MODULE 2

| ANATOMY & PHYSIOLOGY FOR THE

PHLEBOTOMIST
NHA CPT Exam 1

Chapter 6- The Cardiovascular System

• The Circulatory System • Blood Components • Hemostasis & Complications

Career Development: Building a Professional Resume

October 20-22, 2025

Laboratory: Vein
• © McGraw Identification
Hill LLC. All &or distribution
rights reserved. No reproduction Mockwithout Blood Draws
the prior written consent of McGraw Hill LLC.
Learning Outcomes

2
 Why Anatomy & Physiology Matters in
Phlebotomy

This week bridges biology and practice. Understanding how the circulatory system works — how
blood travels, what it’s made of, and how it clots — helps you draw safely, minimize errors, and
interpret patient reactions.
• Anatomy = the structure of the body.
• Physiology = how those structures function.
• Together, they form the scientific foundation for every stick, every test, and every patient encounter.

Clinical Relevance:
Knowing what lies beneath the skin prevents injury. A phlebotomist without anatomy knowledge
risks hitting arteries, nerves, or tendons, mislabeling specimens, or misunderstanding why blood
looks or behaves differently in each patient.

Discussion Prompt 1:
Describe how knowing the structure of veins and arteries affects your confidence during venipuncture.

3
 The Circulatory System: The Body’s
Transportation Network
• The circulatory system connects every organ, tissue, and cell. It delivers oxygen, nutrients, hormones, and removes carbon dioxide
and waste products through a network of 70,000+ miles of interconnected vessels, called the vascular system that never stops —
24/7 from birth to death.

Main Structures
• Heart: : Muscular pump that maintains unidirectional blood flow
• Blood Vessels: Network of arteries, veins, and capillaries
• Blood: The connective tissue that carries essential elements

Circuits:
• Pulmonary Circuit: Right heart → Lungs → Left heart. (gas exchange)
• Systemic Circuit: Left heart → Body → Right heart. (delivery of oxygen/nutrients)
•The average adult has 8–12 pints of blood—about the volume of a gallon of milk.

Clinical Relevance:
Phlebotomists collect systemic venous blood — the blood returning to the heart that carries metabolic by-products from the body’s tissues.
Understanding the circulatory pathways explains why venous blood, part of the systemic return, appears darker in color. This type of sample is
used for most laboratory testing because it provides valuable insight into body metabolism and organ function. Phlebotomists access the
systemic venous circulation to help clinicians evaluate the body’s overall physiological state.

Discussion Prompt 2:
Why is venous blood is typically collected instead of arterial blood?
Arterial blood, shows what the lungs have just oxygenated and what the heart is about to deliver — not what tissues have used. 4
 The Heart: Structure, Function, and Flow

The heart is a strong, hollow muscle about the size of your fist, located in the center of the
chest slightly left of midline. It works like a double pump: the right side sends blood to the
lungs for oxygen; the left side sends oxygen-rich blood through the body. Every beat pushes
~70 mL of blood — the reason you feel a pulse.

•Four Chambers: Right Atrium → Right

Ventricle → Left Atrium → Left Ventricle.

•Septum: wall separating oxygen-poor (right)

from oxygen-rich (left) sides.

•Valves:
• Tricuspid (between RA & RV)
• Pulmonary (between RV & pulmonary
artery)
• Mitral/Bicuspid (between LA & LV)
• Aortic (between LV & aorta).
5
 The Heart: Structure

The heart acts as a muscular dual pump:

•Right side → receives deoxygenated blood

and sends it to the lungs.
•Left side → pumps oxygenated blood to the
rest of the body.

•Atria – upper chambers that receive blood.

•Ventricles – lower chambers that pump blood

out.

6
 The Heart: Structure

The heart is a strong, hollow muscle about the size of your fist, located in the center of the
chest slightly left of midline. It works like a double pump: the right side sends blood to the
lungs for oxygen; the left side sends oxygen-rich blood through the body. Every beat pushes
~70 mL of blood — the reason you feel a pulse.

•Four Chambers: Right Atrium → Right

Ventricle → Left Atrium → Left Ventricle.

•Septum: wall separating oxygen-poor (right)

from oxygen-rich (left) sides.

•Valves:
• Tricuspid (between RA & RV)
• Pulmonary (between RV & pulmonary
artery)
• Mitral/Bicuspid (between LA & LV)
• Aortic (between LV & aorta).
7
 The Heart: Structure

The heart is a strong, hollow muscle about the size of your fist, located in the center of the
chest slightly left of midline. It works like a double pump: the right side sends blood to the
lungs for oxygen; the left side sends oxygen-rich blood through the body. Every beat pushes
~70 mL of blood — the reason you feel a pulse.

•Valves:
• Tricuspid (between RA & RV)
• Pulmonary (between RV & pulmonary
artery)
• Mitral/Bicuspid (between LA & LV)
• Aortic (between LV & aorta).

• maintain one-way flow and prevent

backflow of blood.

8
 The Heart: Layers and Protective Structures
of the Heart

Before we explore how the heart pumps blood, it’s important to understand what the heart is made of. The
heart wall has three main layers — each with a distinct structure, thickness, and function. These layers
work together like the parts of a strong, flexible engine that never stops running. When one layer is
damaged or weakened, circulation — and sometimes life — can be threatened.

•Who: The heart itself — an organ composed of specialized cardiac

muscle tissue.

•What: A three-layered wall surrounded by a protective sac (the

pericardium).

•Where: Located in the mediastinum, the space between the lungs,

slightly left of midline.

•How: Each layer contributes — the inner lining ensures smooth

blood flow, the middle layer provides the pump, and the outer layer
protects and nourishes the muscle.

•Why: These layers maintain continuous, frictionless pumping of

blood throughout the body.
9
 The Heart: Endocardium- The Inner Lining

The endocardium is the heart’s innermost layer — a smooth, delicate lining that touches the blood as it
flows through the chambers. It provides a friction-free surface for blood movement and protects the heart’s
internal structures from damage or clot formation.

Analogy:
The endocardium is like the non-stick coating inside a pot — it keeps blood flowing smoothly so nothing “sticks”
and causes clots.

•Composition: Thin layer of endothelial cells (similar to the inner

lining of veins and arteries).
•Location: Lines all four chambers and covers the valves.
•Function:
• Creates a smooth surface for blood flow.
• Prevents platelets from sticking and initiating clot formation.
• Serves as a barrier to protect the heart muscle from pathogens
in the bloodstream.

•Continuity: The endocardium is continuous with the inner lining

(tunica intima) of blood vessels — connecting the heart and circulatory
system as one unit.
10
 The Heart: Endocardium- The Inner
Lining
The endocardium is the heart’s innermost layer — a smooth, delicate lining that touches the blood as
it flows through the chambers. It provides a friction-free surface for blood movement and protects the
heart’s internal structures from damage or clot formation.

Clinical Relevance:
•Endocarditis is an infection of this layer, often caused by bacteria
entering the bloodstream (e.g., from IV lines or poor aseptic
technique).

•Infected endocardial tissue can shed clots (emboli) into circulation,

causing stroke or organ damage.

•For phlebotomists: maintaining strict aseptic technique prevents

introducing bacteria that could contribute to endocardial infection in
vulnerable patients (e.g., those with heart valves or pacemakers).

11
 The Heart: Myocardium- The Muscular
Pump

The myocardium is the thick, muscular middle layer of the heart and is the reason your heart beats. It
provides the force that pushes blood throughout the body — contracting about 60–100 times per minute
under normal conditions.
•Composition: Specialized cardiac muscle fibers (involuntary,
striated, interconnected).

•Thickness:
• Thicker on the left side because it pumps blood to the
whole body.
• Thinner on the right side because it only pumps to the
lungs.

•Function:
• Generates pressure to move blood.
• Contains intercalated discs for synchronized contraction
(unique to cardiac muscle).
• Uses high amounts of oxygen and glucose — any
interruption leads to muscle death within minutes.
12
 The Heart: Myocardium- The Muscular
Pump
The myocardium is the thick, muscular middle layer of the heart and is the reason your heart beats. It
provides the force that pushes blood throughout the body — contracting about 60–100 times per minute
under normal conditions.
Analogy:
The myocardium is the “engine block” of the heart — it’s what produces the power stroke for every
beat.
Clinical Relevance:
•Myocardial Infarction (MI) Heart Attack: When blood flow through the
coronary arteries is blocked, the myocardium becomes oxygen-deprived and
tissue becomes damaged or dies.

•Cardiac enzymes like Troponin and CK-MB are released into the blood —
tests phlebotomists often draw STAT for heart attack diagnosis.
• Knowledge Check: What color tube would you use? Which
department does it go to?

•Congestive Heart Failure (CHF): Weak myocardium causes blood to back

up into veins → swollen ankles, distended neck veins, and sluggish venous
draws. 13
 The Heart: Epicardium: The Protective Outer
Layer
The epicardium is the heart’s outermost layer — a thin, transparent membrane that protects the heart and houses
blood vessels, lymphatics, and nerves that nourish the underlying muscle.

Analogy:
Think of the epicardium as the “skin” of the heart — it protects and keeps it lubricated, just like oil on gears in an
engine.

•Composition: Connective tissue and simple squamous epithelial cells.

•Location: Lies directly on the myocardium; forms part of the pericardium.
•Function:
• Acts as a protective covering.
• Provides passage for coronary arteries and veins.
• Secretes a lubricating fluid that reduces friction between the heart
and surrounding tissues during contraction.
Clinical Relevance:
•Epicarditis or Pericarditis: Inflammation of the outer surface causes pain and fluid buildup.
•Fluid accumulation (pericardial effusion) can compress the heart (cardiac tamponade) — lowering blood pressure
and making veins engorged.
•For phlebotomists: understanding this condition explains why some cardiac patients have distended neck veins and
why blood flow in peripheral veins may be sluggish. 14
 The Heart: The Pericardium-The Heart’s
Protective
Sac
Surrounding all three layers is the pericardium — a two-layered membrane that encloses and anchors the
heart, preventing friction and over-expansion. It keeps the heart stable inside the chest while still allowing
it to move with each beat.

Analogy:
Imagine the heart sitting inside a water balloon — the outer wall holds it in place while the small amount
of fluid inside lets it move smoothly without friction.
•Fibrous Pericardium: Outer tough layer that anchors heart to diaphragm and chest wall.

•Serous Pericardium: Inner double membrane:

• Parietal layer (lines fibrous sac).
• Visceral layer (Epicardium) directly covers the heart.

•Pericardial Cavity: Space between layers filled with 10–20 mL of pericardial fluid that reduce friction
15
and allow smooth heart movement during contraction (each heartbeat)
 The Heart: The Pericardium-The Heart’s
Protective
Sac
Surrounding all three layers is the pericardium — a two-layered membrane that encloses and anchors the
heart, preventing friction and over-expansion. It keeps the heart stable inside the chest while still allowing
it to move with each beat.

Function Summary:
•Prevents friction and damage from constant movement.
•Limits overfilling of the heart.
•Maintains proper positioning in the chest cavity.

Clinical Relevance:
•Pericarditis: Inflammation of this sac causes sharp chest pain that
worsens with breathing or movement.
•Cardiac Tamponade: Too much fluid in the cavity compresses the heart,
preventing filling and lowering blood pressure — a medical emergency.
•For phlebotomists, these conditions explain why some cardiac patients
appear pale, short of breath, or have distended neck veins during blood
draws.

16
 The Heart: Summary – The Three Layers in
Action

•Endocardium: Inner lining → smooth blood flow.

•Myocardium: Middle muscle → pumping power.
•Epicardium: Outer covering → protection and lubrication.
•Pericardium: Double-layered sac → cushioning and stability.

Clinical Perspective for Phlebotomy:

These layers explain why cardiac disorders influence venous blood collection. All layers remind
phlebotomists that every blood draw interacts with the body’s most vital organ.
• Weak myocardium = poor circulation → slow draws.
• Inflamed pericardium = distended veins → fragile or tense sites.
• Endocarditis risk = strict aseptic technique.

17
 The Heart: Function

The heart is the body’s central pump — a muscular organ that keeps blood moving in a one-way cycle
through every organ, tissue, and cell. It never rests. Its contractions create the pressure that drives
circulation through a network of arteries, veins, and capillaries. The heart works as two pumps in one: the
right side handles deoxygenated blood; the left side handles oxygenated blood.

Analogy:
Think of the heart as a two-sided pump with two “loops”: one sends blood to the lungs to get oxygen, the
other sends oxygen-rich blood throughout the body — all in a closed system

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 The Heart: Function- Systemic
Circulation
The heart pumps blood through three distinct but connected circulatory pathways — systemic, pulmonary,
and coronary. Each has a specific purpose, and together they ensure oxygen and nutrient delivery throughout the
body.

Systemic Circulation — “The Body Loop”

Carries oxygen-rich blood from the left ventricle through the aorta to all body tissues, and returns oxygen-
poor blood to the right atrium.

Pathway:
Left ventricle → Aorta → Arteries → Capillaries
(exchange) → Veins → Vena Cava → Right Atrium.

Key Purpose:
Delivers oxygen, nutrients, and hormones to cells and
removes carbon dioxide and waste.

19
 The Heart: Function- Systemic
Circulation
The heart pumps blood through three distinct but connected circulatory pathways — systemic, pulmonary,
and coronary. Each has a specific purpose, and together they ensure oxygen and nutrient delivery throughout the
body.

Pathway:
Left ventricle → Aorta → Arteries → Capillaries
(exchange) → Veins → Vena Cava → Right Atrium.

Clinical Relevance:
•Phlebotomists access systemic venous blood (returning to the
right atrium).

•Venous blood is darker and under low pressure — ideal for

collection.

•Patients with systemic circulation problems (e.g., shock, heart

failure) may have slow blood flow or collapsed veins, making
draws more difficult.

20
 The Heart: Function- Systemic
Circulation
The heart pumps blood through three distinct but connected circulatory pathways — systemic, pulmonary,
and coronary. Each has a specific purpose, and together they ensure oxygen and nutrient delivery throughout the
body.

Pathway:
Left ventricle → Aorta → Arteries → Capillaries
(exchange) → Veins → Vena Cava → Right Atrium.

Clinical Relevance:
•Phlebotomists access systemic venous blood (returning to the
right atrium).

•Venous blood is darker and under low pressure — ideal for

collection.

•Patients with systemic circulation problems (e.g., shock, heart

failure) may have slow blood flow or collapsed veins, making
draws more difficult.

21
 The Heart: Function- Pulmonary
Circulation
Pulmonary Circulation — “The Lung Loop”
Moves oxygen-poor blood from the right ventricle to the lungs to exchange carbon dioxide for oxygen,
then returns oxygen-rich blood to the left atrium.

Pathway:
Right Ventricle → Pulmonary Arteries → Lungs (gas exchange) → Pulmonary Veins → Left Atrium.

Key Purpose:
Refreshes blood oxygen levels and removes carbon
dioxide — the essential “reset” that keeps systemic
circulation functional.

22
 The Heart: Function- Pulmonary
Circulation
Pulmonary Circulation — “The Lung Loop”
Moves oxygen-poor blood from the right ventricle to the lungs to exchange carbon dioxide for oxygen,
then returns oxygen-rich blood to the left atrium.

Pathway:
Right Ventricle → Pulmonary Arteries → Lungs (gas exchange) → Pulmonary Veins → Left Atrium.

Clinical Relevance:
Blood collected from the venous system during phlebotomy has
just left systemic circulation and is on its way to the lungs.
• Pulmonary disease (e.g., COPD, pneumonia) can lower oxygen
saturation, making blood appear darker and causing slower
venous return.

• Patients with respiratory distress may need to remain seated

upright for phlebotomy to avoid shortness of breath.

Discussion Prompt:
Why is it important to identify changes in blood color during a draw? 23
 The Heart: Function- Coronary
Circulation
Coronary Circulation — “The Heart’s Own Blood Supply”
Feeds the heart muscle (myocardium) itself with oxygen and nutrients. Without coronary blood flow, the
heart can’t function.

Pathway:
Aorta → Coronary Arteries → Myocardium → Cardiac Veins → Coronary Sinus → Right Atrium.

Key Purpose:
Provides oxygenated blood directly to the myocardium
so it can keep contracting.

24
 The Heart: Function- Coronary
Circulation
Coronary Circulation — “The Heart’s Own Blood Supply”
Feeds the heart muscle (myocardium) itself with oxygen and nutrients. Without coronary blood flow, the
heart can’t function.
Pathway:
Aorta → Coronary Arteries → Myocardium → Cardiac Veins → Coronary Sinus → Right Atrium.

Clinical Relevance:
•Blockages in coronary arteries cause myocardial infarction
(heart attack) — damaged cells release Troponin and CK-
MB, tests that phlebotomists often draw STAT.

•Patients recovering from MI may have edema, poor

perfusion, or fragile veins.

•Understanding coronary circulation helps phlebotomists

respond appropriately to STAT orders labeled “rule out MI”
or “Troponin x3.”

25
 The Heart: Function- Summary

The heart and its three circulations form a continuous, closed-loop system:
•Pulmonary circulation oxygenates blood.
•Systemic circulation delivers that oxygen to tissues.
•Coronary circulation keeps the pump itself alive.

When one circuit is disrupted, all others suffer — and phlebotomists will see the effects in blood
color, flow rate, vein quality, and patient condition.

Analogy:
Think of the circulations like a three-phase assembly line:
1. Pulmonary → refills the oxygen tank.
2. Systemic → delivers the product to the customer.
3. Coronary → powers the factory itself.

26
 The Heart: Function- Summary

The heart and its three circulations form a continuous, closed-loop system:
•Pulmonary circulation oxygenates blood.
•Systemic circulation delivers that oxygen to tissues.
•Coronary circulation keeps the pump itself alive.

Clinical Integration to Phlebotomy:

•The type of blood (oxygenated or deoxygenated) explains
its color and flow during venipuncture.

•The health of each circulation affects how easily blood can

be collected:
• Low cardiac output = weak veins.
• Respiratory disease = darker, sluggish blood.
• Coronary disease = urgent draws for cardiac
enzymes.

•Knowing these systems helps you interpret why some

patients bleed longer or why certain tests (like troponin or
BNP) are critical for diagnosis 27
 BLOOD VESSELS —
STRUCTURE, FUNCTION, AND
CLINICAL RELEVANCE

28
 BLOOD VESSELS : STRUCTURE-The Vascular
Pathways of Circulation

Blood vessels form the network — or vascular tree — that connects every part of the body to the heart.
They are flexible, hollow tubes that expand and contract as blood flows.

Analogy:
Imagine the circulatory system like a city highway system:

There are three main types of blood vessels:

1. Arteries – carry blood away from the heart- wide, high-speed outgoing roads.
1. use muscular pressure

2. Veins – carry blood back to the heart- slower return routes with stoplights (valves).
1. use valves and skeletal muscle

3. Capillaries – connect arteries and veins for nutrient and gas exchange- the neighborhood side
streets where exchange happens.
1. rely on diffusion.

Together, they maintain a continuous loop of blood flow that nourishes tissues and removes waste.
29
 BLOOD VESSELS : Structure of Arteries

Although all blood vessels share the same basic layers, their structure and function differ according to their role in
circulation.
Phlebotomists primarily work with veins because they are close to the surface, low-pressure, and have one-way
valves.
Arteries — The Delivery System

Structure: Thick tunica media; elastic and muscular to handle high pressure.

Function: Efferent vessels carry oxygenated blood away from the heart
to tissues (except pulmonary arteries).

Characteristics:
• Deeply located (protected by muscles).
• Strong pulse.
• Bright red blood under pressure.
Phlebotomy Relevance: Artery
• Never intentionally puncture an artery.
• Accidental arterial puncture = bright red spurting blood; apply firm pressure for ≥5 minutes and notify
supervisor.
• Arterial samples are only collected by trained personnel for blood gas testing.
30
 BLOOD VESSELS : Structure of Veins

Although all blood vessels share the same basic layers, their structure and function differ according to their role in
circulation.
Phlebotomists primarily work with veins because they are close to the surface, low-pressure, and have one-way
valves.
Veins — The Return Pathway

•Structure: Thinner walls, larger diameter, valves to prevent backflow.

•Function: Afferent vessels Return deoxygenated blood to the heart

under low pressure.

•Characteristics:
• Superficial veins visible under the skin (ideal for venipuncture).
• Collapse easily if internal pressure drops or tourniquet too tight. Vein
• Darker blood with slower flow.

•Phlebotomy Relevance:
• Primary sites: Median Cubital, Cephalic, Basilic veins in antecubital fossa.
• Vein “bounce” indicates proper elasticity and blood volume.
• Avoid excessive probing — can damage vein wall (phlebitis). 31
• Rotate sites for frequent draws to prevent sclerosis (hardening).
 BLOOD VESSELS : Structure of Capillaries

Although all blood vessels share the same basic layers, their structure and function differ according to their role in
circulation.
Phlebotomists primarily work with veins because they are close to the surface, low-pressure, and have one-way
valves.

Capillaries — The Exchange Network

Structure: One-cell-thick endothelial layer; no muscle or connective tissue.

Function: Site of nutrient, oxygen, and waste exchange between blood

and tissues.
Capillaries
Characteristics:
• Microscopic; connect arterioles to venules.
• Blood flow is slow to allow diffusion.

Phlebotomy Relevance:
• Capillary (dermal) punctures are used for small-volume tests or pediatric patients.
• Capillary samples contain a mix of arterial and venous blood — explaining differences in values compared to
venous samples.
• Warming the site increases capillary flow for better specimen quality. 32
 BLOOD VESSELS : STRUCTURE-The Three Tunics

All arteries and veins (except capillaries) share the same three-layered structure — called
tunics. Each layer has a unique function that affects how blood flows and how the vessel
responds to injury or pressure.
1. Tunica Intima (Inner Layer)
•Structure: Single layer of smooth endothelial cells with a
thin elastic membrane.

•Function: Provides a frictionless surface for blood flow;

regulates passage of materials and prevents clot formation.

•Phlebotomy Relevance:
• This layer is continuous with the heart’s
endocardium — damage to it (from rough needle
insertion or prolonged tourniquet use) triggers
platelet activation and clotting.

• The health of the tunica intima determines vein

elasticity and ease of venipuncture.
33
 BLOOD VESSELS : STRUCTURE-The Three Tunics

All arteries and veins (except capillaries) share the same three-layered structure — called tunics. Each
layer has a unique function that affects how blood flows and how the vessel responds to injury or
pressure.
[Link] Media (Middle Layer)
•Structure: Smooth muscle and elastic tissue.

•Function: Controls vessel diameter and blood pressure

through vasoconstriction (narrowing) and vasodilation
(widening).
• Arteries: Have a thick tunica media to withstand high
pressure from the heart.
• Veins: Have a thinner tunica media — lower pressure,
less muscle.

•Phlebotomy Relevance:
• When the tourniquet is applied, the tunica media
allows veins to expand, creating the “bounce” we
palpate.
• In elderly patients, decreased elasticity in the tunica
media can make veins more fragile, leading to rolling 34
or collapsing veins.
 BLOOD VESSELS : STRUCTURE-The Three Tunics

All arteries and veins (except capillaries) share the same three-layered structure — called tunics. Each
layer has a unique function that affects how blood flows and how the vessel responds to injury or
pressure.

[Link] Adventitia (Outer Layer)

•Structure: Connective tissue containing collagen fibers,
small blood vessels (vasa vasorum), and nerves.

•Function: Anchors the vessel to surrounding tissues and

provides structural support.

•Phlebotomy Relevance:
• A well-developed adventitia prevents veins from
tearing when tension is applied during venipuncture.

• Excessive probing or poor anchoring can damage this

layer, resulting in hematoma or phlebitis.

35
 BLOOD VESSELS : STRUCTURE-The Three Tunics

Clinical Importance for

Layer (Tunica) Composition Primary Function
Phlebotomy

Smooth blood flow; prevents Damaged by rough needle

Intima Endothelial lining
clots insertion

Smooth muscle + elastic Affects vein filling &

Media Controls diameter & flow
fibers “bounce”

Adventitia Connective tissue Strength, protection, stability Prevents tearing during draw

36
 BLOOD VESSELS : Clinical Relevance: How Vessel
Structure Affects Blood Collection

1. Hematoma Formation
1. Occurs when the needle passes through a vein, causing blood to leak into surrounding tissue (damaged
tunica adventitia).
2. Prevention: proper angle (15–30°) and firm post-draw pressure.

2. Vein Collapse
1. Happens when internal pressure drops or suction is too strong (fragile tunica media).
2. Prevention: use smaller tubes or syringe draw for fragile veins.

3. Phlebitis
1. Inflammation of the vein wall (especially tunica intima).
2. Prevention: use aseptic technique and rotate collection sites.

4. Nerve or Arterial Injury

1. Due to deep needle insertion near the brachial artery or median nerve.
2. Prevention: stay within the median cubital area; avoid basilic vein in
inexperienced hands.

5. Elderly & Pediatric Considerations

1. Thinner vessel walls (weakened media/adventitia) → reduced elasticity.
2. Use smaller gauge needles and gentle vacuum to prevent collapse or bruising. 37
 BLOOD VESSELS : Arteries vs Veins vs Capillaries

Arteries – The Delivery Capillaries – The Exchange

Feature Veins – The Return Pathway
System Network

• Thick tunica media (muscular • Thinner walls • One-cell-thick endothelial

& elastic) • Larger lumen layer
Structure
• Narrow lumen • Contain valves to prevent • No muscle or connective
• No valves backflow tissue

Carry oxygenated blood away Allow exchange of gases,

Return deoxygenated blood to
Function from the heart (except nutrients, and waste between
the heart under low pressure
pulmonary arteries) blood and tissues

Deep within muscles for More superficial, especially in Found between arterioles and
Location
protection limbs venules in all tissues

Very low pressure, slow flow to

Pressure & Flow High pressure, strong pulse Low pressure, steady flow
permit exchange

Blood Color Bright red (oxygen-rich) Dark red (oxygen-poor) Mixed (arterial + venous)

Thick elastic walls allow One-way valves prevent pooling Extremely thin walls facilitate
Special Features
expansion during systole and backflow diffusion

38
 BLOOD VESSELS : Arteries vs Veins vs Capillaries

• Never intentionally
• Primary site for • Used for capillary
puncture — risk of severe
venipuncture (Median (dermal) punctures in
bleeding
Cubital, Cephalic, Basilic) infants or small-volume
• Accidental arterial
• Vein “bounce” indicates tests
Clinical Relevance puncture: bright red
good flow • Sample is mixed blood
spurting blood
• Avoid probing — can → explains test variation
• Requires ≥5 min
cause phlebitis or • Warm site to increase
pressure and immediate
hematoma flow
report
Glucose, hematocrit,
Routine venipuncture –
Common Clinical Tests Arterial Blood Gas (ABG) point-of-care testing
CBC, chemistry panels
(POCT)
Not a phlebotomy site Use lancet, gentle
Phlebotomy Technique Preferred for all standard
(specialized training pressure, no squeezing to
Notes blood draws
required) avoid hemolysis

39
From Last Class………

[Link]

40
 BLOOD COMPOSITION — COMPONENTS,
FUNCTIONS, AND CLINICAL RELEVANCE

What Is Blood and Why It Matters

• . A specialized connective tissue made of cells and plasma that carries life-sustaining materials
through the body.
• It delivers oxygen, carries nutrients, removes waste, fights infection, and helps stop bleeding.
• It travels through more than 70,000 miles of blood vessels, reaching every cell of the body. With each
heartbeat, the heart pushes blood through arteries, capillaries, and veins — a complete circuit that
repeats over 1,000 times a day.
• Without proper blood circulation and composition, no organ or tissue can survive — which is why
blood testing gives a “snapshot” of how healthy the body is.
Analogy:
Blood is like a city’s delivery system — the plasma is the highway, carrying trucks (cells) full of oxygen,
nutrients, and repair supplies to every neighborhood (organ). When a phlebotomist draws blood, they’re taking
a sample of everything happening in that city.
Clinical Relevance:
Every tube of blood you draw tells a story about a patient’s organs, nutrition, and immune system. If a sample is
mishandled — shaken too hard, drawn incorrectly, or left too long before processing — that story becomes
inaccurate. Understanding what’s in the blood helps you protect the accuracy of that story.

41
 BLOOD COMPOSITION — COMPONENTS

Component Percentage Description

.
Straw-colored fluid
• Plasma.
• Water. (90-92%)
• Solutes.
• Electrolytes
Plasma (Liquid • Enzymes
~55% • Glucose
Portion)
• Hormones
• Lipids
• Proteins
• Metabolic substances

• Erythrocytes
(RBCs-99%)
• Leukocytes
Formed Elements
~45% (WBCs)
(Cellular Portion)
• Platelets
(thrombocytes
suspended in plasma.

42
BLOOD COMPOSITION — FORMED ELEMENTS

The formed elements are the “active workers” of blood — the red cells that carry oxygen, the white cells
that defend against infection, and the platelets that repair vessel injury.

•Who: Erythrocytes (RBCs), Leukocytes (WBCs), and Thrombocytes (platelets).

•What: Solid components suspended in plasma.
•Where: Produced in the red bone marrow and released into circulation.
•How: Formed through a process called hematopoiesis.
•Why: Each plays a critical role in maintaining oxygenation, defense, and clotting.

Clinical Relevance:
The ratio between plasma and cells affects lab results:
•Dehydration → decreased plasma volume → high hematocrit.
•Overhydration → diluted plasma → low hematocrit.
•Hematocrit is part of a CBC (Complete Blood Count).

•Hematocrit=% of whole blood made up of RBC. It reflects how much of the blood’s volume is occupied by cells versus plasma.

43
 BLOOD CELL FORMATION- HEMATOPOIESIS

Hematopoiesis is the process of blood cell formation —All blood cells start from a hematopoietic stem
cell in the red bone marrow (mainly in sternum, ribs, vertebrae, pelvis).
1. Differentiation Pathways:
•Stem cells divide and specialize into two main lineages:
• Myeloid Line → RBCs, platelets, and most WBCs (except lymphocytes).
• Lymphoid Line → Lymphocytes (T-cells, B-cells).

[Link] & Maturation:

•RBCs lose their nucleus before entering circulation.
•WBCs mature in bone marrow or lymph tissue.
•Platelets break off from megakaryocytes.

[Link]:
•Hormones like erythropoietin (EPO) from kidneys stimulate RBC production when
oxygen levels drop. 44
 BLOOD CELL FORMATION- HEMATOPOIESIS

Hematopoiesis is the process of blood cell formation —All blood cells start from a hematopoietic stem
cell in the red bone marrow (mainly in sternum, ribs, vertebrae, pelvis).

Clinical Relevance:
•Chemotherapy, radiation, or bone
marrow disease can damage this factory
→ low blood counts (pancytopenia).

•Anemia, leukopenia, and

thrombocytopenia are common results of
bone marrow suppression.

•Blood transfusions or bone marrow

transplants may be needed when
production fails.
45
BLOOD CELL FORMATION- HEMATOPOIESIS

46
 BLOOD-ERYTHROCYTES (RBCs):
THE OXYGEN CARRIERS

Red blood cells (RBCs) make up about 99% of all formed elements and are the reason blood appears red. Their
main job is to transport oxygen to tissues and carbon dioxide to the lungs for removal.

•Who: Biconcave disc-shaped cells without a nucleus.

•What: Contain hemoglobin, the iron-based protein that binds oxygen.
•Where: Circulate through arteries, capillaries, and veins for about 120 days.
•How: Pick up oxygen in the lungs, deliver it to tissues, and return carbon dioxide
to be exhaled.
•Why: Every organ depends on this exchange to survive.

Analogy:
RBCs are like delivery trucks carrying oxygen “packages” to the tissues and picking up waste on the return trip.

Clinical Relevance:
•Anemia: Too few RBCs → pale skin, fatigue, poor healing.
•Polycythemia: Too many RBCs → thick blood, risk of clots.
•Hemolysis: RBCs rupture (from small needles, shaking tubes, or prolonged tourniquet use) → inaccurate lab
results.
•Phlebotomy Tip: Avoid excessive suction and use correct gauge to protect RBCs during collection.
47
 BLOOD-LEUKOCYTES (WBCS):
THE DEFENSE TEAM

White blood cells (WBCs) protect the body from infection. Although they make up less than 1% of blood volume,
they are vital for immunity and healing.

•Who: Five major types — Neutrophils, Lymphocytes, Monocytes, Eosinophils, Basophils.

•What: Patrol the bloodstream and tissues, attacking pathogens and clearing debris.
•Where: Circulate in the blood and migrate into tissues when needed.
•How: Identify invaders, engulf or destroy them, or release antibodies.
•Why: They prevent infection and maintain immune defense.

Analogy:
WBCs are like the city’s police and cleanup crew — they detect intruders, destroy them,
and clean up the aftermath.

Clinical Relevance:
•Leukocytosis: Elevated WBC count → infection or inflammation.
•Leukopenia: Low count → viral infection, chemotherapy, or immune suppression.
•Phlebotomy Connection: WBC counts are part of CBC tests. Excessive Shaking
can destroy WBCs or Contamination of tubes (e.g., not following order of draw) can cause false abnormal
counts. 48
 BLOOD-LEUKOCYTES (WBCS):
THE DEFENSE TEAM

Neutrophils are the first white blood cells to arrive at the site of infection or injury —
typically within minutes to hours.

Neutrophils: The Body’s Rapid-Response Team

•Appearance: Multi-lobed nucleus; light-staining cytoplasm.
•Function:
• Engulf (phagocytize) bacteria and debris.
• Release enzymes and antimicrobial chemicals to destroy invaders.
• Form pus — the remains of dead neutrophils, bacteria, and tissue fluid.

•Lifespan: Short (6–8 hours in circulation; a few days in tissue).

•Origin: Produced in bone marrow (myeloid line).

Analogy:
If the immune system were a fire department, neutrophils are the firefighters who arrive first,
douse the flames, and contain the emergency until the specialists arrive.
49
 BLOOD-LEUKOCYTES (WBCS):
THE DEFENSE TEAM

Neutrophils are the first white blood cells to arrive at the site of infection or injury — typically within
minutes to hours.

Neutrophils: The Body’s Rapid-Response Team

Clinical Relevance for Phlebotomists

•Elevated neutrophil count (neutrophilia) often signals acute bacterial infection — common in CBC
results.

•Sites of inflammation (e.g., cellulitis, abscesses) are unsafe for venipuncture due to fragile tissue,
contamination risk, and inaccurate test results.

•Patients on steroids or chemotherapy may not show typical inflammation signs because WBC function
is suppressed.

•During infection, blood becomes more viscous; ensure adequate mixing of tubes to prevent clotting.

50
 BLOOD-LEUKOCYTES (WBCS):
THE DEFENSE TEAM

Inflammation is the body’s first line of defense — a protective response triggered whenever tissue is injured or
invaded by microorganisms.
It’s how the body begins to contain damage, destroy invaders, and start healing.

Latin Term Meaning Physiological Cause Phlebotomy Connection

May see reddened or warm

Rubor Redness Increased blood flow (vasodilation) area on patient’s skin — avoid
drawing from that site

Local temperature rise —

Calor Heat Warm blood arriving at site
inflammation or infection

Puffy or tight skin = harder

Tumor Swelling Plasma and WBCs leaking into tissue (edema)
vein access

Pressure from swelling; release of chemicals Patient may flinch or be

Dolor Pain
like prostaglandins sensitive at affected site

May limit movement of limb

Functio Laesa Loss of Function Tissue damage or restricted motion or complicate venipuncture
positioning

51
 BLOOD-LEUKOCYTES (WBCS):
THE DEFENSE TEAM

White blood cells (WBCs) are the immune soldiers of the blood. They protect the body from infection,
foreign invaders, and abnormal cells like cancer.

Mnemonic: Never Let Monkeys Eat Bananas

Type Function (Neutrophils, Lymphocytes, Monocytes,
Eosinophils, Basophils)
Neutrophils First responders; engulf bacteria ↑ in bacterial infections
Lymphocytes Produce antibodies; remember infections ↑ in viral infections
Monocytes Clean up dead cells/debris ↑ in chronic infection
Eosinophils Fight parasites/allergies ↑ in asthma or allergies
Basophils Release histamine during inflammation ↑ in allergic reactions

Discussion Prompt
True or False. Without WBCs, even a small infection could become life-threatening?
• True 52
 BLOOD-PLATELETS (THROMBOCYTES):
THE FIRST RESPONDERS FOR REPAIR

Platelets are tiny cell fragments that play a huge role in stopping bleeding. They are the “first responders”
when a blood vessel is injured, working with plasma proteins to form clots and repair damage.

•Who: Fragments of large bone marrow cells called megakaryocytes.

•What: Gather at the site of vessel injury to start clotting.
•Where: Circulate freely in the bloodstream for 7–10 days.
•How: Stick to exposed vessel walls, clump together (aggregation), and trigger the
coagulation cascade.
•Why: Without platelets, even a small cut could lead to uncontrolled bleeding.

Normal Count:150,000 – 400,000 per µL of blood.

Analogy:
Platelets act like road repair workers — when a pothole (vessel injury) forms,
they rush in, block traffic, and fill the hole to keep the system running.

53
 BLOOD-PLATELETS (THROMBOCYTES):
HEMOSTASIS AND THE COAGULATION CASCADE

Hemostasis stops flow of blood from injury and involves four major events:

1. Vascular Spasm (Vasoconstriction):

Vessel narrows immediately to slow blood flow.

2. Platelet Plug Formation:

Platelets stick to the damaged vessel wall and each other (primary hemostasis).
They release chemicals (ADP, serotonin, thromboxane A₂) that recruit more platelets.

3. Coagulation (Secondary Hemostasis):

Clotting factors in plasma activate in a cascade to form fibrin, a sticky protein mesh.
Fibrin traps RBCs and WBCs, creating a stable clot.

4. Clot Retraction and Repair:

The clot tightens and pulls wound edges together while new tissue repairs the vessel.

Fibrinolysis:
Once healed, the enzyme plasmin dissolves the clot to restore normal blood
• .
54
 BLOOD-PLATELETS (THROMBOCYTES):
HEMOSTASIS AND THE COAGULATION CASCADE

The coagulation cascade is divided into three interconnected pathways: Intrinsic, Extrinsic, and
Common. Each pathway represents a different route to achieve the same goal: formation of fibrin.

1. Intrinsic Pathway – The Vessel Injury Pathway

What triggers it: Damage inside the vessel or to the endothelium (inner lining).
Where it occurs: Within the bloodstream.
How it works: All necessary factors are intrinsic (already in the blood).

2. Extrinsic Pathway – The Tissue Damage Pathway

What triggers it: Damage outside the vessel — from tissue trauma (cuts, bruises, surgery).
Where it occurs: Begins when tissues release a substance called tissue factor (Factor III).
How it works: A faster, “shortcut” route to activate the cascade.

3. Common Pathway – Where Both Routes Unite

What triggers it: Activation of Factor X by either pathway.
Where it occurs: Final shared steps of the cascade.

[Link]
55
 BLOOD-PLATELETS (THROMBOCYTES):
THE FIRST RESPONDERS FOR REPAIR

Platelets are tiny fragments of large bone marrow cells (megakaryocytes) that circulate in
blood and seal injuries to prevent bleeding.

Clinical Relevance:
•Low Platelet Count (Thrombocytopenia): Causes easy bruising and prolonged bleeding;
apply extra pressure after draws.

•High Platelet Count (Thrombocytosis): May increase risk of blood clots.

•Specimen Handling: Over-shaking tubes can prematurely activate platelets and cause
micro-clots that ruin test accuracy.

Discussion Prompt
1. How would your venipuncture care differ for a patient on anticoagulants or with a low platelet count?
• apply firm pressure for a longer time after venipuncture, use a smaller needle if appropriate, avoid
probing, and closely monitor the site for bleeding or bruising.

2. What color tube test for clotting factors?

• Light Blue
56
 BLOOD-PLATELETS (THROMBOCYTES):
WHAT PHLEBOTOMIST NEED TO KNOW

Clinical Application Examples:

1. Dehydrated patient: Plasma volume ↓ → veins collapse → slower blood flow → difficult
venipuncture.

2. Patient on blood thinners (warfarin/heparin): Platelet plug forms slowly → extend post-draw
pressure.

3. Patient with anemia: Fewer RBCs → less hemoglobin → darker, thinner blood; collect carefully to
prevent hemolysis.

4. Patient with infection: WBC count ↑ → CBC ordered STAT to determine infection type.

Why It Matters:
When you draw a tube of blood, you’re not just collecting “red fluid” — you’re sampling a living,
dynamic system. Each component tells something unique about the patient’s health and helps doctors
make informed decisions.
57
 BLOOD-PLASMA AND SERUM

•Who: The liquid portion of blood that remains after cells are separated — either
plasma or serum.
•What: Plasma and serum look similar (pale yellow fluid) but differ in whether
clotting factors are present.
•Where: Both are obtained from blood samples after collection and centrifugation.
•How: The difference depends on whether an anticoagulant was used in the tube.
•Why: Knowing which one is needed helps ensure the right tests are performed
accurately — because some tests require clotting factors, while others do not.

Analogy:
Think of blood like milk:
•Plasma is the “whole milk” — it still has all its natural proteins (like clotting
factors).
•Serum is the “skim milk” — the clotting proteins have been removed.

58
 BLOOD-PLASMA AND SERUM

Plasma is the fluid portion of blood that has not clotted. It still contains
all clotting factors such as fibrinogen, prothrombin, and other proteins.

How It’s Collected:

•Blood is drawn into a tube containing an anticoagulant (e.g., EDTA,
citrate, or heparin).
•The sample is centrifuged — the cells sink to the bottom, and the plasma
rises to the top.
•Plasma = the supernatant (top layer).

Component Function
Water (≈90%) Solvent for transport of nutrients and waste
Albumin (maintains osmotic pressure), Globulins
Plasma Proteins (≈7%)
(immunity), Fibrinogen (clotting)
Nutrients & Electrolytes Glucose, amino acids, calcium, potassium
Hormones & Enzymes Regulate metabolism
Waste Products CO₂, urea, lactic acid
59
 BLOOD-PLASMA AND SERUM

Plasma is the fluid portion of blood that has not clotted. It still contains all clotting factors such as
fibrinogen, prothrombin, and other proteins.

Component Function
Water (≈90%) Solvent for transport of nutrients and waste
Albumin (maintains osmotic pressure), Globulins
Plasma Proteins (≈7%)
(immunity), Fibrinogen (clotting)
Nutrients & Electrolytes Glucose, amino acids, calcium, potassium
Hormones & Enzymes Regulate metabolism
Waste Products CO₂, urea, lactic acid

Clinical Relevance:
•Used for coagulation tests (PT, aPTT, fibrinogen) because it contains intact clotting factors.
•Light-blue tube (sodium citrate) → plasma specimen for coag studies.
•Green-top tube (heparin) → plasma specimen for chemistry tests.
•Improper mixing can form microclots, invalidating results.
Phlebotomy Tip:
Gently invert anticoagulant tubes 5–10 times immediately after collection to mix and prevent clotting.
60
 BLOOD-PLASMA AND SERUM

Serum is the liquid portion of blood after it has clotted. It is plasma minus fibrinogen and other clotting factors.

How It’s Collected:

Blood is drawn into a tube without anticoagulant (e.g., red-top or gold SST).
The blood clots naturally within 30 minutes.
Centrifugation separates the clot (bottom) from the clear serum (top).

Component Function

Water (≈90%) Carries nutrients, hormones, waste

Proteins (≈7%) Albumin, immunoglobulins (no fibrinogen)

Chemicals Electrolytes, glucose, lipids, enzymes

Hormones Thyroid, reproductive, and metabolic regulation

Clinical Relevance:
•Used for chemistry tests (electrolytes, glucose, cholesterol, enzymes, hormones) and serology (antibody testing).
•Preferred for many automated chemistry analyzers because it lacks fibrin, which can clog instruments.
•Serum separates cleanly when clotted completely — incomplete clotting can trap RBCs and skew results.
Phlebotomy Tip:
Allow red or SST tubes to sit undisturbed for 30 minutes before centrifuging. Premature spinning yields fibrin strands →
causes analyzer errors.
61
 BLOOD-ABO & RH

The ABO system is based on the presence or absence of A and B antigens on the red blood cell surface
and the corresponding antibodies in the plasma.

•Who: Every person has specific antigens on the surface of their red blood cells (RBCs) that determine
their blood type.
•What: These antigens belong mainly to two systems — the ABO system and the Rh system.
•Where: Located on the RBC membrane.
•How: The presence or absence of specific antigens and antibodies defines blood compatibility.
•Why: Knowing a patient’s blood type prevents dangerous transfusion reactions and guides safe
laboratory and transfusion practices.

Analogy:
Think of blood type as an “ID badge” on your RBCs. If a foreign badge (antigen) enters, your immune
system attacks it like a security guard removing an intruder.

•Type A blood cells wear “A” name tags.

•Type B blood cells wear “B” tags.
•Type AB cells wear both — accepted everywhere.
•Type O cells wear no tags — they can visit anyone, but only receive from others with no tags (O). 62
 BLOOD-ABO & RH

The ABO system is based on the presence or absence of A and B antigens on the red blood cell surface
and the corresponding antibodies in the plasma.

63
 BLOOD-ABO & RH
Agglutination Reaction

When mismatched blood types are mixed, the antibodies in the recipient’s plasma attach to the donor’s
RBC antigens. This causes agglutination — visible clumping of red cells — followed by
hemolysis (destruction)

• Blood type A

• Blood type B

• Blood type AB

• Blood type O
64
 BLOOD-ABO & RH

The ABO system is based on the presence or absence of A and B antigens on the red blood cell surface
and the corresponding antibodies in the plasma.

Antibodies in
Blood Type Antigens on RBCs Can Receive From Can Donate To
Plasma
A A Anti-B A, O A, AB
B B Anti-A B, O B, AB
A, B, AB, O
AB A and B None AB only
(Universal Recipient)
A, B, AB, O
O None Anti-A and Anti-B O only
(Universal Donor)

65
 BLOOD-ABO & RH

The Rh system is based on the presence (+) or absence (–) of the Rh (D) antigen on the RBC surface.

Rh Type Antigen Present? Can Receive From Can Donate To

Rh Positive (+) Yes (D antigen present) + or – + only
Rh Negative (–) No (D antigen absent) – only + or –

Clinical Relevance:
•Rh incompatibility occurs when Rh– individuals are exposed to Rh+ blood → their immune system forms
anti-D antibodies.
•During pregnancy, an Rh– mother carrying an Rh+ baby can form antibodies that attack fetal RBCs (a
condition called Hemolytic Disease of the Newborn).
•Rh immune globulin (RhoGAM) is given to prevent this reaction.

Analogy:
If ABO blood types are “name tags,” the Rh factor is the “plus or minus sticker” attached to the badge. It
doesn’t change who you are, but it determines who you can safely interact with.
66
 BLOOD-ABO & RH

Situation Why It Matters

Cross-matching Lab ensures donor and recipient blood are compatible before transfusion.

Giving incompatible blood causes agglutination (clumping) → hemolysis

Transfusion errors
→ kidney failure or death.

Mistyped or mislabeled blood type specimens are among the most serious
Specimen labeling
lab errors. Always check patient ID carefully.

Prenatal screening Determines Rh factor and antibody status in pregnant patients.

Type O- blood is used as the universal donor in life-threatening

Emergency transfusions
emergencies.

67