Additional Duties of the Phlebotomist PROCEDURE:

Step 1. Wash hands.

PATIENT INSTRUCTION Step 2. Remove the lid from the container without touching
1. The phlebotomy department is usually located in or near the the inside of the container or lid.
laboratory patient and sample reception area. Step 3. Separate the skin folds (labia).
2. Depending on the test requested, patients may be collecting Step 4. Cleanse from front to back on either side of the urinary
the sample while at the laboratory or collecting the sample at opening with an antiseptic towelette, using a clean one for
home and returning it to the laboratory. each side.
Step 5. Hold the skin folds apart and begin to void into the
Urine Sample Collection toilet.
Frequently collected urine samples: Step 6. Bring the urine container into the stream of urine and
Random collect an adequate amount of urine. Do not touch the inside
First morning of the container or allow the container to touch the genital
Midstream clean-catch area.
24-hour (timed) samples Step 7. Finish voiding into the toilet.
Catheterized Step 8. Cover the sample with the lid. Touch only the outside of
Suprapubic aspirations the lid and container.
Step 9. Label the container with the name and time of
Types of Urine Specimens and Their Purposes collection and place in the specified area or hand to the
phlebotomist for labeling.
Types of urine specimen Purpose
Random Routine screening Midstream Clean-Catch Urine Collection for Men
First morning Routine screening MATERIALS NEEDED:
Pregnancy tests Requisition form
Orthostatic proteinuria Sterile urine container with label
Fasting Diabetic screening and monitoring Sterile antiseptic towelettes
24-hour (timed) Quantitative chemical tests Written instructions for cleansing and voiding
Catheterized Bacterial culture
Midstream clean catch Routine screening PROCEDURE:
Bacterial culture Step 1. Wash hands.
Suprapubic aspiration Bladder urine for bacterial culture Step 2. Remove the lid from the sterile container without
Cytology touching the inside of the container or lid.
Step 3. Cleanse the tip of the penis with an antiseptic towelette
and let dry. Retract the foreskin if uncircumcised.
1. Random Specimen Step 4. Void into the toilet. Hold back foreskin if necessary.
- are collected by patients while at the laboratory Step 5. Bring the sterile urine container into the stream of
- Patients should be provided with a disposable urine container urine and collect an adequate amount of urine. Do not touch
and directed to the bathroom facility. the inside of the container or allow the container to touch the
genital area.
2. First Morning Sample Step 6. Finish voiding into the toilet.
- the specimen of choice for urinalysis because it is more Step 7. Cover the sample with the lid. Touch only the outside of
concentrated the lid and container.
- collect the sample immediately after arising and to return it Step 8. Label the container with the name and time of
to the laboratory within 2 hours or refrigerate the sample. collection and place in the specified area or hand to the
- used to confirm results obtained from random specimens. phlebotomist for labeling.

3. Midstream Clean Catch 4. 24-Hour (or Timed) Sample

- collected at the laboratory and delivered immediately to the - A carefully timed (usually 24 hours) sample is required for
microbiology section. quantitative measurement of urine constituents.
- For accurate results, it is critical that the patient understand
Midstream Clean-Catch Urine Collection for Women that all urine produced during the collection period be placed
MATERIALS NEEDED: in the container.
Requisition form - To obtain an accurate timed sample, it is necessary for the
Sterile urine container with label patient to begin and end the collection period with an empty
Sterile antiseptic towelettes bladder.
Written instructions for cleansing and voiding
- Sample labels must provide: correct patient identification, the - If a witnessed sample collection is ordered, a same-gender
time of sample collection, the type of preservative used, and collector will observe the collection of 30 to 45 mL of urine.
applicable precautions.

MATERIALS NEEDED: - The urine temperature must be taken within 4 minutes from
Requisition form the time of collection to confirm the sample has not been
24-hour urine sample container with lid Label adulterated.
Container with ice, if required - The temperature should read within the range of 32.5°C to
Preservative, if required 37.7°C.
- Urine temperatures outside of the recommended range may
PROCEDURE: indicate sample contamination. Recollection of a second
Step 1. Provide patient with written instructions and explain sample as soon as possible is necessary.
the collection procedure. - A urine pH of greater than 9.0 suggests adulteration of the
Step 2. Issue the proper collection container and preservative. urine sample and requires that the sample be recollected if
Step 3. Day 1: 7 a.m. Patient voids and discards specimen. clinically necessary.
Step 4. Patient writes the exact time on the sample label and - A specific gravity of less than 1.005 could indicate dilution of
places the label on the container. the urine sample and would require recollection of the sample.
Step 5. Patient collects all urine for the next 24 hours.
Step 6. Refrigerate the sample after adding each urine MATERIALS NEEDED:
collection. Requisition form Gloves
Step 7. Patient should collect urine sample before bowel Bluing agent (dye)
movement to avoid fecal contamination. Sample container Label
Step 8. Continue to drink normal amounts of fluid throughout Chain of custody (COC) form
the collection time. Temperature strip
Step 9. Day 2: 7 a.m. Patient voids and adds this urine to the
previously collected urine. Urine Drug Sample Collection Procedure:
Step 10. Sample is transported to the laboratory in an insulated Step 1. The collector washes hands and wears gloves.
bag or portable cooler. Step 2. The collector adds bluing agent (dye) to the toilet water
Step 11. Upon arrival in the laboratory, the entire 24-hour reservoir to prevent an adulterated sample.
sample is thoroughly mixed, and the volume is accurately Step 3. The collector eliminates any source of water other than
measure and recorded. toilet by taping the toilet lid and faucet handles.
Step 12. An aliquot is saved for testing and additional or repeat Step 4. The donor provides photo identification or positive
testing. The remaining urine is discarded. identification from employer representative.
Step 5. The collector completes step 1 of the COC form and has
5. Catheterized Sample the donor sign the form.
- sample is collected under sterile conditions by passing a Step 6. The donor leaves his or her coat, briefcase, or purse
sterile hollow tube through the urethra into the bladder. outside the collection area to avoid the possibility of concealed
- The most commonly requested test is a bacterial culture. substances contaminating the urine.
- For patient unable to void, babies, or bedridden patients. Step 7. The donor washes his or her hands and receives a
sample cup.
6. Suprapubic Sample Step 8. The collector remains in the restroom but outside the
- collected by external introduction of a needle through the stall, listening for unauthorized water use, unless a witnessed
abdomen into the bladder. collection is requested.
- used when a sample must be completely free of extraneous Step 9. The donor hands sample cup to the collector.
contamination, particularly in infants or children. Step 10. The collector checks the urine for abnormal color and
- for bacterial cultures and cytological examination. for the required amount (30 to 45 mL).
Step 11. The collector checks that the temperature strip on the
Urine Drug Sample Collection sample cup reads between 32.5oC and 37.7oC. The collector
- For urine samples to withstand legal scrutiny, it is necessary records the in-range temperature on the COC form (COC step
to prove that no tampering (e.g., adulteration, substitution, or 2). If the sample temperature is out of range or the sample is
dilution) took place. suspected to have been diluted or adulterated, a new sample
- Acceptable identification of the person requires picture must be collected and a supervisor notified.
identification, the chain of custody (COC) must be carefully Step 12. The sample must remain in the sight of the donor and
documented. collector at all times.
- Urine sample collection may be “witnessed” or “un- Step 13. With the donor watching, the collector peels off the
witnessed. sample identification strips from the COC form (COC step 3)
and puts them on the capped bottle, covering both sides of the - A throat culture is collected using a collection kit that contains
cap. a sterile swab in a transport medium collection tube
Step 14. The donor initials the sample bottle seals.
Step 15. The date and time are written on the seals. MATERIALS NEEDED:
Step 16. The donor completes step 4 on the COC form. Requisition form
Step 17. The collector completes step 5 on the COC form. Tongue depressor
Step 18. Each time the sample is handled, transferred, or Collection swab in a sterile tube containing transport
placed in storage, every individual must be identified and the media
date and purpose of the change recorded. Flashlight
Step 19. The collector follows laboratory-specific instructions
for packaging the sample bottles and laboratory copies of the PROCEDURE:
COC form. Step 1. Wash hands and put on gloves.
Step 20. The collector distributes the COC copies to Step 2. Have the patient tilt the head back and open the mouth
appropriate personnel. wide.
Step 3. Remove the cap with its attached swab from the tube
Fecal Sample Collection using sterile technique.
- Random samples used for cultures, ova and parasites (O&P), Step 4. If necessary, use a flashlight to illuminate the back of
microscopic examination for cells, fats and fibers, and the throat.
detection of blood Step 5. Gently depress the tongue with the tongue depressor.
- collected in cardboard containers with wax-coated interiors Ask the patient to say, “Ah.”
or plastic containers with wide openings and screw- capped Step 6. Being careful not to touch the cheeks, tongue, or lips;
tops similar to those used for urine samples. swab the area in the back of the throat, including the tonsils,
- Containers with preservatives may be required for certain and any inflamed or ulcerated areas.
microbiology tests, including ova and parasites, and can be Step 7. Close the cap.
kept at room temperature. Step 8. Crush the ampule of transport medium (if necessary),
- Kits containing reagent-impregnated filter paper are provided making sure the released medium is in contact with the swab.
to screen for the presence of occult (hidden) blood. Step 9. Label the sample.
- For quantitative testing, such as for fecal fats and Step 10. Remove gloves and wash hands.
urobilinogen, timed samples are required. Step 11. Deliver the sample immediately to the microbiology
- Large paint can–style or plastic hat–style containers are used laboratory.
for collection of 72-hour samples for fecal fats.
- Samples must be refrigerated during the collection time. COLLECTION OF SWEAT ELECTROLYTES
- Containers that contain preservatives for O&P must not be - Measurement of the sweat electrolytes, sodium and chloride,
used to collect samples for other tests. is performed to confirm the diagnosis of cystic fibrosis, a
- For purposes of safety, the outside of the container must not genetic disorder of the mucous- secreting glands.
be contaminated. - Chloride levels in sweat that are 2-5 times the normal value
indicate the presence of cystic fibrosis.
Semen Sample Collection - Patients are induced to sweat using a technique called
- Semen samples are collected and tested to evaluate fertility pilocarpine iontophoresis.
and postvasectomy procedures. - Pilocarpine, a sweat- inducing chemical, is applied to an area
- Patients presenting requisitions for semen analysis should be of the forearm or leg that has been previously cleansed with
instructed to abstain from sexual activity for 3 days and not deionized water.
longer than 5 days before collecting the sample. - The pilocarpine is then iontophoresed into the skin by the
- If the sample is collected at home, it must be kept warm and application of a mild electrical current provided by a device
delivered to the laboratory within 1 hour. designed for pilocarpine iontophoresis.
- Sample should be kept at 37°C. - After iontophoresis, the area exposed to the pilocarpine is
- Record the following on the requisition form because certain again thoroughly cleansed with deionized water and dried.
parameters of the semen analysis are based on specimen life - Several methods are available for collection of sweat for
span: electrolyte analysis, including the use of preweighed gauze,
time of sample collection filter paper pads, or coil collectors.
The time of sample receipt - The collection apparatus is placed on the stimulated area,
covered securely with plastic if the collection material is gauze
COLLECTION OF THROAT CULTURES or filter paper, and allowed to remain for a specified length of
- Performed primarily for the detection of a streptococcal time, usually 30 minutes
infection, “strep throat.”
- Samples may be collected for the purpose of performing a
culture or a rapid immunological Group A Strep test
 Step 8. Dispose of the swab in the appropriate biohazard
PROCEDURE: container.
1. The collection apparatus is handled only with sterile forceps Step 9. Label the sample.
or powder-free gloves and not contaminated by use of the Step 10. Place the sample/transport medium in a slurry of ice.
fingers. Step 11. Deliver the sample to the laboratory immediately after
2. The collection apparatus is tightly sealed during the collection.
collection period to prevent evaporation of the collected
sweat. Collection of Nasopharyngeal Wash
3. The collected sweat is tightly sealed during transportation to MATERIALS NEEDED:
the laboratory to prevent evaporation. Requisition form
Prepackaged sterile 0.9% sodium chloride solution
Sterile ear syringe
Sterile mini-tip Dacron polyester or rayon-tipped swab
Transport medium (saline)
Ice slurry

PROCEDURE
Step 1. Identify the patient.
Step 2. Wash hands and put on gloves.
Step 3. Lay the child down and have another person hold the
child’s head firmly.
Step 4. Swab the inside of each naris with a sterile cotton-
tipped swab to remove any extraneous mucus and to disturb
the epithelial cells where the virus is harbored.
Step 5. Using a prepackaged sterile 0.9% sodium chloride
solution, squeeze the vial and inject half of the solution (1.5 mL)
into each naris.
Step 6. Using a sterile ear syringe, immediately suction the
solution back.
Step 7. Inject the sample into the RSV transport medium.
Step 8. Repeat the procedure for the other naris using the
same transport medium.
COLLECTION OF NASOPHARYNGEAL (NP) SAMPLES Step 9. Label the transport medium.
- NP secretions are collected to detect acute respiratory Step 10. Place the sample in a slurry of ice.
diseases caused by respiratory syncytial virus (RSV) from Step 11. Transport the sample to the laboratory immediately
infants and small children using rapid membrane enzyme after collection.
immunoassay tests.
- NP secretions can also detect influenza A and B and the
organisms that cause pertussis, diphtheria, meningitis, and
pneumonia.

MATERIALS NEEDED:
Requisition form
Sterile mini-tip Dacron polyester or rayon-tipped swab
Transport medium (saline)
Ice slurry

PROCEDURE
Step 1. Identify patient.
Step 2. Wash hands and put on gloves.
Step 3. Gently insert a mini-tip culture swab through the nose
into the nasopharynx.
Step 4. Gently rotate the swab and carefully remove.
Step 5. Place swab sample in 0.75 to 3 μL of transport medium
(saline). BONE MARROW COLLECTION
Step 6. Mix the swab and transport medium vigorously. - Bone marrow is the site of blood cell production. A bone
Step 7. Express excess liquid from the swab. marrow aspiration and biopsy is performed to diagnose
various blood diseases.
- Bone marrow samples are collected by inserting a Jamshidi labels for tubes and formalin containers. Include date, time,
needle into the center of the iliac crest or sternum and initials, and bone marrow site on the tubes.
aspirating liquid bone marrow and a bone core biopsy for Step 14. Deliver specimens to the histology department for
evaluation. processing and examination.
Step 15. Slides are delivered to the hematology department for
MATERIALS NEEDED: staining and examination under the microscope.
Requisition form
Consent form
Ethylenediaminetetraacetic acid (EDTA) tubes
sodium heparin tubes
Glass slides
Transfer devices
10% formalin jars
“Isolator” tubes for culture studies Petri dish
Sterile 4 X 4 gauzes
Wooden applicator sticks
Jamshidi aspiration needle
Sharps container
5 mL syringe
12 mL syringe
1% lidocaine ampules Identification labels

PROCEDURE
BLOOD DONOR COLLECTION
Step 1. Obtain the requisition form
- 405 to 495 mL of blood mixed with 63 mL of anticoagulant
Step 2. Confirm that the patient has signed the consent form.
- Preservative= citrate-phosphate-dextrose (CPD) or CPDA
Step 3. Identify the patient.
(when adenine is added)
Step 4. Wash hands and put on gloves.
- separated by centrifugation into its individual components
Step 5. Set up prep table/counter space to process the bone
marrow aspirate/biopsy.
Step 6. Assist the physician during the procedure.
Blood Components:
Step 7. The physician inserts the Jamshidi needle into the iliac
Red blood cells
crest after anesthetizing the area with lidocaine. The
white blood cells
phlebotomist hands the physician a large syringe that is
Platelets
attached to the needle to aspirate the liquid bone marrow.
Plasma
Step 8. A bone core biopsy is then collected. The core biopsy is
Plasma proteins.
placed on a sterile 4 X 4 gauze. Three to four touch prep slides
are made by gently touching the specimen onto the slide three
times to make imprints of the specimen. The biopsy is then
placed in a 10% formalin container.
Step 9. Dispense three to four drops of the liquid marrow to
run down the center of a slide that is angled down and sitting
in a Petri dish for spicule collection and preparation of thin
prep slides.
Step 10. As the drops of marrow run down the slide, pick up
spicules of marrow and spread onto a spreader slide. Gently
pull the spreader slide across another glass slide resulting in a
thin smear of the marrow. Six to eight thin prep slides are
made.
- Experienced phlebotomists are needed to perform:
Step 11. Transfer 1 to 2 mL of the liquid bone marrow in the
donor unit collections
syringe into the EDTA and sodium heparin tubes. Mix tubes by
assess and screen donors
inversion.
operate specialized equipment.
Step 12. Allow the remaining liquid marrow to clot in the
syringe. When a clot has formed, place the clotted marrow into
- The responsibilities of the phlebotomist include the following:
another 10% formalin container and label appropriately.
● Donor interview and screening
Step 13. Label all slides with patient’s name and date, using
● Donor identification
pencil on the frosted end of the slide. Use patient identification
● Donor informed consent
● Venipuncture
● Product collection > Medical History Interview
● Postdonation care Donors are asked an extensive list of questions regarding their
● Complication management previous medical history that includes:
● Past and current medications and antibiotics
> Donor Selection ● Injected drug use, exposure to infectious diseases
- In addition to testing each donor unit for ABO blood group ● History of infectious disease, venereal disease
and Rh blood type, donor units are always tested with all ● Social habits, particularly related to bloodborne
available tests for bloodborne pathogens pathogen exposure

- There are two boxes on the donor consent form, one giving
permission to use the blood for transfusion and one denying
permission to use the blood.
- The form is sealed until the unit is being processed.
- Another method is to provide the donor with two barcode
labels (Use or Do Not Use), and the donor attaches the
appropriate label to the collected unit.
- The unit is then scanned for acceptability during processing.

> Donor Collection

- sterile, closed systems consisting of one or more plastic bags
connected to tubing and a sterile needle.
- Large-gauge needles (15 to 16 regular gauge or 17 gauge
thin-walled) are used for collection
> Donor Registration and Identification - A large vein, usually located in the antecubital area, is
- Identification (including name, address, telephone number) necessary to accommodate the large needle and supply the
- Date of birth required amount of blood.
- Social security number, and sex - Venipuncture is performed in the usual manner, and when
- Date of last donation (at least 8 weeks is required between blood appears in the tubing, the needle is securely taped to the
whole blood donations) donor’s arm.
- Donors must also sign a consent form permitting the - After confirming that bleeding has stopped, the phlebotomist
laboratory to draw the blood and test it for bloodborne should place a sterile gauze and bandage over the site and
pathogens. instruct the donor to keep the bandage on for 4 hours .
- Observe for any signs of dizziness or nausea during and after
> Infectious Diseases Tested for on Each Unit of Donor Blood the collection.
Chagas disease (Trypanosoma cruzi)
HIV 1 and 2 **Additional Donor Collection
Hepatitis B (HBV) - A specialized area of blood donation is apheresis.
Hepatitis C (HCV) - Apheresis is performed to collect a specific blood component
Syphillis such as double red cells, platelets, or plasma.
West Nile virus (WNV) - Under sterile conditions, donor blood is anticoagulated and
Human T-cell lymphotropic virus (HTLV) sent directly to a specialized separation instrument
(centrifuge).
> Physical Examination
Eligibility requirements for blood donors include: **Autologous Donation
● Appear to be in good health - Patients scheduled for elective surgery may choose to donate
● No evidence of skin infections, rashes, or track marks units of their own blood to be transfused back to them during
● 17 years old, or in some states 16 years old with parental their surgery if blood is needed.
consent - Patients may donate as often as every 72 hours, providing
● Weigh at least 110 pounds they have their health-care provider’s approval and a
● Temperature of 99.5°F or lower hemoglobin level of at least 11.0 g/dL.
● Blood pressure no higher than 180/100 mm Hg
● Pulse rate between 50 and 100 **Therapeutic Phlebotomy
● Hemoglobin level of 12.5 g/dL or higher or a hematocrit of - a unit of blood is collected from patients with conditions
38% or higher causing overproduction of red blood cells (polycythemia) or
iron (hemochromatosis) .
RECEIVING AND TRANSPORTING SAMPLES
- When delivering samples to laboratory sections,
phlebotomists should be sure to alert the technical personnel
about the sample.
- The phlebotomist must be aware of sample preservation
requirements.
- The information should be available in the procedure manual
or may be posted in the section;
- it varies with the type of sample and the section to which it is
delivered.
- For example, cerebrospinal fluid (CSF) samples are
refrigerated in hematology and left at room temperature in
microbiology.
- Samples accepted by phlebotomists, either on the units or in
the laboratory, must be accompanied by a requisition form
containing appropriate information and must have a label
containing information that correlates with the requisition
form.
- Labels should be attached to the actual collection container
and not the lid to avoid a sample mix-up when lids are
removed from containers.
- Samples must be transported in biohazard bags.

Pneumatic tube system

- Delivery of samples through a pneumatic tube system is a
very efficient method because both personnel time and
delivery time are saved.
- Samples must be properly cushioned to prevent breakage or
red blood cell (RBC) hemolysis and enclosed in leak-proof
material. Gloves should be worn when removing samples from
the sample container NONBLOOD SAMPLES

> Cerebrospinal Fluid

- CSF is routinely collected by lumbar puncture between the
third, fourth, or fifth lumbar vertebrae.
Normal CSF appears clear and colorless.
Cerebrospinal fluid is collected to diagnose meningitis,
subdural hemorrhage, and other neurological disorders.

- Samples are collected in sterile tubes usually numbered 1

through 3, representing the order in which the sample was
collected:
● Tube No. 1 is designated for chemistry.
● Tube No. 2 is designated for microbiology.
● Tube No. 3 is designated for hematology.

- An alternate procedure is to collect four tubes numbered one

through four.
- When this is done, Tubes No. 1 and 4 are sent to hematology,
Tube No. 2 to chemistry, and Tube No. 3 to microbiology.
- The RBC counts in Tubes 1 and 4 are compared to determine
possible contamination of Tube No. 1.

Specimen Collection (lumbar puncture) Synovial Fluid

- routinely collected by lumbar puncture between the third, - Synovial fluid, often referred to as “joint fluid” is a viscous
fourth, or fifth lumbar vertebra. Elevated pressure requires liquid found in the cavities of the movable or synovial joints
fluid to be withdrawn slowly, with careful monitoring of the that lubricates and reduces friction between bones during joint
pressure, and may prevent collection of a large volume. movement.
- lumbar puncture (spinal tap) is the insertion of a needle - Normal synovial fluid appears colorless to pale yellow.
between the lamina of the vertebrae and into the thecal sac - Synovial fluid is increased in inflammatory diseases, arthritis,
with the purpose of obtaining cerebrospinal fluid. This is done and gout.
below the L2 level (usually between L3-4 or L4-5) in order not - Samples are collected by needle aspiration and collected into
to injure the spinal cord. tubes based on the required tests:
= sterile heparinized tube for Gram stain and culture and
sensitivity
= heparin or EDTA tube for cell counts and crystal
identification
= sodium fluoride tube for glucose analysis
non-anticoagulated tubes for other tests.

Serous Fluid
- Serous fluid is located between the parietal membrane and
visceral membrane of the pleural, pericardial, and peritoneal
cavities and provides lubrication to prevent the friction
between the two membranes as a result of movement of the
enclosed organs.
- In congential heart failure, hypoproteinemia, inflammation
and infection, or lymphatic obstruction, the amounts of fluid
become increased.
- Fluids for laboratory examination are collected by needle
aspiration from the respective body cavities as follows:
● Pleural fluid: obtained from between the pleural cavity
membranes surrounding the lungs
● Pericardial fluid: obtained from between the pericardial
cavity membranes surrounding the heart
● Peritoneal fluid: obtained from between the membranes
surrounding the abdominal cavity

- Samples are collected into:

= EDTA evacuated tubes for cell counts and differential
= sterile heparinized evacuated tubes for microbiology and
cytology
= heparinized tubes for chemistry.

- The type of fluid should be noted on the sample label.

Pleural Fluid

Peritoneal fluid

Gastric Fluid
- Gastric fluid is tested to determine stomach acid pro- duction.
- Samples are obtained by inserting a gastric tube through the
mouth or nose into the stomach.
- An initial sample is collected and a gastric stimulant, such as
histamine, is injected.
- Subsequent samples are collected at timed intervals.
- Samples are collected into sterile containers and labeled
properly including the time of each collection.
- The phlebotomist may collect blood samples for gastrin levels
concurrently.

Amniotic fluid Sputum

- collected from the fetal sac may be tested for the presence of - Sputum is mucus or phlegm collected from the trachea,
bilirubin, to monitor hemolytic disease of the newborn and bronchi, and lungs and is tested for active tuberculosis (TB) and
lipids, to determine fetal lung maturity. pneumonia.
- In addition, it may be examined by the cytogenetics section - Sputum is obtained by deep coughing to bring the sputum up
for the presence of abnormal chromosomes. from the lungs and then expelled into a sterile container.
- Samples for bilirubin analysis must be protected from light in - The largest amount of sputum is collected in a first morning
the same manner as blood samples, and samples for sample.
cytogenetic analysis should be delivered immediately for - Samples are immediately delivered to the laboratory and kept
processing to preserve the limited number of cells present. at room temperature before processing.
Buccal Swabs Tissue Samples
- Cells for DNA analysis may be obtained from a buccal (cheek) - Tissue samples are routinely received in a preservative
swab. solution and are processed by the histology section.
- The sample is collected by rubbing the inner lining of the
cheek for 20 seconds with a sterile Dacron-tipped cotton swab. SAMPLE PROCESSING, ACCESSIONING, AND SHIPPING
- These samples are collected for legal purposes such as - Centrifuging
paternity testing; therefore, follow strict COC protocol. -Aliquoting
- assigning accession numbers or bar codes to specimens
Saliva before their delivery to the laboratory sections
- Saliva samples can be used to test for HIV antibodies, - In accordance with Occupational Safety and Health
hormone levels, and drug and alcohol abuse. Administration (OSHA) regulations, protective apparel must
-Advantages of testing saliva are that the detection of drugs include gloves, fluid-resistant laboratory coats that are
and alcohol can be made immediately and the tests are completely closed, and goggles or chin-length face shields with
difficult to adulterate. protective sides. Samples must never be centrifuged in
uncapped tubes.
Hair
- Hair samples can detect chronic use of drugs, alcohol, heavy >Sample Processing
metals, poisons, and toxins. - Sample processing involving centrifugation and aliquoting is
- Hair sample testing is becoming more prominent because of primarily associated with laboratory tests performed on
the ease of collection and the sample cannot be easily plasma and serum.
adulterated. - An instrument, called a centrifuge, spins blood tubes at a high
- Hair samples also may be used for DNA paternity testing. relative centrifugal force to separate serum or plasma from the
blood cells.
Breath - Plasma is obtained by centrifugation of anticoagulated blood,
- The presence of Helicobacter pylori, a bacteria that damages and serum is similarly obtained from clotted blood.
the lining of the stomach and causes peptic ulcers, can be - To prevent contamination of plasma and serum by cellular
detected by the C-urea breath test. constituents, it is recommended that samples be separated
- The test measures the amount of CO2 in the patient’s breath. within 2 hours.
- A baseline breath sample is collected by breathing into a - Anticoagulated samples can be centrifuged immediately after
balloon-like collection device. collection, and the plasma removed.
- The patient then ingests urea labeled with a nonradioactive - Samples collected without anticoagulant must be fully clotted
carbon isotope. A second breath sample is then collected. before centrifugation.
- Urease produced by H. pylori degrades the urea and produces
carbon dioxide, which is absorbed into the bloodstream and **THINGS TO REMEMBER:
exhaled. - By 2 hours after blood collection significant changes in some
- The carbon dioxide level in the two samples is compared. analytes, such as decreased glucose, increased potassium, and
- Increased amounts of carbon in the post ingestion sample increased lactate dehydrogenase, are seen in blood that has
indicate the presence of H. pylori in the stomach. not been centrifuged.
- A hydrogen breath test can be used to diagnose: - Fibrin strands in a sample that has not completely clotted can
= lactose intolerance interfere with chemistry analyzers and lead to erroneous
= overgrowth of bacteria in the small bowel results.
= rapid passage of food through the small intestine -Loosening clots from the side of the tube (rimming) before
centrifugation is not recommended because it may cause
- Prior to testing, the patient must have fasted for 12 hours. hemolysis.
- A baseline breath sample is collected by having the patient - Blood tubes must remain closed before, during, and after
exhale into a balloon- type collecting device and the amount of centrifugation to avoid contamination with dust or glove
hydrogen is measured. powder, accidental spills, formation of aerosols, and
- The patient ingests a prescribed amount of lactose and breath evaporation of the specimen. Specimen pH increases when the
samples are collected and analyzed for hydrogen every 15 cap is removed and may cause erroneous pH, ionized calcium,
minutes for 3 and up to 5 hours. and acid phosphatase results.
- Increased hydrogen levels indicate a problem with the
digestion or absorption of lactose resulting in increased lactose > Centrifugation
in the intestinal tract, perhaps indicating lactose intolerance. Types of centrifuges:
- Breath samples also are used in the detection of alcohol use. =Table models
- Various breath-testing devices are available and are often = Floor models
used by law enforcement. = Refrigerated models
- The relative centrifugal force (RCF) of a centrifuge is
expressed as gravity (g) and is determined by the radius of the
rotor head and the speed of rotation (revolutions per minute
[rpm]).
- Most laboratory samples are centrifuged at 850 to 1000 g for
10 minutes.

Rules for Centrifugation of Samples

1. Tubes placed in the cups of the rotor head must be equally
balanced. This is accomplished by placing tubes of equal size
and volume directly across from each other. Failure to follow
this practice will cause the centrifuge to vibrate and possibly > Specimen Storage
break the tubes. A final check for balancing should be made - separated serum or plasma may remain at room temperature
just before closing the centrifuge lid. for 8 hours.
2. A centrifuge should never be operated until the top has - If testing has not been completed in 8 hours, the specimen
been firmly fastened down, and the top should never be should be refrigerated (2°C to 8°C).
opened until the rotor head has come to a complete stop. - If testing is not complete in 48 hours, the serum or plasma
Should a tube break during centrifugation, pieces of glass and should be frozen at or below –20°C.
biohazardous aerosols will be sprayed from a centrifuge that is - Serum can be stored on the gel in gel separator tubes for up
not covered. to 48 hours at 4°C. Confirm the gel barrier integrity.
3. Do not walk away from a centrifuge until it has reached its - Samples collected for electrolytes must not be stored at 2oC
designated rotational speed and no evidence of excessive to 8°C before centrifugation and testing.
vibration is observed. - Specimens can only be thawed once. Repeated freezing and
4. When a tube breaks in the centrifuge, immediately stop the thawing of the specimen can destroy substances for testing.
centrifuge and unplug it before opening the cover. Don
puncture-resistant gloves before beginning the cleanup. The > Specimen Shipping
cup containing the broken glass must be completely emptied - Samples for local transport should be placed in securely
into a puncture-resistant container and disinfected. The inside closed, leak-proof primary containers (tubes and screw-top
of the centrifuge must also be cleaned of broken glass and containers).
disinfected. Deposit any cleaning materials that may contain - The primary containers are enclosed in a secondary
broken glass into a puncture-resistant container. leak-proof container with sufficient absorbent material present
5. Samples should not be recentrifuged. This can cause to separate the samples and absorb the contents of the
hemolysis and erroneous tests results. When the serum or primary containers in case of leakage or breakage.
plasma has been removed from the tube, the volume ratio of - Containers should be labeled as biohazardous.
plasma to red blood cells has been altered. Substances from - Samples that must remain frozen are packaged in carbon
the cellular leakage or ex- change, caused by the blood clotting, dioxide permeable containers with dry ice.
will then be centrifuged into the serum or plasma and alter test - Samples requiring refrigeration can be shipped in Styrofoam
results. containers with refrigerant packs of ice enclosed in a leak-proof
bag.
> Sample Aliquoting - Samples that must remain frozen are packaged in containers
- An aliquot is a portion of the sample that is placed in a with dry ice.
separate tube.
- stoppers should be covered with gauze and twisted rather
than “popped” off.
- Specimens must never be poured from one tube to another,
because this will produce aerosols.
- Disposable pipettes should be used to transfer the specimen
from one tube to another.
- A Plexiglas shield should be used when aliquoting specimens.
USE OF THE LABORATORY COMPUTER
- Phlebotomists may use hand-held computers or personal
digital assistants (PDAs) for patient identification, test requests,
and label printing at the patient’s bedside.
- Point-of-care patient test results from portable hand- held
instruments are directly transmitted to patient’s charts.
- Data can be transferred among the laboratory sections or
other hospital departments and by computer telephone cable,
fiber optics, and wireless radiowave connections to outside
agencies such as health-care providers’ offices.

Laboratory Information Systems (LISS)

LIS clinical applications include the following:
● Generate laboratory orders
● Print labels for sample collection
● Monitor sample status in the laboratory Reimbursement Codes
● Interface with laboratory analyzers for direct - This documentation requires the use of standardized codes by
reporting of results and autoverification both the health-care provider and the department performing
● Archive past patient results the tests or procedures. Patient conditions or symptoms are
● Provide billing of laboratory services classified using the International Classification of Disease, 9th
● Provide a mode for result viewing edition (ICD-9), which will continue to be updated.
● Monitor quality control and compliance - Laboratory tests are also coded using Current Procedure
Terminology (CPT) codes. For reimbursement purposes, the
CPT code (laboratory test) should be consistent with the
medical necessity of the ICD-9 code (patient diagnosis).
Depending on the institution, phlebotomists may need to enter
CPT codes into the computer, particularly when drawing from
outpatients.

Additional Computer Duties

- generation and retrieval of collection lists and schedules
-posting of patient charges
- computing monthly phlebotomy workloads
- retrieving information for personnel in health-care providers’
offices

Password
- Phlebotomists required to input or retrieve data with
the computer are assigned a password that allows them to use
the computer. The purpose of the password is to provide
computer security so that patient data is available only to
authorized personnel.

Data Entry
- Data are frequently entered or retrieved with comput-
ers with the help of codes, which can be numeric (1 = retrieve
information) or memory-aiding abbreviations (mnemonics),
such as typing “RI” to retrieve information.
 - 24-48 hours of life
- for new born with respiratory distress or pre mature

2. FEMORAL ARTERY
- largest artery of the body
- located at the groin and can be palpated easily
- used for cardiac catheterization
- last choice for puncture, not used in new born

3. BRACHIAL ARTERY
- disadvantage: deep in location , major nerves around, difficult
to compress

4. RADIAL ARTERY
- adults
- located at the thumb side of the wrist
- easier to compress due to bony structure, less chance of
hematoma

ALLEN TEST
- All information in the laboratory information system is - to check the collateral arterial circulation, ulnar artery
traceable back to each person who has handled the sample - done so that continuous circulation or supply on the hand
and has significantly reduced errors in identification and after puncture of the radial artery
documentation. - patient comfortable and rests his/her hand on the bed or
=================================================== table
ARTERIAL BLOOD GAS - clenching of the fist
- the examiner used the middle and index finger to press the
Arterial puncture radial and ulnar artery while pressing, instruct patient to
-Not for beginners unclench the fist
- Used for blood gas analysis ( determine patients oxygenation) - the obstructed flow causes blanching of the palm , release
PO2 – dissolved oxygen pressure on the ulnar artery (little finger side of the wrist)
PCO2 – dissolved carbon dioxide - the palm and fingers should show pink about 5 secs after
pH- measure the acid-base balance of the blood ( 7.40 releasing pressure only on the ulnar artery
perfect balance) - the pink coloration indicates that the ulnar artery is providing
- Blood carries oxygen to different parts of the body circulation to the hand and is refilling the capillary bed
- Blood analysis best done during period of steady state
=comfortable and has no recent physical activity Note:
=anxiety excitement can alter blood gas ** in the negative test, hand remains blanched, indicating
=to lessen anxiety prior to puncture, may apply restricted blood flow of the ulnar artery
anaesthetic (lidocoaine) ** with a negative test, the radial artery should not be used
and the opposite wrist should be checked for a positive allen
Complications **if both test are negative, Doppler ultrasound flow to
1. HEMATOMA determine best arterial puncture site
- due to high pressure of arteries compared to venous blood
- Adult > Children ( more hematoma due to less elasticity of
arteries)

2. ARTERIOSPASM
- reflex condition of the arteries when subjected to pain
- difficult to obtain blood gas

Sites for arterial blood gas

1. UMBILICAL ARTERY
- NEW BORN
 -the direction of the bevel of the needle should face the blood
flow
-the pressure in the artery will allow to fill the syringe on its
own
-upon removal of the needle and syringe, apply pressure on the
puncture site for 5 minutes
-the tip of the needle should be covered with a rubber stopper
-alternate procedure, butterfly IV can be used
-avoid air into tubing
-if patient is on anticoagulant, pressure should be longer 10
minutes

BLOOD SAMPLES
- if < 20 minutes: use plastic syringe
- if > 20 minutes: use glass syringe , immersed in a coolant
(1 to 5 Celsius)

ALTERNATIVE TO PERCUTANEOUS ARTERIAL BLOOD GAS

- capilliary puncture
- patient finger or infant foot warmed before puncture
- used heparinized glass capilliary tubes and must not contain
bubbles
- if exposed to air as little as 10 to 30 secs it can alter result
- end of the tip closed with a clay or rubber plug and
immediately placed on ice

BASIC KITS PRIOR TO PUNCTURE:

-antiseptic solution
-gauze
-preload arterial blood gas syringe with heparin 1,000 IU/ml
-hypodermic needle, gauge 22
-syringe 1 to 5 mL
-ice water for specimen placement

Procedure:
-palpate site of the puncture, do not use the thumb to palpate
-perform allen’s test
-antiseptic (povidone iodine), inside to outside
-apply anesthetic, infiltrate on top of the puncture site to
produce a small blister
-patient’s arm should rest on a table or rest on a pillow with
the palm facing up and the wrist extended to stretch the
arteries and tissues
-no tourniquet should be used
-hold the syringe as holding a dart
-puncture the skin about 5 to 10 millimetres down the length
of the artery (toward the palm) from the point the finger is
feeling the pulsating artery
- the needle of the syringe enters the skin at a 45 degree angle