Study with the several resources on Docsity
Earn points by helping other students or get them with a premium plan
Prepare for your exams
Study with the several resources on Docsity
Earn points to download
Earn points by helping other students or get them with a premium plan
Community
Ask the community for help and clear up your study doubts
Discover the best universities in your country according to Docsity users
Free resources
Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors
Please use the restroom facilities before the exam begins, you will not be allowed to leave the test room again until you complete the exam. Good Luck and thank ...
Typology: Summaries
1 / 34
This page cannot be seen from the preview
Don't miss anything!
This document is the property of National Healthcareer Association. It cannot be reproduced or any reason without the written consent from the National Healthcareer Association.
Dear Student:
Please take note of the following test protocols:
Good Luck and thank you for choosing the National Healthcareer Association as your
certification agency.
SPECIAL ACCOMMODATIONS
Special exam accommodations are available for persons with disabilities or other special needs. The participants or their representatives can submit a request, in writing, to the National
Healthcareer Association. The request should include an explanation of the disability and the participants’ specific requirements. Special accommodations may include additional testing time, use of a private room or physical assistance in completing the examination. If you have
questions about special accommodations, please call the NHA’s Corporate Office at 1-800- 499-9092. Requests for special accommodations must be submitted to the NHA at least 45 days prior to the exam date and may be sent via certified mail or faxed to our corporate offices.
This study guide will provide information about phlebotomy as a specialized area of clinical laboratory practice. The role of a phlebotomist has expanded, thus, creating the need to replace on-the-job training with structured training programs, which, in turn, has lead to certification in phlebotomy. Healthcare facilities are finding it advantageous to require national certification of their phlebotomists in order to be within compliance of changing requirements by state and federal agencies. The reader can use this booklet as a study guide for the National Healthcareer Association‟s Certified Phlebotomy Technician exam. As such, this is a supplement for a review and it is not meant to replace training textbooks and/or lecture notes.
PHLEBOTOMY AS A PROFESSION
Role of the phlebotomist:
Professionalism The phlebotomist is a member of a service-oriented industry that requires professional behavior at all times. Professionalism is an attitude and a set of personal characteristics needed to succeed in this area. Other characteristics imperative to a phlebotomist include: A. Dependability B. Honesty C. Integrity D. Empathy and compassion E. Professional appearance F. Interpersonal skills
Ethical Behavior 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 the “code of ethics” provide personal and professional rules of performance and moral behavior that all phlebotomists are expected to follow.
Health Care Settings The following are the medical facilities where the phlebotomist may find work: Physician office laboratories – can range from simple screening tests done in a single practice office or specialized testing done in large group practices. Reference laboratories – These large independent laboratories perform routine and highly specialized tests that cannot be done in smaller ones. The phlebotomist may do either on-site or off-site collections. Urgent care centers Nursing home facilities Wellness clinics
ANATOMY AND PHYSIOLOGY (An Overview)
This study guide will only touch on the basics of the anatomy and physiology of organ systems most relevant to phlebotomy, such as the heart and blood. It is highly recommended that all students who are candidates for Phlebotomy certification to have extensive knowledge of the anatomy of the heart; its‟ structure and function and all candidates should be prepared to demonstrate the ability to label the chambers and valves of the heart. For discussions of the other organ systems not within the scope of phlebotomy, the reader is directed to refer to textbooks on anatomy and physiology.
The circulatory system The function of this system is to deliver oxygen, nutrients, hormones, and enzymes to the cells (exchange is done at the capillary level) and to transport cellular waste such as carbon dioxide and urea to the organs (lung and kidneys, respectively) where they can be expelled from the body. It is a transport system where the blood is the vehicle; the blood vessels, the tubes, and the heart work as the pump.
The heart The heart acts as two pumps in series (right and left sides), connected by two circulations, with each pump equipped with two valves, the function of which is to maintain a one-way flow of blood. The two circulations are:
The tricuspid valve – this is an atrioventricular valve, being situated between the right atrium and right ventricle.
The pulmonic valve – a semi lunar valve situated between the right ventricle and the pulmonary artery.
The leukocytes function is to provide the body protection against infection. The normal amount of WBC‟s (white blood cells) for an adult is 5,000 to 10,000 per microliter. Leukocytosis, which is an increase in WBCs, is seen in cases of infection and leukemia. Leukopenia, which is a decrease in WBCs, is seen with viral infection or chemotherapy.
There are five types of WBCs in the blood. A differential count determines the percentage of each type:
Neutrophils – the most numerous, comprise about 40% to 60% of WBC population. They are phagocytic cells, meaning, they engulf and digest bacteria. Their number increases in bacterial infection, and often, the first one on the scene.
Lymphocytes - the second most numerous, comprising about 20% to 40% of the WBC population. Their number increases in viral infection, and they play a role in immunity.
Monocytes – comprising 3% to 8% of the population, they are also the largest WBCs. They are monocytes while in the circulating blood, but when they pass into the tissues, they transform into macrophages and become powerful phagocytes. Their number increases in intracellular infections and tuberculosis.
Eosinophils - represent 1% to 3% of the WBC population. They are active against antibody-labeled foreign molecules. Their numbers are increased in allergies, skin infections, and parasitic infections.
Basophils - account for 0% to 1% of WBCs in the blood. They carry histamine, which is released in allergic reactions
The thrombocytes (platelets) are small irregularly shaped packets of cytoplasm formed in the bone marrow from megakaryocytes. Essential for blood coagulation, the average number of platelets is 140,000 to 440,000 per micro liter of blood. They have a life span of 9 to 12 days.
HEMOSTASIS Hemostasis is the process by which blood vessels are repaired after injury. This process starts from vascular contraction as an initial reaction to injury, then to clot formation, and finally removal of the clot when the repair to injury is done. It occurs in four stages: Stage 1: Vascular phase Injury to a blood vessel causes it to constrict slowing the flow of blood. Stage 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‟.
Vascular phase and platelet phase comprise the primary hemostasis. Bleeding time test is used to evaluate primary hemostasis.
Stage 3 – Coagulation phase This involves a cascade of interactions of coagulation factors that converts the temporary platelet plug to a stable fibrin clot. The coagulation cascade involves an intrinsic system and extrinsic system, which ultimately come together in a common pathway.
Activated partial thromboplastin time (APTT) – test used to evaluate the intrinsic pathway. This is also used to monitor heparin therapy.
Prothrombin time (PT) – test used to evaluate the extrinsic pathway. This is also used to monitor coumadin therapy.
Stage 4 – Fibrinolysis This is the breakdown and removal of the clot. As tissue repair starts, plasmin (an enzyme) starts breaking down the fibrin in the clot. Fibrin degradation products (FDPs) measurement is used to monitor the rate of fibrinolysis.
SITE SELECTION
The preferred site for venipuncture is the antecubital fossa of the upper extremities. The vein should be large enough to receive the shaft of the needle, and it should be visible or palpable after tourniquet placement.
Three major veins are located in the antecubital fossa, and they are: A. Median cubital vein – 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. It is 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. It is the least firmly anchored and located near the brachial artery. If the needle is inserted too deep, this artery may be punctured.
Unsuitable veins for venipuncture are: A. Sclerosed veins - These veins feel hard or cordlike. Can be caused by disease, inflammation, chemotherapy or repeated venipunctures. B. Thrombotic veins C. Tortuous veins – These are winding or crooked veins. These veins are susceptible to infection, and since blood flow is impaired, the specimen collected may produce erroneous test results.
Note: Do not draw blood from an arm with IV fluids running into it. The fluid will alter the test results. Select another site. Do not draw blood from an artificial a-v fistula site, such as those surgically implanted in dialysis patients.
To be placed on each tube collected after the venipuncture. K. Gloves - Must always be worn when collecting blood specimen L. Needle disposal container – Must be a clearly marked puncture-resistant biohazard disposal container. Never recap a needle without a safety device.
COMPLICATIONS ASSOCIATED WITH PHLEBOTOMY Hematoma: The most common complication of phlebotomy procedure. This indicates that blood has accumulated in the tissue surrounding the vein. The two most common causes are the needle going through the vein, and/or failure to apply enough pressure on the site after needle withdrawal. Hemoconcentration: The increase in proportion of formed elements to plasma caused by the tourniquet being left on too long. (More than two (2) minutes) Phlebitis: Inflammation of a vein as a result of repeated venipuncture on that vein. Petechiae: These are tiny non-raised red spots that appear on the skin from rupturing of the capillaries due to the tourniquet being left on too long or too tight. Thrombus: This is a blood clot usually a consequence of insufficient pressure applied after the withdrawal of the needle. Thrombophlebitis: Inflammation of a vein with formation of a clot Septicemia: This is a systemic infection associated with the presence of pathogenic organism introduced during a venipuncture. Trauma: This is an injury to underlying tissues caused by probing of the needle.
FACTORS TO CONSIDER PRIOR TO PERFORMING THE PROCEDURE: Fasting – some tests such as those for glucose, cholesterol, and triglycerides require that the patient abstain from eating for at least 12 hours. The phlebotomist must ascertain that the patient is indeed in a fasting state prior to the testing. Edema – is the accumulation of fluid in the tissues. Collection from edematous tissue alters test results. Fistula - is the permanent surgical connection between an artery and a vein. Fistulas are used for dialysis procedures and must never be used for venipunctures due to the possibility of infection.
QUALITY ASSURANCE AND SPECIMEN HANDLING Quality assurance (QA) is defined as a program that guarantees quality 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. A QA program is a continuous program, established by the healthcare facility, which will provide guidelines, protocols and continuing education for their employees. Areas in phlebotomy that are subject to quality control:
Patient preparation procedures: Quality control actually starts before the specimen is collected from the patient. To obtain an acceptable specimen, the patient must be prepared properly. In a hospital setting the phlebotomist must check the floor book, to ensure that the nursing department has performed all pre-test preparations. Pre-test preparation will include fasting for specific tests. The phlebotomist must then ensure this information is correct, by asking the patient. The Laboratory/Phlebotomy Specimen Collection Procedures Manual has established these guidelines.
ANALYTICAL ERRORS
Before Collection: During Collection After Collection Patient misidentification Extended tourniquet time Failure to separate serum from cell Improper Time of Collection Hemolysis Improper use of serum separator Wrong Tube Wrong order of draw Processing delays Inadequate fast Failure to invert tubes Exposure to light Exercise Faulty technique Improper storage conditions Patient posture Under filling tubes Rimming clots Poor coordination with other treatments Improper site preparation Medication interference
Collapsed vein. This may be due to excessive pull from the vacuum tube; use of a smaller vacuum tube may remedy the situation. If it does not, remove the tourniquet, withdraw the needle, and select another vein preferably using either a syringe or butterfly.
SPECIAL VENIPUNCTURE Some venipunctures are done using special collecting or handling procedures specific to the test being requested. Some require patient preparation such as fasting, while some needs to be collected at a specific time. Still, others may need special handling such as protection from light.
Fasting Specimens This 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 They are 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:
Two-Hour Postprandial Test This test is 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 (OGTT) This test is used to diagnose diabetes mellitus and evaluate patients with frequent low blood sugar. 3-hour OGTT is used to test hyperglycemia (abnormally high blood sugar level) and diagnose diabetes mellitus. 5-hour OGTT is used to evaluate hypoglycemia (abnormally low blood sugar level) for disorders of carbohydrate metabolism. OGTT are scheduled to begin between 0700 and 0900.
Therapeutic Drug Monitoring This test is used to monitor the blood levels of certain medication to ensure patient safety and also maintain a plasma level. Blood is drawn to coincide with the trough (lowest blood level) or the peak level (highest blood level). Trough levels are collected 30 minutes before the scheduled dose. Time for collecting peak level will vary depending on the medication, patient‟s metabolism, and the route of administration (I.V., I.M., or oral).
Blood Cultures (BC) They are 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 are usually ordered STAT or as timed specimen, and collection requires strict aseptic technique.
This test is 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 Cold agglutinins are antibodies produced in response to Mycoplasma pneumoniae infection (atypical pneumonia). The antibodies formed may attach to red blood cells at temperatures below body temperature, 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 degrees Celsius for 30 minutes.
Chilled specimens Some tests require that the specimen collected be chilled immediately after collection in crushed ice or ice and water mixture. Likewise, the specimen must be immediately transported to the laboratory for processing. Some of the tests that require chilled specimen are: arterial blood gases, ammonia, lactic acid, pyruvate, ACTH, gastrin, and parathyroid hormone.
Light-sensitive specimens Specimens are protected from light by wrapping the tubes in aluminum foil immediately after they are drawn. Exposure to light could alter the test results for: Bilirubin, beta-carotene, Vitamins A & B6, and porphyrins.
DERMAL PUNCTURES (Microcapillary collection) 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. Dermal puncture may be done on both pediatric and adult patients.
Punctures should never be performed with a surgical blade or hypodermic needle because they can be difficult to control. Deep penetration into the skin can cause serious injury such as osteomyelitis (inflammation of the bone and bone marrow). A lancet should be used, which delivers a pre-determined depth that can range from 0.85mm for infants to 3.0 mm for adults.
Site selection for dermal puncture Infants: The heel is used for dermal punctures on infants less than 1 year of age. Areas recommended are the medial and lateral areas of the plantar surface of the foot. These are determined by drawing imaginary lines medially extending from the middle of the great toe to the heel and laterally from the middle of the fourth and fifth toes to the heel.
The American Academy of Pediatrics recommends that heel punctures for infants not exceed 2.0mm.
Often requests are for more than one test to be performed; and as such, more than one collection tube needs to be drawn. The correct order of draw is:
First — blood culture tubes or vials;
Second — sodium citrate tubes (e.g., blue tops);
Third — serum tubes with or without clot activator or gel; (e.g., red tops);
Fourth — heparin tubes (e.g., green tops);
Fifth — EDTA tubes (e.g., lavender tops);
Sixth — oxalate/fluoride tubes (e.g., gray tops).
As you know, it is important for you, the Healthcare Professional to stay current with changes in your industry. Therefore, the National Healthcareer Association and the certification exam, Certified Phlebotomy Technician, CPT, will only accept this as the correct order of draw.
Lavender top tube - Contains the anticoagulant ethylenediaminetetraacetic acid (EDTA). EDTA inhibits coagulation by binding to calcium present in the specimen. The tubes must be filled at least two-thirds full and inverted eight times.
Common tests: CBC (Complete Blood Count); Includes: RBC count, WBC count and Platelet count; WBC differential count; Hemoglobin and Hematocrit determinations; ESR (Erythrocyte Sedimentation Rate); Sickle Cell Screening
Light-Blue top tube - Contains the anticoagulant Sodium Citrate, which also prevents coagulation by binding to calcium in the specimen. Sodium citrate is the anticoagulant used for coagulation studies because it preserves the coagulation factors. The tube must be filled completely to maintain the ratio of nine parts blood to one part sodium citrate, and should be inverted three to four times..
Common tests: Coagulation Studies- Prothrombin Time (PT) – evaluates the extrinsic; system of the coagulation cascade and monitors; Coumadin therapy; Activated Partial Thromboplastin Time (APTT, PTT) - Evaluates the intrinsic system of the coagulation cascade and monitors Heparin therapy. Fibrinogen Degradation Products (FDP) Thrombin Time (TT); Factor assays, Bleeding Time (BT)
Green top tube - Contains the anticoagulant Heparin combined with sodium, lithium, or ammonium ion. Heparin works by inhibiting thrombin in the coagulation cascade. It is not used for hematology because heparin interferes with the Wright‟s stained blood smear. This tube should be inverted eight times.
Common tests : Chemistry tests: performed on plasma such as Ammonia, carboxyhemoglobin & STAT electrolytes.
Gray top tube – Contains additives and anticoagulants. All gray top tubes contain glucose preservative (antiglycolytic agent): sodium fluoride- preserves glucose for 3days; or lithium iodoacetate- preserves glucose for 24 hours. May also contain the anticoagulant potassium oxalate, which prevents clotting by binding calcium. This tube should be inverted eight times.
Common tests: Fasting blood sugar (FBS); Glucose tolerance test (GTT); Blood alcohol levels; Lactic acid measurement
Chemistry Section The most automated section in the laboratory. This section is divided into several areas: Electrophoresis – analyzes chemical components of blood such as hemoglobin and serum, urine and cerebrospinal fluid, based on the differences in electrical charge. Toxicology - analyzes plasma levels of drugs and poisons. Immunochemistry – This section uses techniques such as radio immunoassay (RIA) and enzyme immunoassay to detect and measure substances such as hormones, enzymes, and drugs. Some tests in the chemistry section are ordered by profiles, which are groups of tests ordered by a physician to evaluate the status of an organ, body system or general health of the patient. Examples of these profiles are: Liver profile: tests may include ALP, AST, ALT, GGT and Bilirubin Coronary risk profile: tests may include Cholesterol, Triglycerides, HDL, LDL
Blood Bank Section This is the section where blood is collected, stored and prepared for transfusion. Strict adherence to procedures for patient identification and specimen handling is a must to ensure patient safety.
Blood collected may be separated into components: packed cells, platelets, fresh frozen plasma, and cryoprecipitate.
Serology (Immunology) Section Performs tests to evaluate the patient‟s immune response through the production of antibodies. This section uses serum to analyze presence of antibodies to bacteria, viruses, fungi, parasites and antibodies against the body‟s own substances (autoimmunity).
Microbiology Section
This section is responsible for the detection of pathogenic microorganisms in patient samples and for the hospital infection control. The primary test performed is culture and sensitivity (C&S). It is used to detect and identify microorganisms and to determine the most effective antibiotic therapy. Results are usually available within 24 to 48 hours; but cultures for tuberculosis and fungi require several weeks. One instance when culture and sensitivity is used is to diagnose the cause of a patient‟s fever of unknown origin (FUO).
Urinalysis Section This section performs tests on the urine to detect disorders and infection of the kidney and urinary tract and to detect metabolic disorders such as diabetes mellitus. Urinalysis has three components: Physical examination- evaluates the color, clarity and specific gravity Chemical examination- determines pH, glucose, ketones, protein, blood, bilirubin, urobilinogen, nitrites, and leukocytes. Microscopic examination- identifies presence of casts, bacteria, yeast, and parasites.
Safety hazards abound in the healthcare setting, many of which can cause serious injury or disease. The Occupational Safety and Health Administration (OSHA) is responsible for the identification of the various hazards present in the workplace and for the creation of rules and regulations to minimize exposure to such hazards. Employers are mandated to institute measures that will assure safe working conditions and health workers have the obligation to know and follow those measures.
Types of Hazards Biologic : infectious agents that can cause bacterial, viral, fungal, or parasitic infections. Sharps : needles, lancets, and broken glass can puncture and cut and cause blood- borne pathogen exposure. Chemical : preservatives and chemicals used in the laboratory. There is possible exposure to toxic, carcinogenic or caustic substances. Electrical: high-voltage equipment can cause burns and shock. Fire or explosive : Bunsen burners, oxygen and chemicals can cause burns or dismemberment. Physical : wet floors, heavy lifting can cause falls, sprains and strains. Allergic reaction : latex sensitivity that can cause allergic reactions ranging from simple dermatitis to anaphylaxis.
Emergency First Aid The ability to recognize and react quickly to an emergency may be the difference of life or death for the patient. As patients react differently to various situations, it is important for all healthcare professionals to be prepared in an emergency.
External Hemorrhage : controlling the bleeding is most effectively accomplished by elevating the affected part above heart level and applying direct pressure to the wound. Do not attempt to elevate a broken extremity as this could cause further damage.
Shock occurs when there is „insufficient return of blood flow to the heart, resulting in inadequate supply of oxygen to all organs and tissues of the body.‟ Patients experiencing trauma may go into shock and for some patients, seeing their own blood may induce shock. Common symptoms: Pale, cold, clammy skin Rapid, weak pulse Increased, shallow breathing rate Expressionless face/staring eyes. First Aid for Shock: Maintain an open airway for the victim Call for assistance Keep the victim lying down with the head lower than the rest of the body Attempt to control bleeding or cause of shock (if known) Keep the victim warm until help arrives
