LEARNING GUIDE For Principles of Medical Laboratory ScienceTABLE OF CONTENTS PREFACE neon 3 ACKNOWLEDGMENTS ......- +--+ ++ PARTI Lesson 1 ‘Understanding Phlebotomy Lesson 2 Infection Control, Safety, First Aid, and Personal Wellness Lesson 3 The Circulatory System cj emi are Secor Lesson 4 Blood Collection Equipment, Additives, and Order of Draw . . . Lesson 5 Venipuncture Procedure... .. - ebricct’ asl: scotlaite eae ene Lesson 6 Pre-analytical Considerations in Phlebotomy... 66. ++ + Lesson 7 Capillary Puncture Equipment and Procedure . . . Lesson 8 Special Collections and Point-of-Care Testing... .. . « - Lesson 9 Handling and Processing of Blood Specimens for Laboratory Testing . Lesson 10 Handling and Processing of Non-blood Specimens for Laboratory Testing Lesson 11 Special Procedure: Arterial Puncture. . . - neck peat ea yews Lesson 12 Blood Donor Phlebotomy . . . . shana: netaae eae Lesson13 The Functions and Activities of the Laboratory Sample Reception Area... « Lesson 14 Functions and Procedures Performed by a Laboratory Assistant/ Aide Assigned to the Testing Areas. . pam tet Petes PARTIE ‘Activity 1 Proper Handwashing and Donning and Doffing of Personal Protective Equipment (PPE) . Peete aoe ‘Activity 2 Locating Proper Site and Anchoring Vein in Venipuncture ...-- +++. ‘Activity3 _Familiarization with Phlebotomy Materials... . . . Activity4 Commonly Used Blood Collection Additives and Order of Draw Activity Blood Specimen Collection by Venipuncture . . - eye ear Activity 5.1 Venipuncture through Evacuated Tube System (Single Draw). Activity 5.2 Venipuncture through Evacuated Tube System (Multiple Draw) . Activity5.3. Venipuncture Using Syringe Activity 5.4 Venipuncture Using ButterflyActivity6 _ Familiarization with Capillary Blood Collection Materials. . Activity7 Capillary Blood Collection (Skin Puncture) Following the Proper Order of Draw Activity8 Blood Collection for Culture Activity Accomplishing the Chain of Custody and Control Forms for Drug Testing . Activity10 Bleeding Time Determination (Duke's Method) Activity 11 Coagulation Time Determination (Slide Method) . . . Activity 12. Preparation of Serum or Plasma for Laboratory ‘Testing Activity 13. Point-of-Care Testing (Glucometet) ....... 0.0... Activity 14 Collection and Preparation of Urine Specimen for Laboratory Testing. Activity 15 Physical and Chemical (Reagent Strip) Examination of Urine Specimen. Activity 16 Modified Allen Test Procedure . . Activity 17 Microbiological Culture Media Preparation... ... 243 251 259 -an 277 = 283 - 291 = 297 - 303 = 309 315, 321 323LESSON 1 UNDERSTANDING PHLEBOTOMY LEARNING OUTCOMES “At the end of this lesson, the students must be able to: 1. describe the evolution of phlebotomy and the role of the phlebotomists in today’s healthcare setting; 2, discuss the traits that form the professional image of the phlebotomists; ’ 3, explain the basic concepts of communication as they relate to the healthcare settings 4, distinguish the different types of healthcare settings; and 5, enumerate the clinical analysis areas of the laboratory and the various types of laboratory procedures performed in the respective areas. LEARNING GUIDE eens Resou ee 4, Read Information Sheet 10. 20hours | Information Sheet 10 Understanding Phlebotomy . 44. The Evolution of Phlebotomy and the Role of Phlebotomists in Today's Healthcare Setting 112. Traits that Form the Professional Image of the Phiebotomists 113, Basic Concepts of Communication in the Healthcare Seting 114. The Healthcare Setting 115, The Different Clinical Analysis Areas of the Laboratory and the Types of Laboratory Procedures Performed 2. Suggested Self-Directed Leaning Activities: B0hours | Instructor/Trainer! ‘Attend lecture session, read related articles, and Speaker/Student Portal, ‘watch portal-based presentation on "Understanding Ubrary Phlebotomy’ of observe the set-up and operations of a nearby clinical laboratory (optional). '3, Perform portal-based Self-Check Activity 1.0. Student Portal ‘4, Perform portal-based summative examination ‘Student Portal for Lesson 1. '5. Report to and consult with your instructer regarding ‘Summative examination your examination results. results 6. Proceed to Lesson 2. Lesson 24 Learning Guide for Principles of Medical Laboratory Science 2 Figure 14 Flees Figure 1.2 Cupping and Leeching INFORMATION SHEET 1.0 Phlebotomy is the process of collecting blood through the vein by ‘using incision or puncture methods to draw blood for analysis or as part of therapeutic or diagnostic measures under the physician's request. The ‘word is derived from two Greek words: phlebos, which means vein, and temnein, which means to cut. Itis also called venesection. ‘The Evolution of Phlebotomy and the Role of the Phlebotomists in Today’s Healthcare Setting Evolution of Phlebotomy “The practice of phlebotomy can be traced back to the Stone Age. Back then, humans used crude tools to cut vessels and drain blood from the body. The ancient Egyptians also practiced phlebotomy as a form of “bloodletting” as early as 1400 BC. Hippocrates (460-377 BC), a Greek physician, believed that a person's health was dependent on the balance of the four humors: (1) Earth—blood and brain, (2) Air—phlegm and lungs, (3) Fire—black bile and spleen, and'(4) Water—yellow bile and gall bladder. The removal of excess humor through bloodletting must be performed to keep the balance. During the Middle Ages, barber-surgeons performed bloodletting as part of the treatment for some illnesses. It was only during the 17th and 18th centuries when phlebotomy was treated as a major therapy. Cupping and leeching were performed by phlebotomists using lancets and fleams. Cupping is an alternative medicine that helps ease pain, inflammation, or other health-related concerns. It involves the application of special heated suction cups on the patient’ skin and the incision that is made using a fleam (lancet) which is previously wiped with a rag. Leeching, also known as hirudotherapy, is a method that uses leeches for bloodletting and is currently used for microsurgical replantation. The process involves placing a drop of milk or blood on the patient’ skin and introducing Hirudo medicinalis (medicinal leech) to the site, allowing it to engorge and falloff. Itis believed that the leeches inject local vasodilator, anesthetic, and hirudin, which is an anticoagulant. Phlebotomy has evolved from simple bloodletting in the ancient ‘times into a fundamental diagnostic tool in the healthcare industry today.Understanding Phlebotomy 5 omy practice are: (1) for diagnosis and (2) for transfusion, to remove blood from of blood for polycythemia or therapeutic ‘The main goals of the phlebo! treatment using blood samples, the donor, and (3) for removal purposes. ‘There are nipuncture and the capillary puncture. Venipane t ’ Haare evtion using a needle inserted in.a vein while capillary puncture two main methods used in phlebotomy, namely the ‘ure is the method of je done by puncturing the skin, Role of the Phlebotomists j ‘The main role of phlebotomists assigned in the clinical laboratory is to collect blood samples for laboratory testing or for transfusion. They properly label collected blood samples with the necessary data to identify ' the patient. They are also responsible in delivering or transporting ' collected samples within appropriate prescribed time limits. In other ' institutions, phlebotomists also process collected blood samples such as centifuging and aliquoting samples ready for laboratory testing. Sometimes, they are asked to assist in collecting other specimens such as urine and other non-blood samples from patients. Phlebotomist are also the main players in blood-letting activities such as drawing of blood units from donors for transfusion to a patient requiring whole blood or blood components. Traits that Form the Professional Image of the Phiebotomists Good phlebotomists possess the following skills and knowledge: good manual dexterity, special communication skills, good organizational «kills, thorough knowledge of laboratory specimen requirements, and the ‘raining in phlebotomy skills coupled with standard practice. Credentials Phlebotomists need to maintain certain credentials in the continuous practice of their profession. They should have the following: certification or license and continuing education. They have the official recognition and are certified to have completed the training by an accredited body as required by the healthcare institution. They should have passed a certifying or licensure examination and must be able to present documents granted by an official regulating body for having completed the education, experience, and examination requirements.6 Learning Guide for Principles of Medical Laboratory Science 2 ‘They should also have continuing education and should attend trainings and seminars to keep them updated on the changes in the practice of their profession. Patient-Client Interaction Phlebotomists should be reassuring and pleasant when dealing with patients. They should be able to communicate well despite cultaral and social differences. They should maintain positive customer relations especially since they are the only contact of the patieat from the clinical laboratory, and their attitudes may affect how the patient views the hospital services in general. Moreover, they must understand the diversity of the patients and be able to adjust accordingly. Patients come from various backgrounds and have different customs and traditions, beliefs and values, attitudes, and needs based on their environment and culture, Qualities of Professionalism Phlebotomists are healthcare professionals in a service-oriented industry, and are, therefore, expected to practice professionalism at all times. 1. Professional appearance should be maintained. Phlebotomists should wear conservative clothing and observe proper personal ‘hygiene always. 2, Phlebotomists must have self-confidence especially because they would be directly expressing their decisions and judgments to patients and fellow co-workers. 3, They must be persons of integrity, exhibiting honesty and consistency in their actions, values, and beliefs. 4, As healthcare professionals, they must show compassion, sensitivity to the needs of others, and the ability to stay calm and ‘maintain a helpful demeanor towards those in need. 5, Phlebotomists are self-motivated, having the positive attitude and the initiative to follow through tasks and continuously look for areas of improvement. 6. They are dependable, observe proper work ethic, and take personal responsibility for their actions. 7. They display good ethical behavior, conforming with standards s0/as to avoid exposing patients to harm.Understanding Phlebotomy 7 ings Basic Concepts of Communication eat in the Healthcare Setting Phlebotomists need to have good communication skills which are essential to ensure that the patient feels at ease during the venipuncture procedure. Communication is important in the healthcare setting because of valuable information that needs to be transmitted properly from one person to another. The components of good communication are as follows: Verbal Cornmunication Verbal communication involves expressing ideas through words, ‘To be able to have effective communication in a healthcare setting, it a is important that the sender (speaker) and receiver (listener) are able to accurately exchange ideas by using feedback wherein they are able to clarify and confirm ideas hampered by vagueness, confusion, and biases. Good phlebotomists use words that can be easily understood by the patient, Non-verbal Communication mists Phlebotomists should be keen in observing the patient's facial sonal expressions and other non-verbal communication cues that could tell something about how the patient feels. Non-verbal communication has they many dimensions and elements that include kinesics (body motion and nfs to Janguage), proxemics (individual's concept and use of space), appearance (attire), and touch (thoughtful expression). pand Figure 1.3 Verbal | Reaction Communication Loop on, Feedback inthe Healthcare e a | me 7 Setting — eee ea te jeand | tibet 4; ok for message | +— gv I take Heathcare worker Patent sdards | + ——) ReactionLearning Guide for Principles of Medical Laboratory Science 2 Active Listening Listening is a major part of communication. It leads to better understanding of situations and instructions. Phicbotomists build rapport by listening to their patients. They should ensue that they have interpreted the message correctly by giving feedback. Communication between healthcare professionals and patients is not always easy because there could be issues that may arise on how the patients should be handled. Phlebotomists should always bear in mind the elements in healthcare communication, so they could handle patients ‘more carefully. These include empathy, control, respect and confirmation, and trust. The Healthcare Setting Healthcare facilities are categorized as inpatient (non-ambulatory), that requires patients to stay in the hospital for at least one night to be serviced by tertiary care practitioners, and outpatient, in which patients are served by secondary care specialists on the same day. {All patients can be serviced by primary, secondary, and tertiary levels of healthcare (Williams-Tungpalan, 1981). Primary level refers to health units in the rural areas and sub-units hich are operated by the Department of Health. Secondary level refers to non-departmentalized hospitals that attend to patients during the symptomatic stages of an ailment. Tertiary evel refers to medical centers and large hospitals where services are sophisticated coupled with highly technical facilities that can address serious diseases. ‘There are also other healthcare services such as ambulatory care, homebound services, and public health services which provide services and procedures for patients after their discharge from the hospital ‘Ambulatory care is medical care given to outpatients or patients requiring care or follow-up check-ups after their discharge from the hospital, which can be in the freestanding medical care setting and hhospital-owned clinics, or in the outpatient departments and urgent care facilities. Homebound services refer to procedures, tests, and services provided to a patient which are done ina patients home or in a long-term facility. Public health services belong to the unit at the local level but are still under the jurisdiction of the health department of the government. Services are offered with little or no charge at all.ve t Understanding Phlebotomy The Different Clinical Analysis Areas of the Laboratory and the Types of Laboratory Procedures Performed A hospital is an institution that has permanent inpatient beds with 24-hour nursing service along with therapeutic and diagnostic services managed by organized medical staff or personnel. It houses the clinical laboratory services (clinical lab) where tests requested by physicians are performed. It has two major divisions: the anatomical and surgical pathology area and the clinical analysis area. The anatomical and surgical pathology area handles tests related to histology (microscopic structure of tissues), cytology (structure of cells), and cytogenetics (chromosomal deficiencies and genetic disease) while the clinical analysis area is divided into seven (7) areas. 14 Examples of Tests and Procedures in Clinical Analysis Areas Gmees Poetic tena Hematology — blood | 1. Hematocrit (Hct) — hemoglobin level and red cell count and blood-forming 2. Hemoglobin (gb) — values that rule out anemia tissues 1 2 3, Red Blood Cell (RBC) Count — erythropoietic activity 4, White Blood Cell (WBC) Count — leukocyte response 5, Platelet Count - chemotherapy and radiation conditions 6, Differential White Blood Cell Count ~ changes in the appearance or quantity of specific cell types 7. Indices ~ show the changes in RBC size, weight, and Hgb content 8. Mean Corpusculer Hemoglobin (MCH) — weight of the hemoglobin Inthe cell 9. Mean Corpusculer Volume (MCV) ~ size of the cell 10. Mean Corpuscular Hemoglobin Concentration (MCHC) ~ concentration of the hemoglobin per unit volume of RBCs ‘1, Red Blood Cell Distribution Width (RDW) ~ size differences of the RBCs Coagulation — ability | 1. Activated Partial Thromboplastin Time (APTT) — adequacy of heparin of blood to form and | _ therapy dissolve cots 2, D-cimer ~ thrombin and plasmin activity 3, Fibrin Split Products (FSP) ~ amount of fibrin degradation products (FDPs) Inthe blood 4, Fibrinogen Test — fibrinogen levels in the blood 5, Prothrombin Time (PT) or Intemational Normalized Ratio (INR) ~ iver diseases or deficiency in Vitamin K 940 teaming G' amounts chemical sample Bec ‘Chemistry ~ of certain isin a blood ide for Principles of Mi 2. Aipha-fetoproteln (AFP) 1, alanine Aminotranste “during the second trimestet +3, Alkaline Phosphatese (AP) in the bloodstream cholesystits, ete ‘eminotransferase enzyi™ Bilirubin Test — amount of indicate red blood arterial Blood Gases U partial pressure of the 2 | Blood Urea Nitrogen 1. B-type Natl inthe blood ‘41. C-reactive Protein High that may help diagnose 13, Blood Calcium ~fota a determine | 44, ota Cholesteroh= 45, Cortisol ~ shows adr 16, Creatine Kinase (C)~ ‘72 Creatinine — checks f0F ase ‘or muscular dystrophy 4g. Drug Analysis — 49, Electrolytes (sodium, ‘that determine disor 90, Giucase — used w check steDENe* ler 21, Gamma-Glutamyl Transfer specifically hepatooil 22, Hemoglobin AC ~ 4 jedical Laboratory Sciet eee rose Test (ALT) ~ alpha-fetoproteln level ‘amnmoria — measures the level amylase — checks the enzyme ‘spartate Aminotrensferase fe that may indicate ‘which could determine impalres retic Peptide (BNP) Test = lev ‘which could indicate Congest sensitivity (hs-CRP) ‘CEA protein levels In the bl 42. Carcinoembryonic Antigen eng manage certain types of Conc ‘or monitor the effe indicates risk of cardi ‘enal hypotunction and jetermines glyees ung, kidne} ‘23, Lactate denydrogens nce 2 1 of pregnancy Test — 2 ‘nat could in bilirubin levels in destruction (ARG) - acid-base Dal ee cine —tiver damage smount of alkaline level that could in weoou isin pregnant women phosphatase enzyme dicate cirrhosis and hepatitis dicate liver diseases rest (AST) — levels of aspartate liver Gamage the bloodstream that could lance by measuring the PH bon dioxide and oxyge" (BUN) — amount of UN 1d renal function (cea) Test — mount of calcturn cts of renal ‘ea nitrogen found in blood, jols of the BNP hormone jood inthe blood, which could helP failure jovascular diseases hyperfunetion sed to check muscle damage monitors therapeutic 3 potassium, chloride jer of the kidney 2 iary problems yse — checks I ‘that indicate renal Impairment levels for drugs inge to avoid toxic ls dium values je, CO,) — show the 50% ind edrenals disease, of malnutrition vce (GGT) — used for diagnesis of INF sylated hemogiobin level and liver dysfunctionEmenee Understanding Phlebotomy Examples of Tests and Procedures and What They Determine 24, Lipase — shows the level that could lead to either pancreatitis ‘or pancreatic carcinoma 25. Prostate Specific Antigen (PSA) ~ test that screens patients for the presence of prostate cancer 26. Total Protein ~ used to check liver and kidney disorders 27. Triglycerides ~ serve as index in the evaluation of atherosclerosis and li metabolism disorder 28. Troponin | - used for early diagnosis of small myocardial infarcts 29. Uric Acid Test — used to check levels that indicate gout and renal problems 30. Vitamin B12 and Folate Tests — used to check for anemia and diseases of the small intestine Serology! Immunology —serum and | autoimmune reactions in the blood 4, Bacterial Studies + Antinuciear Antibody (ANA) ~ shows autoimmune disorders such as systematic lupus erythematosus + Antistreptolysin-O (ASO) Titer — indicates streptococcel infection + Cold Agglutinins — checks cases of atypical pneumonia + Febrile Agglutination Test ~ shows the presence of antibodies to specific organisms + FTA-ABS — confirms syphilis, + Ropid Plasma Reagin (RPR) — when positive, itis indicative of syphilis, but it still needs confirmation + Rheumatold Factor (RF) ~ indicates rheumatoid arthritis, 2. Viral Studies + Anti-HIV ~ screens human immunodeficiency virus + Cytomegalovirus Antibody (CMV) ~ a confirmatory test for CMV antibody + Epstein-Barr Virus (EBV) ~ checks for the presence of heterophil antibody, which indicates infectious mononucleisis, + Hepatitis B Surface Antigen (HBSAg) ~ checks for the presence of hepatitis antigen on the surface of the red cells 3, General Studies + C-Reactive Protein (CRP) ~ indicates inflammation when levels are increased + Human Chorionic Gonadotropin (HCG) Test - the hormone is present when patient is pregnant42 Learning Guide for Principles of Medical Laboratory Science 2 Ene Urinalysis ~ tests urine specimen es of Tests and Procedures and WWhat They Determine: 1. Physical Evaluation + Color indicates the presence of blood melanin, bilirubin, or urobilin Inthe urine specimen, + Clarity/transparency shows the presence of fat, chyle, or bacteria which affect the turbicity. + Specific gravity suggests renal tubular involvement or ADH deficiency 2. Chemical Evaluation «Blood ~ hematuria could be due to hemorrhage, infection, or trauma + Blirubin — helps differentiate between obstructive jaundice and hemolytic jaundice + Glucose ~ glucosuria may be a result of diabetes mellitus, renal impairments Ketones — uncontrolled diabetes mellitus or starvation + Leukocyte — indicates urinary tract infection if there is alot of neutrophils pH ~ indicates the acid-base balance Protein — proteinura is an indicator of renal dysfunction or disorder Nitrite — positive results could mean bacterial infection Urobilinogen ~ increases in amount when the patient suffers from hepatitic issues 3. Microscopic Evaluation «+ shows the status of the urinary tract, hematuria, pyurria, etc. Microbiology — ‘microorganisms in body fluids or tissues 1. Acid Fast Bacili (AFB) — used to monitor the treatment for TE. 2. Blood Culture - checks for the presence of bacteria indicative of bacteremia or septicemia 3, Compylobacter-like Organism (CLO) Test ~ shows the presence cof Helicobacter pylori 4, Culture and Sensitivity (C&S) ~ indicates infection if there is growth in the pathogenic microorganism 5, Fungus Culture and Identification ~ used to determine the type of fungi if present 6. Gram Stain ~ it is done to allow antimicrobial therapy while waiting for culture results 7. Occuit Blood ~ checks for blood in the stool which could result from gastrointestinal bleeding 8. Ova and Parasites (O&P) Exam ~ solves “etiology unknown" Intestinal disorders"Amn i Scena nen ee atc 5. Copy eng ace tater aatnnbon nce statLabs Than Scy wy tl me eer en sf sone ne tw ht tt nt ne ‘macy enacted Referonce Laboratory chs hry i gn oy atLESSON 2 INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS h LEARNING OUTCOMES — At the end of this lesson, the students must be able to: 1, identify the components of the chain of infection and give examples of each, describe infection-control procedures used to break the chain of infection, and explain the four functions of infection-control program; 2. perform proper procedures for hand hygiene, putting on and removing protective clothing, and entering the ORs and ICUs; 3. discuss the standard and transmission-based precautions for blood-borne pathogens; 4, list examples of blood-borne pathogens and describe their means of transmission in a healthcare settings 5. describe hazards, identify warning symbols, list actions to take if incidents occur, and specify rules to follow for proper biological, electrical, fire, radiation, and chemical safety; 6. identify symptoms of shock, first-aid procedures, and the main points of the international cardiopulmonary resuscitation (CPR); and 7. explain the role of personal hygiene, proper nutrition, rest, exercise, back protection, and stress management in personal wellness. [LEARNING GUIDE ees 4. Read Information Sheet 2.0, Infection Control, Safety, First Aid, | _ aid Personal Wetness 21. Components ofthe Chain of infection, Infection- Control Program, and Infection-Cantrol Procedures | 2.2. Proper Procedures of Hand Hygiene, Putting on | Gonos Resources Information Sheet 2.0 ‘and Removal of Protective Clothing, and Entering the Operetion Rooms (ORs) and Intensive Care Units (Cs) 23. Standard and Transmission-Based _Precaution for Blood-Bome Pathogens16 Learning Guide for Principles of Medical Laboratory Science 2 ieee Gena Resources 2.4, Hazards, Warning Symbols, Actions to Teke if incidents Occur, and Laboratory Safety Risks 2.5, Symptoms of Shock, Firstaid Procedure, ‘and Cardiopulmonary Resuscitation (CPR) | 26. Personal Welln 72. Suggested Self-Directed Learning Acti ‘Attend lecture session, read related articles, anc watch portal-based presentation on “Understanding 30hours | Instructor/Trainer! | Speaker/Student Portal, | Library/Simulated Phlebotomy’ or observe the set-up and operations of a Clinical Laboratory | nearby clinical laboratory (optiona). Laboratory Activity: EB Activity #1 Page 169) 3. Perform portal-based Self-Check Activity 2.0. ‘Student Portal ‘4. Perform portal-based summative examination ‘Student Portal for Lesson 2._ poe matey anes feel on po & Report to and consult with your instructor regarding | ‘Summative examination your examination results. _ results a G: Proceed to Lesson 3. _[tesson 3: E} [Ei ncormarion sHeet 2.0 i) ‘Although phlebotomy is considered one of the most commonly performed procedures in the field of medicine, there are stil risks involved that can be hazardous to both patient and healthcare personnel. When not done properly, this procedure could result in injury of the patient, errors in laboratory findings and exposure to infection, and other safety hazards. Risk could be reduced if best practices in prevention and control are followed, ‘An infection happens when @ microorganism invades the body, multiplies, and causes injury or disease. A pathogen isa disease-causing microbe which could be classified as bacteria, fungi, protozoa, or virus, There are two types of infections: communicable infections and nosocomial and healthcare-associated infections (HAls). Communicable infections can spread from person to person while nosocomial and healthcare-associated infections (HAls) are usually caused by infected personnel, patients, visitors, food, drug, or equipment while a patient isin the hospital or other healthcare facilities. Components of the Chain of Infection For the infection to escalate to an epidemic, all components or links should be favorable to the pathogenic microbe. The following table shows the six links of the chain of infection and their description.7 Infection Control, Safety, First Ald, and Personal Wellness Table 24 Six Components of the Chain of Infection as pene Infectious Pathogenic microbe such as virus, bacteria, fungus, protozoa, and rickettsia [causative) agent wes 5 i. | Reservoir ‘Source of the agent of infection or place where the microbe could grow, survive, | [a ‘and mutiply, which could be in humans, animals, food, water, soil, or equipment Exit pathway | Away or manner wherein an infectious agent can leave the reservoir host, which \ ‘could be through secretions and exudates, tissue specimens, blood, feces, or urine Nearsor]Aifoore, dect touching or kissing) or inerect contac (contaminated objects), Messmssion | droplets (coughing or sneezing), vector (nsec, arthropod, or animal, and vehicle (food, water, or drugs) Enty patrway | The way on infectious agent enters «host, which includes body onfies, mucous membranes, ad breaks Inthe sn TSuscepae host | Someone who is pone to infecton, especial the elder, newborn babies patients wh are Immune-suppressed or unvaccinated, and those suffering from | aeute or chronic ness Infection Control Program 7 A healthcare institution should have a set of procedures to break the chain of infection, These measures include effective hand hygiene procedure, good nutrition, immunization against common pathogens, insect and pest control, isolation and decontamination procedures, use of proper safety devices, wearing of personal protective equipment (PPE) when needed, and proper disposal of sharp objects and other waste materials, An infection-control program has four main functions: 1. to protect patients, employees, and visitors from infection 2eto screen employees for infectious diseases and to require immunization when needed 3, to provide evaluation and treatment to health workers who have y been exposed to infections while performing their duty 4, to monitor employees and patients who are at risk of infection and to collect data from patients and health workers who have been exposed to such danger Infection-control Procedures Infection-control methods or procedures must be followed at all times, These include ensuring that proper hand hygiene is practiced consistently using alcohol-based antiseptic hand cleaners, and that the personal protective equipment (PPE) is clean and properly donned and removed. ' —O stsie for Principles of Medical Laboratory Science 2 Proper Procedures of Hand Hygiene, Putting on and Removal of Protective Clothing, and Entering the Operating Rooms (ORs) and Intensive Care Units (ICUs) Hand Hygiene Hand hygiene is an essential part of standard precautions in the healthcare setting because it isan effective way to prevent infections that ‘can be transmitted from the patient and healthcare personnel during the procedure. There are two methods for hand hygiene: 1. routine hand washing «uses plain soap and water + when hands are visibly dirty « after known exposure to Clostridium difficile, Bacillus ‘anthracis, and infectious diarrhea during norovirus outbreaks «before eating + after using the restroom 2. hand antisepsis + an antimocrobial soap or alcohol-based hand sanitizer to remove transient microorganisms + alcohol-based hand sanitizer is preferred when hands are not visibly dirty «put the sanitizer on hands, rub the hands together for about 20 seconds or until it fels dry “The Centers for Disease Control and Prevention (CDC) Guidelines for Hand Hyglene in Health Settings recommends the folowing: | When weshing hands with soap and water, wethands with water, apply soap, and rub hands vigorously making sure that ali the surfaces are covered for at least 15 seconds. «Rinse the hands:with water (do not use hot water because ft will cause dryness inthe skin} and use disposable towel to dry hands. + Use disposable towel to tum off the faucet. Note: Otferenties nave recommended 20 seconds as the duration of hand rubbing whieh sslso acceptable <= Jong asthe hands are cloaned atte right time.Infection Control, Safety, First Aid, and Personal Wellness 19 Steps in Performing the Routine Hand-washing Technique 1. Stand a few inches from the sink to avoid contamination. 2. Turn on the faucet and place hands under the running water, Use soap and work up lather to ensure that hand surfaces are reached, :. Scrub for at least 15 seconds. Make sure to scrub all surfaces ) the 7 especially between the fingers and the knuckles. ythe 5. Apply alittle friction and rub hands together for at least 15 seconds, 6. Rinse the hands from the wrist to fingertips using a downward motion. 7. Dry hands using a clean paper towel. 8. Use the paper towel to close the faucet, except when the latter is foot- or motion-activated, Personal Protective Equipment (PPE) ‘The personal protective equipment (PPE) includes the gloves, gowns, lab coats, masks, face shields, goggles, and respirators. er to Gloves Phlebotomists should always wear gloves during blood collection and when handling specimen. Gloves are worn to prevent contamination of the hands and reduce chances of transmission of microorganisms from personnel to patients, They should be worn over the cutis of the lab gown to ensure protection. e not out Proper Removal of Gloves 1. The wrist part of one glove is grasped by the opposite hand. 2, The glove is pulled inside out and off the hand. 3. The recently removed glove must be placed in the gloved hand. The fingers of the non-gloved hand are slipped under the wrist of the Figure 24 Proper Personal remaining glove but make sure not to touch the exterior surface. Protective Equioment (PPE). 28 @head cap, @Satety 4. The second glove is pulled inside out. goggles/glasses, @Face mask, @Laboratory gown’ coat, @Gloves, @Long pants, @Closed-toe shoes (Courtesy ofthe School ‘of Mecical Technology, Centro Escolar University) 5. The gloves must be dropped in the proper receptacleFigure 2.2 Disposable Mask Figure 2.3 Disposable Gloves Figure 2.4 Disposable Laboratory Gown Figure 2.5 PPE Worn inthe Operating Room Learning Guide for Principles of Medical Laboratory Science 2 Donning and Doffing of PPE The PPE is kept clean and is worn to protect the healthcare worker from splashes of blood and specimen during the patient-care activities. It includes the laboratory gown or coat, face mask, and gloves. These items are removed at the anteroom or before leaving the room of the patient in an aseptic, sterile, and pathogen-free way to avoid contamination. Nowadays, disposable PPE is also available in the market, Donning of PPE 1. Gown should be put on first. Make sure that it is fastened, and the belt is tied. 2. Mask should cover both the nose and mouth. 3. Gloves should be pulled over the gown cuff. Doffing of PPE 1. Gloves are removed first. The contaminated areas should not be touched with ungloved hands. 2. Gown should be pulled from the shoulders towards the hand so it is turned inside out. 3. Mask should be removed by only touching the string, Note: Wash hands immediatly after removal of the PPE Additional Information When the colored portion of the mask Is exposed, you are protecting yourself from infection, However ifthe vihite portion is the one exposed then that means thet {you are protacting others from being infected because ‘you might be a cartier of a disease,Infection Control, Safety, First Aid, and Personal Wellness 21 Nursery and Neonatal ICU Infection-control Technique Since newborns are most susceptible to infections because of their underdeveloped immune system, anyone who enters the nursery area or neonatal ICU should follow the infection-control procedure: 1. Proper hand washing procedure should be done before putting on the PPE. 2, The phlebotomists should only bring items necessary for the specimen collection. 3. Blood collection tray should be left outside the nursery, preferably the anteroom. F 4, Gloves should be removed; hands should be washed; and a new pair of gloves should be used between patients. Standard and Transmission-based Precaution for Blood-borne Pathogens In the clinical laboratory, health workers may be exposed to blood- be borne pathogens (BBP) by needlestick or other injuries caused by sharp objects, BBP are microorganisms in the human blood that are cs snfectious and can cause diseases. The most common pathogens include hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency wus (HIV). able 2.2 Defense, Hazards, and Symptoms of Blood-bome Pathogens 7 enor Stee Boo Hepattis8 | HBV + Blood and other body fuids | Fluke, fetigue, loss of ; Weus (HBV) | vaccination + Can survive a week on objects | appetite, mild fever, muscle/ t + Transmitted via needlesticks, Jointabdorninal pain, nauses, © sexual contact omitting, HepattisD | None 7 Blood and other body fuids | Flusike fatigue, loss of =x ves = Can survive a week on objects _| appetite, mild fever, muscle/ 1 aremitted via neediestcs, | Jol/abdominal pain, nauses, i sexual contact vonitting SecattisC | None > Blood and serum; sometimes | Fivske, fatigue, oss of fess (HO) saliva appetite, mild fever, muscle! + Infection primarily occurs after _| jolntiabdominal pain, nausea, large and muitiple exposures _| vomiting + Transmitted via needlesticks, sexual contact22 Learning Guide for Principles of Medical Leboratory Science 2 Exposure Control Plan Healthcare workers are at risk of being exposed to blood-borne / pathogens as they perform their duties. Exposure can occur when the following happens: a. A contaminated needle or sharp object pierces the skin of the health worker », Body fluid or blood splashes in the eyes, nose, or mouth of the health worker ¢. Cut, scratch, or abrasion of the health worker has made contac: with blood or body fluid of an infected patient . Human bite cuts the skin of the health worker i During BBP exposure, this procedure should be followed: | a. BBP Exposure Caused by Needlestick or Any Sharp Objects y 1. Carefully remove the sharp or foreign object. 2. Wash the site thoroughly with soap and water for at least 30 seconds. b. BBP Exposure through Mucous Membrane 1. Flush with water or saline for at least 10 minutes. 2. For the eyes, use eyewash station for flushing, if available. Remember to remove the contact lenses (if there are any) and make sure to disinfect them, 3. Report the incident to the immediate supervisor so tha! evaluation, treatment, and counseling can be provided, For surface decontamination, use 1:10 bleach solution or other disinfectants for the specimen collection and processing areas. Remembe: to wear gloves and use an absorbent material when cleaning the arec to avoid spreading the spills over a wider area. As a precaution, 2! non-reusable items contaminated by blood or other body fluids should be placed in biohazard waste containers for proper disposal.Infection Control, Safety, First Ald, and Personal Wellness © 23 Hazards, Warning Symbols, Actions to Take if Incidents Occur, and Laboratory Safety Risks Biohazard Biohazard refers to any material that could be harmful to ones health. Biosafety is used to prevent and protect clinical laboratories from harmful incidents caused by laboratory specimens that are potential biohazards. ‘A health worker could be exposed to a biohazard in various ways. These ways are called the biohazard exposure routes. 1. Airborne - from splashes and aerosols during centrifuge and aliquot; patients with airborne diseases. © ct Figure 2.6 Biohazard Symbol a. Observe proper handling practices, b, Wear PPE properly. c. Use safety shield and guards. a 2. Ingestion — hands are not sanitized before handling food. a. Wash hands frequently. 'b. Avoid hand-to-mouth activities. a c. Avoid placing items in the mouth. eid 3. Non-intact skin - contamination through breaks or cuts in the skin. bat a. Cover skin breaks or cuts with non-permeable bandages 4, Percutaneous ~ exposure through the skin due to injuries from cher needlesticks and other sharp objects. nber a, Use needle safety devices. eo 'b. Wear heavy-duty utility gloves when cleaning broken glass. wabe ¢. Never handle broken glass with bare hands, 5 Permucosal ~ infection through mucous membranes of the mouth and nose and the conjunctiva of the eyes. 2. Observe proper handling to avoid aerosols and splashes. '. Avoid rubbing and touching the eyes, nose, and mouth.Learning Guide for Principles of Medical Laboratory Science 2 Electric Shock Another potential hazard that a health worker faces in the workplace is electric shock especially when dealing with electrical equipment. ‘The following actions should be taken if electric shock occurs: 1, Remove the source of electricity using a non-conductive object or simply turn off the source of electricity. 2, Ask for medical assistance. 3, Start cardiopulmonary resuscitation (CPR) if necessary. 4, Keep the victim warm, Fire Fire is another potential work hazard. Regular fire drills should be conducted so employees know what to do in case of fire. They should also be familiar with the location of emergency exits and evacuation plans or routes. The location of fire extinguishers and heavy blankets should be posted, and the staff should know how to use them. Fire extinguishers are classified by the type of fire that they are designed to extinguish. The classification is listed in Table 2.3. Table 2.3 Five Classes of Fire ‘This refers to fre caused by ordinary combustible mater require water or water-based solutions to extinguish, ls such as wood or paper, which This refers to fire caused by flammable liquids and vapors such as paint, oll, grease, and gasoline which require blocking oxygen to snuff out ‘This refers to fre caused by live electrical equipment, which requites the use of non-conducting agents to extinguish. ‘This refers to fire caused by combustible and reactive metals such as sodium, potassium, magnesium, and lithium which need powder agents or sand to put out. ‘This refers to fre caused by cooking oll, grease, or fats with high temperature which ‘require agents that prevent splashing, cooling, and smothering the fire. Radiation Radiation safety is another consideration of the phlebotomists Radiation exposure depends on time, distance, and protection shielding. The length of time of the exposure and the distance of theace tor id be ialso ns or Id be comists. tion oF e of the Infection Control, Safety, First Aid, and Personal Wellness 25 “ctesdual from the source of radiation matter because the effect is ccemiative. The protection worn at the time also has a bearing on the sceesesy of exposure. It is a must that a radiation symbol (Figure 2.7) be sesed in areas where radioactive materials are used and kept. Sodistion hezard can be encountered by the phlebotomists when “etecsing specimens from patients who have been injected with Geseoctive dyes or from the nuclear medicine department or simply sexe= EElivering specimens to the radioimmunoassay sections of the berzcory. Chemicals are used as cleaning reagents, in adding preservatives in “ne container (24-hour), or in delivering specimens to the laboratory. “Sexcscopriate handling can pose a problem not only to the phlebotomists ‘get sso to other health workers. ‘As 2 general rule, the phlebotomists should always wear the PPE sexes working with chemicals. Chemical clean-up materials should be sexpeciy used in case of chemical spills. “The following practices should NEVER be done: 1. Storing chemicals above eye level 2. Adding water to acid 3. Mixing chemicals indiscriminately Storing chemicals in unlabeled containers 5. Pouring chemicals into used or dirty containers ‘5. Using chemicals in ways other than their intended uses “The healthcare worker should be informed where the safety showers 22 cyewash stations are located, in the event of chemical spill or splash ‘he eyes or body. The personnel exposed to chemical spill or splash eccld fiush the affected part with water for at least 15 minutes and visit Se emergency room (ER) for evaluation. ‘Symptoms of Shock Shock is a condition when there is not enough blood that circulates eck to the heart, which results in inadequate supply of oxygen in she body. It may be caused by hemorthage, heart attack, trauma, and cag reactions. The common symptoms of shock are as follows: pale, cold and lammy skin; rapid and weak pulse; increased and shallow breathing; and expressionless face with a blank stare. RADIATION Figure 2.7 Radiation Symbol Figure 2.8 Safety Shower ‘and Eyewash Station Figure 2.9 Performing CPR26 _Leaming Guide for Principles of Medical Leboratory Science 2 First-aid Procedures ‘When the patient isin shock, perform the following steps as fist aid: 1. Keep the airway open. 2. Call for medical assistance. 3, Keep the patient lying down. : 4, Control any bleeding or other cause of shock. | 5, Keep the patient warm. Cardiopulmonary Resuscitation (CPR) Catdiopulmonary resuscitation (CPR) is procedure done on = person who is suffering from cardiac arrest. Being able to perform CPR ‘on a patient increases his/her chance of survival. Performing CPR Properly 1. While the patient is lying on his/her back on a steady surface, knee! beside the patient and place your hands in the middle of the patients chest. 2, Cover the first hand with the heel of the other hand, interlocking the ‘Angers. The fingers should be raised so they do not touch the ribcags 43, Lean forward (shoulders directly over the patients chest) and pres down on the chest for about two inches. Release the pressure to allo the chest to come back up. Do not release your hands. Repeat. Giv= 30 compressions at a rate of 100 compressions per minute, 4, Tile the patients head and hft the chin to open the airway allow:ng the mouth to fall open slightly. 5, Using your hands, pinch the nostrils and support the chin is the other hand. Take a normal breath, place your mouth over “= patient, and blow until you see the chest rise. 6, Remove your mouth and watch the chest fall. Repeat steps five <= six once. 7, Replicate the cycle of 30 chest compressions, to be followed by = rescue breaths, Repeat this cycle until the patient becomes stable = ora medical professional has arrived to help.Infection Control, Safety, First Aid, and Personal Wellness Personal Wellness Personal wellness begins with personal hygiene, which includes bothing regularly, using deodorant, brushing one’ teeth after eating, Keeping one’s hair neat and clean, trimming and cleaning one’s Sngernails, and avoiding the use of heavy lotions and colognes. (One should have proper nutrition and have a balanced diet consisting of vegetables, fruits, and legumes. Getting enough sleep and staying fit by having a regular exercise routine are also necessary. It is important to maintain proper posture and to keep one’ back safe from any injury by using proper techniques and equipment when lifting heavy objects, One must achieve and maintain work-life balance by finding time to relax and to relieve oneself of stress from work. Figure 240 Components of Personal Wellness Source: Quad IT Solutions, nc 27LESSON 3 THE CIRCULATORY SYSTEM 2 LEARNING OUTCOMES At the end of this lesson, the students must be able to: 1. distinguish the layers and other structures of the heart and give their functions; 2. cite the disorders and diagnostic tests of the circulatory system; 3. identify the two main divisions of the vascular system, describe the function of each, and trace the flow of blood throughout the systems 4, point out the different types of blood vessels and describe the structure and function of each; 5, enumerate the major constituents of blood and describe the function of each of the formed elements; 6. differentiate serum, plasma, and whole blood; describe the vessels, structure, and functions of the lymphatic system; 8, define hemostasis and explain the basic coagulation and fibrinolysis processes; and 9. specify and locate major veins in the arms and legs and discuss the suitability of each for venipuncture. LEARNING GUIDE fees Gene fe 1, Read Information Sheet 3.0. ‘The Circulatory System 34, Layers and Other Structures of the Heart and Their Functions 3.2, Disorders and Diagnostic Tests of the Circulatory System 3.3, Two Main Divisions and Functions of the Vascular System 3.4. Types, Structures, and Functions of Blood Vessels 3,5, Major Constituents and Functions of the Blood Cells 36, Whole Blood, Serum, and Plasma Information Sheet 3.0BO Leaming Guide for Principles of Medical Laboratory Science 2 ec arena 37, Structure and Functions of the Lymphatic System 3.8, Hemostasis, Basic Congulation, and Fibrinolysis. Processes 3.9. Major Arm and Leg Veins for Venipuncture | 2, Suggested Self-Directed Learning Activities: | 3.0 hours tr 31, Attend lecture session, read related articles, watch Speman ane ] Portal based presentation on “The Circulatory Uren eet ona 5 late . 32. aon Activity 2: "Locati i tty | 3.2. Perform 'y 2: “Locating the Proper Site and u | Anchoring Veins in Venipuncture* sein ety | 3, Perform portal-based Self.Check Activity 3,0, | 3. foto ol : Student Portay ; form tal-based summati | feleacna. ive examination ‘Student Portaj 5. Report to and consult with your instru: your examination results, pentane S. Proceed to Lesson 4, ‘Summative examin, ato results " Lesson 4. INFORMATION SHEET 3.0 The circulatory system is responsible for transporting throughox: the body oxygenated blood from the heart and lungs via the ater, Then the oxygen-depleted blood is returned to its origin through the veins. The circulatory system delivers the oxygen and nutrients to ali cells in the human body. It transports carbon dioxide and other wastes to the other organs of the body and away from the cells. It helps in the coagulation process, regulates body temperature, and assists the body in fighting diseases. This system is made up of two main components: the cardiovascular system that is composed of the heart, blood vessels, and blood which helps in the circulation; and the lymphatic system which is made up of the lymph, lymph nodes, and vessels, Layers and Other Structures of the Heart and Their Functions The heart is a hollow muscular organ that has four chambers (left atrium, right atrium, left ventricle, and right ventricle) and is surrounded by a thin, fluid-filled sac called pericardium. A human heatt is about the same size as that of a person's clenched fist.The Circulatory System 31 rennet tot Spot its cores rien + expats ine cet of onset od fem chen oot a sew oe Figure 3. The Blood Flow of the Human Heart Layers of the Heart 1. Epicardium — thin, watery membrane on the outer layer of the heart Function: covers the heart and is attached to the pericardium 2, Myocardium — thick layer of cardiac muscles in the middle layer of the heart Function: pumps blood into the arteries by contracting 3, Endocardium - thin layer of epithelial cells in the inner layer of the heart Function: lines the valves and interior chambers Chambers of the Heart 1. Right Atrium - upper right chamber Function: receives deoxygenated blood from the body 2. Right Ventricle - lower right chamber Function: receives the blood from the right atrium and pumps it into the pulmonary artery 3. Left Atrium — upper left chamber Function: receives oxygenated blood from the lungs and pumps it into the left ventricle 4. Left Ventricle — lower left chamber Function: receives blood from the left atrium and pumps it into the aorta32__ Learning Guide for Principles of Medical Laboratory Science 2 Valves of the Heart + Right AV valve ~ tricuspid valve located between the right atrium and the right ventricle Function: closes as the right ventricle contracts preventing blood from flowing back to the right atrium + Left AV valve ~ bicuspid or mitral valve located between the left atrium and the left ventricle Function: closes as the left ventricle contracts preventing blood from flowing back to the left atrium + Right semilunar valve - pulmonary or pulmonic valve located at the entrance of the pulmonary artery Function: closes when the right ventricle relaxes preventing blood from flowing back to the right ventricle + Left semilunar valve ~ aortic valve located at the entrance of the aorts Function: closes when the left ventricle relaxes preventing blood from flowing back to the left ventricle Septa 1, Interatrial septum ~ partition that separates the right from the atria 2, Interventicular septum ~ separates the right and the left ventricles Coronary Circulation ‘The heart receives blood supply through the left and right coronary arteries, and the coronary veins return the oxygen-depleted blood from the heart muscle back to the heart. Heart Function The coronary circulation supplies the blood as well as provid. drainage to the tissues. It is composed of the left and right corona arteries and coronary veins. Poor circulation could lead to ischer which is caused by inadequate supply of oxygen and myocardiThe Circulatory System = 33 infarction or heart attack which may be due to complete obstruction of the coronary artery. The following table shows several terms related to the functions of the heart: Table 34 Functions of the Human Heart [Cardiac Cycle ‘Systole (contraction) and diastole (relaxation) which lasts about 0.8 seconds Zlecrical Sends electric impulses throughout the myocardium whichis initiated by the Conduction sinoatvial (SA) node (pacemaker | System Eleciocardiogram | Provides the graphical representation of the cardlac yes actly pe) Origin ofHear | *Lubb* which s the frst sound as the venticles contractor the AV vaes dose | Sounds and “éupp” or the second sound which is heard wien the semiluner valves close | and the venticles relax. L |Heart Rate and | The average heart rate is 72 beats per minute (opm) and the cardiac output Cardiac Output __| refers to the volume of blood pumped per minute Pulse: A thythmic throbbing resulting from the alternating expansion and contraction of the artery Blood Pressure | The force exerted by the blood on the walls of the vessel measured by the ‘sphygmomanometer; the difference between the systolic (pressure during contraction) and diastolic (pressure during relaxation) Disorders and Diagnostics Tests The human heart may have disorders that can be detected and addressed using the proper diagnostic tests 1, Angina pectoris ~ chest pain resulting from reduced blood flow to the heart 2, Aortic stenosis ~ a murmuring sound produced when the aortic leaflets fail to fully open during systole . Bacterial endocarditis - an infection that happens when a bacteria enters and resides in the heart lining or blood vessel Congestive heart failure ~ a chronic progressive condition that affects the pumping power of the heart muscles ‘Myocardial infarction — known as heart attack, itis caused by a decrease or full stoppage of blood flow that damages the heart muscle . Pericarditis inflammation of the pericardial sac that may be due to viral infeBA Leaming Guide for Principles of Medical Laboratory Science 2 List of diagnostic tests for heart disorders: + Arterial blood gases (ABG) + Aspartate aminotransferase (AST) or serum glutamic-oxaloacetic transaminase (SGOT) + Cholesterol + Creatine kinase (CK) + Creatine kinase (CK)-MB + Digoxin + Hlectrocardiogram (ECG or EKG) + Lactate dehydrogenase (LDH) isoenzymes + Microbial cultures + Myoglobin + Potassium (K) + Triglycerides ‘+ ‘Troponin T (TT) Two Main Divisions and Functions of the Vascular System ‘The vascular system is the loop consisting of a network of blood vessels through which blood is circulated to the rest of the body. There are two divisions: the pulmonary circulation and the systemic circulation. ‘The pulmonary circulation moves the blood between the right ventricle of the heart to the lungs. During the process, oxygen is absorbed and Pulmonary veins Aorta and branches: Right Left atrium Left ventricle Hl onysenvich C0, p00" ood I on serp001 0, eh Blood Figure 3.2 The Pulmonary and the Systemic Circulations35 The Circulatory System carbon dioxide is released, after which, the ‘oxygenated blood flows back to the left atrium of the heart. The systematic circulation moves eee ‘Arterial system the oxygenated blood and nutrients from the left ventricle of the heart to the rest of the body. The deoxygenated blood with carbon dioxide and ‘wastes flows back to the right atrium. Structure of the Vascular System a, Arteries ~ thick-walled blood vessels that carry ‘oxygen-rich blood from the heart to the tissues ofthe body b, Arterioles ~ small-diameter blood vessels that branch out from the arteries and lead to the capillaries ¢. Veins - tubes with thin walls that carry deoxygenated blood from tissues to the heart 4, Venules - very small veins that collect blood from the capillaries ¢. Capillaries ~ fine hair-like blood vessels that connect arterioles and veins Figure 3.3 Venous and Arterial Systems Types, Structures, and Functions of Blood Vessels Blood Vessel Structure a. Layers ~ the blood vessels have three layers: + tunica adventitia (outer connective tissue); + tunica media (middle, muscle and elastic fiber); and + tunica intima (inner, endothelial cell), b, Lumen ~ space inside the blood vessel where the blood flows. c. Valves - found in the veins, these are thin membranous leaflets that prevent the backflow of blood. The Flow of Blood ‘The pathway for the blood flow of the human body consists of arteries, veins, and capillaries that allow the transport of oxygen and nutrients to the cells of the body and also make it possible to removea rinciples of Medical Laboratory Sclence 36 Learning Guide for P deoxygenated blood eonygenated from upper body flood t 13098 ideoxygena Blood to lungs renated blood from lungs + eowygensted 20% ghygeated blood fromlowerbody — tolewerbody .e Human Heart Figure 3.4 Blood Flow of th materials of metabolism. The order of carbon dioxide and other wast vascular flow is as follows: to the heart through the superior «+ Oxygen-poor blood is returnes and inferior venae cavae, It enters the right atrium ofthe heart. ‘The right atrium contracts, pushing blood through the tricuspid valve, and into the right ‘ventricle. ‘The contraction on the right ventric the pulmonary semilunar valve into the pulmonary artery It flows through the pulmonary artery to the capillaries of cle forces the blood through the lungs. Oxygen-rich blood flows back to the heart through the pulmonary veins and enters the left atrium. ‘The left atrium contracts forcing the blood through the bicuspid valve into the left ventricle. ‘The contraction of the left ventricle forces the blood through the aortic semilunar valve into the aorta. ‘The blood travels through the body by way of the arteries. These arteries branch into smaller ones, the smallest of which are the arterioles. »+ The arterioles connect with the capillaries. Oxygen, water, and nates fom the Hod are diffused through the capillary walls to the cells and carbon dioxide and oth oe jer end products enter the «+ The capillaries connect with the venules, «+ The venules merge into larger veins until the blood returns to the heart by the superior or inferior vena cava. | Please visit the student portal to download th reality application of the “Human Heart.” See Disorders of the Vascular System ‘Aneurysm — enlargement of the artery due to the weakening of the artery wall ‘Arteriosclerosis - hardening of the artery wall due to aging “Atherosclerosis ~ formation of plaques in the inner walls Embolism - clot or bubble that causes obstruction of an artery Embolus ~ obstruction that is carried and lodged in a vessel Hemorrhoids ~ swollen veins in the area of the anus Phlebitis ~ inflammation of the veins particularly the wall ‘Thrombophlebitis - swelling of the’ veins of the legs that usually occurs during pregnancy ‘Thrombus ~ blood clot that impedes blood flow 10. Varicose veins ~ usually found in the legs, these are veins that have been twisted and enlarged ~ Diagnostic Tests « D-dimer + Fibrin degradation products (FDP) + Lipoproteins + Prothrombin time (PT) « Partial thromboplastin time (PTT/APTT) + Triglycerides The Circulatory System | 37BS_ Learning Guide for Principles of Medical Laboratory Science 2 Major Constituents and Functions of Blood Cell "The blood is the red fluid that is transported throughout the body via the circulatory system. There are two types, namely arterial blood in which oxygen and nutrients are carried to the tissues, and venous blood in which carbon dioxide and metabolic by-products are carried to the Tungs and kidneys for removal from the body. ——Tunica media —— Tunica adventitia, | "—~Red blood cell White blood cell | “Platelet ~Piasma Figure 3.5 Composition of the Blood “The human blood is composed of plasma and other formed elements. Plasma is a clear, straw-colored liquid portion of the blood which is 90% water. It contains gases (O,, CO,, N), minerals (Na, K, Ca, Mg), carbs anc lipids, proteins et. The formed elements are cells, cell remnants, and cel fragments found in the human blood. In the human blood there are thre: types of cells: 1. Erythrocytes (red blood cells) - carry O, and CO, and ere produced in the bone marrow. 2, Leukocytes (white blood cells) - formed in the marrow and the lymphatic tissue, They neutralize pathogens. The two types <= granulocytes and agranulocytes. 3, Thrombocytes (platelets) ~ pieces of very large cells in the bon marrow that help form blood clots. Blood Type ‘The human blood type is inherited and determined by the anti ‘on the surface of the red blood cells. The blood contains or can develop antibodies directed at the opposite blood type. Blood type matchre he re sas op. important especially during blood transfusion because the wrong type could agglutinate the red blood cells. When a doctor mentions blood ‘type, he/she is referring to a person's ABO blood group system or Rhesus (Bh) factor, ABO Blood Group System This is a system of classifying human blood by the presence of antigens A and B and based on the antigenic components found on the sarface of the red blood cells. A person's blood could be classified as A,B, O (universal donor), or AB (universal recipient). ‘This system of classification is of primary importance in obstetrics because of the hemolytic disease of the newborn (HDN). This is based on the “D” antigen or the Rh factor. Rh positive (Rh+) has red blood cells that have the D antigen while the Rh negative (Rh-) does not have the D antigen. The Circulatory System 39 ep stoop cet. agit cow receave AND anTigeN 1000 FROM 4,0 oN icine antigen BO 7 x Anti-A antibodies ¥ Bantgen A,B, AB,O ‘No antibodies ‘Universal recipient ie antigen “Antigen 9 ) Both Anti and Univers donor No antigen Anti-B antibodies ® Figure 3.6 ABO System Blood Types40 Learning Guide for Principles of Medical Laboratory Science 2 F el REDELOOD CELLS 536 Figure 37 Whole Blood Specimen Cross-matching is necessary to determine the compatibility of the donor's blood with the recipient’s blood because an individual who does not produce the D antigen will produce anti-D which could be fatal ifit encounters the D antigen. RH blood-group system Whole blood, serum, and plasma There are three blood specimens that are collected for test purposes: serum, plasma, and whole blood. Serum is the fluid part of blood that is left after clotting because it does not have fibrinogen. Th can be separated by centrifugation. Plasma refers to the fluid porti ‘that is separated by centrifugation from the red blood cells, white blooe cells, and platelets, It has fibrinogen and could be collected using anticoagulant tube. It is also collected in cases where serum could no: be used. The whole blood is the same as blood in the bloodstream it should neither clot nor separate. Just like plasma, it could be collected using the anticoagulant tube and must be mixed for a minimum ‘of 2 minutes prior to testing. Blood Disorders 1, Anemia - caused by not having enough healthy red blood ce! or hemoglobin 2, Leukemia - cancer of the blood; the formation of abnormal tissu= or cells in the bone marrow or the lymphatic system. 3. Urinary tract infection - shown by high number of leukocytes 4, Leukocytosis ~ increased number of white blood cells in the blo due to illness or infection 5, Leukopenia - reduced number of white cells in the blood 6. Polycythemia - the marrow produces too many red blood « resulting in the thickening of blood 7. Thrombocytosis - the body produces too many platelcs (thrombocytes) which affect the blood clotting 8. Thrombocytopenia - characterized by low platelet counthe es rit es ood cells ‘ets Diagnostic Tests + ABO and RH type + Hematocrit (Het) + Bone marrow examination + Hemoglobin (Hb or Hgb) + Complete blood count (CBC) + Hemogram + Cross-matching + Indices (MCH, MCV, MCHC) + Differential (diff) count + Iron (Fe) + Eosinophil (Eos) count + Reticulocyte (retic) count, + Erythrocyte sedimentation + Total iron-binding rate (ESR) capacity (TIBC) + Ferritin Structure and Functions of the Lymphatic System ‘The lymphatic system is a network of tissues and organs responsible for the removal of toxins and waste in the human body. Its primary function is to transport the white blood cells to and from the lymph nodes throughout the body. Structure of the Lymphatic System The lymphatic system is composed of fluids or lymph which similar to plasma but is composed of 95% water. The lymph is ‘transported throughout the system through the lymphatic vessels, ducts, and masses of lymph tissue called nodes. The body's excess tissue fluid filters into lymphatic capillaries which join larger lymphatic vessels until they empty into either the right lymphatic duct or the thoracic duct. The lymph moves through the vessels with the help of skeletal muscle contraction. It passes through the lymph nodes, which produce lymphocytes, before it reaches the duct. Functions of the Lymphatic System Aside from transporting white blood cells to and from the lymph ‘nodes, the lymphatic system has other functions: 1, It transports the tissue fluids back into the bloodstream. 2. TItremoves impurities. 3, Itprocesses lymphocytes. 4, It transports the fats absorbed from the small intestine into the bloodstream. The Circulatory Systemf | 42__ Learning Guide fr Principles of Medical Laboratory Science 2 Tonsils = ' Thymus ; co j i J Mammary Axillary, an ‘Thoracic eee mn is es a ic SiS Bb afbtnaip i skepess vi Lymphatic Tissue Celis lymph | capillay Venuiz "Vessel «== teriole Figure 3.8 The Lymphatic System43 The Circulatory System ‘The lymph is an excess tissue fluid that filters through the lymphatic illaries, The capillaries are joined and form the larger vessels that empty into the right lymphatic duct and thoracic duct, which, in turn, empty into the larger Veins of the upper body. The lymph is moved as a result of skeletal muscle contraction. Impurities are removed when the .ph passes through the lymph nodes. Disorders of the Lymphatic System 1. Lymphangitis - inflammation of lymphatic channels resulting from an infection ata site distal to the channel . Lymphadenitis - refers to the inflammation of the lymph nodes . Lymphadenopathy ~ also called adenopathy, a disease in which there is abnormality in the size or number of lymph nodes 4, Splenomegaly ~ enlargement of the spleen 5, Hodgkin's disease - cancer that affects the immune system and is characterized by enlarged lymph nodes 6, Lymphosarcoma - a type of cancer that develops from lymphocytes Lymphoma ~ cancer of the lymphatic system that begins in the lymphocytes Diagnostic Tests + Bone marrow biopsy + Lymph node biopsy + Complete blood count + Mononucleosis test + Culture and sensitivity Hemostasis, Basic Coagulation, and Fibrinolysis Processes Hemostasis is the stoppage of bleeding as a response to an injury whether it be normal vasoconstriction where the vessel walls close temporarily, abnormal obstruction like plaque, or coagulation such aslitigation. ‘This process happens daily just like the repair of a vessel. It requires coordination between the endothelial cells lining the blood vessels, platelets, and other blood cells, and the plasma proteins. There are four interrelated responses: 1. Vasoconstriction the vessel walls are constricted after an injury, which results in reduced flow of blood in the site of injury44 Learning Guide for Principles of Medical Laboratory Science 2 Vasoconstriction 2, Formation of the primary platelet plug ~ platelets stick together on the site of the injury forming a plug 3. Progression to the stable blood clot 4, Fibrinolysis or dissolving of clot Coagulation Factors and Pathways Coagulation or clotting is the process in which the blood changes from a liquid state into a gel that forms the blood clot. The coagulation factors refer to the proteins that are needed in the coagulation. ‘There are three types: enzyme precursors that turn into enzymes when activated, cofactors that accelerate enzymatic reactions, and substrates which are the substances that are acted on and changed by the enzymes. The clotting cascade has two separate but interacting pathways the extrinsic pathway which is activated by external trauma (initiates coagulation) and the intrinsic pathway which is activated by trauma inside the bloodstream (produces thrombin). It has three cell-based coagulation phases, namely initiation, amplification, and propagation, Role of the Thrombin Thrombin is an enzyme that plays an important role in coagulation, It is produced at the site of injury from the prothrombin. It amplifies coagulation and converts fibrinogen into soluble fibrin. This supports the platelet plug formation by activating factor XIII to cross-link fibrin and also to control the formation and coagulation process by activating protein C. Pater pus Scag + ductocontecionofsnecihmiscefber female Ses + decreases ood fow ad ants lod ne eo See + recs orete of bond veal Bors Figure 3.9 The Hemostatic Process in VivoFibrinolysis Fibrinolysis is the process in which the fibrin is dissolved, It has two main activities: 1, reopens intact vessels by dissolving clots 2. removes hemostatic clots from the tissue as part of the healing Process The Role of the Liver in Hemostasis The liver’s role in hemostasis is to synthesize coagulation factors such as V, VII1, prothrombin, and fibrinogen. This organ produces heparin and bile salts needed for synthesis, It is also responsible for the production of bile salts needed for vitamin K absorption, Hemostatic Disorders 1. Deep venous thrombosis (DVT) happens when blood clot forms in ‘one or more deep veins, usually in the legs. 2. Disseminated intravascular coagulation occurs when the formation ‘of small clots blocks the small blood vessels. 3. Hemophilia is a disorder involving the lack of sufficient blood- clotting proteins. 4. Thrombocytopenia is a condition characterized by abnormally low levels of platelets in the blood. Diagnostic Tests + Bleeding time + Platclet function assay (PEA) = D-dimer + Prothrombin time (PT) ~ Factor assays + Partial thromboplastin time Fibrin degradation products (PTT or APTT) (FDP) Major Arm and Leg Veins in Venipuncture + Antecubital fossa, also called the elbow pit, is the triangular area on ‘he anterior of the elbow, which is a site of major veins. This is the Srst choice for routine venipuncture because there are several major 2m veins called antecubital veins which are close to the surface ‘which makes them easy to locate and penetrate, The Circulatory System 4546 Cegnatevein Biceps brachi Baste vein Pronatr teres este vain Cephalic vein Mesion vin otiereom: Figure 3.1 M-shaped Antecubital Veins 2. H-shaped antecubital veins refer to a vein arrangement that occurs in about 70% of the population. + Median cubital vein is the preferred venipuncture site, It is the easiest to access and least painful for the patient. + Cephalic vein is the second choice for venipuncture. It is harder to palpate but is usually better when drawing blood from ex ‘obese patient. + Basilic vein is last choice-vein for venipuncture as it is not wel! anchored and punctures on this vein are more painful, 3. M-shaped antecubital veins are the intermediate antebrachial veins Which include the median, median cephalic, and median basilic veins + Median vein ~ intermediate antebrachial vein; first-choice vein safest and less painful Figure 342 H-shaped Anaabaiveres + Median cephalic vein - intermediate cephalic vein; second choics for venipuncture; less likely to roll + Median basilic vein - intermediate basilic vein; last choice because it is more painful 4, Other arm and hand veins are used only if the antecubital veins e- oe Metacarpal not accessible. The veins at the back of the hand that can be u: plexus are smaller, so using them may be very painful. Take note that Figure 313 Hand Veins underside of the wrist is never used as a venipuncture site,5. Leg, ankle, and foot veins must not be used in venipuncture without the permission of a physician due to complications such as thrombosis. Inferior vena cava. ‘Common iiae External tiae ‘Common femoral ‘Superficial femoral Popliteat Posterior tibial Peroneal Anterior tbat . n i Figure 344 Major Veins in the Leg and Foot 6. Arteries are not used for routine blood collection and are limited to the collection of arterial blood gas. Special training is needed and the procedure is risky for the patient. The Circulatory System 47LESSON 4 BLOOD COLLECTION EQUIPMENT, Pye) rn P- ke).1).ae) a D>) LEARNING OUTCOMES é ‘Atthe end of this lesson, the students must be able to: 1. discuss the use of equipment and supplies needed to collect blood by venipuncture; 2, distinguish between antiseptics and disinfectants and cite examples of each; 3, identify appropriate phlebotomy needles by length, gauge, and any associated color coding: 4 illustrate how the evacuated tube system (ETS) and syringe system components work, and when they are used; 5, enumerate the general categories of additives used in blood collection; 6. describe the color coding used in identifying additives in blood collection tubes; and 7. explain the “order of draw” followed in blood collection using multiple tubes. Bi LEARNING GUIDE ieee eens ao 4, Read Information Sheet 4.0. 2.0 hours, Blood Collection Additives and Order of Draw 44. Equipment and Supplies Used in Venipuncture 42, Antiseptics and Disinfectants Used in Venipuncture 43, Phlebotomy Needles 4.4, Syringe System and Evacuated Tube System (ETS) Components 48, Catagories of Additives Used in Blood Collection 46. Color Cocing Used in Identifying Additives in Blood Collection Tubes | 43. The “Order of Draw’ Followed in Blood Collection Using Multiple Tubes Information Sheet 40‘ulde for Principles of Med! 5O Learning G 30 hours | Instructor/Trainer, nus 2, Suggested Self-Directed Act ces sar z yn, read relates arn ‘a1, Attend lecture sessio ono oi A beni, ere Laboratory Activity and watch portal-base Collection Equipment, Aadiives: an Activity #3 Page ea ei ynlebotomy 4.2, Perform Activity 3: «Famitorization with P ee Materials” 14,3. Perform Activity 4: “Commonly uses ano |_| Collection Adelitves and Order = eo iecheck Activity amare results [resots_ | [tessons ‘Summative examination for Lesson 4. | Report to and consult with Your instr ‘your examination results. sponsible for collecting blood specimen for ‘Eis imperative that they are knowledgeable rat equipment, devices, and supplies used for the different methods of drawing blood so they could prepare them appropriately. Selecting the correct tools and using them properly during the testing procedure does not only ensure safe collection but also guarantee accurate results. Phlebotomists are Te testing in the laboratory. about the pieces of differe lection Equipment and Supplies Iood collection equipment and supplies that are commonly used by the phlebotomist regardless of the collection method ‘These should be calibrated and maintained on a regular basis for the safety ofthe patient and health worker during blood collection. « The blood-drawing station is primarily used for the o department and typically has a table for supplies, a comfortable chair for the patient to sit on during the procedure, and @ bed or padded table for the heelstick procedure for infants and young children, + The phlebotomy chair should be comfortable and with # adjustable arm rest. General Blood Co! There are general bl utpatientBlood Collection Equipment, Additives, and Order of Draw An equipment carrier makes the collection portable. A hand-held mieten eaaemen ieused Gs “stat” cases and a phicbotomy ate early-morning, phlebotomy rounds. ft in the hallway to avoid nosocomial infection. A new pair of gloves and glove liners should be used when performing blood collection. Gloves should have a good fit The gloves that are approved to be used during phlebotomy are: (1) non-sterile, (2) disposable latex, (3) nitrile, (4) neoprene, (5) polyethylene, and (6) vinyl. It is best if the phlebotomist uses liners when his/her skin is prone to allergies and dermatitis. Antiseptics are used to prevent sepsis, which is the presence of harmful bacteria that typically enters the human body through a wound or a break in the skin. Disinfectants, which are used in killing microorganisms on surfaces and instruments, should be handled with care because they could be harmful to the skin. The use of hand sanitizer or wall-mounted hand sanitizer dispenser is recommended as a substitute for hand washing except when the hands are visibly soiled. Gauze pads are clean 2x2-inch gauze folded in fourths. They can be used to hold pressure after blood collection instead of cotton balls, since they have fluid-proof backing that prevents contamination. Bandages can be used on the blood collection site once the bleeding has stopped. Other materials such as paper, cloth, or knitted tape can also be used over folded gauze. 1x3-inch glass microscope slides for blood films are used in hematology determinations. A pen with non-smear ink is recommended to be used when labeling specimens. ‘A watch with timer can be used to determine collection times and to time tests. Sharps disposal containers, commonly called “sharps containers; are used as receptacle for needles, syringes, Jancets, and other sharp objects. Biohazard bags are used to transport blood and other specimens to the laboratory. These are leak-proof bags marked with biohazard logo. An outside pocket is used to hold requisitions and other documentation. 51for Principles of Medical Laboratory Science 2 Venipuncture Equipment [Aside from the general collection tools discussed previously there ere pieces of equipment that are used for venipuncture purposes only, The’ are as follows: 1. Vein-locating devices are transillumination portable devices the: tse infrared light to help health professionals locate and asses veins for safe venous access. boy ‘velroceree 2, Tourniquet is a constricting device applied to a patients ar prior 10 venipuncture with the aim of inflating the veins & restricting venous blood for a period of time. This device come in different sizes and is intended for single use only. 3, Needles are used for withdrawing blood samples. These == sterile and for single use only. The 3 types of needles uss< Jo venipuncture are multi-sample, hypodermic, and winess infusion. Figure 4.2 Patient with 4, Needle gauge is classified according to the diameter of « Tourniquet Jumen. The higher the number, the smaller the actual nee= diameter. The appropriate gauge used should be 20 to 23, be a1 needle gauge is the most commonly used. The length of needle in venipuncture is 1 to 1.5 inches. The needles « ‘with color-coded caps and hubs for easy identification. They = equipped with safety features such as resheathing, blunting retraction devices. 5, Evacuated tube system (ETS) is a closed collection sy Figure 4.3 Blood Collection composed of multi-sample needle, tube holder, and eva aie a ary tubes, which prevents exposure to contaminants. One enc cos the needle is pierced through the vein and the other enc the stopper of the evacuated tube allowing the blood to into the tube. This allows numerous tubes to be collected = single venipuncture. Antiseptics and Disinfectants Used in Venipuncture ‘The disinfectants preferred to be used in venipuncture Environmental Protection Agency (EPA)-registered sodium hypo== ‘with 1:100 dilution. For spills clean-up procedures, the 10% di: used, The contact time required is 10 minutes.ere are - They es that assess 's arm ins by comes se are s used ringed of the needle buta come ey are z, and ystem uated ad of is in flow lina Pare jorite on is There are different antiseptics that are used in blood collection. The == of alcohol-based preparations is becoming popular because many Patients have allergies when exposed to povidone iodine. The following 2:¢ antiseptics that are used in blood collection: 70% ethyl alcohol, 70% Ssopropyl alcohol, benzalkonium chloride, chlorhexidine gluconate, Sydrogen peroxide, povidone-iodine, and tincture iodine. Phlebotomy Needles There are three types of phlebotomy needles used in evacuated tube system or syringe system. These are the multi-sample, hypodermic, and winged infusion. The multi-sample needles are used in the evacuated tube system (ETS) and are equipped with safety features. Color-coded needles that do not have safety features must be used with tube holders shat have safety features. A hypodermic needle is used in the syringe system and comes with different gauges and lengths for different types of usage. A winged infusion set (butterfly) is used for difficult veins such 2s those of pediatric or elderly patients because it is more flexible than the needle or syringe. It is composed of % to % inch stainless needles, 23 to 25 gauge, with 5- to 12-inch tubing. It has a Luer attachment for syringes or multi-sampler Luer adapter for ETS. The wings or the plastic extensions facilitate the easy manipulation of the shallow angle needle insertion. Blood Collection Equipment, Additives, and Order of Draw 53 on “ auf ee Tod fatter ioe a orca aneane ‘ier | — J \ oer a Sr Mutt-sampie Hypodermic Winged Infusion (Butterfly) Figure 4.4 The Different Types of Phlebotomy Needles54 Learning Guide for Principles of Medical Laboratory Science 2 Figure 4.5 Components of the Syringe System Figure 4.6 Syringe Transfer Device Figure 47 Components of an Evacuated Tube System (ETS) Syringe System and Evacuated Tube System (ETS) Components Syringe System ‘The syringe system is used as an alternative method when drawing blood from patients with small or difficult veins. It is a traditional collection procedure that uses a syringe to draw blood from the patient, ‘and the collected specimen is transferred into tubes. The components o this system include (1) a syringe needle that has a resheating feature, 2-2 (2) a syringe that is divided into a graduated barrel and plunger. When drawing blood, the plunger is pulled back slowly, thus, cre== a vacuum that causes the barrel to fill with blood. It uses a hypodermic needle and sterile plastic syringe with Luer lock tip. Syringes that are commonly used in phlebotomy are 2 mL, 5 mL, and 10 mL. The blood collected by the syringe should be transferred into tubes using a syringe transfer device which is attached to the hub of the syringe after the syringe draw is completed, Syringe transfer devices facilitate the transfer of blood into tubes without stopper removal or the use of a syringe. Evacuated Tube System Evacuated tube system (ETS) is a closed collection system that is considered the most efficient system for collecting blood samples. The procedure involves piercing one end of the double-pointed needle into the vein and the other end in the stopper of the evacuated tube allows the blood to flow into the tube. This method enables numerous tubes to be collected in a single venipuncture. The system is composed of multi-sample needles, tube holders, and evacuated tubes that prevent the exposure of the specimen to contaminants, The ETS needles are threaded in the middle and the bevel point on each end. The threaded portion is then attached to a tube holder with the sleeve that retracts when the needle goes through the tube stopper. The sleeve slides back once the tube is removed to prevent leakage, The tube holders can accommodate different-sized tubes. Should it lack safety features, the phlebotomist must make sure that the needle used has a safety feature. The needle and the tube-holder device are permanently attached as a unit or come pre-assembled. Evacuated tubes are color-coded tubes filled with predetermined volume of blood by vacuum. They are used in both the ETS and syringewing jonal ent, ts of and ating rmic are ood singe r the asfer ysthe tobe iders, en to d the tube a the event nould cedle are method and can be an additive or non-additive tube. They are available in different sizes and volumes and can be made of glass or plastic. The usage depends on factors which include the age of the patient, size and condition of the vein, and the volume of blood that is needed. Categories of Additives Used in Blood Collection The blood collection tube may contain one or more additives depending on the test ordered by the physician. They can be in liquid, spray-dried, or powdered form and each additive has @ specific function. The tube should be gently inverted 3 to 10 times after the collection to mix the additive with the specimen. Listed are the categories of additives sed in blood collection: + Anticoagulants, commonly called blood thinners, are chemical substances that prevent blot clots. The two methods are by precipitation of calcium or by preventing thrombin formation. The different types of anticoagulants are ‘ethylenediaminetetraacetic acid (EDTA), citrates, heparin, and oxalates. + Special-use anticoagulants include acid citrate dextrose, citrate phosphate dextrose, and sodium polyanethol. + Antiglycolytic agents are substances that prevent the breakdown of glucose by blood cells or glycolysis. The most common is sodium fluoride which preserves glucose and prevents growth of bacteria, It is usually used with potassium oxalate for rapid response. + Clot activators enhance coagulation in serum specimen tubes. There are two types of activators: clotting factors such as thrombin, and substances that provide more surface for platelet activation such as glass (silica) particles and inert clays (celite). + Thixotropic gel separator inhibits cells from metabolizing substances and moves between cells and serum or plasma when centrifuged. + Trace clement-free tubes are made of materials that are free of trace element contamination. They have royal-blue stoppers and are used for a variety of purposes such as trace element tests, toxicology studies, and nutrient determination. Blood Collection Equipment, Additives, and Order of Draw‘Table 44 Color Coding for Tube Caps 56 _ Learning Guide for Principles of Medical Laboratory Science 2 Cap Color Ses Red |Noaddve "1 orange (Cougulant z Tetow | Coagulant and Separation Gel |Green [Heparin Sodium Light Green| Heparin Lithium ee Purple [EDTA coagulant Light Biue | Socium Curate 13 Black Sodium Chrate 14 rey Potassium Oxalate Monohydrate and Soclum Fluoride Order of Draw for Multiple Tube Collections eects tang in NC reamed ‘hee Dra OE HOA 032, 8102) ‘BD Vecutainer® Blood Collection Tes (glass or plastic) (oats toss Ba + Ctra Tube" 3 to 4 times, Mess meer re zo to 10 times oor ‘to 10 times Wit ea EDTA Tie 8 t0 10 times 7 Tube ba sens ning Ned aot er inci Se ioTit bac ten geomet seers ‘SRLS cli Sete Sed rere ad SEeidecn es “ced snce with os hte aed "Ei ctet ned tbe ont le Th npoot ao al etre nlnaas othe rope ods aane to of teed UME dnd ut iste sean orcnpaion ab NOTE: Always folow your facility's protocol fr order of draw Color Coding in Identifying Additives Blood Collection Tubes ‘An additive is any substance that is placed within the tube and can be used in ETS tubes to prevent clotting and to preserve the components. The amount in the tubes is calibrated by the manufacturer. Blood collection stoppers have color-coded caps depending on the additives that they contain. Listed are the cap colors and their additives (Table 4.1). Order of Draw Order of draw refers to the specific order that must be followed by a phlebotomist when collecting blood samples to prevent any cross- contamination, especially when dealing with multiple collection tubes. Not following the prescribed sequence affects the test results due to cross-contamination.order when 085- with 5 the s due _ESSON 5 VENIPUNCTURE PROCEDURE LEARNING OUTCOMES At the end of this lesson, the students must be able to: 1. describe the test request process, types of requisitions used, and requisition information; . discuss test status designations, status priorities, and the procedure to follow for each status designations 3. explain proper “bedside manner” and demonstrate how to handle special situations associated with patient contact; 4, justify the importance of proper patient identification; 5, explain how to prepare patients for testing and answer inquiri and what to do ifa patient objects to @ test; 6. describe how to verify fasting and other diet requirements; 7. cite each step in the different venipuncture procedures; 8. list necessary information found on specimen tube labels and state acceptable reasons for inability to collect specimens 9, perform the different venipuncture procedures and the proper way to safely dispense blood into tubes following a syringe collection; and 10. state the unique requirements associated with drawing blood from special populations including pediatric, geriatric, and long- term care patients. & LEARNING GUIDE meee 4, Read Information Sheet 5.0. \Venipuncture Procedure 51. The Test Request Process, Types of Requisitions, ‘and Requisition Information 5.2, Test Status Designations, Status Priorities, and the Procedure for each Status Designation 5.3, Proper "Bedside Manner” and Handling Special Situations Associated with Patient Contact, 5.4, The Importance of Proper Pationt Icentifcation 55, Patlent Preparation for Testing eee Resources Information Sheet 5.05B _ Leeming Gude for Pncples of Medical Laboratory Scence 2 eo '56, Verifying Fasting and Other Diet Requirements '57, Steps in Equipment Preparation forthe Different \Venipuncture Procedures . 5.8. Necessary Information Included in Specimen Tube Labeling 5.9, Requirements Associated with Drawing Blood from ‘Special Populations Including Pediatic, Gevatic, fens \ al | for Lesson 5. and Long term Care Patients. a 2, Suggested Self Directed Activities: Instructor Trainer! ‘31, Attend lecture session, read related articles, Speaker/Student Portal ‘and watch portal-based presentation Library/Simulated ‘on “Venipuncture Procedure.” Clinical Laboratory | 5.2. Perform Activity 51 “Venipuncture through Laboratory Activity: Evacuated Tube System (Single Draw)” | activity #51 (Page 205) | 53. Perform Activity 52: “Venipuncture through ‘Activity #5.2 (Page 213) Evacuated Tube System (Multiple Draw)" ‘Activity #53 Page 223) 54, Perform Activity 5:3:“Venipuncture using Syringe” ‘ctvty #5.4 Page 223) 55, Perform Activity 5.4 “Venipuncture using Buttery” 3 portatbased Selt.Check Activity 5.0. Student Portal “a. Perform portal-based summative examination Student Portal . Report to and coneult with your instructor regarding ‘Summative examination results your examination results. th 8 | [6 Proceed to Lesson 6. put ot INFORMATION SHEET 5.0 [Lesson 6 ‘The term venipuncture refers to the process of collecting © sasawing” blood from a vein of the patient for laboratory testins purposes. Phlebotomists should possess the necessary knowledge en ils to perform venipuncture since they will perform this proceds frequently as part oftheir duties and responsibilities in the healthcare institution. ‘Test Request Process, Types of Requisitions Used, and Requisition Information “The first step of the pre-examination phase is the test request th form includes information on t comes from a physician. The request of test ordered and any special instructions or conditions that sho: ya and examination phas: be considered during the pre-examinatio ‘This form will be part of the patient’ medical record and can be referss- to, should issues regarding the test arise.or ing and ure are that bald ses. cred, \Venipuncture Procedure “The test requisition could be manual, computerized, or bar-coded. Manual requisition forms usually have parts for request, report, and billing. With the advances in technology, the use of the manual method has declined. However, these forms still serve as back-up when the computerized system fails, ‘The computerized requisition form includes patient information, test status, and other details that are useful for the test. A computer- generated label for the collection tube is made available, with which the phlebotomist must note the time of collection and confirm the information by affixing his/her initials. The required pieces of ‘information in the requisition form are as follows: Name of the physician who ordered the test + Patient’ full name including the middle initial + The medical record number for inpatients + Birthday and age of the patient Room number and bed number if inpatient + Type of test ordered «Date when the testis to be performed «Billing information (if required) + Teststatus «Special precaution ‘The manual or computerized request may contain a barcode, which is scanned into a computer using a special device with a laser. The information in the code is then interpreted and processed. The use of these codes greatly help in minimizing clerical errors. Venipuncture Steps Step 1: Review and Accession the Test Request The venipuncture procedure begins with a thorough review of the test requisition to avoid duplication of request, to ensure proper collection timing, and to identify special instructions or equipment required for the test. In reviewing the request, the phlebotomist must (1) check the completeness of the required information, (2) verify the tests to be collected including information such as the time and date of collection, (3) take note of any dietary restrictions or special conditions that should be followed before the actual collection, and (4) determine the test status or priority of collection. 596O Learning Guide for Principles of Medical Laboratory Science 2 ‘The test request is then accessioned, which means that the specimen to be collected is assigned a special number that will serve as the reference number for all associated processes and paperwork. Accessioning the test request helps improve the documentation, handling, and reporting of test results. Status Designations, Status Priorities, and Procedure for Each Status Designation Table 54 Common Test Status Designations So eco aie ey stat | immediately | Results are Immediately collect, | Glucose, HaH, | Fist needed forcrtical |test,and report | Electraytes, patient resut. Alen when | Cardiac Enzymes delivered. ER stats ae priory Med [Medical | Results are Immediately collect, | Glucose, HH, _ | Fist Emerg Emergency needed for critical | test, and report Electrolytes, patient resuit Alertwhen | Cardiac Enzymes doivered. ER stats ate prion. Timed [Collectata | Timing Collet cose ZhourPRGTT | Second speciictime |ofeoliecion | torequiredtime | Cortisol, Carciac isimportant | andrecord actual | Enzymes, TDM, time. Blood ASAP [Assoonas | Resultsneededto | Fotow hospital | Electroites, _| Second possible” | respond to serous | protocol Guucose, HH | or third but not yet crtcal situation Fasing | Prorto | Elminate effects | Very fine patient | Gucose, Fourth collection, | ofthe det had fasted, Fhe dé _| Cholesterol, there should ‘not, check if the test | Triglycerides be no food or oul stil proceea crink intake for 12 hours PO | Nothing by | Priorto surgery | Donotgwve food or | NA NA mouth orotheranesthesia | water, procedures Preop | Betorean | Determine Collect before | CBC, PTT Second operation | elgiity surgery, Platelet function | or third for surgery studies | Postop | Afteran | Assess condition | Callct after surgery. | HEH ‘Second operation _| after surgery orthird | Routine [Relating | Estabisn Colectontime but | CBC, Chem [None | tocstablisned | diagnosis or | not urgent. Profle procedure monitor progress |== 2: Approach, Identify, and Prepare the Patient Proper “Bedside Manner” and Handling Speci ‘Situations Associated with Patient Contact Phlebotomists should organize the test request according to priority, “set prepare all the necessary equipment and supplies needed to complete ‘Sex collection round. ‘They should check for phlebotomy-related signs and warnings “csciing the condition of the patient such as “No taking of blood “sccssure (BP) or venipuncture on the right arm.” These signs are usually Seed on the door or wall next to the patient’ room. “Bedside manner” refers to the behavior of a healthcare worker as “scxceived by the patient which is applicable to both in- and out-patient “esings. Proper approach, conduct, and demeanor which help the “oicbotomists gain the trust and confidence of the patient are part ofthe Secessional bedside manner. The following practices of phlebotomists “Sow proper bedside manner: Knock on the door gently before entering the room. Make a good impression by greeting the patient warmly. Stay organized and have all the supplies available and approach the patient in a professional manner that goes well with having a neat appearance. Maintain a calm expression as most patients are afraid of blood collection. Introduce yourself and explain the procedure. Obtain the verbal or expressed consent of the patient before proceeding with the test. «Remain compassionate and professional during the procedure. + Thank the patient for his/her cooperation before leaving. 1f there is a physician or clergy in the room, the phlebotomists may -cterrupt only if the ordered testis stat or timed. They have to excuse and ack permission to proceed with the test, Family members or visitors can “cay in the room, but it would be better if they could step out of the room “entil the process is finished. If the patient to be tested is not available end the phlebotomists are unable to obtain the specimen, it should be “ncicated in the form that no collection has been made. The form should be submitted to the nurses’ station. Venipuncture Procedure 61Learning Guide for Priel ples of Medical Laboratory Science 2 Importance of Proper Patient Identification Positively confirming the identity ofthe patient is important pe! of specimen collection. Obtaining a specimen from the wrong pers: eran have serious consequences and can even Be fatal in cases that invol blood transfusion. Misidentifying patients can be a reason or cause a phlebotomist’s dismissal or lawsuit against ‘him/her on the grounds malpractice. ‘When identifying patients, confirm the name and date of birth of patient. The patient’ response should ‘match the information on the te Fequest form, Otherwise the difference or err should be resolved anc rectified before collection. The identification ‘racelets should also mate! nd the phlebotomist should inform the nurse 0° duty if there are = discrepancies or missing IDs. If the patient is fast asleep, the phlebotomist should wake up th patient gently for proper identification, ‘A patient in the emergenc Pom or intensive care unit may be unconscious during the time of retteetion, Ask for the help of a relative, nurse, or PRYS\"AN identifyinz the patient, Make sure to.note the name of the person who confirmed t identity of the patient. ifthe patient is young, mentally-incapactated, oF there is a langu: barrier, the phlebotomist should ask a relative, 2 attendant, or the nurs to identify the patient. ‘The information provided should match those ve cord and the pieces of details indicated inthe 1D bracelet. ‘The ID bands for inpatient newborns or babies under 2 years old 2: placed in the lower leg. "The nurse, guardian, or relative must confi: wi identity ofthe child. The identity of the person ‘who confirmed th: ‘entity must be noted on the request form. Patient Preparation for Testing ‘The phlebotomist should explain the test procedure to the patie and confirm thatthe patient understood swhat has ‘been discussed. As Pe sf the informed consent advocacy, a verbal OF expressed consent shoul= be obtained before proceeding with the collection. itis best to direct a patients inquiries on the purpo®s or result of test to the patient's nurse or physician to avoid any miscommunication If the patient objects to the collection, respect the right of the patient « refuse testing, The refusal should be noted in the test request and th uthorized personnel should be informed: about the refusal.ant part person involve ause for mands of h of the the test ved and > match, are any -up the exgency 2 of the ratifying med the anguage he nurse ¢hose on < old are confirm med the > patient As part t should alt of the nication, atient to and the Venipuncture Procedure A patient must be treated with care under all circumstances, and the shlebotomist must remain calm and professional even if the patient is ‘cing difficult or is exhibiting needle-phobia. Special attention should be sen to minimize the trauma. Step 3: Verify the Patient's Diet Restrictions end Latex Sensitivity Verifying Fasting and Other Diet Requirements Phlebotomists should verify if there are special instructions on the et of the patient that need to be followed such as fasting for about 8 to 20 hours. During fasting, the patient may be allowed to drink water to avoid dehydration. It is best to advise the doctor if the patient has not ‘been able to follow the fasting requirement so a decision could be made if the collection will proceed as scheduled. ‘A patient with allergic reaction to latex can have life-threatening seactions upon exposure, so it is important to check if all pieces of equipment used on the patient are latex-free, and there are no latex items in the room. Step 4: Sanitize Hands Proper hand hygiene should be observed to prevent the spread of infection. Step 5: Position the Patient, Apply the Tourniquet, and Ask Patient to Make a Fist During the venipuncture procedure, an inpatient is usually lying down in bed, while an outpatient is seated on a blood-drawing chair, except when the patient is prone to fainting in which case he/she is placed in a reclining chair, sofa, or bed. Be sure that the hand or arm for ‘venipuncture procedure is well supported. The phlebotomist can then proceed to the tourniquet application and fist clenching. The tourniquet should be placed 3 to 4 inches from the intended site. Apply over a gauze ifthe patient has sensitive skin, and never apply a tourniquet over an open sore. When the tourniquet is in place, ask the patient to clench his/her fis. 63