., boxes and patient transfers) • ***Sharps: Needles, lancets, and broken glass• Chemical: Preservatives and reagents (laboratory- grade chemicals) • Radioactive reagents• X-ray equipment • Electrical: Dangerous high-voltage equipment • Fire or explosive: Open flames, oxygen, and chemicals (e.g., nitrous oxide) • Gases under pressure • Latex sensitivity: Allergic reaction to latex in gloves or other equipment In addition to specific safety precautions for phlebotomy procedures, a number of general pre- cautions can reduce your risk of injury:• Practice hand hygiene, as discussed in Chapter 4. • Always wear the appropriate personal protective equipment (PPE) when handling specimens.• Avoid touching your face, nose, or mouth in the work area. Do not rub your eyes, handle contact lenses, or apply cosmetics, especially when wearing gloves.• Never store food or beverages in the laboratory refrigerator with reagents or specimens.• Do not let anything hang loose that might get contaminated or caught in equipment. Tie back shoulder-length hair, and never wear long chains, large or dangling earrings, or loose bracelets.• Protect your feet from spills, slips, and falling objects. Never wear open-toe or open-back shoes. Shoes should be sturdy, made of nonabsorbent material, and have nonskid soles.

respiratory system

Disorders affecting the respiratory system include infection, inflammation, obstruction, insufficient ventilation, developmental disorders, and neoplastic diseases (Box 6-7). Respiratory failure occurs when the respiratory system cannot supply adequate gas exchange to maintain body function. It is a life- threatening condition and is treated by temporary or permanent mechanical devices to aid ventilation. Diseases of the upper respiratory tract are com- monly treated by a primary care physician or an ear, nose, and throat (ENT) specialist. Disorders of the lower respiratory tract are most often treated by a pulmonologist. Common laboratory tests ordered for these disorders are listed in Table 6-7.

Color-Coded Tops*

Each combination of additives is distinguished by a different colored top. However, different manufacturers may use slightly different color-coding schemes. AND however, it cannot eliminate it entirely. For this reason, the CLSI has developed a set of standards dictating the proper order of draw for a multitube draw AND The order-of-draw standards have under-gone several revisions within the past decade, and not all institutions have adopted the most recent set of standards

Electrical Hazards

Electrical hazards in the laboratory may result in shock or fire. General rules of electrical safety apply in health care institutions as well, including the following:• Avoid using extension cords. • Report frayed cords, overloaded circuits, and ungrounded equipment. • Unplug a piece of equipment before servicing it. • If a piece of equipment is marked with an electri- cal caution warning, do not attempt to open it, even for inspection. It may contain batteries or electrical capacitors that store electricity even when unplugged.• Know the location of the circuit breaker box for the equipment you are using.• Avoid contact with any electrical equipment while drawing blood. Electricity may pass through you and the needle and shock the patient.

Bloodborne Pathogen Standard

Employers must have a written BBP exposure control plan Employers must provide PPE to employees at no charge, train employees in use, and require employees to wear PPE Employers must implement work practice and engineering controls Employers must provide HBV vaccine at no charge Employers must provide postexposure medical care at no charge Employers must provide education and safety training for employees at time of hire and annually thereafter

Tube Additives

Except for the glass red-topped tube, which has no additives, all tubes contain one or more additives. Additives include anticoagulants to prevent clot- ting, clot activators to promote it, thixotropic gel to separate components, and preservatives and inhibitors of various cellular reactions to maintain the integrity of the specimen.

chapter 14 Special Collections and Procedures

Factors That Influence Blood Composition -Age -Altitude -Body position -Dehydration -Diet -Diurnal variation -Drugs -Environment -Exercise -Gender -Pregnancy -Smoking -Stress

chapter 18

Features of Quality Phlebotomy -Quality phlebotomy refers to a set of policies and procedures designed to ensure the delivery of the highest-quality patient care and consistent specimen analysis -Quality control (QC) refers to the quantitative methods used to monitor the quality of procedures, such as regular inspection and calibration of equipment, to ensure accurate test results -QC is part of quality assurance (QA), the larger set of methods used to guarantee quality patient care, including the methods used for patient preparation and collection and transportation protocols - QA programs are mandated by the Joint Commission The Joint Commission standards require that systematic progress be in place to monitor and evaluate the quality of patient care The Joint Commission stresses the collection and analysis of data to understand where the organization is weakest, and where to focus on improvements

Fibrinolysis

Fibrin degradation products (FDPs) are monitored to diagnose disseminated intravascular coagulation (DIC), a condition in which blood clots abnormally in the circulatory system Fibrinolysis is controlled by plasmin, an enzyme made from plasminogen by tissue plasminogen activator (t-PA)

Fire and Explosive Hazards

Fires or explosions in the laboratory may occur as a result of chemical or electrical accidents or careless- ness with flames or other fire sources. In addition to preventive measures, the most important steps to take to minimize the risk of injury are summarized in the acronym RACE: Rescue. Remove any patients from the immediate area where fire risk is present (Figure 3-9). Alarm. Call 911 or the appropriate number for fire emergency in your facility. Confine. Close all windows and doors. Radioactive hazard symbol. Extinguish. If the fire is small and contained, use a fire extinguisher (Figure 3-10) or fire blanket to put it out. Know how to use a fire extinguisher. The proper technique is summarized in the acronym PASS: Pull the pin. Aim at the base of the fire. Squeeze the handle. Sweep. ----Fire. In the event of a fire, the HUC may be responsible to assist in the evacuation of the patients who are endangered by the fire. If the fire is elsewhere, the HUC is expected to assist the nursing personnel in closing the doors to the patient rooms. Fire doors must be closed also. It is important to remember the RACE system which is implemented by many hospitals: R Rescue individuals in danger A Sound the alarm C Confine the fire by closing all doors and windows E Extinguish the fire with the nearest suitable fire extinguisher

Hematology continuation.

Flow cytometry is a special analytic technique that is used in hematology, immunology, and ana- tomic pathology. Flow cytometry identifies cellular markers on the surface of WBCs. This is done to determine lymphocyte subclasses in patients with acquired immunodeficiency syndrome (AIDS), as a measure of the disease process, and to determine CD4/CD8 ratios of helper to suppressor cells, as a means of tracking the health of patients infected with human immunodeficiency virus (HIV).

Capillary Collection Sites for Infants

For children younger than 1 year, there is too little tissue available in any of the fingers. For this reason, the dermal puncture is performed in the heel (Figure 10-5). As shown in Figure 10-6, only the medial and lateral borders of the plantar (bottom) surface can be used. The center of the plantar surface is too close to the calcaneus, as is the posterior (back) surface. The arch is too close to nerves and tendons. For older infants, the big toe may be used if the heel is unacceptable. Be aware that the heel may be callused on young children who have begun to walk.

formed elements

Formed Elements The formed elements constitute 45% of blood volume. Of these, 99% are red blood cells (RBCs), with white blood cells (WBCs) and platelets making up the rest. All blood cells are formed in the bone marrow from the division of long-lived progenitors called stem cells.

chapter 16

General Guidelines forSpecimen Transport Tubes with additives should be inverted gently and completely 5 to 10 times immediately after being drawn Thorough mixing allows the additives to be evenly distributed throughout the sample -> An efficient and safe way to transport samples is in a leak-resistant bag with zip closure Specimen bags are marked with a biohazard symbol and have a separate front pouch for requisitions to prevent contamination of the requisition should the specimen leak -> Tubes should remain upright during transport This accomplishes several purposes: It promotes complete clot formation when there is no additive present It prevents sample contamination due to prolonged contact with the stopper It reduces the likelihood of aerosol formation during uncapping, as there is no residual blood clinging to the stopper

HIPPA

Health Insurance Portability and Accountability Act. --> The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge.

Routine venitpture

Hemoconcentration - An increase in the ratio of formed elements to plasma Hemolysis - Destruction of red blood cells can alter test results Petechiae - Small red spots on the skin caused by a tourniquet that is too tight.

Hemostasis

Hemostasis refers to the processes by which blood vessels are repaired after injury There are four phases: Vascular phase Platelet phase Coagulation phase Fibrinolysis

opportunistic microorganisms

Hospitalized patients usually have a lowered resistance to infection by potential pathogens and opportunistic organisms.

What would you do?

If you are stuck by a used needle or other sharp object that has been in contact with blood, or if you get blood in your eyes, nose, mouth, or broken skin, you should perform the following steps: 1. Immediately flood the exposed area with water and clean any wound with soap and water or a skin disinfectant. 2.Report this immediately to your employer. Your employer is required to keep a log of such inci- dents. 3.Follow your facility's exposure control plan for reporting and medical treatment for an accidental needle exposure. 4.Seek immediate medical attention, including counseling for exposure to HIV, HBV, and HCV.

Immunochemistry

Immunochemistry tests use antibodies to detect a range of substances in the blood. Electrophoresis separates chemical components of blood based on differences in electrical charge

Airborne Precautions

In addition to Standard Precautions, Airborne Infection Isolation Precautions are used for patients known to have or suspected of having a disease transmitted by airborne droplet nuclei. Examples of such illnesses are measles, varicella (including dis-seminated zoster), and tuberculosis. Airborne Precautions include having the patient in a room with special air handling and ventilation. People entering the room must perform hand hygiene and wear an N95 respirator. A fit check must be done each time the respirator is put on.

Contact Precautions

In addition to Standard Precautions, Contact Precautions are used for patients known to have or suspected of having diseases or conditions transmit- ted by direct patient contact or by contact with items in the patient's environment. Examples are listed in Box 4-3. Contact Precautions include performing hand hygiene, donning gloves, and wearing a gown for all interactions with the patient or if you will be exposed to materials in the patient's room.

Droplet Precautions

In addition to Standard Precautions, Droplet Precautions are used for patients known to have or suspected of having a disease transmitted by large infectious droplets that can be deposited on the conjunctivae or mucous membranes of a susceptible host.

OTHER HEALTH CARE SETTINGS

In addition to working in hospitals, phlebotomists may be employed in other health care settings, including the following: Health maintenance organizations (HMOs): HMOs have become major providers of health care in the past two decades. HMOs typically function as full-service outpatient clinics, pro- viding most medical specialties under one roof. Preferred provider organizations (PPOs): A PPO is a group of doctors and hospitals that offer their services to large employers to provide health care to employees. Urgent care center: An urgent care center is an outpatient clinic that provides walk-in services to patients who cannot wait for scheduled appoint- ments with their primary health care providers or who do not have a primary health care provider. Physician office laboratories (POLs): Physi- cians in a group practice may employ a phleboto- mist to collect patient samples, which are then usually analyzed by a separate reference labora- tory or, if the facility is large enough, in an on- site laboratory. Reference laboratories and private testing lab- oratories: These are independent laboratories that analyze samples from other health care facilities or from outpatients sent to the laboratory by their health care providers. The phlebotomist may travel to other facilities to obtain samples (mobile phlebotomy) or may collect samples on site. Nursing homes: Phlebotomists may be employed by a nursing home to obtain samples from clients for analysis by a reference laboratory. Blood donor services or health fairs: Phleboto- mists may be hired to draw blood donations

Blood Vessels

In general, blood vessels (except for capillaries) have three discrete layers surrounding the lumen or the space in which blood flows (Figure 7-3). The tunica adventitia, or outer layer, is composed of connective tissue; the tunica media, or middle layer, is made of smooth muscle; and the tunica intima, or inner layer, is composed of a single layer of endothelial cells.

Lymphatic System

Includes lymphatic vessels (veins, capillaries and ducts), lymph nodes, and several organs plus the lymph fluid flowing through the vessels The lymphatic system returns tissue fluid to the circulatory system, in the process screening it for signs of infection, and provides a passageway for lymphocyte patrolling the tissues

Preventing Latex Reactions

Individuals with known sensitivity to latex should wear a medical alert bracelet. Patients should be asked about allergies or other reactions to previous latex exposure. The substances causing latex allergy are similar to ones found in chestnuts and some tropical fruits, such as kiwi, avocado, and banana. Patients should be asked about allergies or reactions to any of these fruits.

Principal occupational risk of infection for Phlebotomists

Infection from an accidental needle stick

Means of Transmission

Infectious agents can spread by five means: 1. Contact, both direct and indirect 2. Droplet 3. Airborne 4. Common vehicle 5. Vector --Contact transmission is the most frequent and im- important transmission route for healthcare-associated infections. Direct contact involves the transfer of microorganisms from an infected or colonized per- son directly to a susceptible host by physical contact between the source and the susceptible host. have bigger than 5 mm, they have propelled only a short distance before falling and coming to rest. Therefore droplet transmission is likely for only a brief time and within a short distance (approximately 3 feet) of the source, meaning that specialized ventilation or air-filtering equipment is not needed to prevent the transmission of infectious agents via droplets

ISOLATION CONTROL MEASURES

Isolation means the separation of an infection source from susceptible hosts, thereby breaking the chain of infection. Isolation control measures can be used to protect the patient from infectious agents in the environment or carried by staff or visitors, or they can be used to protect staff, visitors, and other patients from patients with certain infectious diseases and conditions.

Features of Joints

Joints connect one bone to another. There are three types of joints: 1. Synarthrosis (immovable): Fixed or immovable joints include the sutures of the cranium and facial bones 2. Amphiarthrosis (partially movable): The vertebral joints are partially movable, restrained to protect the spinal cord from trauma. 3. Diarthrosis (free-moving): The appendicular joints, such as the shoulder, elbow, and knee, are free moving. The two bones are held together with ligaments, a type of tough, fibrous connective tissue. The fluid-filled synovial cavity is enclosed within the synovial membrane. The bearing surfaces of the bones are lined with smooth articular cartilage. The combination of synovial fluid and articular cartilage allows the two bone surfaces to slide against each other without becoming damaged or irritated.

LEVELS OF ORGANIZATION

Just as a complex institution such as a hospital has different levels of organization, so does the human body. At the most basic level, the body is composed of cells. Cells of similar type join to form tissues, and tissues interact to form discrete units of a function called organs. When different organs interact to carry out common tasks, they form an organ system. Organ systems themselves interact, making an integrated, functioning body. At each level, the body acts to maintain homeostasis or the dynamic steady state we think of when we refer to good health. Homeostasis requires many functions: nutrition, materials processing, and waste elimination; repair of injury, defense against infection, and regulation of growth; and communication and coordination among the parts of the body.

SENSITIVITY TO LATEX AND OTHER MATERIALS

Latex sensitivity is an important problem in the health care field. Today, many health care facilities have stopped using latex gloves, replacing them with stretch nitrile or vinyl. The reaction to latex products can take a variety of forms. Irritant contact dermatitis occurs as a result of direct skin contact with materials left on the latex surface during manufacturing, such as processing chemicals. Redness, swelling, and itching may occur within minutes to hours of exposure. Removing the glove and washing the exposed area is enough to reduce the reaction within several hours. The skin may become highly sensitized with repeat exposure. Allergic contact dermatitis is a true allergic response in which the body's immune system reacts to the proteins or other components of the latex that are absorbed through the skin. Perspiration increases absorption.

Common Health Care Abbreviations (continuation)

MI Myocardial infarction MRI Magnetic resonance imaging NPO Nothing by mouth OR Operating room os Mouth P Pulse PC/PDAfter meals pp Postprandial pre-op Before operation prn As required qd Every day qns Quantity not sufficient Rx Prescription SOB Shortness of breath stat Immediately TB Tuberculosis TIA Transient ischemic attack TPR Temperature/pulse/respiration URI Upper respiratory infection UTI Urinary tract infection wt Weight

Review for Certification

Medical terms are most commonly formed from Greek or Latin. Each term contains a root and may contain a prefix, suffix, combining vowel, or other root. A combining vowel, usually an o, is used with a root to create a combining form for ease of pro- nunciation. A large number of abbreviations are used in the health care environment

Advance Beneficiary Notice of Non coverage

Medicare regulations require that the pa- tient sign an Advance Beneficiary Notice of Noncov- erage (ABN). This form is signed by the patient to indicate he or she understands that the service may not be reimbursed by Medicare.

Microsample Containers

Micro collection tubes (also called "bullets") hold up to 750 mL of blood. They are made of plastic and are available with a variety of anticoagulants and additives (Figure 10-2). The tubes are color-coded by additive to match the coding of evacuated containers. Micro collection tubes are used for all types of dermal puncture collections and are the most common type of collection container used for dermal puncture samples. They are also available with a plastic capillary tube that is fitted inside the container to aid in the collection of the sample.

Molecular Diagnostics

Molecular diagnostics testing is used to diagnose genetic disorders, analyze forensic evidence, track disease, and identify microbiologic pathogens. At the heart of these techniques is the analysis of the deoxyribonucleic acid (DNA) in the sample. In the clinical laboratory, molecular diagnostic techniques are used most commonly to identify infectious agents, such as HIV, and genetic diseases, such as cystic fibrosis; to test for parentage; and to perform forensic studies on criminal evidence. Specimens analyzed include blood, body fluids, skin cells, hair, and other body tissues that contain DNA. Special tubes and handling procedures are required for these specimens. The most important aspect of this type of test is to keep the sample free from contamination with DNA from other sources. Keeping the labora- tory clean is important, and usually only authorized personnel are allowed entrance.

DISASTER EMERGENCY PLAN

Most institutions have disaster emergency plans that describe procedures in the event of a large-scale disaster, such as a flood, hurricane, fire, or earthquake. Learn your institution's procedures so that you are prepared to respond in an emergency. Pay special attention to your responsibilities. These may range from reporting to a specific place or person outside your facility in case of a fire in your building to helping remove patients from danger. If you are assigned to multiple institutions, be sure to check procedures and your responsibilities at each one. You may also have responsibilities as a responder in the event of a health-related emergency, for instance, when a surge of injured patients arrives at your hospital, as they might in the event of a multicar accident or building collapse. In such an event, you may be called on to take on responsibilities outside of your normal duties, whether in processing patients as they arrive, taking samples in the emergency room, or work- ing longer shifts. Again, know your institution's plan and your responsibilities, and be prepared to respond quickly.

muscle tissue

Muscle Tissue Muscle tissue is contractile, meaning that it can shorten its length. Muscle cells contain long fibers of the proteins actin and myosin, whose movements produce muscle contraction. Muscles receive the stimulus to contract when the axon terminals of motor neurons (neurons that stimulate muscle) make contact with the muscle. The neuron releases a chemical (called a neurotransmitter) onto the muscle cell surface at the neuromuscular junction, causing the chemical changes within the muscle that leads to contraction. Muscle tissue occurs in three forms, which differ in both structure and function (Figure 6-3): 1. Skeletal muscle, or striated voluntary muscle, is the most widespread type, constituting all the muscles that move the skeleton. Under the microscope, striated muscle has a striped appearance. Cardiac muscle, or striated involuntary muscle, is found in the heart. It looks similar to skeletal muscle but has features that are unique to it. Cardiac muscle cells do not need stimulation by the nervous systems to start a contraction. However, electrical stimulation is required to maintain the coordinated rhythm of the cells. This function is performed by the heart's physiologic pacemaker, found in the right atrium. Smooth muscle, or non-striated involuntary muscle, lines blood and lymph vessels within the body just below the epithelial tissue, such as around the gut, lungs, bladder, and circulatory and reproductive systems. Smooth muscle contractions regulate the passage of materials through the vessel.

NAACLS

National Accrediting Agency for Clinical Laboratory Sciences

NHA

National Healthcareer Association

NPA

National Phlebotomy Association

Nerve Tissue

Nerve Tissue Nerve tissue is specialized for intercellular communication by the conduction of electrical impulses and the release of chemical messages. Nerve tissue is composed of neurons and neuroglial cells. Neurons are excitable cells, meaning that they can be stimulated to undergo electrical and chemical changes. Neurons are found in the brain and spinal cord and throughout the body. Neuroglial cells nourish and support neurons in the brain and spinal cord. The three major portions of the neuron are the dendrite, cell body, and axon (Figure 6-4). Axons can be extremely long; each of the motor neurons controlling the toes, for instance, has an axon that stretches from the spinal cord, down the leg, through the ankle, and to the muscles of the foot. Axons are insulated by a fatty sheath of myelin. One neuron conveys information to another by releasing a chemical, called a neurotransmitter, at the small gap where they meet, called the synaptic cleft, or synapse. The neurotransmitter leaves the axon of the first neuron, crosses the synaptic cleft, and lands on a receptor on the dendrite of the second neuron, beginning a cascade of chemical changes down the length of the neuron. This may ultimately cause the second neuron to release its own neurotransmitter, thereby conveying information farther along the neural chain.

Immune system

Nonspecific immunity refers to defense against infectious agents independent of the specific chemical markers on their surfaces Nonspecific immunity includes physical barriers, the complement system, and phagocytes (WBCs), which engulf and destroy foreign cells without regard to their exact identity --> Specific immunity involves recognition of antigens (particular markers) on the surface of a foreign agent Recognition of these antigens triggers activation of T cells and B cells Cellular immunity is T cell-based immunity Antibody-based immunity is B cell-based immunity

Nucleus

Nucleus The nucleus contains deoxyribonucleic acid (DNA). DNA is arranged in functional units called genes, and genes are linked together in long strings called chromosomes.

Identification of Chemicals

OSHA adopted the Globally Harmonized System (GHS) of Classification and Labeling of Chemicals. The new GHS label contains information on the identity of the chemical, the chemical manufacturer or other responsible party, appropriate hazard warnings communicated through the visual symbols called pictograms, explanations of the hazards involved in exposure to the chemical. OSHA also requires that each chemical come with a safety data sheet (SDS; also called a mate- rials safety data sheet), which provides information about the chemical, its hazards, and the procedures for cleanup and first aid.

Reducing Risk

OSHA further requires that every workplace develop and train its employees in a chemical hygiene plan (CHP). The plan describes all safety procedures, special precautions, and emergency procedures used when working with chemicals.

OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION'S BLOODBORNE PATHOGENS STANDARD

OSHA is a regulatory enforcement agency for employee health and safety that has authority over all industries, including hospitals and health care facilities. In 1992 OSHA gave the Standard Precautions the force of law by making them part of a larger set of standards designed to protect health care workers from infection • Employers must have a written bloodborne pathogen exposure control plan in the workplace, and it must be readily accessible to employees. • Employers must provide the proper PPE to employees at no charge, train employees in the use of PPE, and require employees to wear PPE. • Employers must mandate that all blood and body fluids and other potentially infectious materials

Needle disposal containers

Once you have withdrawn the needle from the patient's arm, it must be handled with extreme care to avoid an accidental needle stick. A used needle is considered biohazards waste and must be treated as such. Dispose of the needle with the adapter still attached immediately after activating the needle safety device.

Problems in Completing the Procedure

Patient requests Sometimes a patient may ask you for water or a change in bed position Prolonged bleeding Normally, the site should stop bleeding within 5 minutes In all cases, you must continue to apply pressure until the bleeding has stopped Inform the nurse if the patient has a prolonged bleeding time.

ROUTINE VENIPUNCTURE WITH A SYRINGE

Patients with fragile veins may need to have blood drawn using a syringe because the stronger vacuum of the evacuated tube may collapse the vein. A small needle is usually used for the draw. After the blood is drawn, the needle safety shield is activated. Blood is transferred to evacuated tubes using a needleless blood transfer device.

Pediatric Collection

Pediatric specimens for routine urinalysis can be collected using a soft, clear plastic bag with an adhesive that fits over the genital area of the child

ORGANIZING AND TRANSPORTING EQUIPMENT

Phlebotomists use a portable tray to carry all necessary equipment. Like a carpenter's toolbox, the tray is a compact, efficient way to store and transport the tools of the trade to a work site

Plasma

Plasma constitutes 55% of the volume of blood. It is 90% water, with the rest made up of dissolved proteins, amino acids, gases, electrolytes, sugars, hormones, lipids, and vitamins, plus waste products such as urea, destined for excretion. The most significant elements of plasma are albumin, a plasma protein responsible for osmotic pressure and transport of many types of molecules; the immunoglobulins, or antibodies, which are important parts of the immune system; and fibrinogen, responsible for blood clotting. Other proteins include hormones, such as insulin, and transport proteins, such as transferrin, which carries iron. Plasma also contains complement, a group of immune system proteins that, when activated, destroy target cells by puncturing their membranes. Electrolytes include the major ions of plasma— sodium (Na1) and chlorine (Cl2), plus potassium (K1), calcium (Ca21), magnesium (Mg21), bicarbonate (HCO32), phosphate (PO432), and sulfate (SO422) ions.

Platelets

Platelets Platelets are created in the bone marrow from megakaryocytes, which package and release them into the circulation. Although they are also called thrombocytes, platelets are not actually cells; they are simply membrane-bound packets of cytoplasm Platelets play a critical role in blood coagulation, as discussed later. Every 1 mL of blood contains approximately 200,000 platelets, each of which remains in circulation for 9 to 12 days.

Features of Needles

Point A sharp needle provides smooth entry into the skin with a minimum of pain. Bevel The bevel, or angle, eases the shaft into the skin and prevents the needle from coring out a plug of tissue. Shaft Shafts differ in both length and gauge. The needles used for routine venipuncture range from 3⁄4 inches for "butterflies" (see below) to 1 to 11⁄2 inches long for standard needles. Hub The needle attaches to the collecting tube or syringe at its hub.

Polymer Gel

Polymer gel, also called thixotropic gel, is an inert, synthetic substance whose density is between that of cells and that of blood serum or plasma. When the specimen is centrifuged, the gel becomes a liquid and moves between the lower cell layer and the upper serum or plasma layer.

ROUTINE VENIPUNCTURE..

Position and prepare the patient Never draw blood from a patient sitting on a high stool or standing Outpatients can be seated in a special chair with arm support For inpatients, you may lower the bed rail for better access, but you must remember to raise it again after the procedure Support the arm for venipuncture under the elbow with a pillow and ask patients to remove foreign objects from the mouth --> The tourniquet should not be on the arm for longer than 1 minute Improper tourniquet application can cause: Hemoconcentration - An increase in the ratio of formed elements to plasma Hemolysis - Destruction of red blood cells can alter test results Petechiae - Small red spots on the skin caused by a tourniquet that is too tight --> Explain the procedure and get verbal consent from the patient <-- --> Explain to the patient that he or she will feel a small poke or pinch and should remain still throughout the collection <-- --> Apply the tourniquet about 3 to 4 inches above the puncture site <--

Accreditation

Programs that train phlebotomists receive ac- creditation or approval from a professional orga- nization by meeting and documenting established requirements, called standards. An accredited education program exposes students to both class- room and clinical experiences and fully prepares them to become professional phlebotomists. As shown in Table 1-1, the organizations that provide accreditation or approval are the American Medi- cal Technologists (AMT), the American Society of Phlebotomy Technicians (ASPT), the National Accrediting Agency for Clinical Laboratory Sci- ences (NAACLS), and the National Phlebotomy Association (NPA). The program you are enrolled in may be accredited by one or more of these or- ganizations. As discussed later, California accred- its training programs within that state.

PHI

Protected Health Information

Radioactive Hazards

Radioactive materials are used in health care facilities to perform diagnostic tests and deliver treatment. In areas in which radioactivity is used, the radioactive hazard symbol is displayed (Figure 3-8). Although the duties of a phlebotomist do not involve direct handling of radioactive materials, you may be exposed to small amounts of such materials when drawing blood from a patient in the radiology department, for instance, or when drawing blood from a patient receiving radioactive treatments or undergo- ing imagery with a radioactive substance. X-rays are used for diagnosis. Precautions taken by the staff of the radiology department should prevent you from ever being exposed to x-rays. You should not be drawing blood while a patient is receiving an x-ray.

Part of a words

Root, or main part Example: Cubit, meaning "elbow" Prefix, or part at the beginning Example: Ante-, meaning "forward of" or "before" Suffix, or part at the end Example: -al, meaning "pertaining to" Word: antecubital, meaning "area before elbow"

Vascular Phase

Rupture of a vein or artery causes an immediate vascular spasm, or contraction of the smooth muscle lining the vessel This reduces the vessel diameter, substantially reducing the blood loss that would otherwise occur

REVIEW FOR CERTIFICATION

Safety is a paramount concern in the health care workplace. OSHA is responsible for workplace safety and has created rules and regulations to im- prove safety. These regulations govern the handling of sharps, chemicals, and other occupational hazards. The phlebotomist must pay close attention to workplace safety and learn the most effective ways to avoid hazards such as biological, physical, sharps, chemical, radioactive, electrical, and fire dangers. Most important of all is the danger of accidental contamination with blood or other body fluids.

Routine Venipuncture

Select the best site The median cubital vein is the first choice The cephalic vein is the second choice The basilic vein is the third choice ( maximum of 2 arms)

Why Collect a Semen Specimen?

Semen specimens are used to determine whether viable sperm are present in the semen, either for fertility testing or to assess the success of a vasectomy

Serum

Serum Plasma without its clotting factors is called serum. The serum is formed when a blood sample is collected in a glass or plastic container that has no additives and is induced to clot (a serum separator tube is used for this purpose).

serum

Serum is normally a clear, pale yellow fluid. The color and appearance of the serum sample can be al- tered by both the patient's condition and the collec- tion technique. Liver disease can increase the amount of bilirubin in the serum, making it appear a darker yellow (called icteric serum). Recent ingestion of fats or other lipids can make the sample cloudy (lipe- mic serum). Hemolysis, or breakage of RBCs, can give the serum a pink tinge (hemolyzed serum). He- molysis may occur as a result of a poorly performed draw.

Sharps Hazards

Sharps, especially needles and lancets, are the most common hazards you will encounter as a phleboto- mist. Sharps are dangerous both because of the physical injury they may cause and because they may carry bloodborne pathogens such as human immuno- deficiency virus (HIV), hepatitis B virus (HBV), or hepatitis C virus (HCV)

Skin Puncture Devices

Skin puncture devices in the modern health care environment are designed with a retractable blade per Occupational Safety and Health Administration (OSHA) safety regulations. Some devices are contact-activated, whereas others require the phlebotomist to depress a trigger to release the blade. Automatic puncture devices (Figure 10-1) deliver a swift puncture to a predetermined depth, which can be a significant advantage at sites where the bone is close to the skin (see "Site Selection"). The dimensions of the puncture are controlled by the width and

Temperature Considerations: Keeping Specimens at Room Temperature

Some specimens must be kept at room temperature If the specimen is being delivered outside the facility by courier, it may be placed in an insulated container to protect it from extreme heat or cold

Temperature Considerations: Keeping Specimens Warm

Specimens that must be maintained at 37º C during transport and handling include cold agglutinins, cryoglobulins, and cryofibrinogen The tubes for these specimens should be warmed using a heel warmer packet before collection, and the sample should be transported wrapped in a heel-warmer packet as well Specimens for cold agglutinin testing and cryofibrinogen must also be kept warm -> Chilling a specimen slows metabolic processes and keeps analytes stable during transport and handling Samples that need to be chilled include pyruvate and lactic acid To chill a sample, place it in a slurry of chipped or shaved ice and water This promotes complete contact between the sample and the ice bath

Standard Precautions

Standard Precautions refer to infection control measures that use barrier protection and work prac- tice controls to prevent contact between skin or mucous membranes and blood, other body fluids, and tissues from all people. Standard Precautions are based on the difficulty of identifying all indi- viduals who are infected or harboring infectious agents with whom the health care worker may come in contact. Standard Precautions should be the minimum level of precautions applied when coming in contact with all patients. Guidelines for Standard Precautions were published by the Centers for Dis- ease Control and Prevention (CDC) in 1996 and include the following: • Hand hygiene. Disinfect hands whether or not gloves are worn. Use an alcohol-based hand agent unless hands are visibly contaminated, in which case, use soap and water. Gloves. Wear gloves when collecting or handling blood, body fluids, tissue samples, secretions, excretions, and items contaminated with blood or body fluids. Remove gloves promptly after use and disinfect your hands. Gowns. Wear fluid-resistant gowns when there is a likelihood of contamination of your clothing or skin with blood or body fluids. Face protection. Wear appropriate protection (mask and goggles or chin-length face shield)

Laws (different types of Medical law)

Statutory law: Created by a legislative body. At the federal level, this is Congress, made up of the Senate and the House of Representatives. Case law: Determined by court decisions, usually as an interpretation of existing statutory law. Administrative law: Created by administrative agencies such as the Internal Revenue Services or OSHA. --> Laws are also classified as either public or private -When a public law is violated, the offense leads to a criminal act, and the violator is prosecuted by the public in the person of the government's attorney -The offense may be either a felony (goes to jail) or a misdemeanor(doesn't go to jail), depending on the seriousness of the crime. --> "If a patient refuses to have his or her blood drawn, the phlebotomist must not attempt to force the patient to comply" -To persist can lead to criminal charges of assault and battery -Assault is an unjustifiable attempt to touch another person, or the threat to do so -Battery is the intentional touching of another person without consent -In contrast to public law, when a private law is violated, the offense may lead to a civil action, in which the defendant is sued in civil court by the plaintiff, the person claiming to have been harmed by the defendant -Civil wrongs include torts A tort is defined as any wrongful act that causes harm or injury to another person -Torts can be either intentional(something done on purpose) or unintentional(accident)

Complications During Collection

Syncope Syncope is the medical term for fainting Before syncope, patients' skin often feels cold, damp, and clammy; beads of sweat may form on the forehead or upper lip; patients may state that they are not feeling well, or will stop talking; their eyes may start to roll back, or their head could tilt either forward or backward Fainting is more common with outpatients; inpatients lying in bed are less likely to faint Seizures If a patient has a seizure during the procedure, remove the tourniquet and needle immediately and apply pressure to the site Nausea and vomiting (emesis) When emesis occurs, reassure the patient and make him or her comfortable Pain To prevent the startle reflex, warn the patient before the needle stick that there may be a little poke, pinch, or sting Hematoma When blood oozes from the vein into the surrounding tissue, a hematoma is formed If this occurs during the procedure, remove the tourniquet and needle immediately and apply pressure to the site Lack of blood flow Lack of blood flow can be caused by a defective tube, an improperly positioned needle, or a missing the vein Defective evacuated tube Occasionally, blood will not flow into a tube because the vacuum in the tube has been depleted This may occur from a manufacturing defect, use of an expired tube, or a very fine crack (which may occur if the tube is dropped) Improperly positioned needle If the tube is not the problem, the needle may not be properly positioned in the vein, and you may need to adjust it Collapsed vein A collapsed vein is caused by too much vacuum on a small vein When using the evacuated tube system, a collapsed vein becomes evident when the tube is pushed onto the inner needle Inadvertent puncture of the artery Puncture of the artery produces bright red blood and may cause spurting or pulsing of blood into the tube. Failure to collect on the first try The policy at most institutions is that a second try is acceptable A new needle and tube must be used For second tries, go below the previous site or use the other arm.

Total Quality Management (TQM)

TQM focuses on gradual, continual improvements in the quality of services provided by the laboratory Rather than merely setting a minimum standard to be met, the TQM philosophy sees the potential for improvement in every area, no matter how high the current performance level, to improve the services provided to "customers"

TEST

Test Alkaline phosphatase (ALP) Calcium Erythrocyte sedimentation rate (ESR) Fluorescent antinuclear antibody (ANA) Magnesium Rheumatoid factor (RF) Synovial fluid analysis Uric acid AND disorder Bone metabolism marker Mineral calcium imbalance General inflammation test Systemic lupus erythematosus (SLE) Mineral magnesium imbalance Rheumatoid arthritis (RA) ArthritisGout

test for urine / disorders

Test Blood urea nitrogen (BUN) CreatinineCreatinine clearance Culture and sensitivity (C&S) Electrolytes Osmolality Protein/microalbumin Renin/angiotensin-converting enzyme (ACE) --> Routine urinalysis Common Laboratory Tests for Urologic Disorders Disorder or Purpose Kidney disease Kidney disease Glomerular filtration Urinary tract infection (UTI) Fluid balance Fluid balance Kidney disorders Hypertension Screening for renal or metabolic disorders

Reproduction test

Test Culture and sensitivity (C&S) Estradiol EstrogenFluorescent treponemal antibody absorption test (FTA-ABS) Human chorionic gonadotropin (hCG) Pap smear Prostate-specific antigen (PSA) Rapid plasma reagin (RPR) Semen analysis Testosterone Disorder or Purpose Microbial infectionAssess ovarian or placental functionAssess ovarian function Syphilis Assess for pregnancy or ectopic pregnancy Cervical or vaginal carcinoma Prostate cancer SyphilisInfertility; assess effectiveness of vasectomy Evaluation of testicular function

Safety

The Occupational Safety and Health Administration (OSHA) requires personal protective equipment (PPE) to be worn during sample processing

callipary collection

The capillary collection is the preferred method for obtaining blood from newborns and infants for neonatal bilirubin, newborn screening, and point-of-care testing. The capillary collection is also used for ancillary blood glucose testing.

CHAIN OF INFECTION

The chain of infection requires a continuous link through three primary elements: the reservoir, the means of transmission, and the susceptible host (Figure 4-1). In addition, other links in this chain include a portal of exit (the means by which the infectious agent leaves the source) and a portal of entry (the means by which the infectious agent enters the host, resulting in infection or colonization). ***The reservoir, the source of the infection, can be an infected person, who may be either symptomatic or asymptomatic. The source may also be a contaminated object (called a fomite), such as equipment or supplies, or it may be food or water contaminated with the infectious agent. The susceptible host may be a patient, a health care professional, or a visitor. Microorganisms can be transmitted by contact (either direct or indirect), droplets, or air-borne routes.

Chemistry

The chemistry department performs a range of tests on the chemical components of blood. Chemistry tests may be performed as either single tests or as groups, called chemistry panels.

CIRCULATORY SYSTEM

The circulatory system is a system of closed tubes. Circulation occurs in two large loops: pulmonary circulation and systemic circulation. The pulmonary circulation carries blood between the heart and the lungs for gas exchange, and the systemic circulation carries blood between the heart and the rest of the body's tissues. In both cases, arteries carry blood from the heart to capillary beds, where exchange occurs. Veins return blood to the heart.

2. INTRODUCTION TO THE CLINICAL LABORATORY

The clinical laboratory is divided into two main areas: the anatomical and surgical pathology area, which analyzes the characteristics of cells and tissues, and the clinical pathology area, which analyzes blood and other body fluids. The phle- botomist works in the clinical pathology area of the clinical laboratory.

Personnel

The clinical laboratory is usually under the supervi- sion of a pathologist, who is a physician with spe- cial training in laboratory analysis of tissues and fluids or a physician who has a minimum of 2 years' experience directing or supervising high complexity testing or a one who holds an earned doctorate in chemical, physical, biological, or clinical laboratory science from an accredited institution.

STANDARDS AND ACCREDITATION FOR THE CLINICAL LABORATORY

The clinical laboratory must meet rigorous perfor- mance standards to ensure the quality of its proce- dures and results. Congress passed the Clinical Laboratory Improvement Act of 1988 (CLIA '88), which mandated the regulation of all facilities that perform patient testing. Standards and guide- lines are set by the Clinical and Laboratory Stan- dards Institute (CLSI), a nonprofit organization formerly known as the National Committee for Clinical Laboratory Standards (NCCLS). Labora- tories that meet these standards are eligible to re- ceive accreditation from one or more agencies. Accreditation is required for the health care facility to receive Medicare or Medicaid reimbursement. The following agencies are involved in the ac- creditation of clinical laboratories: • The Joint Commission: Laboratories must be in- spected and accredited every 2 years. This organi- zation was previously known as the Joint Commis- sion on Accreditation of Healthcare Organizations, and you may still hear it referred to by its acronym JCAHO (pronounced "Jayco"). • College of American Pathologists (CAP): Inspection and accreditation occur every 2 years.

Puncture Depth and Width

The depth of the puncture depends on the site and the patient (Table 10-2). To minimize the risk of inflammation and infection, the lancet should never penetrate more than 3.0 mm. For a heel puncture, the maximum depth is 2.0 mm, because the calcaneus, or heel bone, can lie very close to the surface. For premature babies, the recommended depth is 0.65 to 0.85 mm.

ENDOCRINE SYSTEM

The endocrine system comprises the glands and other tissues that produce hormones, which are released from glandular tissue directly into the circulatory system (Figure 6-19). The endocrine system functions with the nervous systems to tightly regulate body function, maintaining ho- meostasis. Because of the fine degree of control required, endocrine glands are themselves regu- lated by other endocrine glands, in multiple con- trol systems known as feedback loops. Many of these feedback loops involve the brain as well, especially the small portion of the brain known as the hypothalamus.

Heart

The heart is a muscular double pump whose contractions push blood through the circulatory system. It is located in the thoracic cavity behind and slightly to the left of the sternum, between the lungs. The heart is surrounded by a thin membranous sac, the pericardium, which supports and lubricates the heart during contraction. The outer layer of the heart, the epicardium, consists of epithelial cells and underlying fibrous connective tissue. The coronary arteries, which supply oxygen to the heart, are embedded in this layer. The middle layer, the myocardium, is composed of cardiac muscle, whose cells make extensive contacts with adjacent cells to allow electrical activity to spread easily from one cell to the next. The innermost layer, the endocardium, is made up of endothelial cells, modified epithelium that is continuous with the endothelium lining the blood vessels that enter and exit the heart's chambers. The four chambers of the heart are the left and right atria (singular: atrium) and the left and right ventricles (Figure 7-1). The atrial septum divides the two atria, and the interventricular septum divides the two ventricles. The heart has four valves that prevent the back-flow of blood. The right atrioventricular (AV) valve, also called the tricuspid valve, separates the right atrium and the right ventricle, and the pulmonary semilunar (pulmonic) valve separates the right ventricle from the pulmonary arteries. The left atrioventricular (AV) valve, also called the bicuspid valve or mitral valve, separates the left atrium from the left ventricle, and the aortic semilunar valve separates the left ventricle from the aorta.

Hematology

The hematology department analyzes blood for evidence of diseases affecting the blood-forming tissues and the cells produced by those tissues— namely, RBCs, WBCs, and thrombocytes/platelets (Plt). This department also analyzes the clotting ability of the blood. In the hematology laboratory, blood is analyzed in a computer-controlled instrument that counts and identifies the various types of cells (Figure 2-4). The most common hematology test is the complete blood count (CBC). This automated test includes a hemo- globin (Hb) determination, hematocrit (Hct), WBC count, RBC count, and platelet count. It may also include a WBC differential (diff), which determines

****Viral Survival - HBV can survive how long? 7 days (week)w. dried blood HCV can survive how long ? 3 weeks HIV can survive how long? 42 days

The hepatitis B virus can survive outside the body for at least 7 days. During that time, the virus is still capable of causing infection. --> Bloodborne viruses have been reported to survive outside the body for much longer than was once believed possible. For example, the hepatitis B virus (HBV) can survive in dried blood for up to 1 week. This prolonged survival means that, as a phlebotomist, you must be even more aware of potential sources of infection in your environment.

HOSPITAL ORGANIZATION

The hospital laboratory in which a phlebotomist works is one part of a large organization. Organiza- tion of the hospital may vary, with larger hospitals having more complex and varied structures than smaller hospitals

bloodborne pathogen (BBP)

The infectious agent carried in the blood.

culture and sensitivity (C&S) tests,

The most common microbiology tests are culture and sensitivity (C&S) tests, which detect and iden- tify microorganisms and determine the most effec- tive antibiotic therapy.

Collection Procedures for Urine Specimens

The most common procedure for collecting many types of urine specimens is known as the midstream clean catch -It is collected after the patient has passed several milliliters of urine -This allows microorganisms from the urethra to be flushed out and not collected in the sample

Medical Terminology /Part of a word

The parts of a word include the root, or main part; a prefix, or part at the beginning; and a suffix, or part at the end. The reading of the word starts with first defining the suffix, moving to the prefix, and then to the root word. For instance, antecubital includes the suffix -al, meaning "per- taining to"; the prefix ante-, meaning "forward of" or "before"; and the root cubit, meaning "elbow." Therefore the word means "pertaining to the region forward of the elbow." list commonly used prefixes, suffixes, and roots. Words may also contain a combining vowel, added to make pronunciation easier. For instance, called the combining form of the root. Combin- ing vowels usually are not used when the suffix begins with a vowel. For instance, no combining vowel is used to form leukemia, which combines the root leuk and the suffix -emia, meaning "blood condition."

Empathy and Compassion

The phlebotomist is often called on to interact with patients experiencing health crises or undergoing painful or unpleasant treatments. Patients may be worried about the procedure being performed, the condition for which they are being treated, or the cost of their care.

Telephone Skills

The phlebotomist is often required to answer calls and take messages in the laboratory. The informa- tion that comes in over the phone may be critical for patient care or for the operation of the laboratory. It is essential that you display the same high level of professionalism in answering the phone as in deal- ing directly with patients and coworkers. If you are staffing the desk, do the following: • Answer the phone promptly.• Smile when speaking, even though you can't be seen; it will positively affect your voice tone.• Identify the department and yourself, and ask how you can help.• Write everything down, including the name of the person calling, their phone number, and the date and time of the call. Be prepared to take a message by having writing materials at hand. • Speak slowly and clearly.• Do not put the caller on hold until you determine it is not an emergency call.• Make every attempt to help, but give only ac- curate information. If you do not know the an- swer to a question, find out and call back, if necessary.

job duties

The principal purpose of phlebotomy is to obtain blood samples, at the request of a physician or qualified health care professional such as a nurse practitioner, for analysis in the laboratory. Performing these duties ensures that patients receive prompt and complete medical care. Failure to perform these duties correctly can lead to significant adverse consequences for the patient, including improper care and even death.

Time Constraints

The quality of test results depends heavily on the time between when the sample is drawn and when it is analyzed: The longer the interval, the more likely the results will be inaccurate Ongoing glycolysis (metabolic sugar breakdown within cells) within the specimen is a primary cause of inaccurate test results As a general rule, an uncentrifuged blood sample should be delivered to the laboratory within 45 minutes of being drawn -> A few sample types can wait longer before processing without loss of viability Because fluoride inhibits glycolysis, glucose samples collected in gray-topped tubes can be held for 24 hours at room temperature and for 48 hours at 2º to 8º C Blood smears made from such samples must be done within 1 hour of collection because EDTA will eventually distort cell morphology

SKELETAL SYSTEM

The skeletal system includes all the bones, plus the connective tissue at the joints. It functions to support the body, provide movement, and protect the internal organs. Bones also store the minerals phosphorus and calcium, and the marrow of certain bones is the site of hematopoiesis, the formation of blood cells. Features of Bone Bone is formed by osteoblasts. These cells produce collagen fibers and deposit calcium salts (principally calcium phosphate). This mixture of protein and minerals gives bone its unique combination of hardness and resiliency. Bone growth and development involve a complex balance between the action of osteoblasts and that of other cells, called osteoclasts, whose job is to break down bone and release stored minerals. This dynamic balance allows the growth of bone despite its rigidity and allows it to be remodeled to accommodate changing stresses. There are 206 bones in the adult skeleton. Bones are classified by their shapes as long, short, flat, sesamoid, or irregular.• Long bones include those in the arms and legs• Short bones are found in the wrists and ankles• Flat bones protect inner organs such as the heart and brain• Sesamoid means "shaped like a sesame seed"; the patella (kneecap) is an example Irregular bones are those that are not classified as one of the other types, for example, the vertebrae. Hematopoiesis takes place principally in spongy tissue within bone called marrow.

Hemoconcentration

The tourniquet must be removed before the needle is removed from the vein to prevent the formation of a hematoma, which is a reddened, swollen area where blood collects under the skin.

Why Collect a Fecal Specimen?

The two most common reasons for ordering a fecal sample are to look for intestinal infection and to screen for colorectal cancer Microscopic examination of feces reveals the presence of intestinal ova and parasites (O&P) from organisms such as Giardia and tapeworm Feces can be cultured to look for diarrhea-causing bacterial diseases such as cholera or Salmonella Types of Fecal Specimens -A random specimen is used for most determinations, including bacterial cultures, O&P, and fats and fibers Occult blood specimens are collected after 3 days of a meat-free diet -A 72-hour stool specimen is used for quantitative fecal fat determination Occult Blood Specimen Several types of special test cards are available, which may be prepared by the patient at home and sent in

Winged Infusion Sets or Butterflies

The winged infusion set also called a winged collection set or butterfly, is used for venipuncture on small veins, such as those in the hand, and in elderly or pediatric patients. Without the bulk of a syringe or collection tube in the way, the butterfly needle allows you great flexibility in placing and manipulating the needle. AND Most butterfly needles are now designed to be used with an evacuated tube system. Those that are not can be fitted using a Luer adapter

differenttypesoftubes

These tubes are used primarily for the collection of samples for CBG determinations. Caraway or Natelson pipets are narrow glass tubes with capacities up to about 470 mL. The use of these tubes has declined in recent years because of heightened attention to sharps injury prevention, and OSHA recommends against using glass tubes of this sort. Microhematocrit tubes are small tubes, either plastic or glass, with a volume of up to 75 mL. These tubes are used infrequently and have been largely replaced by micro-collection containers. However, when a spun hematocrit is requested, a plastic capillary tube can be used.

Anatomic and Surgical Pathology Area

This area is usually divided into three sections, or departments. The cytogenetics department examines chromo- somes for evidence of genetic disease, such as Down syndrome. The cytology department processes and stains cells that are shed into body fluids or removed from tissue with a needle (aspiration) and examines them for the presence of cancer or other diseases. The cytotech- nologist assists in this work. One of the most com- mon tests performed in cytology is the Pap smear. The histology department prepares tissues from au- topsy, surgery, or biopsy for microscopic examination by a pathologist. Special stains are used to highlight particular cell morphology. The histotechnologist helps prepare samples for the pathologist to examine

Coagulation and Hemostasis

This department is usually part of the hematology department, but it may be separate in larger hospitals. Hemostasis refers to the process by which the body stops blood from leaking out of a wound. He- mostasis involves coagulation and other processes. Coagulation depends on the presence of clotting factors and platelets.

PE

This is termed a protective environment (PE). These units are designed to minimize the risk of acquiring environmental fungal infections (e.g., Aspergillosis). Such patients may include patients receiving chemotherapy and those who have had transplants. PE rooms have HEPA- filtered air and positive air pressure (air flows out, not in) with respect to adjacent areas.

TYPES OF BLOOD SPECIMENS

Three types of blood specimens are used for analysis: 1. Whole blood is blood collected and mixed with an anticoagulant so that it will not clot. Whole blood is used for most hematology tests, including blood type and cell counts, and to determine the level of certain hormones and metals. 2. The serum is the fluid portion of blood that remains after clotting. No anticoagulant is used when collecting a serum sample. (red top tubes).. Plasma is the fluid portion of blood, including fibrinogen and other clotting factors. Plasma is obtained by collecting whole blood in a tube containing an anticoagulant and then centrifug- ing. Plasma is used for coagulation studies.

EPs

Tier 2 isolation uses Expanded Precautions (EPs). This tier is targeted at patients known to be or suspected of being infected with a highly trans- missible pathogen. It also applies to pathogens that are considered epidemiologically important, such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE).

BT test

To perform a BT test, an automated incision device is used, with the depth set at 1 mm, and length at 5 mm Normal BT is 2 to 10 minutes and depends somewhat on the device used

BREAKING THE CHAIN OF INFECTION

Transmission is prevented by practicing appropriate hand hygiene, using PPE, and using the set of practices known as Standard Precautions. In addition, patients at risk for spreading or contracting infections may be isolated. OSHA requires all facilities to have an exposure control plan (ECP) that describes all these elements for preventing the spread of infection.

EVACUATED COLLECTION TUBES

Tubes hold blood for later testing in the laboratory, and each type of tube may contain different sets of additives, which are chemicals designed to promote or prevent certain changes in the blood sample. AND Adapters have a tube advancement mark indicating how far the tube can be pushed in without losing the vacuum

Labels

Two other types of secondary labels are still in use to identify hazardous materials. The Department of Transportation (DOT) label displays the type of hazard, the United Nations hazard class number, and an identifying number. The National Fire Protection Association (NFPA) label is a design recognized by firefighters that warns of the location of hazardous materials in the event of a fire. It uses a diamond-shaped symbol whose four quadrants contain numbers indicating the relative danger level in four areas: health, fire, chemical stability, and specific hazard types. Higher numbers indicate higher risk. Primarily designed for fixed installations, this symbol has been widely used to indicate hazards at the entrances to laboratory facilities within buildings.

using isopropyl alcohol/ perform

Using 70% isopropyl alcohol or other antiseptic, clean the area in concentric circles spiraling Allow the site to air dry for maximum bacteriostatic action Reapply the tourniquet if it was removed during the cleansing process Uncap the needle and examine it for any defects --> to perform Perform the venipuncture Anchor the vein by gently pulling the skin taut with the thumb of the non-dominant hand Hold the needle assembly with your dominant hand, with the tube inserted up to the line on the adapter

Veins

Veins carry blood back toward the heart. Capillary blood enters venules, the smallest veins. Venules join to form larger veins. Veins have thinner walls and less muscle than arteries do, because they do not experience large fluctuations in blood pressure.

callipary collection con..

Venipuncture may be contraindicated for patients with burns or scars over venipuncture sites or for those at risk for venous thrombosis (caused when clots form within the veins) venipuncture increases the risk of venous thrombosis. Other patients may be at risk for serious complications associated with deep venipuncture, including iatrogenic anemia, hemorrhage, infection, organ or tissue damage, artery spasm, or cardiac arrest. The capillary collection is usually the preferred method of collection for newborns, infants, and children younger than 2 years.

White blood cells (WBCs)

White blood cells (WBCs) or leukocytes protect the body against infection. WBCs are produced in the bone marrow and lymph nodes and undergo a complex maturation process, which may involve the thymus and other organs. There are 5000 to 10,000 WBCs in 1 mL of whole blood. At any time, most WBCs are not in the blood but in the peripheral tissues and lymphatic system. Two major categories of leukocytes exist granulocytes and mononuclear leukocytes. Granulocytes get their name because of the presence of visible granules in their cytoplasm. The granulocytes include neutrophils, eosinophils, and basophils. Mononuclear leukocytes have larger, unsegmented nuclei. They include lymphocytes and monocytes. They all contain powerful chemicals that destroy Neutrophils, so-called because their granules do not take up either acidic or basic dyes, make up 40% to 60% of all leukocytes in the blood. They are phagocytes, whose role is to at- tack and digest bacteria, and their numbers increase during bacterial infection. They are often the first WBCs on the scene of infection, and their rather short life span (approximately 3 to 4 days) is further shortened when they engulf and digest bacterial and cellular debris. Neutrophils are also called poly- morphonuclear (PMN) leukNeutrophilsocytes, or segmented neutrophils (segs), because of their highly divided and irregularly shaped nuclei.

chapter 15 Special Non-blood Collection Procedures

Why Collect a Urine Specimen? -Urine is created by the kidneys as they filter the blood -Urine contains excess salts, waste products, and small amounts of the many types of molecules that naturally circulate in the bloodstream -For this reason, urine provides a valuable snapshot of the inner workings of the body Types of Urine Specimens -A random specimen can be collected at any time -It is used to screen for obvious metabolic abnormalities by measuring the presence of protein, glucose, blood, and other significant constituents of urine -A first-morning specimen, also called an 8-hour specimen, is collected immediately after the patient awakens -It is a concentrated specimen that ensures the detection of chemicals or pathogens that may not be found in a more dilute, random sample -A timed specimen is a series of samples often collected over 24 hours and combined to provide a single, large specimen -It is used to measure the amounts of protein, creatinine, and hormones -The typical procedure is to have the patient void and discard the first-morning sample, and then collect and combine all urine for the next 24 hours, ending at the same time as the patient started the test the previous day

chapter 19 Legal Issues in Phlebotomy

Why Study Legal Issues? -> Gradual inflation in the price of all goods and services -Higher costs for equipment purchase and maintenance -The need for highly trained operators at all levels of health care delivery -> The availability of sophisticated technology has meant that more doctors order more tests on more patients and that more patients expect them to order the tests As the standard of care has risen, multiple sophisticated and expensive tests have been prescribed to supplement a physician's clinical judgment Fear of litigation has also fueled the rise in the use of multiple tests -> The rising cost of health care has led to efforts to keep costs under control -Reimbursement restrictions on diagnostic tests and limitations on prescription drugs rights of patients have been increasingly recognized and expanded The Patient Care Partnership - What to expect during a hospital stay -High-quality hospital care -A clean and safe environment -Involvement in your care -Protection of your privacy -Help when leaving the hospital -Help with your billing claims

OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION

Workplace safety is regulated by OSHA. The regu- lations are designed both to inform workers about hazards in the workplace (e.g., by requiring that workers know the health effects of the chemicals they use) and to protect workers from harm (e.g., by requiring an emergency shower nearby in case of chemical spills). Your employer is required by OSHA to maintain a safe workplace, provide a comprehensive safety training program, and report accidents that occur on the job. OSHA regulations are revised as needed to increase workplace safety in light of new information or new hazards. -> Organization is responsible for regulations governing workplace safety.

Chemical Hazards

You will encounter many different chemicals in your work as a phlebotomist, including several that can be quite harmful if handled improperly. For example, hydrochloric acid (HCl), which burns mucosal tissue and skin, is used as a preservative for urine. Bleach, which causes irritation of muco- sal tissue and skin, is used as a disinfectant in the laboratory.

Positive Attitude

Your attitude affects everyone you interact with, and having a positive attitude toward your job makes others around you more positive as well.

Standards

a basis of comparison for measuring the extent to which various kinds of organizational performance are satisfactory or unsatisfactory

panel continue

a group of people gathered for a special purpose to discuss an issue.

Needle Adapter (tub holder)

a multisample needle and an evacuated collection tube. To ensure a firm, stable connection between these two essential parts, a needle adapter (also called a tube holder). A needle adapter is a translucent plastic cylinder.

NEEDLES

a needle inserted into a vein allows blood to flow out into an evacuated collection tube or syringe. (ONLY USE ONCE!!!!)

outpatient

a patient who receives medical treatment without being admitted to a hospital.

Examples of Prefixes

a-, an- Without Anemia ante- Before Antecubital anti- Against Anticoagulant brady- Slow Bradycardia inter- Between Interstitial peri- Around Pericardium post-AfterPostprandial

Prefixes for Color

albi- White Albino cirrho- Tawny yellow Cirrhosis cyan- Blue Cyanotic erythro- Red Erythrocyte leuko- White Leukocyte melano- Black Melanoma rube- Red Rubella

Continuing Education Units (CEUs)

are required to renew licenses or maintain certification or registration in many states.

Examples of Word Roots

arterio- Artery Arteriosclerosis derm- Skin Dermal puncture heme- Blood Hematology hepato- Liver Hepatitis nephr- Kidney Nephron osteo- Bone Osteoma phlebo- Vein Phlebotomy

CEUs

continuing education units

Metric Prefixes

deca- Ten Decaliter kilo- Thousand Kilogram deci- Tenth Deciliter centi- Hundredth Centimeter milli- Thousandth Milliliter micro- Millionth Microgram nano-BillionthNanogram

gauge

describes the diameter of the needle's lumen, the hollow tube within the shaft. The smaller the gauge number, the larger the lumen diameter; the larger the number, the smaller the lumen. Needle packs are color-coded by gauge for easy identification. AND The largest-diameter needles routinely used in phlebotomy are 21 to 22 gauge. (most-commonly used)The blood bank uses 16- to 18-gauge needles to collect blood from donors for transfusions (Largest gauge). The smallest needles commonly used are 23 gauge, for collection from small, fragile veins. (BUTTERFLY NEEDLE = 23 GAUGE)

FBS

fasting blood sugar

Examples of Number

hemi-, semi- Half Hemiplegia mono-, uni- One Mononuclear bi-, di- Two Bilaterally tri- Three Tricuspid valve tetra-, quad-FourQuadriceps

inpatients

hospitalized patients

STAT

immediately, at once

panel

is a group of test that we do for each system.

Anaphylaxis

is a rapid, severe immune reaction that can be life-threatening if not treated. During anaphylaxis, the airway may swell shut, the heart rate may increase, and the blood pressure drops. Epinephrine injection and emergency room management are needed for anaphylaxis.

implied consent

is consent which is not expressly granted by a person, but rather implicitly granted by a person's actions and the facts and circumstances of a particular situation

resident flora

microorganisms that normally reside on the skin, mucous membranes, and inside the respiratory and gastrointestinal tracts

electrolytes

minerals that carry electrical charges that help maintain the body's fluid balance

PPE Personal Protective Equipment

personal protective equipment Personal protective equipment (PPE) consists of barriers and respirators used alone or in combina- tion to protect skin, mucous membranes, and cloth- ing from contact with infectious agents.

PBT

phlebotomy technician by AMT

accreditation

process by which an educational program is evaluated and then recognized as having met certain predetermined standards of education

PHI

protected health information, individually identifiable health information.

RPT

registered physical therapist

Chapter 9 Routine Venipuncture

requisition: For out- patients, the laboratory processes the physician's request and generates a requisition, a set of labels for the collection tubes, or both.

Fire label

stands for fire

approval

the belief that someone is doing something right

root word

the foundation of the most medical term - gives the essential meaning to the term.

1. introduction to phlebotomy key terms

the modern phlebotomist is a professional trained to draw blood who has a variety of job skills and personal characteristics, including communication skills, organizational skills, and compassion.

Multisample Needles

the multisample needle, which has a retractable rubber sleeve that covers the second tip when it is not inserted into a tube. A multisample needle remains in place in the patient's vein while one tube is replaced with another. The sleeve keeps blood from leaking onto or into the adapter or tube holder while you are changing tubes.

Computer-printed label for specimen tube.

to determine what type of sample to collect from the patient.

ROUTINE VENIPUNCTURE

venipuncture using evacuated tubes, from the first encounter with the patient until the sample is complete and labeled, the puncture site has stopped bleeding, and the patient is discharged or the phlebotomist leaves the patient's room. 1. Greet and identify the patient 2. Position and prepare the patient 3. Perform hand hygiene, and put on gloves 4. Apply the tourniquet. 5. Select the site. 6. Palpate the vein 7. Assemble your equipment 8. Clean the site. 9. Reapply the tourniquet. 10. Examine the needle. 11. Perform the venipuncture. 12. Fill the first tube. 13. Advance and change the tubes 14. Remove the tourniquet. 15. Prepare for needle removal. 16. Withdraw the needle 17. Dispose of the entire used needle collection system in the needle collection container. 18. Label the tubes. 19. Attend to the patient. 20. Deliver the specimen.

Equipment Used in Routine Venipuncture

• Antiseptic cleaning solution • Bandages• Collection tubes• Gauze pads • Gloves• Marking pens• Needle disposal containers• Needle holders• Needles• Syringes with transfer device• Tourniquets• Winged infusion sets (butterflies)

contact with blood-borne pathogens

• Contact of mucous membranes (eyes, nose, and mouth) via splashes or touching eyes, nose, or mouth with contaminated gloves or hands. • Contact of nonintact skin via splashes or contact with contaminated gloves or hands. Nonintact skin contact occurs through preexisting wounds, scratches, abrasions, burns, or hangnails. • Human bite.• Contact with equipment or laboratory instruments contaminated with body fluid, as well as contact through nail-biting, smoking, eating, or manipulating contact lenses. • Droplet transmission. Such transmission can occur by removal of rubber stoppers; centrifuge accidents; splashing or spattering, especially during the transfer of blood or other body fluids between containers; or failure to wear a proper face shield. -stick with a needle (it happens all the time!) viral survivor: