Phlebotomy NHA Questions and Answers

Phlebotomy NHA Questions and Answers Role of the phlebotomist 1. Collect routine capillary and venous specimens for testing as requested 2. Prepare specimen for transport, ensuring its stability. 3. Transport specimen to the laboratory 4. Promote good public relations with hospital staff and patients 5. Comply with new and revised procedures as described in the procedures manual 6. Assist in collecting and documenting monthly workload and recording data 7. Maintain safe working conditions 8. Perform laboratory computer operations 9. Participate in continuing education programs 10. Perform other tasks assigned by supervisory personnel. Characteristics that a phlebotomist should have: Requires professional behavior at all times A. Dependability B. Honesty C. Integrity D. Empathy and Compassion E. Professional Appearance F. Interpersonal Skills Ethical Behavior Entails conforming to a standard of right and wrong to avoid harming the patient in any way. Standards of right and wrong called "code of ethics" provide personal and professional rules of performance and moral behavior that all phlebotomists are expected to follow. Places where phlebotomists can work: Physician Office Laboratories: can range from simple screening test done in a single practice office or specialized testing done in large group practices. Reference Laboratories: large independent laboratories perform routine and highly specialized test that cannot be done in smaller ones. (on site or off site) Urgent Care Centers Nursing Home Facilities Wellness clinics The Circulatory System Function is to deliver oxygen, nutrients, hormones, and enzymes to the cells (exchange at capillary level) and to transport cellular waste such as carbon dioxide and urea to the organs (lungs, kidneys) where they can be expelled from the body. It's a transport system The heart Acts as 2 pumps in a series, connected by 2 circulations with each pump equipped with 2 valves, the function of which is to maintain a 1-way flow of blood. Has 2 circulations: 1. Pulmonary circulation: carries deoxygenated blood from right ventricle to the lungs (oxygenated) and returns oxygenated blood from the lungs to the left atrium 2. Systemic Circulation: carries oxygenated blood from the left ventricle throughout the body. Each side of the heart is composed of an upper chamber, atrium, lower chamber and ventricle Right side has 2 valves: Tricuspid valve: atrioventricular valve, being situated between the right atrium and right ventricle Pulmonic valve: semi lunar valve situated between the right ventricle and the pulmonary artery Left side has 2 valves: Mitral Valve: (bicuspid) another atrioventricular valve, between left atrium and left ventricle Aortic valve: semi lunar valve situated between the left ventricle and the aorta Layers of the heart Endocardium: endothelial lining of the heart Myocardium: muscular layer. this is the contractile element of the heart Epicardium: fibrous outer layer of the heart. Coronary arteries, which supply blood to the heart, are found in this layer Blood Vessels: They are: Aorta, arteries, arterioles, capillaries, venules, veins, superior and inferior vena cavae. -Aorta, arteries, and arterioles carry oxygenated blood from the heart to the various parts of the body -Venules, veins, and the superior and inferior vena cavae carry de-oxygenated blood back to the heart Layers of blood vessels: Tunica Adventitia: outer connective tissue layer Tunica media: middle smooth muscle layer Tunica intima: inner endothelial layer Capillaries: composed of only a layer of endothelial cells, connect the arterioles and venules. Capillary blood is a mixture of arterial and venous blood. Thin walls of capillaries allow rapid exchange of oxygen, carbon dioxide, nutrients and waste products. Blood Average adult has about 5-6 liters of blood 2 Components of blood: -Plasma (55% of blood): --- contains proteins, amino acids, gases, electrolytes, sugars, hormones, minerals, vitamins, and water (92%) -Formed Elements (45% of blood): ---contains erythrocytes (RBCs), which comprise 99% of formed elements. ---Leukocytes (WBCs) ---Thrombocytes (platelets) all blood cells originate from stem cells in the bone marrow Erythrocytes Contain hemoglobin, the oxygen-carrying protein Enters blood as an immature reticulocyte. In 1-2 days it matures to a erythrocyte 4.2-6.2 million RBCs per microliter of blood. Normal Life Span: 120 days Leukocytes Function is to provide the body protection against infection Normal amount of WBCs for an adult is 5,000-10,000 per microliter Leukocytosis: increase in WBCs, seen in cases of infection and leukemia Leukopenia: decrease in WBCs, seen in viral infection or chemotherapy. 5 Types of WBCs Neutrophils: -most numerous -comprise 40%-60% of WBC population. -Are phagocytic (engulf and digest bacteria). -Their numbers increase in bacterial infection, first one to appear. Lymphocytes: -Second most numerous. -Comprises 20-40% of the WBC population. -Numbers increase in viral infection. -Play a role in immunity. Monocytes: -Comprises 3-8% of the population. -Largest WBCs. -They are monocytes while circulating in the blood, but when they pass into the tissues, they transform into macrophages and become powerful phagocytes. -Their numbers increase in intracellular infections and tuberculosis Eosinophils: -Represent 1-3% of WBC population -Active against antibody-labeled foreign molecules -Their numbers increase in allergies, skin infections, and parasitic infections Basophils: -0-1% of the WBC in the blood -Carry histamine, which is released in allergic reactions. Thrombocytes (Platelets) -Small irregularly shaped packets of cytoplasm formed in the bone marrow from megakaryocytes -Essential for blood coagulation -Average number of platelets: 140,000-440,000 per microliter of blood -Lifespan of 9-12 days Hemostasis -Process by which blood vessels are repaired after injury Stages: Primary Hemostasis: 1: Vascular Phase: injury to blood vessel causes it to constrict slowing the flow of blood 2: Platelet Phase: injury to the endothelial lining causes platelets to adhere to it -Additional platelets stick to the site finally forming a temporary platelet plug in a process called 'Aggregation' 3: Coagulation Phase: involves a cascade of interactions of coagulation factors that converts the temporary platelet plug to a stable fibrin clot. -Coagulation cascade involves an intrinsic and extrinsic system, which ultimately come together in a common way. APTT- intrinsic (heparin therapy) PT- extrinsic (coumadin therapy) Site Selection: -Preferred site for venipuncture in the antecubital fossa of the upper extermities. -The Vein should be large enough to receive the shaft of the needle, and it should be visible or palpable after tourniquet placement 3 Major Veins: A. Median Cubital Fossa- the vein of choice because it is large and does not tend to move when the needle is inserted B. Cephalic Vein: the second choice. Usually more difficult to locate and has a tendency to move, however, it is often the only vein that can be palpated in the obese patient C. Basilic Vein: the third choice. Least firmly anchored and located near the brachial artery. If the needle is inserted too deeply, this artery may be punctured Unsuitable veins: Sclerosed Veins: veins feel hard or chordlike -Can be caused by disease, inflammation, chemotherapy, or repeated venipunctures Thrombotic Veins: Tortuous Veins: Winding or crooked veins. Veins are susceptible to infection, and since blood flow is impaired, the specimen may produce erroneous test results. ***Do NOT draw blood in an arm with an TV running into it ***Do NOT draw blood from an artificial a-v fistula (dialysis) Venipuncture Recommended Supplies: -Laboratory Requisition slip and pen -Antiseptic (70% isopropyl alcohol--best) (Povidone-iondine or chlohexidine gluconate) -Vacutainer tubes: color-coded for specific tests -Vacutainer Needles: Disposable, needle sizes differ in length and gauge. The smaller the gauge, the bigger the needle -Needle Adapters: Tube holder -Winged Infusion sets (WIS): used for venipuncture on small veins, used on elderly and pediatric patients. Most common size is 23 gauge, 1/2 to 3/4 inch long -Sterile Syringes and needles: 10-20 mL syringe -Tourniquets: prevents the venous outflow of blood from the arm causing the veins to buldge thereby making it easier to locate the veins. -Chux: impermeable pad used to protect the patient's clothing and bedding -Specimen labels -Gloves: always worn -Needle Disposal container: clearly marked, puncture resistant biohazard disposal container Never recap a needle without a safety device Complications associated with phlebotomy Hematoma: most common, indicates that blood has accumulated in the tissue surrounding the vein. Caused by needle going through the vein and or failure to apply enough pressure on site after needle withdrawal. Hemoconcentration: increase in proportion of formed elements to plasma caused by tourniquet left on too long Phlebitis: inflammation of vein as a result of repeated venipuncture on that vein Petechia: tiny non-raised red spots that appear on the skin from rupturing of the capillaries due to tourniquet left on too long or too tight Thrombus: blood clot usually a consequence of insufficient pressure applied after the withdrawal of the needle Thrombophlebitis: inflammation of vein with formation of a clot Septicemia: systemic infection associated with the presence of pathogenic organism introduced during venipuncture Trauma: injury to underlying tissue caused by probing of needle. Factors to consider prior to performing the procedure: Fasting: some tests (glucose, cholesterol, and triglycerides) require that the patient abstain from eating for at least 12 hours. Edema: accumulation of fluid in the tissues. Collection from edematous tissue alters test results Fistula: permanent surgical connection between an artery and vein. Used for dialysis and must NEVER be used for venipunctures due to increased risk for infection. Quality Assurance (QA) QA: defined as a program that guarantees patient care by tracking the outcomes through scheduled audits in which areas of the hospital look at the appropriateness, applicability, and timeliness of patient care Is a continuous program that provides guidelines, protocols, and continuing education for employees Quality Control (QC): starts before the specimen is collected from the patient To obtain an acceptable specimen, the patient must be properly prepared The Phlebotomist must check the floor book to ensure all pre-test preparations have been performed. pre-test preparations include fasting. The Phlebotomist must ensure all information is correct before collecting specimen. Analytical Errors: Before collection Patient misidentification Improper time of collection Wrong tube Inadequate fast Exercise Patient Posture poor coordination with other treatments improper site perparation Medication interference Analytical Errors: During Collection Extended tourniquet time Hemolysis Wrong order of draw Failure to invert tubes Faulty technique Under Filling tubes Analytical Errors: After Collection Failure to separate serum from cell Improper use of serum separator Processing delays Exposure to light Improper storage conditions Rimming Clots Routine Venipuncture 1. Verify the requisition for the tests 2. Identify the patient: check the patients ID number and have them state their name 3. Identify yourself to the patient, explain the procedure, and secure consent 4. Palpate the veins in the antecubital fossa using your index finger 5. Gather the necessary equipment 6. Wash hands; put on gloves 7. Tie on the tourniquet; it should be applied 3-4 inches above the site where the venipuncture will be made. Ask the patient to make a fist or open and close his/her hand to help engorge the veins 8. Palpate the vein while looking for the straightest point. Cleanse the area using a circular motion starting at the inside of the venipuncture sire. 9. Assemble the needle and tube holder while the alcohol is drying. Uncap the needle and examine it for defects such as blunted or barbed point. 10. Hold the patient's arm, by placing 4 four fingers under the forearm and your thumb below the antecubital area slightly pulling the skin back to anchor the vein 11. Bevel facing upward, insert the needle at an angle 0f 15-30 degrees. 12. Once the needle is inside the vein (feel a give as the vein is entered) push the collection tube into the holder to puncture the tube stopper with the back-end of the needle 13. Release the tourniquet once blood flow has begun. The tourniquet should not be left on for more than 1 minute in order to prevent hemoconcentration 14. Fill the needed tubes, according to the order of draw 15. Pull out collection tube from the holder 16. Place folded gauze over the venipuncture side and withdraw the needle. Then apply pressure until bleeding stops. This is done to prevent hematoma. Do not ask patient to bend the arm as it does not offer enough pressure. 17. Discard needle into the biohazards shard container. 18. Label each collected specimen, writings the patient's name, I Venipunctures Do not's Do not label the tubes prior to the venipuncture Do not leave the patient's room before labeling the tubes Do not dismiss an outpatient before labeling the tubes Do not label tubes using a pencial; black ink should be used Do not leave the patient until you checked and ensure that the bleeding has stopped. Failure to Obtain Blood The Tube has lost its vacuum, This may be due to: -Manufacturing defect -Expired tube -Very fine crack in the tube Improperly position needle -the bevel of the needle is resting against the wall of the vein. Slightly rotate the needle -The needle is not fully in the vein. Slowly advance the needle. ' -The needle has passed throught the vein. Slowly pull back on the vein. -The vein was missed completely. With a gloved finger, gently determine the positions of the vein and the needle, and redirect the needle. Collapsed Vein: -excessive pull on vacuum Fasting Specimens requires collection of blood while the patient is in the basal state, that is, the patient has fasted and refrained from strenuous exercise for 12 hours prior to the drawing. It is the phlebotomists responsibility to verify if the patient indeed, has been fasting for the required time Timed Specimens Often used to monitor the level of a specific substance or condition in the patient. Blood is drawn at specific times for different reasons. They are: -To measure blood levels of substances exhibiting diurnal variation (cortisol hormone) -To determine blood levels of medications (disoxin for cardiovascular disease) -To monitor changes in a patient's condition (steady decrease in hemoglobin level) 2 Hour Postprandial Test Used to evaluate diabetes mellitus Fasting glucose level is compared with the level 2 hours after eating a full meal or ingesting a measured amount of glucose. Oral Glucose Tolerance Test (GTT) Used to diagnose diabetes mellitus and evaluate patients with frequent low blood sugar. 3-hour OGTT is used to test hyperglycemia (high blood sugar level) and diagnose diabetes mellitus 5-hour OGTT used to evaluate hypoglycemia (low blood sugar) for disorders of carbohydrate metabolism OGTT are scheduled to begin between 0700 and 0900 Therapeutic Drug Monitoring Used to monitor blood levels of certain medication to ensure patient safety and also maintain a plasma level Blood also drawn to coincide with the trough (lower blood level) or the peak (highest blood level) Trough levels are collected before the scheduled dose Time for collecting peak level vary depending on the medication, patient's metabolism, and the route of administration Blood Culture (BC) Ordered to detect presence of microorganisms in the patient's blood. The patient will usually have chills and fever of unknown origin (FUO), indicating the possible presence of pathogenic microorganisms in the blood (septicemia). Blood cultures usually ordered STAT or as timed specimens, and collection requires strict aseptic techniques PKU Test ordered for infants to detect phenylketonuria, a genetic disease that causes mental retardation and brain damage Test is done on blood from newborn's heel or on urine Special Specimen Handling: Cold Agglutinins Antibodies produced in response to Mycoplasma pneumoniae infection Antibodies formed may attach to red blood cells at temperatures below body temp, and as such, the specimen must be kept warm until the serum is separated from the cells. Blood is collected in red-topped tubes pre-warmed in the incubator at 37 C for 30 minutes Special Specimen Handling: Chilled Specimens Some tests require that the specimen collected be chilled immediately after collection in crushed ice or ice and water mixture Specimen must be immediately transported to the laboratory for processing Tests: ABGs, ammonia, lactic acid, pyruvate, ACTH, gastrin, and parathyroid hormone Special Specimen Handling: Light-sensitive specimens Specimens protected from light by wrapping the tubes in aluminum foil immediately after they are drawn Tests: Billirubin, beta-carotene, Vitamins A&B6 and porphyrins Dermal Punctures When venipuncture is inadvisable, it is possible to perform a majority of laboratory tests on micro samples obtained by dermal (skin) puncture, with the exception of ESR, blood cultures, and other tests that require a large amount of serum. Can be done on both pediatric and adult patients Depth for Dermal punctures 0.85mm for infants 3.0 mm for adults Site Selection Dermal Punctures: Infants Less than 1 year of age Areas recommended are the medial and lateral areas of the plantar surface of the foot Heel punctures for infants not exceed 2.0 mm Precautions for dermal punctures Do not puncture deeper than 2.0 mm Do not perform dermal punctures on previous puncture sites Do not use the back of the heel or arch of the foot Use the medial and lateral areas of the plantar surface of the heel Dermal Puncture: Older children and adults Distal segment of the third and fourth finger of the non-dominant hand is the recommended site Puncture is made in the fleshy portion of the finger slightly to the side of the center of the perpendicular to the lines of the fingerprint Dermal Puncture Procedure 1. Identify the patient 2. Assemble the equipment 3. Warm the site: this is an essential part of the procedure when collecting specimens for pH or blood gases. Warming the site can increase the blood flow up to seven times the normal amount. The specimen is an arterialized specimen because of the increase arterial flow to the area. This is accomplished by warming the site for a min 3 minutes with a warm moistened towel. 4. Clean the site: use 70% isopropyl alcohol. Allow the site to dry for maximum antiseptic action. Alcohol residue can cause hemolysis of the red blood cells and may interfere with glucose testing. Povidone-iodine (Betadine) is not used for cleaning the site because it interferes with several tests like billirubin, uric acid, phosphorus, and potassium 5. Prepare the puncture device 6. Perform the dermal puncture Order of Draw for capillary specimens 1. Lavender tube 2. Tubes with other additives 3. Tubes without additives