lOMoARcPSD|35237847

MLSP2 Prelims Reviewer

Medical Laboratory Science Program (Our Lady of Fatima University)

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MLSP2 PRELIMS REVIEWER material spill must be cleaned up using:

- Spill cleanup kit
1. LABORATORY SAFETY
- Common aqueous detergent
Safety Standards and Agencies - 10% bleach using appropriate contact time
- Occupational Safety and Health Administration - OSHA
OSHA Blood Borne Pathogens standard requires written
- Clinical and Laboratory Standards Institute - CSLI
“Exposure Control Plan”
- Centers for Disease Control and Prevention - CDC
- College of American Pathologists - CAP Categories of Exposure:
- The Joint Commission (Formerly JCAHO) - TJS
a. Category I
– daily exposure to blood and body fluids
OSHA: Occupational Health and Safety
b. Category II
Administration within the U.S. Department of Labor
– regular exposure to blood and body fluids
to set levels of safety and health for all workers in the
c. Category III
United States.
– no exposure to blood and body fluids
CLSI: Clinical and Laboratory Standards Institute
→ Employers must offer HBV vaccine to all personnel
Nonprofits educational organization that sets
(Category I and II)
voluntary consensus standards for all areas of clinical
laboratories; Biohazard Symbol
CDC: Center for Disease Control and Prevention
Federal agency that carries out mandated public
health laws and reporting requirements.

All Clinical Lab should have:

- Chemical Hygiene Plan

- Exposure Control Plan
- Copy of MSDS

Safety begins with the recognition of hazards and is

achieved through the following:

- Application of common sense Chemical Hazard

- Listen to the instructions
- A safety-focused attitude Chemical spills: When skin contact occurs, the best first
- Good personal behavior aid is to flush the area with large amounts of water for at
- Good housekeeping in all laboratory work and storage least and then seek medical attention.
areas Chemical Handling: Chemicals should never be mixed
- Continual practice of good laboratory technique. together unless specific instructions are followed, and
they must be added in the order specified. This is
Two primary causes of accidents: particularly important when combining acid and water.
- Unsafe acts Chemical Hygiene Plan: OSHA also requires all facilities
- Unsafe environmental conditions that use hazardous chemicals to have a written chemical
hygiene plan (CHP) available to employees. The purpose
Safety Equipment:
of the plan is to detail the following:
- Safety showers and Eyewash Stations
Appropriate work practices, Standard operating
- Fire Extinguishers
procedures, PPE, Engineering controls, such as
- Fume Hoods
fume hoods and flammable safety cabinets,
- Biosafety Cabinets
Employee training equipment's and Medical
- Complete PPE
consultation guidelines.

Storage and Handling of Chemicals

Flammable/Combustible Chemicals
Classified according to flash point → the
temperature at which sufficient vapor is given off
to form an ignitable mixture with air .

Corrosive Chemicals
injurious to the skin or eyes by direct contact or
Biological Hazard to the tissue of the respiratory and
- These microorganisms are frequently present in the gastrointestinal tracts if inhaled or ingested
specimens received in the clinical laboratory.
- CDC → Universal Precautions (1987) Reactive Chemicals
- Blood and body fluid precautions should be consistently spontaneously explode or ignite or that evolve
used for all patients heat or flammable or explosive gases
- Specimens should be “capped” during centrifugation Carcinogenic Chemicals

*Any blood, body fluid, or other potentially infectious

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NFPA Labelling System • Laboratory personnel should be familiar with

The National Fire Protection Association (NFPA) has these procedures. When a fire is discovered, all
developed the Standard System for providing codes and employees are expected to take the actions in the
standard information about the chemicals/solutions acronym: RACE
 Rescue
 Alarm
 Contain
 Extinguish
. Electrical Hazard
• Ungrounded or wet equipment; frayed cords
• Electrical Safety
• Lock-out or tag malfunctioning electrical or
mechanical equipment until serviced
• Know how to knock a shocked person loose
using a non-conductive material
Radiation Hazard
• Equipment and radioisotopes
• Radiation Safety
- All areas where radioactive materials are used
or stored must be posted with caution signs, and
traffic in these areas should be restricted to
essential personnel only.
- Radiation monitoring utilizes film badge or
survey meter → maximum permissible dose is
5000 mrem/year whole body
Mechanical Hazards
Fire Hazard ● Centrifuges - must be balanced to distribute
Class A the load equally.
• Ordinary ○ Never open the lid until the rotor has
• Combustible: Wood, Paper, Cloth, etc. come to a complete stop
Use these type of Extinguisher: ○ Safety locks on equipment should
 Pressured Water never be rendered inoperable
 Dry Chemical ● Glass beads - help eliminate bumping/boil
over when liquids are heated
Class B
● Infectious sharps - disposed in OSHA-approved
• Flammable
containers
• Liquid
• Grease Disposal of Hazardous Materials
• Gasoline 4 Basic Waste Disposal Technique
• Paints  Flushing down the drain
• Oils, etc.  Incineration
Use these type of Extinguisher:  Landfill burial
 Carbon Dioxide  Recycling
 Dry Chemical
Chemical Waste
Class C • Flush water-soluble substances down the drain with
• Electrical Equipment large quantities of water
• Motors • Strong acids and bases should be neutralized before
• Switches disposal
Use these type of Extinguisher: • Foul smelling chemicals should never be disposed down
 Carbon Dioxide the drain
 Halon • Flammable solvents → collected in approved
 Dry Chemical containers • Flammable material → specially designed
Class D incinerators
 Flammable Radioactive Waste
 Metals • depends on the type of waste (soluble or no
 Magnesium soluble), its level of radioactivity, and the
Use these type of Extinguisher: radiotoxicity and half-life of the isotopes involved
 Metal X
Biohazardous Waste
Cover burning material with sprinkler, scoop. • All biological waste (EXCEPT URINE) should be
P - Pull Pin placed in appropriate containers labeled with
A - Aim for Nozzle biohazard symbol.
S - Squeeze Trigger • URINE: may be discarded by pouring it into the
S - Sweep Nozzle lab sink.
Fire/Explosive Hazards • The sink should be flashed also with water Auer
• The Joint Commission on Accreditation of the urine has been discarded.
Healthcare Organizations (JCAHO) requires that • Decontaminate the sink by 1:5 or 1:10 dilution
all health-care institutions post evacuation routes of sodium hypochlorite (bleach solution).
and detailed plans to follow in the event of a fire.
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• Incineration, inactivation, burial, chemical - Be willing to demonstrate your commitment to

disinfection, encapsulation in a solid matrix your job and your cooperation to assist fellow
employees.
Inactivation: - A committed phlebotomist attends staff
•Heat sterilization (250oC for 15 minutes) meetings, reads pertinent memoranda, and
•Ethylene Oxide (450-500 mg/L at 55-60oC ) observes notices placed on bulletin boards or in
•2% Glutaraldehyde newsletters.
•10% hydrogen peroxide
•5.25 hypochlorite (bleach) 2. Compassionate, courteous, respectful
•10% (v/v with tap water) of common household - Phlebotomists deal with sick, anxious, and
bleach) → HBV (10 minutes), HIV (2 minutes) frightened patients every day. They must be
2. Introduction to Phlebotomy sensitive to their needs, understand a patient’s
concern about a possible diagnosis or just the
Phlebotomy fear of a needle, and take the time to reassure
▪ Defined as an incision or a puncture into a vein each patient.
in order to obtain blood
- A smile and a cheerful tone of voice are simple
▪ One of the oldest medical procedures, dating techniques that can put a patient more at ease.
back to the Early Egyptians and was termed as
“bloodletting”. Phlebotomy - Courteous phlebotomists introduce themselves
▪ Defined as an incision or a puncture into a vein to the patients before they approach them. This
in order to obtain blood also aids in identifying the patient as you can
then ask them to state their name in the same
Evolution of Phlebotomy conversation. Phlebotomists must also
▪ Hippocrates believed that disease was caused understand and respect the cultural diversity of
their patients.
by an excess of body fluids
▪ Bile, Phlegm and Blood - Cultural diversity includes not only language but
also religious beliefs, customs, and values. Do not
Techniques for bloodletting: expect every patient to respond to you in the
- Suction Cup Devices with lancets same way and do not force your mannerisms and
- Application of blood-sucking worms , called approach on them.
“leeches,”
- Barber Surgery, in which blood from an Organized, Responsible, Flexible
incision produced by the barber’s razor was - Phlebotomists need to organize their collection
collected in a bleeding bowl. equipment and maintain well stocked collection
 RED STRIPE POLE - Arterial Blood tray or station. They must also organize and
 WHITE STRIPE POLE - Bandages prioritize their work.
 BLUE STRIPE POLE - Venous
Appearance
Blood
- Phlebotomists should be neat and should have
Arterial Blood, Bandages, Venous Blood clean looking appearance that portrays a
Bloodletting is now called “therapeutic phlebotomy” professional attitude to the patient.
and is used as a treatment for only a small number of - Remember first impressions are lasting
blood disorders such as hemochromatosis impressions often made within 30 seconds and
the phlebotomist represents the entire laboratory
Phlebotomy at Present:
staff.
 Primary role of phlebotomy is the collection of
Communication Skills
blood samples for laboratory analysis to diagnose - Good communication skills are needed for the
and monitor medical conditions. phlebotomist to function as the liaison between
 Phlebotomist should obtain certification, the laboratory and the patients, their family and
accreditation or licensure, and continuing visitors, and other health-care personnel.
▪ The three components of communication:
education from a nationally recognized
- verbal skills
professional organization because it serves to
- listening skills
enhance their position within the health-care field - nonverbal skills or body language
and documents the quality of their skills and Verbal Skills
knowledge - to introduce themselves, explain the procedure,
reassure the patient, and help assure the patient
Duties of The Phlebotomist in Today’s Healthcare that the procedure is being competently
Setting performed.
- Barriers to verbal communication that must be
▪ A phlebotomist is a person trained to obtain blood considered include physical handicaps such as
samples primarily by venipuncture and micro techniques. hearing impairment; patient emotions; and the
level of patient education, age, and language
Traits that Form the Professional I
proficiency.
mage of the Phlebotomist
1. Dependable, cooperative, committed

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- Increased activity of muscle enzymes

- Elevated concentration of sex hormones
- Elevated concentration of steroids

Listening Skills
- Looking directly and attentively at the patient Stress
-nervous patient before sample collection may increase
- Encouraging the patient to express feelings,
anxieties, and concerns levels of adrenal hormones, increase WBC counts,
decrease serum iron, and markedly affect arterial blood
- Allowing the patient time to describe why he or
she is concerned gas (ABG) results.
- Providing feedback to the patient through Smoking
appropriate responses - Acute effects:
- Encouraging patient communication by asking increase in glucose, BUN, cholesterol and triglycerides
questions -Chronic effects:
Increase in blood hemoglobin values
Nonverbal Skills
- include facial expressions, posture, and eye (carboxyhemoglobin) Decrease in IgG, IgA, and IgM →
weak immune system
contact.
- If you walk briskly into the room, smile, and look Altitude
directly at the patient while talking, you -RBC counts and hemoglobin (Hgb) and hematocrit (Hct)
demonstrate positive body language. This makes levels are increased in high-altitude areas such as the
patients feel that they are important and that mountains where there are reduced oxygen levels.
you care about them and your work
- Allowing patients to maintain their zone of Age and Gender
comfort (space) is important in phlebotomy even - Laboratory results vary between infancy, childhood,
though you must be close to them to collect the adulthood, and the elderly
sample. → gradual change in the composition of body fluids.
-Hormone levels vary with age and gender
Telephone Skills -RBC, Hgb, and Hct values
▪ The phlebotomy department frequently acts as → higher in male patients
a type of switchboard for the rest of the
laboratory because of its location in the central Pregnancy
processing area. - caused by the physiological changes in the body
▪ This is a prime example of the phlebotomist’s including increases in plasma volume.
role as a liaison for the laboratory, and poor Alcohol ingestion
telephone skills affect the image of the
laboratory. Venipuncture

3. Phlebotomy Technique EVACUATED TUBE SYSTEM

 Whole Blood has Plasma and formed elements
(un-clotted) • Blood is collected directly into the evacuated tube,
eliminating the need for transfer of specimens and
Blood Serum minimizing the risk of biohazard exposure INCLUDES:
• Liquid portion of clotted blood • Double-pointed needle
• Without anticoagulant • Needle holder
• Contains albumin and globulin • Color-coded evacuated tubes
Plasma NEEDLES
• Liquid portion of un-clotted blood • Needle size varies by both length and gauge
• With anticoagulant (diameter)
• Contains albumin, globulin and fibrinogen • Needle gauge: refers to the diameter of the
Pre-Examination Variables needle bore.
Diet • The smaller the gauge number the bigger the
-The tests most affected are glucose and triglycerides. diameter of the needle.
- Serum or plasma collected from patients shortly after a • Needles should be visually examined before use
meal may appear cloudy or turbid (lipemic) due to the to determine if any structural defects, such as
presence of fatty compounds such as meat, cheese, non beveled points or bent shafts, are present.
butter, and cream.
NEEDLE HOLDERS
- Alcohol consumption • Made of rigid plastic and may be designed to
→ transient elevation in glucose and act as a safety shield for the used needle.
→ chronic consumption • Occupational Safety and Health Administration
→ liver function tests and triglycerides (OSHA) directs that holders must be discarded
- Caffeine with the used needle.
→ hormone levels
NEEDLE DISPOSAL SYSTEMS
Posture •To protect phlebotomists from accidental needle
- Can cause variations in some blood constituents, such as sticks by contaminated needles
cellular elements, plasma proteins, compounds bound to • Rigid, puncture-resistant, leak-proof disposable
plasma proteins, and high molecular weight substances. “sharps” containers labeled BIOHAZARD that are
easily sealed and locked when full.
Exercise
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COLLECTION TUBES • Phlebotomy collection tray

• Evacuated tubes • Slides
- also known as Vacutainers and are • Antimicrobial hand gel
available in glass and plastic. • Marking pen
- Contain a premeasured amount of
vacuum for blood collection
- The amount of blood collected in an Venipuncture Procedure
evacuated tube ranges from 1.8 to 15 mL • Checking Requisition forms
and is determined by the size of the tube - provide the phlebotomist with the information needed
and the amount of vacuum present. to correctly identify the patient, organize the necessary
equipment, collect the appropriate samples, and provide
legal protection.
- Patient’s name, age and gender
- Patient’s date of birth
- Patient’s location
- Ordering health-care provider’s name
- Tests requested
- Requested date and time of sample collection
• Greeting the patient
-Phlebotomists should introduce themselves and
explain that they will be collecting a blood
sample.
• Patient Identification
-The most important procedure in phlebotomy
• Patient Preparation
- Positioning the Patient: supine (lying) or sitting
upright positions
- Position of the Phlebotomist: remains in the
standing position for better and greater freedom
of movement and control of the situation
- If a fasting specimen is required, confirm that
the fasting order has been followed
• Tourniquet application
-maximum amount of time the tourniquet should
remain in place is 1 minute to avoid hemo-
Order of Draw concentration
The order of draw as recommended by the CLSI for both • Site selection
the evacuated tube system and when filling tubes from a Antecubital fossa
syringe is: - The preferred site for venipuncture and
• Blood cultures (yellow stopper tubes, culture is located anterior and below the bend of
bottles) the elbow.
•Light blue stopper tubes (sodium citrate)
•Red/gray, gold stopper tubes (serum separator 3 major veins
Median cubital vein - vein of choice because it is
tubes), red stopper plastic tubes (clot activator),
and red stopper glass tubes large and does not tend to move when the needle
is inserted
•Green stopper tubes and light green (plasma
separator tubes) (heparin) Cephalic vein- usually more difficult to locate,
except possibly in larger patients, and has more
•Lavender stopper tubes (EDTA)
•Gray stopper tubes (potassium oxalate/sodium tendencies to move.
Basilic vein- the least firmly anchored; has a
fluoride) •Yellow/gray or orange stopper tubes
(thrombin clot activator) tendency to “roll” and hematoma formation is
more likely to occur.
Syringe
• Routinely used for venipuncture range from 2 • Quite often the veins cannot be seen but usually felt by
touching or palpating with the index finger of the non-
to 20 mL
• For single draw dominant hand
• They will reveal themselves as elastic tubes beneath the
• For drawing blood from patients with small or
fragile veins. surface of the skin.
Arrangement of veins in the antecubital fossa
Winged Blood Collection Sets
• for performing venipuncture from very small or • H-shaped pattern
- includes the cephalic, median cubital, and
very fragile veins often seen in children and in the
geriatric population basilic veins in a pattern that looks like a slanted
H.
*Reminder:
• Always hold the apparatus by the needle wings • M-shaped pattern
- Includes the cephalic, median cephalic, median
and not by the tubing.
Other Venipuncture Equipment basilic, and basilic veins.
• Tourniquets Areas to Be Avoided
• Vein locating devices • Damaged Vein
• 70% isopropyl alcohol, iodine swabs • Hematoma
• 2x2 inch gauze pads • Edema
• Bandage or adhesive tape
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• Burns, Scars and Tattoos •General Delayed Complications

• Mastectomy - Serum Hepatitis, AIDS Prevention:
• Obesity •Use of disposable syringe or vacutainer set
• IV Therapy •Follow the procedures from the Universal Precautions
• Heparin and Saline Locks in handling infectious specimens
• Cannulas and Fistulas • Collection Attempts
-When blood is not obtained from the initial
venipuncture, the phlebotomist should select
another site. Repeat the procedure using a new
• Cleansing the site needle
- Cleansing is performed with a circular motion,
starting at the inside of the venipuncture site and • Nerve Injury
working outward in widening concentric circles -Temporary or permanent nerve damage can be
about 2 to 3 inches. caused by incorrect vein selection or improper
• Assembling equipment venipuncture technique and may result in loss of
• Examine the Needle movement to the arm or hand and the possibility
-visually examined for any defects such as a non- of a lawsuit.
pointed or rough (barbed) end. • Iatrogenic Anemia
• Anchoring the Vein - pertains to a condition of blood loss caused by
- Place the thumb 1 or 2 inches below and slightly treatment. An anemia can occur when large
to the left of the insertion site and the four amounts of blood are removed for testing at one
fingers on the back of the arm and pull the skin time or over a period of time.
taut. • Hemolysis Samples
• Inserting the Needle -Rupture of the red blood cell membrane releases
-bevel up, at an angle of 15 to 30 degrees cellular contents into the serum or plasma and
depending on the depth of the vein. produces interference with many test results
• Filling the Tubes
• Removal of the Needle Special Blood Collection
-Place folded gauze over the venipuncture site Collection Priorities
and withdraw the needle in a smooth swift • Routine Samples
motion. Apply pressure to the site as soon as the - are usually collected early in the morning but
needle is withdrawn. can be collected throughout the day during
*Never draw out the needle without removing first the scheduled “sweeps” (collection times) on the
tourniquet to avoid hematoma floors or from outpatients.
• Disposal of the needle • ASAP Samples-means “as soon as possible.”
• Labeling the tubes The response time for the collection of this test
- Patient’s name and identification number sample is determined by each hospital or clinic
- Age and Gender of the Patient and may vary by laboratory tests.
- Date and time of collection • Stat Samples
- Phlebotomist’s initials - sample is to be collected, analyzed, and results
• Checking the patient’s arm reported immediately.
-examine the patient’s arm to be sure the • FASTING SAMPLE
bleeding has stopped. - npo (nothing per orem);
-adhesive bandages/micropore tape over a “nothing by mouth”
folded gauze square. -FBS
• Completing the Venipuncture procedure -Lipid Profile
-deliver the sample to the laboratory in • TIMED SAMPLES
satisfactory condition and all appropriate -Glucose Tolerance Tests
paperwork should be completed. -2-Hour Oral Glucose Tolerance Test
- Lactose Tolerance Test
Patient Complications • Blood Culture
•Immediate Local Complications
➢Localized hem concentration or Venous Stasis ARTERIAL PUNCTURE
Remedy: One-minute application of tourniquet • Generally used for the determination of blood
➢Syncope or Fainting Remedy: Let the patient lie oxygen, carbon dioxide tension and blood pH
down (Blood Gas Analysis).
➢Failure to obtain blood Needle Position Bevel • Blood collected is called arterial blood or
Against the Wall of the Vein Needle Too Deep/ oxygenated blood
Too Shallow Collapsed Vein Needle Beside the • Special training is required for this procedure
Vein Faulty Evacuated Tube • Tourniquet is not required
•Delayed Local Complications • After removing the needle, apply moderate
- Thrombosis of veins pressure with 2 x 2 sterile gauze until bleeding
- Formation of blood clots inside the lumen of the ceases
vein due to trauma • Insert needle (still attached to syringe) in
- Thrombophlebitis stopper to prevent air from entering needle
- Inflammation of the vein due to thrombus as Arterial Puncture: Sites of Puncture
manifested by an inflammatory reaction on the •Radial artery
outer skin surface •Femoral artery (fem tap)
- Hematomas •Brachial artery
-Blue or black skin discoloration commonly due to •Scalp artery
repeated trauma or puncture of the veins •Umbilical artery
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Modified Allen Test

• Before performing a radial artery puncture, the Special Dermal Puncture
Modified Allen Test is performed to determine if Collection of Newborn Bilirubin
the ulnar artery is capable of providing collateral • Bilirubin is a very light-sensitive chemical and is
circulation to the hand. rapidly destroyed when exposed to light.
• Samples must be collected quickly and
protected from excess light during and after the
4. Dermal Puncture collection.
Dermal Puncture
•Also known as Capillary or Skin puncture
•Blood collected by dermal puncture comes from the
capillaries, arterioles, and venule Newborn Screening
•The method of choice for collecting blood from infants • Require testing for as many as 29 metabolic
and children younger than 2 years. disorders.
• because many of these disorders cause the
Dermal puncture may be required in many adult
buildup of un-metabolized toxic food ingredients,
patients, including:
it is important that the defects be detected early
- Burned or scarred patients
in life.
- Patients receiving chemotherapy who require
• The testing of newborn babies for genetic,
frequent tests and whose veins must be reserved
metabolic, hormonal, and functional disorders
for therapy
that can cause physical disabilities, mental
- Patients with thrombotic tendencies
retardation, or even death, if not detected and
- Geriatric or other patients with very fragile
treated early.
veins
• Levels of these substances are elevated more
- Patients with inaccessible veins
rapidly in blood than urine.
- Obese patients
• Testing for many substances is now performed
- Patients requiring home glucose monitoring and
using tandem mass spectrophotometry (MS/MS).
point-of-care tests
MS/MS is capable of screening the infant blood
sample for specific substances associated with
Lancets
particular IEMs.
• Sterile, disposable, sharp-pointed or bladed
• Performed from blood collected by heel stick
instrument
and placed on specially designed filter paper.
• Punctures or cuts skin to obtain capillary blood
specimen
Capillary Blood Gases
• Designed for either finger or heel puncture
•Arterial blood is the preferred sample for blood
gases (oxygen and carbon dioxide content) and
Dermal Puncture Devices
pH levels in adults
• Primary danger in dermal puncture:
•Samples are collected in heparinized blood gas
Accidental contact with the bone, followed by
pipettes
infection or inflammation (osteomyelitis or
•The pipette should fill in less than 30 seconds.
osteochondritis)
• To prevent contact with bone, the depth of the
puncture is critical.
• The Clinical and Laboratory Standards Institute
(CLSI) recommends that the incision depth should
not exceed 2.0 mm in a device used to perform
heel sticks.

Capillary Tubes
• Also known as micro hematocrit tubes
• small tubes used to collect approximately 50 to
75 µL of blood for the primary purpose of
performing a micro hematocrit test.
• One end of tube is sealed with plastic or clay
sealants

Microtainer Tubes
• Small plastic tubes designed to hold
approximately 600 µL of blood.
• Color coded in the same way as evacuated
tubes.
• Some have stoppers & markings for min/max
fill levels.
Warming equipment
- Warming the site increases blood flow as much as 7
times
• Commercial Heel Warmer A packet containing
sodium thiosulfate and glycerin that produces
heat when the chemicals are mixed together by
gentle squeezing of the packet.
• Warm washcloths or towels
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