PMLS 2 (2nd Semester MIDTERM)

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1. (1 Topic LEC) Patient and
st
Specimen Consideration
2. (1st Topic LAB) Lab Special
Patient Consideration
3. (2nd Topic LEC) Specimen
Consideration
1st Topic: (LEC) Patient and Specimen
Consideration
Quality Assurance Cycle
- Quality control not once a week
but every day (Morning and
Night).
- Reason: process a lot of
samples.
- 3 Controls:
Known-Normal (normal)
Known-Low (abnormally low)
Known-High (abnormally high)
Post-Analytic
• Record Keeping
• Reporting
Importance of Accessioning:
- Helps keep track of records.

Laboratory Work Flow Cycle:

3 Phases of Laboratory Testing:
1.) Pre-Analytical
- Test ordering, specimen
collection, transport, and
processing.
2.) Analytical (sample evaluation)
- Testing
3.) Post-Analytical
- Results transmission,
interpretation, follow-up, re-
testing.

Centrifugation
Quality Assurance Cycle - Both pre-analytical and
- Ensured quality of specimens being analytical, but if there are no
released in laboratory. ‘both’ option, you choose pre-
- CPD (Continual Personnel analytical.
Development) Post-centrifugation (sample evaluation)
Pre-Analytic - Analytical
Examples:
• Patient/Client Prep Sample
Yielding results – analytical
Collection
Machinery – analytical
• Personnel Competency Test
Result already printed – post-analytical.
Evaluations.
Pre-analytical (MOST IMPORTANT, since
• Sample Receipt and Accessioning
this is where most errors occur.)
• Sample Transport
Analytic
• Quality Control (Testing)/ Processing
- Ensures machines are working
properly to produce accurate
results.
- Using known reagents to test if
it's reading.

1|A .J.S. -MLS1H

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Pre-Analytical Phase • Patient Preparation
• Requisition
• Patient
• Doctor
Within Laboratory:
• Sample receiving (check if it's viable
to test).
• Analysis
• Results
• Reports

PATIENT CONSIDERATION
Mainly involves “PREPARATION.”

1.) Test request

Examples of patient preparation:
2.) Preparation of the Patient
(Instructions and pre-collection)
Variations in laboratory determination
3.) Considerations before specimen
• Diurnal variations
collection (tubes)
4.) Specimen collection (which • Physical activity or exercise
method?) • Fasting
5.) Specimen transport, preservation, - Glucose (6-8 hours)
retention, and processing. - Triglycerides (10-12 hours)
• Diet
• Alcohol
- May interfere with some
elements in the blood, reduce
the number of interferences to
yield accurate results.
• Tobacco smokers
- Increase, decrease CO2,
arterial.
• Drugs
• Posture
- Electrolytes and analyte levels.
- Reference range; supine, sitting,
FACTORS INFLUENCING “internal quality” standing.
• Tourniquet application
• Stress, anxiety.
- Electrolytes and analyte levels.
• Hyperventilation

Additional note:
Bilirubin – Destroyed in UV lights.

Outside Laboratory:
• Sample Transport
• Sample Handling
• Sample Collection

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Diurnal Variations
• Levels are highest in the MORNING
• Cortisol (stress)
- Adrenal Glands, hormone.
- Release source of energy.
- After 8 AM (increase)
- Get samples in the highest (to
ensure you get cortisol)
• Serum Iron
- ↑ = AM ↓ = PM (After 8PM)
• Neutrophil (WBC) count
- ↓ = AM ↑ = PM (After 8PM)
- For bacterial infection
• ACTH, Aldosterone, Insulin
- ACTH (stimulates release of
cortisol)
- Hormone
- Lowest at day time
Diet
• Fatty foods
• High Meat or Protein rich (increased)
• High unsaturated to saturated fatty
acid ratio
• Purine-rich (from vegetables,
decrease levels of uric acid,
inflammatory)
• Fruits (affects pH of blood like citrus)
• Caffeine rich (ulcer)
• Vegetarian (protein-deficiency)
Smoking
Acute (immediate) effects (increased)
• Carboxyhemoglobin
- CO2 retained in blood,
combined with your hemoglobin.
- Inefficient exchange of gas.
• Catecholamines
- Stimulates release of
Amphetamine (your fight and
flight:stimulant)
- Important in stress response.
- High levels can lead to high
blood pressure.
• Cortisol
- Stress
- triggers the release of glucose
(sugar) from your liver for fast
energy during times of stress.
Chronic (timely) effects (increased)
• Hemoglobin concentration
- To hold oxygen; increase
hemoglobin production.
• RBC and WBC count (increase)
• MCV (Mean Corpuscular Volume)
- Blood volume of RBCs
Do not collect specimen from your patient
without the TEST REQUEST FORM.
Test Request slip
Purpose:
• Screening for disease or case
finding.
• Diagnosis of disease
• Therapeutic monitoring
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POST-ANALYTICAL PHASE

Patient’s demographics
• Patient’s name
• Sex
• Age
• Date of birth
• Date of admission (if applicable)
• Date of measurement
• Hospital number 1.) Generation of the laboratory result
form.
• Room number/OPD
2.) Final Evaluation of results
• Physician
(validation)
3.) Releasing of results (transmission,
Specimens labels should include:
interpretation and follow up)
1. Patient’s name
4.) QC (quality control) performed. (QC
2. Age
data from analytic phase is
3. Sex
processed).
4. Room number/OPD
5.) Waste management.
5. Draw time
6. Test names/section
Additional Notes from MLS 1F Sophia
Pulgado ily:
ANALYTICAL PHASE
(PROPER STAGES)
PHASES OF MICROBIOLOGY TESTING
1.) Pre-pre analytical
1. Pre-analytical phase
- No samples yet.
a.) Patient assessment and test
Process:
ordering
Request of physician -> Collection ->
b.) Specimen collection
Identification -> Transportation.
c.) Specimen transport
2.) Pre-analytical proper
2. Analytical phase
Preparation of samples:
a.) Specimen evaluation
1. Centrifuge
b.) Specimen processing 2. Aliquoting
c.) Validation results
3.) Analytical - Analysis
3.) Post-analytical phase
4.) Post-analytical
a.) Reporting
- reporting of results.
b.) Interpretation
5.) Post-post analytical
c.) Diagnosis and treatment
- interpretation.

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Pre-analytical
- Last phase = centrifugation
Analytical
- Last phase = reporting.

Controls
- To test if the machine can detect
abnormal results.
Calibration
- Machine being set normal.
- Kind of quality control.
- Focuses on correcting the
machines.
Quality Control
- In ALL phases (machines).
- A continuous cycle of checking
the quality of the overall
laboratory results during the
analytical phase.
Quality Assurance
- Keeping QC in all phases.

Made on March 09,

2024. Revised on
March 11, 2024

5|A .J.S. -MLS1H

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1st Topic (LAB) Lab Special Patient
Consideration
Phlebotomist’s Roles
- professional, courteous, and
understanding.
- greet the patient and identify.
- establish effective
communication through verbal
and non-verbal.
- Patients are often courteous and
kind to health care personnel.
- However, UNEXPECTED
situations can arise and
phlebotomists need to be
1.) PEDIATRIC PATIENTS
- Special attention is necessary
when performing venipuncture
involving children below two (2)
years old.
CHALLENGES
- Small and underdeveloped
veins, making it difficult to draw.
- Dealing with the parents or
guardians could also be
challenging.
WHAT SHOULD THE PHLEBOTOMIS DO?
1.) The Phlebotomist should approach
slowly and be able to determine the
level of anxiety of the patient, so they
can gain the child’s trust.
2.) The procedure should be explained
clearly using terms that the child
understands.
3.) Reward can be given for the
cooperation.
Eutectic Mixture of Local Anesthetics
(EMLA)
- pain interventions
- cream and oral form
- takes about AN HOUR to take
effect and anesthetize the area.
Restrain patient movement
• Infants - wrapped in blankets.
• toddlers - usually held in parent’s
lap.
• children - 2nd person usually leans
in towards the child.
2.) GERIATRIC PATIENTS
- elderly patients need special attention due
to conditions such as arthritis, diabetes,
stroke, and etc.
CHALLENGES
- comorbidities (diabetes,
arthritis, hypertension, and etc.)
- hearing, visual and neutral
impairment.
- thinner skin and smaller
muscles (easily roll veins).
IN WHEELCHAIRS, ensure that wheels are
locked during the procedure, and they have
assistance when using the wheelchair.
ALTERNATIVE FOR DIFFICULT DRAW
- Change the syringe hub from 23g
to 25 gauge (orange).
WHAT SHOULD THE PHLEBOTOMIST DO?
1.) Identify the patient properly.
2.) Carefully select which needle to use.
3.) Apply tourniquet carefully to make
sure that skin will not be damaged.
4.) Make sure the site is not the previous
site of the previous venipuncture.
5.) Avoid rubbing the site vigorously
during cleaning.
6.)
7.)
3.) DIALYSIS PATIENTS
- Dorsum of their hands can be
used for venipuncture to
preserve the veins of the arms.
- Select other site other than the
arm used with Arteriovenous
(AV) fistula.
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TAKING BLOOD SAMPLE DURING Made on March 15,
DIALYSIS 2024
- Reduce blood flow rate to Special Thanks to
100mls/min and stop re-infusion Lyrene Sy MLS1H<3
on HDF .
- Clean arterial blood port with
CHLORHEXIDINE 2% in 70%
ISOPROPYL
- Leave to dry and take a sample
using a sterile syringe.
- Do not forget to return blood flow
and HDF pump rate back to
required settings.
4.) HOSPICE PATIENTS
- Patients that need end-of-life
care wherein one must have a
prognosis of 6 months or less.
- Phlebotomists should work with
extra care with these patients.
- Treat them kindly and with
respect, giving them comfort and
dignity.
5.) MASTECTOMY PATIENTS
- Use the opposite, venipuncture
should not be performed on the
mastectomy side.
REMEMBER: lymph node
preservation is a given.
6.) PSYCHIATRIC PATIENTS
- Be modified for the comfort and
safety of the patient and YOU!
- ex. manic, behavior,
schizophrenia, dementia, ADHD,
and etc.
WHAT SHOULD THE PHLEBOTOMIST DO?
- Show respect.
- Be calm.
- Inform the patient about the
procedure.
- Do not argue, whisper, nor
secretively.
- Avoid laughing.
- Do not leave any phlebotomy
materials.
GOOD TO KNOW!
- psychiatric may act
unexpectedly or in a violent
manner.

7|A .J.S. -MLS1H

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2nd Topic (LEC) Specimen Consideration 2.) GOLD OR MOTTLED-RED-GRAY
TOP TUBE
Specimen Consideration
- also called SAMPLE
consideration.
Blood Collection Tubes
➢ Contain a vacuum.
➢ Used with vacutainer and syringe
systems.
➢ Stoppers universal color coded:
indicates content.
➢ Have an expiration date.

- Contain clot activator and gel

(SST)
- Invert to mix and initiate clotting
sequence.
- SERUM
1.) RED-TOP TUBE (How many layers centrifuged tubes with no
anticoagulants? 2 layers)
(with SST? 3 layers)
3.) ROYAL BLUE-TOP TUBE
- Trace metal-free
- Metals to trace:
➢ Glass Iron, cooper, zinc
- No additive
- Glass surface activates clotting
sequence. Label color indicates contents:
- Do not mix - Red: no additive = serum.
- SERUM: Used for TDM
- Purple: EDTA = whole blood or
(Therapeutic Drug Monitoring).
➢ Plastic plasma.
- Contain additive to activate - Green: heparin = whole blood
clotting sequence. or plasma.
- Contain inert gel -> SST (Serum
Separator Tubes)
(Do tubes that have SST have clot activators?
There are some but mostly none.)
- Do invert to mix additive and
initiate clotting sequence.
- SERUM

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- Preferred for evaluation of trace - Inhibits thrombin formation.
metal. - Must be full and on ice if need
(What color top tubes serum samples for pH, ionized Ca. (test: arterial
trace metal-free? Royal-Blue Top) blood gas)
(What 3 tubes have SST? Red plastic, gold or (notes: When blood outside, cells still active,
mottle-gray top tube) have metabolism, there are by-products <
4.) BLUE-TOP TUBE this decreases pH. Which is the reason we
put ice to reduce the metabolic functions of
blood since the sample will deteriorate.)
Common: Lithium Heparin and Sodium
Heparin
Most common: Lithium Heparin
- Anticoagulant = SODIUM - Most Chemistry tests, STAT lab
CITRATE. (PST)
- Binds Calcium o Decreases time needed
Products: for blood to clot, makes
- Wala na centrifuge = CITRATED turnaround time better.
WHOLE BLOOD. 6.) PURPLE/LAVENDER-TOP TUBE
- Na centrifuge = PLASMA

- Must be full.
• Blood: anticoagulant
ratio critical
- Must be on ice if not analyzed - Anticoagulant = EDTA
within 30 minutes. (Ethylenediaminetetraacetic
- FOR COAGULATION STUDIES Acid)
5.) GREEN-TOP TUBE - Binds Calcium
Products:
- centrifuged: Plasma
- not centrifuged: Whole blood
Used for Hematology Studies: CBC
Inversion = 8x
7.) GREY-TOP TUBE
- Anticoagulant = HEPARIN
- Inhibits THROMBIN form.
Three (3) formulations:
o Lithium Heparin (most common)
o Ammonium Heparin
o Sodium Heparin
Products: Plasma, Whole Blood. - Anticoagulant = POTASSIUM
OXALATE
- Binds Calcium
- PLASMA, whole blood.
➢ Antiglycolytic agent = SODIUM
FLUORIDE
- Maintains plasma glucose
levels.
Limited use: glucose, lactic acid (by-product
of glucose, synthesis is lactic acid,
degradation of glucose turning to lactic
acid.)

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8.) FIBRIN-SPLIT PRODUCTS TUBE

- Anticoagulant: SOYA BEAN

THROMBIN
- Light blue top with 2 yellow
bands.
- Assess Fibrin.
9.) YELLOW-TOP TUBE
- Anticoagulant: ACD (Acid
Citrate Dextrose)
o Paternity Test
o DNA
- Anticoagulant: SPS (Sodium
Polyanethol Sulfonate)
o Used for Special blood
culture studies.
o Inhibits certain
antibiotics.
o Prevent further growth of Activation Sequence: NEEDS CALCIUM.
bacteria. - All pathway leads to
o BACTERIOSTATIC. PRODUCTION OF THROMBIN.
- 2 Types: - Most inhibit calcium.
1. Bactericidal – agent which - Heparin inhibit thrombin.
kills bacteria. End-product of Coagulation Process:
2. Bacteriostatic – agent Covalently crosslinked fibrin clot.
prevents the growth of
TYPES OF ANTICOAGULANTS
bacteria.
- To differentiate what is inside the
a.) Ethylenediamine Tetra-Acetic Acid
tube, is it ACD or SPS: CHECK
- Optimal concentration in the blood:
THE LABEL.
1.5mg/ml of blood
- Universally: it’s usually SPS
(Appropriate amount of blood to prevent
inside.
hemodilution)
Product/Sample: Plasma, Whole blood (not
(More than 1/5mg/ml of blood – RBC
centrifuged).
SHRINKS.)
---
Anticoagulant – means against or
preventing.
Coagulant – pertaining to coagulation or act
of clotting.
Main purpose of ANTICOAGULANTS are:
- TO PREVENT THE CLOTTING
PROCESS by interfering in the
coagulation cascade; and TO
PRESERVE CERTAIN ANALYTES
AND CELL MORPHOLOGY prior
to testing.

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- Mode of action: removes ionized ➢ Two (2) forms:
calcium through the process of 1.) BLUE-TOP:
chelation. o 0.105M or 3.2%: most
- Principle of EDTA: Chelation commonly used.
(removal of ionized calcium) o Blood to anticoagulant ratio:
- Ionized calcium (active form of 9:1
calcium. For coagulation to occur.) 2.) BLACK-TOP:
Anticoagulant of choice for hematology o 0.129 or 3.8% buffered
because: sodium citrate.
- Preserves cellular morphology. o Blood to anticoagulant ratio:
(morphology: size/shape of cells.) 4:1
- Excellent for cell counting. o For Erythrocyte
- Blood is stable for 2-3 hours before Sedimentation Rate using
smearing. (good preservative) Westergren Method
- Prevents platelet aggregation.
(Platelets will clump together if not - No hemolysis/lipemic sample. (can
for EDTA) interfere with method.)
Disadvantage: causes cell shrinkage in c.) HEPARIN
excess. - Optimal concentration:
15-20U/mL of blood (units)
➢ Two (2) forms: 0.2mg/mL of blood
1.) 𝑲𝟐 EDTA - Mode of action:
o spray-dried; plastic tube; will accelerating the action of
not dilute the sample. antithrombin III, neutralizing
2.) 𝑲𝟑 EDTA thrombin and preventing the
o liquid form; glass tubes; formation of fibrin
dilutes sample; 1.3% (DOES NOT DIRECTLY ACT UPON
THROMBIN)
PINK-TOP:
- used in blood banking for blood - Isolated from live cells and is known
typing; Rh typing and antibody to be the naturally occurring
screening; 𝐾2𝐸𝐷𝑇𝐴. anticoagulant.
(Liver cells produce heparin.)
WHITE-TOP: (What cells? Hepatocytes (liver cells).)
- EDTA + gel
- Used more often for molecular ➢ Two (2) forms:
diagnostic testing. 1.) Lithium heparin
b.) CITRATE - May be used for most chemistry
Mode of action tests except lithium and folate
- Precipitates calcium into an levels.
unusable form/nonsoluble complex; - For lithium test: Royal Blue Sodium
non-ionized form heparin can be used instead.
Anticoagulant of choice for COAGULATION 2.) Sodium heparin
STUDIES. - Is the injectable form used for
- Preserves the anticoagulant therapy.
labile factors V and - Recommended for trace elements,
VII better. lead and toxicology.
o Concentration:
0.2mg/mL of blood
- Anticoagulant of choice for:

11 | A . J . S . - M L S 1 H
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• Blood Gas Analysis e.) OXALATE
(0.05 ml per ml of blood) Mode of action:
• Osmotic Fragility Test - Combines with calcium to form an
• Trace elements and insoluble salt/complex
toxicology. ➢ Three (3) forms:
- DOES NOT affect levels of calcium. 1.) Potassium oxalate
- Preferred for potassium measurement. 2.) Ammonium oxalate
(LITHIUM HEPARIN green tube than red tube 3.) Double oxalate
because process of clotting can utilize) Disadvantages:
- Gives a BLUE background with Wright’s - Distorts cells morphology.
stain after 2 hours. (DON’T USE HEPARIN - Potassium oxalate: shrinks the RBCs
FOR SMEARING: gives a blue background) - Ammonium oxalate: swells RBCs

Ammonium oxalate used for - Erythrocyte

Sedimentation rate using Wintrobe
method (test)

d.) FLUORIDE Other tubes:

Gray top tube contains preservative or
antiglycolytic agents such as:
- SODIUM FLUORIDE
o Preserves glucose for 3
days
- Lithium iodoacetate
o Preserve glucose for 24
hours
- Prevents glycolysis because it
fluoride forms and ionic complex
with magnesium, thereby inhibiting
the Mg** dependent enzyme,
enolase.
(prevents glycolysis;
Glycolysis: turns glucose to energy. NEEDS
ENOLASE.
(If fluoride forms and ionic complex with
magnesium, thereby inhibiting the Mg
dependent enzyme, enolase)
(To activate enolase: inhibition of enolase by
forming ionic complex magnesium.)
Enolase - antiglycolytic
- red/gray and gold tops
- Generally called the SSTs (Serum
separator tubes) because they
contain.
clot activator + separation gel
- Mostly used for chemistry test
except for therapeutic drug
monitoring, blood bank, and
immunologic reactions
➢ Clotting time:
- With gel separators: 30 minutes
- With gel activator: 5 minutes
- Plain tubes: 60 minutes
Quizlet link:
https://quizlet.com/892904257/specimen-
consideration-flash-
cards/?i=4ybvje&x=1jqY&fbclid=IwAR1G1C
REGpyhfJ129rU5vhGasDmc7nMeAUAbaPd
6uw-Ak9FfDOzSHvfDCm4
Special Thanks to Lyrene Sy and
Eldrex Andrade (MLS 1H-ily)
Made on: March 16, 2024

12 | A . J . S . - M L S 1 H
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Sodium Polyanethol Sulfonate

Additional Notes of Ronalie: lavender/violet

Yellow or Gold Top - EDTA (additive) K2 EDTA: 8-10
- Sodium polyanethole TIMES; HEMATOLOGY SECTION cbc
sonulfonate, 8-10 times; blood and platelet count.
culture. Gray
Light Blue - sodium fluoride: 8-10 times:
- sodium citrate 3.2% ratio 1:9; glucose monitoring/EXAM/TEST
coagulation studies, AND BLACK (preserve glucose) with
(ratio 1:4) 3-4 TIMES antiglycolytic agents.
Red
- no additive plain top (examine
serum AND CHEMISTRY EXAM). Special Thanks: Table
- Plastic: 5 times inverted, Glass: no made by Sophia Pulgado,
additive has blood, walang my sweetheart, from
inversion. MLS-1F.
Love u <3. Made on
Green
Feb. 9, 2024
- sodium heparin (most probably): 8-
10 times; chemistry exam ex:
electrolytes.
- Light green; lithium heparin (pwede) (TAKEN FROM PRELIMS REVIEWER)

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14 | A . J . S . - M L S 1 H