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Principles of Medical Laboratory Science, Lecture notes of Medical Sciences

Principles of Medical Laboratory Science

Typology: Lecture notes

2020/2021

Uploaded on 01/29/2023

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Bianca Adrianne C. Carilla | MLS 1-4
PMLS 2 Laboratory
Familiarization to Phlebotomy & Order of Draw
PHLEBOTOMY or venesection act of opening a
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.
phlebos which means vein, and
temnein which means to cut.
- Phlebotomy is the process of making an incision or
puncture to collect blood samples
Evolution of Phlebotomy
Stone Age used crude tools to cut vessels
and drain blood from the body.
Ancient Egyptians a form of "Bloodletting"
(1400 B.C.)
Hippocrates (460 - 377 BC) balance of the
four humors, removing the excess by
bloodletting.
Middle ages used to treat illness and
performed by barber-surgeons
Patients with Polycythemia Vera, heart
problem with overproduction of RBCs,
monthly phlebotomy for treatment
17th and 18th century treated as major
therapy
Cupping
alternative medicine
application of special heated suction cups on
the patient's skin
used to ease pain
incision using a fleam or lancet
Leeching
known as Hirudotherapy
uses leeches for bloodletting
used for microsurgical replantation
Role of Phlebotomist
(1) for diagnosis and treatment using blood
samples
Ex: Bacterial infection antibiotic, to measure
effectivity of antibiotic
(2) for transfusion, to remove blood at the donor
center
(3) for removal of blood for polycythemia or
therapeutic purposes
Credentials
important to maintain professionalism,
recognition and certification from accredited
body that is required by the healthcare
institution
Certification
Licensure
Continuing education
Patient Client Interaction
(1) Reassuring and pleasant
(2) Able to communicate well
- despite social and cultural differences
(3) Maintain positive customer relations
- smooth process, proper identification,
politeness, and proper orientation
(4) Understand the diversity of the patients and be
able to adjust accordingly
Qualities of Professionalism
(1) Professional appearance
- wearing conservative clothing and proper
personal hygiene, must be presentable
(2) Self-confidence
- the ability to trust ourselves in making a
personal decision
(3) Integrity
- honesty and consistency as part of values
and beliefs
(4) Compassion
- being sensitive to the needs of others
(5) Self-motivation
- having the positive attitude and initiative to
follow through task and continuously look for
areas of improvement
(6) Dependability
- taking personal responsibility for our
actions
(7) Ethical Behavior
- conforming with the standards to avoid
harming patients
Communication in the healthcare setting
o Verbal Communication
expressing ideas through words
o Nonverbal Communication
facial expressions, kinesics or body
motions, body language
o Active listening
able to listen and comprehend what
must be done from instructions
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PMLS 2 Laboratory Familiarization to Phlebotomy & Order of Draw PHLEBOTOMY or venesection act of opening a 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. ▪ phlebos which means vein, and ▪ temnein which means to cut.

  • Phlebotomy is the process of making an incision or puncture to collect blood samples Evolution of PhlebotomyStone Age – used crude tools to cut vessels and drain blood from the body. ▪ Ancient Egyptians – a form of "Bloodletting" (1400 B.C.) ▪ Hippocrates (460 - 377 BC) – balance of the four humors, removing the excess by bloodletting. ▪ Middle ages – used to treat illness and performed by barber-surgeons ▪ Patients with Polycythemia Vera, heart problem with overproduction of RBCs, monthly phlebotomy for treatment ▪ 17th and 18th century – treated as major therapy Cupping ▪ alternative medicine ▪ application of special heated suction cups on the patient's skin ▪ used to ease pain ▪ incision using a fleam or lancet Leeching ▪ known as Hirudotherapy ▪ uses leeches for bloodletting ▪ used for microsurgical replantation Role of Phlebotomist (1) for diagnosis and treatment using blood samples Ex: Bacterial infection – antibiotic, to measure effectivity of antibiotic (2) for transfusion , to remove blood at the donor center (3) for removal of blood for polycythemia or therapeutic purposes Credentials ▪ important to maintain professionalism, recognition and certification from accredited body that is required by the healthcare institution ✔ Certification ✔ Licensure ✔ Continuing education Patient – Client Interaction (1) Reassuring and pleasant (2) Able to communicate well - despite social and cultural differences (3) Maintain positive customer relations - smooth process, proper identification, politeness, and proper orientation (4) Understand the diversity of the patients and be able to adjust accordingly Qualities of Professionalism (1) Professional appearance - wearing conservative clothing and proper personal hygiene, must be presentable (2) Self-confidence - the ability to trust ourselves in making a personal decision (3) Integrity - honesty and consistency as part of values and beliefs (4) Compassion - being sensitive to the needs of others (5) Self-motivation - having the positive attitude and initiative to follow through task and continuously look for areas of improvement (6) Dependability - taking personal responsibility for our actions (7) Ethical Behavior - conforming with the standards to avoid harming patients Communication in the healthcare setting o Verbal Communication - expressing ideas through words o Nonverbal Communication - facial expressions, kinesics or body motions, body language o Active listening - able to listen and comprehend what must be done from instructions

Elements in healthcare communication ✔ Empathy ✔ Control ✔ Respect ✔ Confirmation ✔ Trust Verbal Communication Loop in Health care setting Health care worker ▪ maintain calmness Clinical analysis areas and the types of procedures Hospital

  • with permanent inpatient beds
  • 24 - hour nursing service
  • Managed by organized medical team 2 major divisions
  1. Anatomical and Surgical Pathology area
  2. Clinical analysis area Clinical analysis areas
  1. Hematology
  2. Coagulation
  3. Chemistry
  4. Serology
  5. Urinalysis – clinical microscopy
  6. Microbiology – bacteriology
  7. Blood bank/immunohematology HEMATOLOGY – blood and blood forming tissues NAME OF TEST AND PROCEDURES ▪ Complete Blood Count (CBC)
    1. Hematocrit (Hct) checks the hemoglobin level and the red cell count.
    2. Hemoglobin (Hgb) tests the value to rule out anemia.
      1. Red Blood Cell (RbC) count is used to measure the erythropoietic activity.
      2. White Blood Cell (WbC) count checks the leukocyte response
      3. Platelet (Plt ct) count usually used to monitor chemotherapy and radiation conditions.
      4. Differential White Count (Diff) monitors changes in the appearance or quantity of specific cell types
      5. Indices shows the changes in RBC size, weight and Hgb content
      6. Mean Corpuscular hemoglobin (MCH) gives the weight of the hemoglobin in the cell.
      7. Mean Corpuscular volume (MCV) shows the size of the cell.
      8. Mean Corpuscular hemoglobin concentration (MCHC) gives information on the concentration of the hemoglobin per unit volume of RBCs.
      9. Red blood distribution width (RDW) measures the size differences of the RBCs COAGULATION – ability of blood to form and dissolve clots NAME OF TEST AND PROCEDURES
      10. Activated partial thromboplastin time (APTT) reflects the adequacy of herapin therapy.
      11. D-dimer checks the thrombin and plasmin activity – to diagnose Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE)
      12. Fibrin split products (FSP) measures if the level is high because it results to FDP fragments.
      13. Fibrogen tests are performed to check any fibrogen deficiency.
      14. Prothrombin Time (PT) or International Normalized Ratio (INR) evaluates liver diseases or deficiency in Vitamin K CHEMISTRY – performs most lab test for plasma, white blood, urine, etc. NAME OF TEST AND PROCEDURES
      15. Alanine amino tranferase (ALT) is used to monitor liver disease.
      16. Alpha-fetoprotein (AFP) checks levels especially for prenatal screening
      17. Alkaline phosphatase (ALP) determines level to check obstructions and bone disease.
      18. Ammonia measures the level which could indicate cirrhosis and hepatitis.
      19. Amylase checks the enzyme level which could indicate liver disease, cholesystitis, etc.
      20. Aspartate amino-transferase (AST) measures the level which is indicative of liver dysfunction.
      21. Bilirubin shows the level in the bloodstream that shows red blood destruction

▪ Leukocyte – indicates urinary tract infection if there is a lot of neutrophils ▪ pH – indicates in acid-base balance ▪ Protein – Proteinura is an indicateor of renal dysfunction or disorder ▪ Nitrite – positive results could mean bacterial infection ▪ Urolibinogen – increases in amount when patient suffers from hepatitis issues

  1. Microscopic Evaluation ▪ shows the status of the urinary tract, hematuria, pyuria, etc. MICROBIOLOGY – micro organisms in body fluids or tissues NAME OF TEST AND PROCEDURES
  2. Acid-fast bacili (AFB) is used to monitor treatment for TB
  3. Blood culture checks presence of bacteria which indicates bacteremia or septicemia
  4. CLO test shows presence of Helicobacter pylori
  5. Culture & Sensitivity (C&S) indicates infection if there is growth in the pathogenic microorganism
  6. Fungus culture and identification - used to determine the type fungi if present
  7. Gram stain – done to allow antimicrobial therapy while waiting for culture results
    • initial diagnosis of presence of microorganism
  8. Occult blood – checks for blood in the stool which could result from gastrointestinal bleeding
  9. Ova and parasites – solves "etiology unknown" intestinal disorders BLOOD BANK/IMMUNOHEMATOLOGY – blood transfusion NAME OF TEST AND PROCEDURES
  10. Antibody (Ab) screen – agglutination means presence of abnormal antibodies in the blood
  11. Direct antihuman globulin test (DAT) determines transfusion incompatibility
  12. Type and RH – shows the blood group (ABO) and type (Rh)
  13. Type and crossmatch shows the blood group and screens for antibodies in the recipient's blood
  14. Compatibility testing – detects antibodies and antigen in both recipient's and donor's blood Stat labs
  • Established in the emergency room
  • Intensive care unit or Point-of-care testing Reference laboratory
  • Large independent laboratory that receives specimen from many facilities in the area.
  • Provide routine and specialized analysis of the specimen
  • Offer fast turnaround time and reduced cost Example Reference Laboratories: Clinical Chemistry – Lung Center of the Philippines Hematology – National Kidney and Transplant Institute Blood Bank – Research Institute for Tropical Medicine Bacteriology – Research Institute for Tropical Medicine 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 and results due to cross contamination. Categories of Additives used in Blood Collection
  • anticoagulants
  • EDTA, heparin to prevent blood clotting
  • special-use anticoagulants
  • antiglycolytic agents
  • to prevent glycolysis
  • clot activators
  • thrixotropic gel separator
  • trace element-free tubes Color Coding for tube caps Cap Color Specification Red No additive Orange Coagulant
  • clot activator Yellow Coagulant and Separation Gel Green Heparin Sodium Light Green Heparin Lithium Purple EDTA Coagulant
  • Ethylenediaminetetraacetic acid (EDTA) Light Blue Sodium Citrate 1:
  • 1 part of sodium citrate and 9 parts of blood Black 2 Kinds: ▪ Sodium Citrate 1: ▪ Potassium Oxalate Monohydrate Grey Sodium Flouride

Order of draw and stopper color Example order: Blood culture, CBC, CRP, Na, K, Cl, Ionized Calcium

  • Bottles: Blood culture (yellow), CBC (EDTA – purple), CRP & NA, K, Cl (yellow/red), Ionized Calcium (green)
  • Order of Draw: from sterile to prevent contamination (yellow, light blue, red, so on)
  1. Blood Culture
  2. CRP & Na, K, Cl
  3. Ionized Calcium
  4. CBC Order of Draw Tube stopper color Blood Culture (sterile collections) Yellow SPS (Sodium polyanethole sulfonate) Coagulation tube Light Blue Glass non-additive tube Red Plastic clot activator tube Red Serum separator tube (PSTs) Red and grey rubber, Gold top Heparin tube Green and grey rubber, Light green top EDTA tube Lavender , pink or purple Plasma-preparation tube (PPTs) Pearl top Oxalate/fluoride tubes Gray 1. Yellow SPS ▪ Additive: Sodium Polyanethol Sulfonate (SPS) ▪ Department: Microbiology (Blood Culture) 2. Light Blue ▪ Additive: Sodium Citrate ▪ Department: Hematology (Coagulation - PT, PTT, APTT) 3. Red / Red Rubber ▪ Glass Nonadditive tube ▪ Department: Chemistry, Blood Bank and Serology 4. Red and Gray Rubber, Gold or yellow
  • Gold top is more common ▪ Additive: Serum Separator Tubes ▪ Department: Chemistry 5. Light Green (Plasma barrier tubes) ▪ Additive: Lithium heparin or Sodium heparin with Gel Separator ▪ Department: Chemistry 6. Lavender ▪ Additive: EDTA (Ethylene Diamine Tetra acitic Acid) ▪ Department: Hematology (CBC) 7. Gray ▪ Additive: Sodium fluoride (with potassium oxalate) ▪ Department: Chemistry (Blood glucose and alcohol) ORDER OF DRAW (Simplified) MNEMONICS A PHLEBOTOMISTS SHOULD… ❖ THE ORDER OF DRAW SHOULD…. ❖ B e Loving, R espectful, G racious, L ighthearted, and G entle. ▪ B lood Culture ▪ L ight Blue ▪ R ed ▪ G reen ▪ L avender ▪ G ray Blood Collection Equipment, Additives, and Order of Draw Equipment and Supplies Used in Venipuncture General Blood Collection Equipment and Supplies
  1. Blood – Drawing Station
  2. Phlebotomy Chair
  3. Equipment carrier
  4. Gloves and glove liners
  5. Antiseptics
  6. Disinfectants
  7. Hand sanitizer& wall-mounted hand sanitizer dispenser

Syringe System and Evacuated Tube System (ETS) Components Categories of Additives used in Blood Collection

  1. Anticoagulants
  2. Special – use anticoagulants
  3. Anti – glycolytic agents
  4. Clot activators
  5. Thixotropic gel separator
  6. Trace element – free tubes Actions of Additives Additives or Anticoagulants Actions

1. Potassium oxalate Precipitates Calcium 2. Sodium fluoride Inhibits glycolysis 3. Sodium citrate Binds Calcium 4. Sodium polyanethol sulfonate Binds Calcium and allows bacteria to grow for culture 5. Solutions A and B (ACD) Binds Calcium 6. EDTA Binds Calcium 7. Lithium heparin; sodium heparin; and ammonium heparin Inhibits prothrombin to thrombin 8. Silica/glass particles and Thrombin Accelerates clotting 9. Silicon Promotes faster centrifugation and a sample with fewer cells 10. No additive Natural formed clot

VIDEO CLIPS

Basic Introduction to Venipuncture 1 st^ Step : Identify the patient

  • Wear gloves
  • Then palpate the vein to where blood will be extracted
  • Before puncture, disinfect and apply tourniquet
  • Needle must be BEVEL UP
  • Left hand is anchored to assist and fix vein, right hand is holding needle
  • Needle angle 15 - 30 degrees
  • If vein is hit, blood collection tubes is inserted
  • Practice ORDER OF DRAW to prevent contamination After extraction:
  • Remove tourniquet
  • Apply cotton or gauze on puncture site
  • Pull out the needle then press the gauze to prevent bleeding
  • If needle has safety cover, cover it first before discarding in sharps container Post Procedure:
  • Identify patient based on full name
  • Label the tubes No extractions for : o IV Fluids o Signs of infection o Haematoma o Fistulas o Clotting disorders Phlebotomy Venipuncture (ETS)
  • Every change of collection tubes you must invert the tubes