CLINICAL LABORATORY TECHNIQUES

INTRODUCTION
Have you ever donated blood or had blood drawn as part of your annual physical?
If so, in both
cases, your blood would have gone to a clinical laboratory for analysis. The donated
blood would
have been for blood type and disease then prepared for a blood bank or other medical
applications.
The drawn blood for the physical could have been checked for components such
as the number of red and white blood cells, platelets and various enzymes and possibly,
antibodies.
Clinical laboratories perform several different types ofprocedures:
A
nalyze body fluids, cells and other components like DNA and RNA.
L
ook for the presence of pathogenic entities such as bacteria, viruses and other
microorganisms.
Analyze the chemical content of fluids.
Match blood for transfusions.
In order to accurately perform these tests, the technicians must be properly trained and
the tools and equipment used must be able to accurately test for the components being
analyzed. To understand which tests can be adapted with microtechnology, it is
advantageous for one tounderstand what clinical laboratory personnel do, how they do it,
and the regulations that govern
their training and laboratory activities.
VENIPUNCTURE GUIDELINES
MATERIALS
1.

Safety Needles, 22g or less

2.

Butterfly needles. 21g or less

3.

Syringes

4.

Blood Collection Tubes. The vacuum tubes are designed to draw a predetermined

volume of blood.
Tubes with different additives are used for collecting blood specimens for specific
types of tests.
The color of the rubber stopper is used to identify these additives.
See Selecting the Appropriate Collection Tube and Specimen Container Types.
5. Tourniquets. Latex-free tourniquets are available
6. Antiseptic. Individually packaged 70% isopropyl alcohol wipes.
7.

2x2 Gauze or cotton balls.

8.

Sharps Disposal Container. An OSHA acceptable, puncture proof container marked

"Biohazardous".
9.

Bandages or tape

SAFETY
1.

Observe universal (standard) safety precautions. Observe all applicable isolation

procedures.
2.

PPE's will be worn at all time.

3. Wash hands in warm, running water with the chlorhexidine gluconate hand washing
product (approved
by the Infection Control Committee), or if not visibly contaminated with a
commercial foaming
hand wash product before and after each patient collection.
4.

Gloves are to be worn during all phlebotomies, and changed between patient

collections.
Palpation of phlebotomy site may be performed without gloves providing the skin is
not broken.
5. A lab coat or gown must be worn during blood collection procedures.
6.

Needles and hubs are single use and are disposed of in an appropriate 'sharps'

container as one unit.

Needles are never recapped, removed, broken, or bent after phlebotomy
procedure.
7.

Gloves are to be discarded in the appropriate container immediately after the

phlebotomy procedure.
All other items used for the procedure must be disposed of according to proper
biohazardous
waste disposal policy.
8.

Contaminated surfaces must be cleaned with freshly prepared 10% bleach solution.

All surfaces
are cleaned daily with bleach.
9.

In the case of an accidental needlestick, immediately wash the area with an

antibacterial soap, express blood

from the wound, and contact your supervisor.
PROCEDURE
1.

Identify the patient. Outpatients are called into the phlebotomy area and asked their

name and date of

birth. This information must match the requisition.

Inpatients are identified by

their arm band.

If it has been removed, a nurse must install a new one before the patient can be
drawn.
2.

Reassure the patient that the minimum amount of blood required for testing will be

drawn.
3. Assemble the necessary equipment appropriate to the patient's physical
characteristics.
4. Wash hands and put on gloves.

5.

Position the patient with the arm extended to form a straight-line form shoulder to

wrist.
6.

Do not attempt a venipuncture more than twice. Notify your supervisor or patient's

physician if
unsuccessful.
7.

Select the appropriate vein for venipuncture.

The larger median cubital, basilic and cephalic veins are most frequently used, but

other may be necessary

and will become more prominent if the patient closes his fist tightly. At no time
may phlebotomists
perform venipuncture on an artery. At no time will blood be drawn from the
feet unless there is a specific order in the computer.
Factors to consider in site selection:
* Extensive scarring or healed burn areas should be avoided
* Specimens should not be obtained from the arm on the same side as a
mastectomy.
* Avoid areas of hematoma.
* If an IV is in place, samples may be obtained below but NEVER above the IV
site.
* Do not obtain specimens from an arm having a cannula, fistula, or vascular
graft.
* Allow 10-15 minutes after a transfusion is completed before obtaining a blood
sample.
8.

Apply the tourniquet 3-4 inches above the collection site.

Never leave the tourniquet on for over 1 minute.

If a tourniquet is used for preliminary vein selection, release it and reapply after two
minutes.
9. Clean the puncture site by making a smooth circular pass over the site with the 70%
alcohol pad,
moving in an outward spiral from the zone of penetration. Allow the skin to dry
before proceeding.
Do not touch the puncture site after cleaning.
10.

Perform the venipuncture

A. Attach the appropriate needle to the hub by removing the plastic cap over the

small end of the

needle and inserting into the hub, twisting it tight.
B.

Remove plastic cap over needle and hold bevel up.

C.

Pull the skin tight with your thumb or index finger just below the puncture site.

D.

Holding the needle in line with the vein, use a quick, small thrust to penetrate

the skin and

enter the vein in one smooth motion.
E.

Holding the hub securely, insert the first vacutainer tube following proper order

of draw into
the large end of the hub penetrating the stopper. Blood should flow into the
evacuated tube.
F. After blood starts to flow, release the tourniquet and ask the patient to open his
or her hand.
G. When blood flow stops, remove the tube by holding the hub securely and
pulling the tube off
the needle. If multiple tubes are needed, the proper order of draw to avoid
cross
contamination and erroneous results is as follows:
1.

Blood culture vials or bottles, sterile tubes

2.

Coagulation tube (light blue top)

(Routine PT/PTT may be performed if blue top is first tube collected. It

may be desirable to
collect a second tube for other coagulation assays.)

H.

3.

Serum tube with or without clot activator or silica gel (Red or Gold)

4.

Heparin tube (Green top)

5.

EDTA (Lavender top)

6.

Glycolytic inhibitor (Gray top)

Each coagulation tube (light blue top) should be gently inverted 4 times after

being removed from the hub. Red and gold tops should be inverted 5 times. All other
tubes containing an additive should be gently inverted 8-10 times. DO NOT SHAKE
OR MIX VIGOROUSLY.
I.

Place a gauze pad over the puncture site and remove the needle.
Immediately apply slight pressure. Ask the patient to apply pressure for at least

2 minutes.
When bleeding stops, apply a fresh bandage, gauze or tape.
J.

Properly dispose of hub with needle attached into a sharps container. Label all

tubes with
patient labels, initials, date and time.
SPECIAL NOTE WHEN USING BUTTERFLY COLLECTION DEVICE: When
coagulation tube (light blue top)
will be the first tube collected, it is MANDATORY to collect a DISCARD light blue top
first to remove
the air from the tubing. A second light blue top can then be collected appropriately.
Failure to
collect the discard tube may result in specimen being rejected due to inappropriate

volume.
UAMS CLINICAL LABORATORY BLOOD DRAW MINIMIZATION
1.

Increasing the number of point of care glucose and electrolyte testing devices

which use a
fingerstick sample to perform test instead of drawing a whole tube of blood to send
to the lab.
2.

Doing a thorough search in our LIS to see if blood can be used from an earlier
draw whenever
there is an add-on test requested to prevent patient from being drawn again.

3.

The Clinical Lab coordinated an intradisciplinary committee to reduce mislabeled

and unlabeled
specimens to prevent patient redraws . The lab audits and sends out notification for
corrective
action in cases of non-compliance.

4.

Designing our LIS system to identify minimum volumes of blood to be drawn for
all tests and
print out the appropriate number of labels to match the different types of blood
tubes to be drawn.

5.

Purchasing testing equipment in the nursery laboratory which uses a lesser volume
of blood than
previous equipment.

6.

Participating in Nursery quality control meetings weekly which address methods of

improvement
for reducing the volume of blood collection.

7.

Participating in the IRB to have a voice in encouraging research studies to be

conservative in blood
collection.

8.

Communicating with nurse managers and staff education to improve blood draw
techniques to
minimize hemolyzed, clotted and unsatisfactory specimens to prevent redraws.

9.

Assuring the competence and accuracy of phlebotomists by prompt

communications when
specimen collection problems occur and providing solutions and corrective action
when needed.

10.

Saving blood specimens in the proper environment for the maximum usage time
span to increase
opportunities for not having to redraw a specimen.

TROUBLESHOOTING HINTS FOR BLOOD COLLECTION

If a blood sample is not attainable:
Reposition the needle.
Ensure that the collection tube is completely pushed onto the back of the needle in
the hub.
Use another tube as vacuum may have been lost.
Loosen the tourniquet.
Probing is not recommended. In most cases, another puncture in a site below the
first site is advised.
A patient should never be stuck more than twice unsuccessfully by a phlebotomist.
The Supervisor should be called to assess the patient.
BLOOD SPECIMEN COLLECTION AND PROCESSING
The first step in acquiring a quality lab test result for any patient is the specimen
collection procedure. The venipuncture procedure is complex, requiring both knowledge
and skill to perform. Several essential steps are required for every successful collection
procedure:

VENIPUNCTURE PROCEDURE:
1. A phlebotomist must have a professional, courteous, and understanding manner in
all contact with all patients.
2. The first step to the collection is to positively identify the patient by two forms of
identification; ask the patient to state and spell his/her name and give you his/her
birth date. Check these against the requisition (paper or electronic).
3. Check the requisition form for requested tests, other patient information and any
special draw requirements. Gather the tubes and supplies that you will need for the
draw.
4. Position the patient in a chair, or sitting or lying on a bed.
5. Wash your hands.
6. Select a suitable site for venipuncture, by placing the tourniquet 3 to 4 inches
above the selected puncture site on the patient. See below for venipuncture site
selection notes.
7. Do not put the tourniquet on too tightly or leave it on the patient longer than 1
minute.
8. Next, put on non-latex gloves, and palpate for a vein.
9. When a vein is selected, cleanse the area in a circular motion, beginning at the site
and working outward. Allow the area to air dry. After the area is cleansed, it
should not be touched or palpated again. If you find it necessary to reevaluate the
site by palpation, the area needs to be re-cleansed before the venipuncture is
performed.
10. Ask the patient to make a fist; avoid pumping the fist. Grasp the patients arm
firmly using your thumb to draw the skin taut and anchor the vein. Swiftly insert
the needle through the skin into the lumen of the vein. The needle should form a
15-30 degree angle with the arm surface. Avoid excess probing.
11. When the last tube is filling, remove the tourniquet.
12. Remove the needle from the patient's arm using a swift backward motion.

13. Place gauze immediately on the puncture site. Apply and hold adequate pressure to
avoid formation of a hematoma. After holding pressure for 1-2 minutes, tape a
fresh piece of gauze or Band-Aid to the puncture site.
14. Dispose of contaminated materials/supplies in designated containers.
Note: The larger median cubital and cephalic veins are the usual choice, but the
basilic vein on the dorsum of the arm or dorsal hand veins are also acceptable.
Foot veins are a last resort because of the higher probability of complications.
FINGERSTICK PROCEDURE:
1. Follow steps #1 through #5 of the procedure for venipuncture as outlined above.
2. The best locations for fingersticks are the 3rd (middle) and 4th (ring) fingers of the
non-dominant hand. Do not use the tip of the finger or the center of the finger.
Avoid the side of the finger where there is less soft tissue, where vessels and
nerves are located, and where the bone is closer to the surface. The 2nd (index)
finger tends to have thicker, callused skin. The fifth finger tends to have less soft
tissue overlying the bone. Avoid puncturing a finger that is cold or cyanotic,
swollen, scarred, or covered with a rash.
3. When a site is selected, put on gloves, and cleanse the selected puncture area.
4. Massage the finger toward the selected site prior to the puncture.
5. Using a sterile safety lancet, make a skin puncture just off the center of the finger
pad. The puncture should be made perpendicular to the ridges of the fingerprint so
that the drop of blood does not run down the ridges.
6. Wipe away the first drop of blood, which tends to contain excess tissue fluid.
Collect drops of blood into the collection tube/device by gentle pressure on the
finger. Avoid excessive pressure or milking that may squeeze tissue fluid into
the drop of blood.
7. Cap, rotate and invert the collection device to mix the blood collected.
8. Have the patient hold a small gauze pad over the puncture site for a few minutes to
stop the bleeding.

9. Dispose of contaminated materials/supplies in designated containers.

10. Label all appropriate tubes at the patient bedside.
HEELSTICK PROCEDURE (INFANTS):
The recommended location for blood collection on a newborn baby or infant is the heel.
The diagram below indicates the proper area to use for heel punctures for blood
collection.
1. Prewarming the infant's heel (42 C for 3 to 5 minutes) is important to increase the
flow of blood for collection.
2. Wash your hands, and put gloves on. Clean the site to be punctured with an
alcohol sponge. Dry the cleaned area with a dry gauze pad.
3. Hold the baby's foot firmly to avoid sudden movement.
4. Using a sterile blood safety lancet, puncture the side of the heel in the appropriate
regions shown above. Make the cut across the heel print lines so that a drop of
blood can well up and not run down along the lines.
5. Wipe away the first drop of blood with a piece of clean, dry cotton gauze. Since
newborns do not often bleed immediately, use gentle pressure to produce a
rounded drop of blood. Do not use excessive pressure because the blood may
become diluted with tissue fluid.
6. Fill the required microtainer(s) as needed.
7. When finished, elevate the heel, place a piece of clean, dry cotton on the puncture
site, and hold it in place until the bleeding has stopped. Apply tape or Band-Aid to
area if needed.
8. Be sure to dispose of the lancet in the appropriate sharps container. Dispose of
contaminated materials in appropriate waste receptacles.
9. Remove your gloves and wash your hands.

ORDER OF DRAW:

Blood collection tubes must be drawn in a specific order to avoid cross-contamination of

additives between tubes. The recommended order of draw for plastic vacutainer tubes is:
1. First - blood culture bottle or tube (yellow or yellow-black top)
2. Second - coagulation tube (light blue top).
3. Third - non-additive tube (red top)
4. Last draw - additive tubes in this order:
o SST (red-gray or gold top). Contains a gel separator and clot activator.
o Sodium heparin (dark green top)
o PST (light green top). Contains lithium heparin anticoagulant and a gel
separator.
o EDTA (lavender top)
o Oxalate/fluoride (light gray top) or other additives
NOTE: Tubes with additives must be thoroughly mixed. Clotting or
erroneous test results may be obtained when the blood is not thoroughly
mixed with the additive.
LABELING THE SAMPLE
All specimens must be received by the laboratory with a legible label containing at least
two (2) unique identifiers.
The specimen must be labeled with the patient's full name (preferably last name first,
then first name last) and one of the following:
GHS medical record number (MRN) - for Geisinger locations, this is the required
second identifier
Patient's full date of birth (must include the month, day, and year)
Unique requisition identifier/label
AREAS TO AVOID WHEN CHOOSING A SITE FOR BLOOD DRAW:
Certain areas are to be avoided when choosing a site for blood draw:

 Extensive scars from burns and surgery - it is difficult to puncture the scar tissue
and obtain a specimen.
The upper extremity on the side of a previous mastectomy - test results may be
affected because of lymphedema.
Hematoma - may cause erroneous test results. If another site is not available,
collect the specimen distal to the hematoma.
Intravenous therapy (IV) / blood transfusions - fluid may dilute the specimen, so
collect from the opposite arm if possible.
Cannula/fistula/heparin lock - hospitals have special policies regarding these
devices. In general, blood should not be drawn from an arm with a fistula or
cannula without consulting the attending physician.
Edematous extremities - tissue fluid accumulation alters test results.
TECHNIQUES TO PREVENT HEMOLYSIS (WHICH CAN INTERFERE WITH
MANY TESTS):
Mix all tubes with anticoagulant additives gently (vigorous shaking can cause
hemolysis) 5-10 times.
Avoid drawing blood from a hematoma; select another draw site.
If using a needle and syringe, avoid drawing the plunger back too forcefully.
Make sure the venipuncture site is dry before proceeding with draw.
Avoid a probing, traumatic venipuncture.
Avoid prolonged tourniquet application (no more than 2 minutes; less than 1
minute is optimal).
Avoid massaging, squeezing, or probing a site.
Avoid excessive fist clenching.
If blood flow into tube slows, adjust needle position to remain in the center of the
lumen.

BLOOD SAMPLE HANDLING AND PROCESSING:

Pre-centrifugation Handling - The first critical step in the lab testing process, after
obtaining the sample, is the preparation of the blood samples. Specimen integrity can be
maintained by following some basic handling processes:
Fill tubes to the stated draw volume to ensure the proper blood-to-additive ratio.
Allow the tubes to fill until the vacuum is exhausted and blood flow ceases.
Vacutainer tubes should be stored at 4-25C (39-77F).
Tubes should not be used beyond the designated expiration date.
Mix all gel barrier and additive tubes by gentle inversion 5 to10 times immediately
after the draw. This assists in the clotting process. This also assures homogenous
mixing of the additives with the blood in all types of additive tubes.
Serum separator tubes should clot for a full 30 minutes in a vertical position prior
to centrifugation. Short clotting times can result in fibrin formation, which may
interfere with complete gel barrier formation.
Blood Sample Centrifugation It is recommended that serum be physically separated
from contact with cells as soon as possible, with a maximum time limit of 2 hours from
the time of collection.
Complete gel barrier formation (gel barrier tubes) is time, temperature and G-force
dependent. The uniformity of the barrier is time dependent; an incomplete barrier
could result from shortened centrifugation times.
In general, for a horizontal, swing-bucket centrifuge, the recommended spin time
is 10 minutes. For a fixed-angle centrifuge, the recommended spin time is 15
minutes.
NOTE: Gel flow may be impeded if chilled before or after centrifugation.
Tubes should remain closed at all times during the centrifugation process.
Place the closed tubes in the centrifuge as a balanced load noting the following:

o Opposing tube holders must be identical and contain the same cushion or
none at all.
o Opposing tube holders must be empty or loaded with equally weighted
samples (tubes of the same size and equal in fill).
o If an odd number of samples is to be spun, fill a tube with water to match
the weight of the unpaired sample and place it across from this sample.
CENTRIFUGE SAFETY
Interference with an activated centrifuge by an impatient employee can result in
bodily injury in the form of direct trauma or aerosolization of hazardous droplets.
Centrifuges must never be operated without a cover in place.
Uncovered specimen tubes must not be centrifuged.
Centrifuges must never be slowed down or stopped by grasping part(s) of the
device with your hand or by applying another object against the rotating
equipment.
Be sure the centrifuge is appropriately balanced before activating. If an abnormal
noise, vibration, or sound is noted while the centrifuge is in operation,
immediately stop the unit (turn off the switch) and check for a possible load
imbalance.
Clean the centrifuge daily with a disinfectant and paper towel. Broken tubes or
liquid spills must be cleaned immediately.

HEMATOLOGY
Hematology, also spelled haematology (from the Greek , haima
"blood," and is the branch of medicine concerned with the study,
diagnosis, treatment, and prevention of diseases related to blood.
Hematology includes the study of etiology. It involves treating diseases

that affect the production of blood and its components, such as blood
cells, hemoglobin, blood proteins, bone marrow, platelets, blood
vessels, spleen, and the mechanism of coagulation. The laboratory
work that goes into the study of blood is frequently performed by a
medical technologist or medical laboratory scientist. Hematologists
also conduct studies in oncology and work with oncologists, people
who may specialize only in that field instead of both-the medical
treatment of cancer. There are various disorders that people are
affected by hematology. A few of these different types of blood
conditions that are looked at include anemia, hemophilia, general
blood clots, bleeding disorders,etc. As for related blood cancers such
as leukemia, myeloma, and lymphoma, these are more serious cases
that need to be diagnosed.
SPECIALIZATION
Physicians specialized in hematology are known as hematologists or haematologists.
Their routine work mainly includes the care and treatment of patients with hematological
diseases, although some may also work at the hematology laboratory viewing blood films
and bone marrow slides under the microscope, interpreting various hematological test
results and blood clotting test results. In some institutions, hematologists also manage the
hematology laboratory. Physicians who work in hematology laboratories, and most
commonly manage them, are pathologists specialized in the diagnosis of hematological
diseases, referred to as hematopathologists or haematopathologists. Hematologists and
hematopathologists generally work in conjunction to formulate a diagnosis and deliver
the most appropriate therapy if needed. Most may consider hematologists to only
diagnose the blood, but that isn't entirely true. Hematologists observe and find the right
treatment first, then sit down and deliver the various types of treatments fitted for that
particular being. No one being is exactly the same, just as each organism has its
individual genes that cause an issue in their blood, each organism has a different reaction

to different treatments. It is essential hematologists look in depth and deliver the message
immediately with the right diagnostics. Hematology is a distinct subspecialty of internal
medicine, separate from but overlapping with the subspecialty of medical oncology.
Hematologists may specialize further or have special interests, for example, in:
treating bleeding disorders such as hemophilia and idiopathic thrombocytopenic
purpura
treating hematological malignancies such as lymphoma and leukemia (cancers)
treating hemoglobinopathies
the science of blood transfusion and the work of a blood bank
bone marrow and stem cell transplantation
TRAINING
To begin in this career, hematologists complete a four-year medical degree which is
followed by three or four more years, depending on the person, in residency or internship
programs. After completion, they further expand their knowledge of hematology by
spending two or three more years learning how to experiment, diagnose, and treat blood
disorders. When applying for this career, most job openings look for first hand practical
experiences in a recognized training program that provides practice in the following:
Cause of abnormalities in formation of blood and other disorders, diagnosis of numerous
blood related conditions or cancers using experimentation, and the proper care and
treatment of patients in the best manner.

TREATMENTS
Treatments include:
Diet advice

 Oral medication tablets or liquid medicines

Anticoagulation therapy
Intramuscular injections (for example, vitamin B12 injections)
Blood transfusion (for anemia)
Venesection also known as therepeutic phlebotomy (for iron overload or
polycythemia)
Bone marrow transplant (for example, for leukemia)
All kinds of anti-cancer chemotherapy
Radiotherapy (for example, for cancer)
ALPHABETICAL LISTS
Blood disorders
Hematologists
Hematology topics

BLOOD BIOCHEMICAL ANALYSIS

A basic metabolic panel measures sodium, potassium, chloride, bicarbonate, blood urea
nitrogen (BUN), magnesium, creatinine, glucose, and sometimes includes calcium. Blood
tests focusing on cholesterol levels can determine LDL and HDL cholesterol levels, as
well as triglyceride levels.
Some blood tests, such as those that measure glucose or a lipid profile, require fasting (or
no food consumption) eight to twelve hours prior to the drawing of the blood sample.
For the majority of blood tests, blood is usually obtained from the patient's vein.
However, other specialized blood tests, such as the arterial blood gas, require blood
extracted from an artery. Blood gas analysis of arterial blood is primarily used to monitor

carbon dioxide and oxygen levels related to pulmonary function, but it is also used to
measure blood pH and bicarbonate levels for certain metabolic conditions.
While the regular glucose test is taken at a certain point in time, the glucose tolerance test
involves repeated testing to determine the rate at which glucose is processed by the body.

NORMAL RANGES
Blood tests results should always be interpreted using the ranges provided by the
laboratory that performed the test. Example ranges are shown below:
Test
Sodium (Na)
Potassium (K)
Urea
Urea
Creatinine - male
Creatinine - female
Creatinine - male
Creatinine - female
Glucose (fasting)
Glucose (fasting)

Low
136
3.5
2.5
15
62
53
0.7
0.6
3.9
70

High
145
5.0
6.4
40
115
97
1.3
1.2
5.8
120

Unit
mmol/L
mmol/L
mmol/L
mg/dL
mol/L
mol/L
mg/dL
mg/dL
mmol/L
mg/dL

Comments

BUN - blood urea nitrogen

See also glycated hemoglobin

COMMON ABBREVIATIONs
Abbreviation
HDL

LDL

CRP

Stands for
High Density
Lipoprotein
Low Density
Lipoprotein

C-Reactive Protein

Description
Level of "good cholesterol" in the blood (ratio of
HDL:LDL is usually more significant than actual
values)
Level of "bad cholesterol" in the blood (ratio of
HDL:LDL is usually more significant than actual
values)
Level of inflammation with the body. If the immune
system is fighting an infection or illness, CRP will
be higher.

Complete Blood
CBC

Count

Analysis of 15 different blood test readings to

(UK: FBC)

(UK: Full Blood

provide information about overall health.

Count)
TSH

ESR

INR

Thyroid Stimulating
Hormone
Erythrocyte
Sedimentation Rate
International
Normalized Ratio

Thyroid regulates the function of metabolism. Low

levels can lead to weight loss, while high levels lead
to weight gain.
Indicates the time it takes for red blood cells to
move down a tube. This shows signs of
inflammation within a body.
This is a blood clotting test.
This test reveals the levels of waste products,

LFT

U+E
CMP
WBC
RBC
HBC
HCT
PLT

Liver Function Test

Urea and Electrolytes

Comprehensive
Metabolic Panel
White Blood Cell
Count
Red Blood Cell
Count
Hemoglobin
Hematocrit
Platelets

enzymes and proteins that are processed by the

liver.
This test is performed to measure the function of
kidney.
This analysis provides an overall picture of the
metabolism and chemical balance of the body.
The level of white blood cells.
The level of red blood cells.
Level of hemoglobin molecules.
Similar to RBC but in percentage.
Platelets levels in the blood.

MOLECULAR PROFILES
Protein electrophoresis (general techniquenot a specific test)
Western blot (general techniquenot a specific test)
Liver function tests

 Polymerase chain reaction (DNA). DNA profiling is today possible with even very
small quantities of blood: this is commonly used in forensic science, but is now
also part of the diagnostic process of many disorders.
Northern blot (RNA)
Sexually transmitted diseases
CELLULAR EVALUATION
Full blood count (or "complete blood count")
o Hematocrit and MCV ("mean corpuscular volume")
Erythrocyte sedimentation rate (ESR)
Cross-matching. Determination of blood type for blood transfusion or transplants
Blood cultures are commonly taken if infection is suspected. Positive cultures and
resulting sensitivity results are often useful in guiding medical treatment.
URINE DIPSTICK CHEMICAL ANALYSIS
A dipstick is a paper strip with patches impregnated with chemicals that undergo a color
change when certain constituents of the urine are present or in a certain concentration.
The strip is dipped into the urine sample, and after the appropriate number of seconds, the
color change is compared to a standard chart to determine the findings.

Findings: Leukocyte esterase 3+, Nitrite Pos; pH 7.0; Protein Neg; Blood Neg; Sp Gr
1.015; Ketones 1+, Glucose 1+; Bilirubin Neg

PH
The glomerular filtrate of blood plasma is usually acidified by renal tubules and
collecting ducts from a pH of 7.4 to about 6 in the final urine. However, depending on the
acid-base status, urinary pH may range from as low as 4.5 to as high as 8.0. The change
to the acid side of 7.4 is accomplished in the distal convoluted tubule and the collecting
duct.

SPECIFIC GRAVITY (SP GR)

Specific gravity of urine is determined by the presence of solutes represented by particles
of varying sizes, from small ions to larger proteins. Urine osmolality measures the total
number of dissolved particles, regardless of their size. The most common method of

measurement is freezing point depression. A refractometer measures the change in

direction of a light path (refraction) based upon particle concentration and size in a fluid.
Larger particles such as glucose and albumin will alter refraction to a greater degree. The
urine dipstick measurement of specific gravity is an approximation that is most sensitive
to cationic concentration in urine. Therefore, dipstick specific gravity is altered by very
high or low urine pH, but not large particles like proteins.
Urine specific gravity (U-SG) is directly proportional to urine osmolality (U-Osm). A UOsm of 400 mOsm/Kg equates to sp gr of 1.010, and 800 mOsm/kg to sp gr of 1.020
(Note: the amount of solute in a kilogram of solvent is termed osmolality, and the amount
per liter of solvent is osmolarity). The ability of the kidneys to concentrate or dilute the
urine over that of plasma is being measured.
Specific gravity between 1.002 and 1.035 on a random sample should be considered
normal if kidney function is normal. Since the sp gr of the glomerular filtrate in
Bowman's space ranges from 1.007 to 1.010, any measurement below this range indicates
hydration and any measurement above it indicates relative dehydration.
If sp gr is not > 1.022 after a 12 hour period without food or water, renal concentrating
ability is impaired and the patient either has generalized renal impairment or nephrogenic
diabetes insipidus. In end-stage renal disease, sp gr tends to become 1.007 to 1.010.
Any urine having a specific gravity over 1.035 is either contaminated, contains very high
levels of glucose, or the patient may have recently received high density radiopaque dyes
intravenously for radiographic studies or low molecular weight dextran solutions.
Subtract 0.004 for every 1% glucose to determine non-glucose solute concentration.

PROTEIN
Dipstick screening for protein is done on whole urine, but semi-quantitative tests for
urine protein should be performed on the supernatant of centrifuged urine since the cells
suspended in normal urine can produce a falsely high estimation of protein. Normally,
only small plasma proteins filtered at the glomerulus are reabsorbed by the renal tubule.
However, a small amount of filtered plasma proteins and protein secreted by the nephron
(Tamm-Horsfall protein) can be found in normal urine. Normal total protein excretion
does not usually exceed 150 mg/24 hours or 10 mg/100 ml in any single specimen. More
than 150 mg/day is defined as proteinuria. Proteinuria > 3.5 gm/24 hours is severe and
known as nephrotic syndrome.
Dipsticks detect protein by production of color with an indicator dye, Bromphenol blue,
which is most sensitive to albumin but detects globulins and Bence-Jones protein poorly.
Precipitation by heat is a better semiquantitative method, but overall, it is not a highly
sensitive test. The sulfosalicylic acid test is a more sensitive precipitation test. It can
detect albumin, globulins, and Bence-Jones protein at low concentrations.
In rough terms, trace positive results (which represent a slightly hazy appearance in
urine) are equivalent to 10 mg/100 ml or about 150 mg/24 hours (the upper limit of
normal). 1+ corresponds to about 200-500 mg/24 hours, a 2+ to 0.5-1.5 gm/24 hours, a
3+ to 2-5 gm/24 hours, and a 4+ represents 7 gm/24 hours or greater.

GLUCOSE
Less than 0.1% of glucose normally filtered by the glomerulus appears in urine (< 130
mg/24 hr). Glycosuria (excess sugar in urine) generally means diabetes mellitus.

Dipsticks employing the glucose oxidase reaction for screening are specific for glucos
glucose but can miss other reducing sugars such as galactose and fructose. For this
reason, most newborn and infant urines are routinely screened for reducing sugars by
methods other than glucose oxidase (such as the Clinitest, a modified Benedict's copper
reduction test).
KETONES
Ketones (acetone, aceotacetic acid, beta-hydroxybutyric acid) resulting from either
diabetic ketosis or some other form of calorie deprivation (starvation), are easily detected
using either dipsticks or test tablets containing sodium nitroprusside.

NITRITE
A positive nitrite test indicates that bacteria may be present in significant numbers in
urine. Gram negative rods such as E. coli are more likely to give a positive test.

LEUKOCYTE ESTERASE
A positive leukocyte esterase test results from the presence of white blood cells either as
whole cells or as lysed cells. Pyuria can be detected even if the urine sample contains
damaged or lysed WBC's. A negative leukocyte esterase test means that an infection is
unlikely and that, without additional evidence of urinary tract infection, microscopic
exam and/or urine culture need not be done to rule out significant bacteriuria.

PH MEASUREMENT

Equipment Required:
pH-Meter
Buffers (4.01 and 7.00)
Deionized or distilled water
150ml Glass Beaker
Magnetic Stirrer
Stir Bar
100ml Graduated Cylinder (optional for pH measurement)
After calibrating your meter with the buffers, rinse the electrode(s) and glassware with
distilled or deionized water. Carefully measure 100 ml of your sample and place in a 150
ml beaker for the pH and alkalinity part. Place the rinsed electrode in the test sample. We
strongly encourage letting all samples come to room temperature in the tightly capped
bottle before analyzing. If you are conducting other analyses with the sample water, keep
in mind that pH should be analyzed within 5 minutes of uncapping the sample bottle. The
sample should be stirred very gently, preferably with a magnetic stirrer. It may take up to
3 minutes for the reading to become stable. When stable, but not in excess of 5 minutes,
record the sample pH to the nearest 0.01 pH unit

ALKALINITY MEASUREMENT
Equipment required:
pH-Meter
Refillable Electrode
Buffers (4.01 and 7.00)
Deionized or distilled water

 150ml Glass Beaker

Magnetic Stirrer
Stir Bar
100ml Graduated Cylinder
Digital Titrator
0.16N Sulfuric Acid Cartridge
After placing the sulfuric acid cartridge in position in the Hach Digital Titrator, be sure to
advance the plunger manually until titrant is forced out of the delivery tip. Do this as you
would a hypodermic syringe, with the delivery tip up to remove bubbles. Get all the
bubbles out! Then advance the plunger using the delivery knob on the end of the titrator
until you are sure that the delivery tip is filled with solution. Check for leaks where the
tip connects to the cartridge. Rinse the tip WELL with distilled water or sample; this is
important because the titrant is concentrated and a little bit goes a long way. Reset the
counter to zero and you are ready to titrate.
After completing a titration and recording the digits of titrant used, rinse the delivery tip
with distilled water or the next sample, reset the counter (THIS IS EASILY
FORGOTTEN WHEN BUSY), and you are immediately ready for the next sample.
Titrations go better if the delivery tip is positioned under the surface of the solution being
titrated. For one or two samples, the titrator can be held in the hand, however, it is easier
to mount the titrator on a ring stand using a clamp. Try to keep the titrator vertical
through all titrations; putting the titrator horizontally on the bench between titrations may
introduce bubbles in the tip.
The acid cartridges provided are 0.16N sulfuric acid. Our waters are typically quite low
in alkalinity, so we use a special double end-point alkalinity procedure to accurately
measure alkalinity below 20 mg L-1.

After reading and recording the pH as described above, titrate

with the digital titrator and sulfuric acid cartridge to pH 4.5; record titrant used to this
point as A. Continue the titration to pH 4.2. Record the titrant used to this point as B. If
the initial pH is less than 4.5, record the initial pH value. Titrate until the pH is 0.3 units
below the starting point. Enter the digits of titrant used as B; A = 0. Write down the pH
reading where you stopped (as an accuracy check). We will use computers to calculate
the alkalinity, but you may do your own calculations using the formulas below. The
examples will help to clarify what can be somewhat confusing formulas.

A = digits used to pH 4.5

B = digits used to pH 4.2 or 0.3 pH units below initial value (total titrant including A)
Double end-point alkalinity= (2A - B) x 0.1
EXAMPLE: A sample required 120 digits to reach pH 4.5. An additional 15 digits were
required to reach pH 4.2, for a total of 135 digits. Therefore, A = 120 and B = 135.
Double end-point alkalinity = (240 - 135) x 0.1 = 10.5 mg/l
EXAMPLE: A sample had an initial pH of 4.3. The sample required 22 digits to lower
the pH to 4.0. Therefore, A = 0; B = 22.
Double end-point alkalinity = (0 - 22) x 0.1 = -2.2 mg/l
Although the negative alkalinity value may seem not to make much sense, it is an
extremely important measurement for assessment of acidification.

pH ELECTRODE CARE AND MAINTENANCE

Storage
Reference Electrode Filling Solution

 Preliminary Electrode Response Testing

Glass Electrode Rejuvenation
Final Test For Linearity
Movement Sensitivity
Calibration
Buffer Values at Various Temperatures
pH & alkalinity QA/QC
General electrode care and handling procedures are very important in your lab because
pH measurements will only be as good as the condition of your electrode(s). For greater
accuracy in your measurements and longer electrode life, there are a few areas of
electrode care with which you should be familiar.

STORAGE
Glass combination or separate pH and reference electrodes should be kept wet. The
reference electrode requires a free-flowing junction, so be sure to maintain the reference
filling solution at a level significantly above the storage or sample solution level at all
times This will provide a positive head pressure, which forces the filling solution out
through the junction rather than the storage solution into the probe.
For dry storage, the sleeve or plug should cover the filling hole to reduce the flow of
filling solution. During the measurement or storage in pH 4 buffer, however, this sleeve
or plug must be slid away or removed to allow flow of the reference solution into the
sample.
To obtain a faster electrode response, the glass electrode should be stored in a slightly
acidic solution. In the protective cap for the glass electrode, put a drop or two of pH 4

buffer and put the cap on the electrode, carefully. Distilled water extracts ions from the
bulb causing a slower response; pH 7 buffer over a long time period ages the electrode
slightly.
If using a separate reference electrode, the best solution would be to place the reference
electrode in its own filling solution but this can be messy. Providing KCl to both sides of
the junction keeps it flowing freer. To reduce the salt crust of saturated solution, an
approximately 0.1 M KCl solution may be used, but for storage only. Experience
indicates that simply covering the filling hole with the protective sleeve and storing dry
suffices in most instances as long as the soaking procedure is followed.
For combination electrodes, store the electrode in a combined solution of approximately
0.1 M KCl in pH 4 buffer.
One day or more prior to analysis, soak both electrodes in pH 4 buffer and, during
analysis, place the electrodes in the same buffer when not in use.
REFERENCE ELECTRODE FILLING SOLUTION
Read the instructions that came with your electrodes carefully. Saturated calomel
reference electrodes such as those used by the Acid Rain Monitoring Project must not be
filled with filling solutions containing silver chloride (AgCl). We use 4M KCl solutions
only. However, the most common filling solution for combination electrodes is 4 M KCl
saturated with AgCl. Be sure to ascertain which filling solution is correct for your
electrode(s) and double check that your filling solution matches these requirements.
Permanently filled or Gel electrodes Due to their unique micropore junction, it is
recommended that they be stored hanging dry.
Preliminary Electrode Response Testing

If your electrode exhibits slow response, poor span between two buffer values or undue
sensitivity to movement of the electrode, rejuvenation may be necessary to improve
performance.
Response varies with the electrode and the solution it is in. Generally working electrodes
reach 0.05 pH units of the final reading in buffer within 10 seconds. A stable reading (less
than 0.01 pH units per minute change) should be reached in fresh water samples within a
minute or two. If you have to wait too long (5 minutes or more) then the pH itself may
change due to the contact of the water sample with air.
Electrodes may also require adjusting the slope to values significantly different from
100% for two point calibration. Perform the following test if in doubt:
Set your meter to 100% slope and room temperature, then standardize as usual with pH 7
buffer. Without moving the slope dial, read a pH 4 buffer. It should read between 3.85
and 4.15; set the slope to read pH 4, the slope should be 95% to 105%.
If your electrode exhibits either of the above problems or is sensitive to movement,
rejuvenation is in order.

GLASS ELECTRODE REJUVENATION

To treat the bulb of the pH electrode:
Use 1 bottle each of acid and base (0.1N).
BE CAREFUL WHEN HANDLING THESE SOLUTIONS. IF YOU GET ANY ON
YOU RINSE OFF WITH LOTS OF WATER.
Dip the electrode bulb into the acid and wait until meter reads pH ~1

 Rinse electrode, then dip into the base. Wait until meter reads pH ~ 13
Repeat this rinsing and dipping cycle several times (at least 3 times, 6 times are
better)
For the last cycle, you can leave electrode in base 5 min, then in acid briefly until
it reaches pH ~ 1
Then rinse the electrode under tap water and let sit in pH 4 buffer for 2 hours
Rinse electrodes and re-calibrate meter as you normally do with pH 7 and pH 4
buffers.
To treat the reference electrode:
Replace the 4M KCl solution in the reference electrode and get rid of crystals that may
have formed. If there are lots of crystals, then shake out the solution and put deionized
pure water into the filling hole and soak the electrode tip in hot tap water for 15 minutes
or so until the crystals have dissolved. Then shake all the liquid out of the filling hole in
the reference electrode and refill with fresh 4 M KCl. Let the electrode sit at room
temperature for hour before use. Frequently add more 4M KCl solution to the reference
electrode since it will continually leak out and evaporate. The solution in the electrode
should be within inch of the filling hole. The hole should be open when reading pH but
close it when you are through for the day or else the solution will evaporate and new
crystals will form (but do not close the hole if you will be storing the electrode soaking in
pH 4 solution). If you still have problems with slow response, try rubbing the tip on your
blue jeans or on very fine (600 grit) sandpaper.
For combination electrodes, do both treatments described above.

FINAL TEST FOR LINEARITY

Standardize the meter as described below. Rinse the electrodes and your sample cup with
pure deionized water. Then titrate 100.0 ml of deionized water with your 0.16N acid as
follows: Make sure your digital titrator is working and reset to zero. Add 10 digits of
acid, record digits and pH, increase acid to 20 digits, record pH; repeat until you have
added 100 digits of acid and stop. Send the results to us and we will send you a report. If
you want to see the results yourself, try plotting the hydrogen ion concentration (H = 10(pH)) vs. digits and see if the line is straight.

MOVEMENT SENSITIVITY
If your meter gives wild readings and is sensitive to your touch, it may not be properly
grounded. Try using a three prong power plug or attach a wire from the meter to a cold
water pipe. Sometimes a problem of fluctuating readings or consistency wrong readings
can be solved by disconnecting and reconnecting the electrode connectors several times.
Apparently an oxide layer can sometimes cause these symptoms.

CALIBRATION
The pH meter should be standardized (calibrated) prior to sample analyses and after
every 25 sample analyses. Buffers should be at room temperature (68F). Remove the
electrodes from the pH 4 buffer solution where they have been soaking for at least one
day. Rinse with deionized water. Insert the electrodes in pH 7.00 buffer and adjust the
calibration dial until exactly pH 7.00 shows on the meter. Remove the electrodes and
rinse with deionized water. Place the electrodes in pH 4.01 buffer and adjust the slope
until the meter shows pH 4.01. Rinse with deionized water.

A note on buffers. The accuracy of your pH measurement is in direct relation to the

accuracy of the standard buffer solution used to calibrate your pH meter
1. Do not use buffers after their expiration date. Mold growth, CO2 absorption and
contamination cause changes in the buffer pH.
2. Do not use buffers which have mold growth floating in the buffer.
3. Always cap the buffer container when storing to prevent contamination and reduce
CO2 pickup.
4. pH buffer values change with temperature. Be sure to measure the temperature of the
buffer and look up its value at that temperature before standardizing the meter (see
below).
5. Do not pour used buffer back into the bottle.
Buffer Values at Various Temperatures
Temperature
C
0
5
10
15
20
25
30

F
32
41
50
59
68
77
86

Buffers
pH 4
4.003
3.998
3.996
3.996
3.999
4.004
4.011

pH 7
7.119
7.086
7.058
7.035
7.015
7.000
6.998

pH & ALKALINITY QA/QC

Quality control for pH and alkalinity consists of normal pH measurement and titration of
a sample prepared by the WRRC and sent to you prior to field collection. There will be
three of these samples. Several days prior to sampling, you will receive the first QA/QC
sample from us, along with a postcard for reporting your results. This is a diagnostic

sample. Follow the procedures described for pH and alkalinity measurement. Analyze
two separate aliquots of this sample and report your results to us on the postcard. You will
be called if we find a significant discrepancy between what we expect and what you
measured. We will work with you to troubleshoot the problem so that you are confident
of quality analysis for the field samples. Two other QA/QC samples will arrive just
before field sampling. Unlike the first QA/QC sample, these are used to document data
quality by helping us to statistically define the accuracy and precision of your analyses.
Analyze two separate aliquots of one of these immediately prior to measuring pH and
alkalinity on field samples; analyze two separate aliquots of the second QA/QC sample
immediately after analyzing the field samples. In other words, the first two samples
analyzed should be from one of the QA/QC bottles, then analyze the field samples, and
finally analyze two samples from the other QA/QC bottle. Results should be reported on
the pH & alkalinity lab data sheet.

HEMOCYTOMETER
The hemocytometer is a device used to count cells. It was originally designed for the
counting of blood cells.
The hemocytometer was invented by Louis-Charles Malassez and consists of a thick
glass microscope slide with a rectangular indentation that creates a chamber. This
chamber is engraved with a laser-etched grid of perpendicular lines. The device is
carefully crafted so that the area bounded by the lines is known, and the depth of the
chamber is also known. It is therefore possible to count the number of cells or particles in
a specific volume of fluid, and thereby calculate the concentration of cells in the fluid
overall.

Principles
The gridded area of the hemocytometer consists of nine 1 x 1 mm (1 mm2) squares. These
are subdivided in 3 directions; 0.25 x 0.25 mm (0.0625 mm2), 0.25 x 0.20 mm (0.05 mm2)
and 0.20 x 0.20 mm (0.04 mm2). The central square is further subdivided into 0.05 x
0.05 mm (0.0025 mm2) squares. The raised edges of the hemocytometer hold the
coverslip 0.1 mm off the marked grid, giving each square a defined volume (see figure on
the right).
Dimensions
1 x 1 mm
0.25 x 0.25 mm
0.25 x 0.20 mm
0.20 x 0.20 mm
0.05 x 0.05 mm
Usage

Area
2

1 mm
0.0625 mm2
0.05 mm2
0.04 mm2
0.0025 mm2

Volume at 0.1 mm depth

100 nL
6.25 nL
5 nL
4 nL
0.25 nL

To use the hemocytometer, first make sure that the special coverslip provided with the
counting chamber is properly positioned on the surface of the counting chamber. When
the two glass surfaces are in proper contact Newton's rings can be observed. If so, the cell
suspension is applied to the edge of the coverslip to be sucked into the void by capillary
action which completely fills the chamber with the sample. The number of cells in the
chamber can be determined by direct counting using a microscope, and visually
distinguishable cells can be differentially counted. The number of cells in the chamber is
used to calculate the concentration or density of the cells in the mixture the sample comes
from. It is the number of cells in the chamber divided by the chamber's volume, which is
known from the start, taking account of any dilutions and counting shortcuts:
where the volume of the diluted sample (after dilution) divided by the volume of the
original mixture in the sample (before dilution) is the dilution factor. For example, if the
volume of the original mixture was 20L and it was diluted once (by adding 20L
dilutant), then the second term in parentheses is 40L/20L. The volume of the squares

counted is the one shown in the table at the top, depending on the size (see figure on the
right). The number of cells counted is the sum of all cells counted across squares in one
chamber. The proportion of the cells counted applies if not all inner squares within a set
square are counted (i.e., if only 4 out of the 20 in a corner square are counted, then this
term will equal 0.2).

The parts of the hemocytometer (as viewed from the side) are identified.
For most applications, the four large corner squares are only used. The cells that are on or
touching the top and left lines are counted, but the ones on or touching the right or bottom
lines are ignored

SPUTUM COLLECTING A SAMPLE

Patients with a strong cough can provide an ample sputum specimen by expectorating
into a sterile cup. To prepare your patient, have him drink plenty of fluids on the evening
before the test, provided that he's not on a fluid restriction. The additional intake will
boost sputum production overnight and assure that you'll get a good sample.
For best results, obtain the sample first thing in the morning. If you can't obtain the
sample before the patient has breakfast, though, wait at least an hour after he's eaten
before trying. Before you begin, describe the procedure to him.
To get a good sample, instruct the patient to take at least three deep breaths, then force
out a deep cough. Explain that deep breathing helps loosen secretions and bring them to
the back of the throat. Emphasize the importance of bringing up sputum, the thick

secretions from the lungs, rather than expectorating saliva, the thin secretions from the
mouth.
Once the patient is comfortable with his part in the procedure, set up your equipment at
the bedside. You'll need an emesis basin, a sterile specimen cup with a tight-fitting cap,
the appropriate label, gloves, and goggles.
You should also have an aerosol of 10% sodium chloride or sterile water on hand to
administer via nebulizer if needed. This can help loosen tenacious secretions.
Position your patient in a chair or on the side of the bed. If he's unable to sit up on his
own, place him in a high-Fowler's position. Remove his dentures, if he has them.
Next, have the patient rinse his mouth with plain water so that he doesn't contaminate the
sputum being coughed up with the bacteria in his mouth. But don't allow him to brush his
teeth or use mouthwash. Doing so could kill bacteria in the sputum, rendering it useless.
When you're ready, don gloves and goggles. Uncap the container, but avoid touching the
inside to ensure that it's sterile. Then, have the patient perform the deep breaths and
cough as instructed, expectorating the sputum into the container.
If you don't get an adequate sample on the first try, have him continue to cough until
you're able to collect a minimum of 15 ml. If the patient has trouble bringing up
secretions, however, have him breathe into the nebulizer and try again.
Once you've collected the specimen, securely cap the container. Remove and discard your
gloves and wash your hands thoroughly. Allow the patient to rinse out his mouth and
provide a tissue. Send the sample to the lab immediately, without refrigeration.

CONCLUSION
Much of the costly misuse and misinterpretation of diagnostic tests is due to the fact that
physicians are not always able to manage intuitively the probabilistic information that
most laboratory tests provide. The diagnostic process is one of successive probability
revision. Knowledge of the operating characteristics of laboratory tests (i.e., sensitivity,
specificity, and predictive value) can greatly facilitate this process. Knowledgeable use of
these operating characteristics allows test choices to be tailored to the specific purposes
of diagnosis, monitoring, and screening. In addition, such use allows proper interpretation
of normal test results, as well as discriminate use of common strategies such as screening,
rule-out testing, repeating tests, and combination testing.
REFERENCES
1. Bradwell AR, Carmalt MHB, Whitehead TP. Explaining the unexpected abnormal
results of biochemical profile investigations. Lancet. 1974;1:107174.
2. Casscells W, Schoenberger A, Graboys TB. Interpretation by physicians of clinical
laboratory results. N Engl J Med. 1978;299:9991001.
3. Connelly D, Steele B. Laboratory utilization: problems and solutions. Arch Pathol
Lab Med. 1980;104:5962.
4. Dixon RH, Laszlo F. Utilization of clinical chemistry services by-medical
housestaff. Arch Intern Med. 1974;134:106467.
5. Durbridge TG, Edwards F, Edwards RG. et al. Evaluation of benefits of screening
tests done immediately on admission to hospital. Clin Chem. 1976;22:96871.
6. Elstein AS, Shulman LS, Sprafka S, et al. Medical problem solving: an analysis of
clinical reasoning. Cambridge: Harvard University Press, 1978.
7. Fineberg HV. Clinical chemistries: the high cost of low-cost diagnostic tests. In:
Altman S, Blendon R, eds. Medical technology: the culprit behind health care
costs? DHEW Publication (PHS)793216. Washington D.C.: GPO, 1979.

CONTENTS
CLINICAL LABORATORY TECHNIQUES
INTRODUCTION
VENIPUNCTURE PROCEDURE
BLOOD SAMPLE HANDLING AND PROCESSING
HEMATOLOGY
BLOOD BIOCHEMICAL ANALYSIS
CLINICAL URINE ANALYSIS
PH METHOD
HEMOCYTOMETER
SPUTUM SAMPLE COLLECTION
CONCLUSION