I. PRE-ANALYTICAL CONSIDERATIONS IN PHLEBOTOMY Flashcards
1
Q
Before analysis
A
Preanalytical
2
Q
Preanalytical begins when a test is
A
ordered
3
Q
Preanalytical ends when testing
A
begins
4
Q
Resting metabolic state of the body early morning after approximately 12 hours fasting
A
Basal state
5
Q
Basal state is resting metabolic state of the body early morning after approximately
A
12 hours fasting
6
Q
Basal state is influenced by a number of physiologic variables such as _____ that cannot be
eliminated
A
age, gender, and conditions of the body
7
Q
State: Physiological Variables that Influence Laboratory Test Results
A
- Age
- Altitude
- Dehydration
- Diet
- Diurnal Variation
- Drug Therapy
- Exercise
- Gender
- Jaundice
- Intramuscular Injection
- Position
- Pregnancy
- Smoking
- Stress
- Temperature & Humidity
8
Q
- RBC and WBC values higher in newborns
- Kidney function (creatinine clearance) decrease with age
A
Age
9
Q
RBC and WBC values higher in
A
newborns
10
Q
Kidney function (creatinine clearance)
A
decrease with age
11
Q
Red blood cell (RBC) counts elevated at
A
higher altitude
12
Q
Hemoconcentration
- RBCs, enzymes, iron (Fe), calcium (Ca), sodium (Na)
A
Dehydration
13
Q
➢ Lipids increase with ingestion of fatty foods
➢ Electrolytes altered by drinking excessive water
➢ Ammonia, urea increase in patients on high-protein diets
➢ Glucose increase with the ingestion of carbohydrates
A
Diet
14
Q
increase with ingestion of fatty foods
A
Lipids
15
Q
altered by drinking excessive water
A
Electrolytes
16
Q
increase in patients on high-protein diets
A
Ammonia, urea
17
Q
increase with the ingestion of carbohydrates
A
Glucose
18
Q
State: Tests that requires FASTING
A
- FBS
- Glucose tolerance test
- Triglycerides & lipid panel
- Gastrin
- Insulin
- Aldosterone & renin
- Electrolytes
19
Q
●Melatonin levels are affected by light
○Increase at night and decrease during day
●Renin and thyroid-stimulating hormone (TSH)
○Peak levels in the predawn hours of the morning during sleep
●Cortisol levels
○Peak: later in the morning, around 8:00am
●Exhibit diurnal variation with highest levels in the morning:
aldosterone, bilirubin, cortisol, hemoglobin, insulin, iron, potassium,
testosterone, and RBCs
A
Diurnal/Circadian Variations
20
Q
levels are affected by light: Increase at night and decrease during day
A
Melatonin
21
Q
Peak levels in the predawn hours of the morning during sleep
A
Renin and thyroid-stimulating hormone (TSH)
22
Q
Peak: later in the morning, around 8:00am
A
Cortisol levels
23
Q
- aldosterone
- bilirubin
- cortisol
- hemoglobin
- insulin
- iron
- potassium
- testosterone
- RBCs
A
Exhibit diurnal variation with highest levels in the morning
24
Q
● Chemotherapy drugs can cause a decrease in blood cells, especially WBCs and platelets
● Many drugs are toxic to the liver
● increase levels of liver enzymes:
○ Aspartate aminotransaminase (AST)
○ Alkaline phosphatase (ALP)
○ Lactate dehydrogenase (LDH)
● Steroids and diuretics: increase amylase and lipase
A
Drug Theraphy
25
can cause a decrease in blood cells, especially WBCs and platelets
Chemotherapy drugs
26
toxic to the liver
Drugs
27
These increase levels of liver enzymes
○ Aspartate aminotransaminase (AST)
○ Alkaline phosphatase (ALP)
○ Lactate dehydrogenase (LDH)
28
Steroids and diuretics
increase amylase and lipase
29
● Arterial pH and PCO2 levels are reduced
● Glucose can be elevated by moderate muscular activity
● Potassium (K+) is increased in the plasma
● Skeletal muscle enzymes creatine kinase (CK) and lactate dehydrogenase (LDH) are increased by exercise
Exercise
30
In exercise, these levels are reduced
Arterial pH and PCO2
31
In exercise, this can be elevated by moderate muscular activity
Glucose
32
In exercise, this increased in the plasma
Potassium (K+)
33
In exercise, Skeletal muscle enzymes which are: _____ and ___ increased
creatine kinase (CK) and lactate dehydrogenase (LDH)
34
○ Increases hormones insulin and glucagon
○ increases cortisol
Fever
35
RBC, hemoglobin (Hgb), and hematocrit (Hct) normal values are higher for males than for females
Gender
36
Patient with fever, It increase hormones _____ and _____ and cortisol
insulin and glucagon
37
This normal values are
higher for males than for females
RBC, hemoglobin (Hgb), and hematocrit (Hct)
38
increases levels of creatine kinase (CK) and the skeletal muscle fraction of LDH
Intramuscular Injection
39
● icteric : deep yellow to yellow-brown color of serum or plasma
● interferes with chemistry tests based on color reactions
Jaundice
40
deep yellow to yellow-brown color of serum or plasma
icteric
41
from supine to an upright sitting or standing position
causes blood fluids to filter into the tissues, and _______
decreasing plasma volume
42
In body position, protein in nature or bound to protein—such as aldosterone, bilirubin, blood cells, calcium, cholesterol, iron, protein, and renin are
Increase
43
State: protein in nature or bound to protein
aldosterone, bilirubin, blood cells, calcium, cholesterol, iron,
protein, and renin
44
In body position, potassium (K) levels are
increase
45
lower RBC counts
pregnancy
46
● Increased cholesterol, cortisol, glucose, growth hormone, and triglyceride levels and WBC counts
● Chronic smoking : decreased pulmonary function and increased RBC counts and hemoglobin levels
● Smoking can also affect the body’s immune response, lowering the conc. of immunoglobulins
Smoking
47
Increased cholesterol, cortisol, glucose, growth hormone, and
triglyceride levels and WBC counts
Smoking
48
decreased pulmonary function and increased RBC counts and hemoglobin levels
Chronic smoking
49
can also affect the body’s immune response, lowering the
concentration of immunoglobulins
Smoking
50
● Increases in WBC counts
● Decrease serum iron levels
● Increase adrenocorticotropic hormone(ACTH), catecholamine, and cortisol levels
Stress
51
hemoconcentration caused by
Temperature and Humidity
52
State Common Preanalytical Errors: Before collection
1. Incorrect test ordered
2. Inadequate patient preparation
3. Misidentification of Patient
53
State Common Preanalytical Errors: During collection
1. Wrong container/wrong additive
2. Short draws/ wrong anticoagulant/blood ratio
3. Prolonged torniquet time
4. Hemolysis due to incorrect technique
54
State Common Preanalytical Errors: After collection
1. Inadequate mixing/clots
2. Mislabeling of specimen
3. Improper transport
- Exposure to light
- Extreme temperature
- Delayed delivery
4. Processing errors:
- Incomplete centrifugation
- Incorrect log-in
- Improper storage
- Improper aliquoting
55
1. Burns, scars, or tattoos
2. Damaged Veins
3. Edema
4. Hematoma
5. Mastectomy (surgical breast removal)
6. Obesity
Problem Venipuncture Sites
56
Healed burn sites & areas with extensive scarring may have
impaired circulation
57
Newly burned areas
painful and susceptible to infection
58
○ impaired circulation,
○ more susceptible to infection
○ contain dyes that can interfere with testing
Tattooed areas
59
hard and cord-like; occluded or obstructed
Damaged Veins
60
sclerosed
hardened
61
thrombosed
clotted
62
caused by numerous venipunctures
Scarring
63
● hard and cord-like; occluded or obstructed
● sclerosed (hardened)
● thrombosed (clotted)
● Scarring caused by numerous venipunctures
● Choose another site if possible
● draw below (distal to) damaged veins
Damaged Veins
64
● may yield inaccurate test results (contamination with tissue fluid)
● veins are harder to locate
● tissue is often fragile and easily injured by tourniquet and antiseptic application
● healing may be prolonged
Edema
65
Swelling or mass of blood that can be caused by blood leaking from a blood vessel during or following venipuncture
Hematoma
66
● Lymph node removal causes lymphostasis (obstruction or stoppage of normal lymph flow)
● susceptible to swelling and infection
● Applying a tourniquet to the arm can cause injury
● lymphostasis can change blood composition in that arm
Mastectomy (surgical breast removal)
67
obstruction or stoppage of normal lymph flow
lymphostasis
68
● Veins may be deep and difficult to find
● Proper tourniquet selection and application
● median cubital vein
● cephalic vein
● To locate the cephalic vein, rotate the patient’s arm so that the hand is prone
Obesity
69
In obese patient, rotate the
patient’s arm so that the hand is prone
To locate the cephalic vein
70
A tube inserted into a vein or artery, providing ready access to the patient’s circulation while eliminating multiple phlebotomies.
Vascular Access Device (VAD)
71
A catheter placed in an artery, most commonly in the radial artery, used for continuous blood pressure monitoring and blood gas analysis.
Arterial Line (A-line or Art-line)
72
A surgically created fusion of a vein and artery, primarily used for hemodialysis treatment. Never apply a blood pressure cuff, tourniquet, or perform venipuncture on the affected arm.
Arteriovenous Shunt (AV Fistula)
73
A small catheter placed in a vein in the lower arm above the wrist for medication administration or blood draws, flushed with heparin or saline to prevent clotting.
Heparin or Saline Lock (Hep Lock)
74
A thin plastic tube or catheter inserted into a vein to administer fluids, with precautions to avoid blood contamination or dilution from IV fluids.
Intravenous (IV) Site
75
Turning off the IV for 2 minutes, applying the tourniquet and selecting a venipuncture site distal to the IV, performing venipuncture in a different vein if possible, restarting the IV after collection, and documenting the procedure, fluid type, and arm used.
Performing Venipuncture Below an IV
76
Blood should not be collected from a previous IV site within 24 to 48 hours after IV discontinuation; always follow facility protocol.
Previously active IV sites
77
A needleless closed blood sampling device connected to an arterial or central venous catheter, used for blood collection to reduce infection risk, prevent needlesticks, and minimize waste from line draws.
Blood Sampling Device
78
An indwelling line consisting of tubing inserted into a main vein or artery, primarily used for administering fluids and medications, monitoring pressures, and drawing blood. Includes central venous catheter, implanted port, and peripherally inserted catheter.
Central Vascular Access Device (CVAD)
79
A line inserted into a large vein, such as the subclavian, and advanced into the superior vena cava.
Central Venous Catheter (CVC) or Central Line
80
A surgically implanted, disk-shaped chamber attached to an indwelling line, placed on the upper chest just below the collarbone.
Implanted Port
81
A line inserted into a vein in an extremity and threaded into a main vein leading to the heart.
Peripherally Inserted Central Catheter (PICC)
82
Placing folded gauze over the site instead of adhesive, instructing the patient to hold pressure for 5 minutes instead of using a bandage.
Adhesive Allergy
83
Ensuring alternate antiseptics are readily available for patients with antiseptic sensitivity.
Antiseptic Allergy
84
Using non-latex gloves, a non-latex tourniquet, and non-latex bandages to prevent allergic reactions.
Latex Allergy
85
Patients on aspirin or anticoagulant therapy; maintain pressure over the site until bleeding stops, notify personnel if bleeding continues after 5 minutes, never use a pressure bandage instead of applying direct pressure, and do not dismiss the patient until bleeding has stopped.
Excessive Bleeding
86
Temporary loss of consciousness due to insufficient blood flow to the brain.
Fainting (Syncope)
87
Sudden faintness or loss of consciousness due to a nervous system response to abrupt pain, stress, or trauma, related to vagus nerve action on blood vessels.
Vasovagal Syncope
88
Conditions that increase the risk of fainting, including illness, hypoglycemia, anemia, dehydration, emotional distress, fatigue, hyperventilation, needle phobia, or compromised breathing.
Syncope: Contributing Factors
89
Symptoms such as paleness, sweating, hyperventilation, dizziness, light-headedness, vertigo, or nausea.
Signs of Syncope
90
Steps to follow if a patient faints during venipuncture: release the tourniquet, remove the needle, apply pressure, have the patient lower their head and breathe deeply, provide support, loosen tight clothing, apply a cold compress, ensure someone stays with the patient, call first aid if needed, and document the incident.
Managing Syncope During Venipuncture
91
patient is nauseous or show signs similar to fainting:
○ blood draw should not be attempted until the feeling subsides
○ blood draw that is in progress should be discontinued
○ Ask the patient to breathe slowly and deeply
○ Apply a cold, damp washcloth or other cold compress to the patient’s forehead
Nausea and Vomiting
92
Marked or extreme pain, numbness of the arm, a burning or electric-shock sensation, or pain that radiates up or down the arm
Signs of nerve involvement
93
Pain persists after needle removal
Apply an ice pack to the site
94
● Tiny, non-raised red (or purple) spots that appear on the patient’s skin when a tourniquet is applied
● Minute drops of blood that escape the capillaries
● Result of capillary wall defects or platelet abnormalities
Petechiae
95
● Discontinue the draw immediately
● Hold pressure over the site
● Do not attempt to put anything into the patient’s mouth
● Notify the appropriate first-aid personnel
SEIZURES and CONVULSIONS
96
○ Most common complication
○ swelling or mass of blood that can be caused by blood leaking from a blood vessel during or following venipuncture
Hematoma Formation
97
State what to do in case of hematoma
- first 24 hrs: apply ice (20 to 30 mins)
- After 24 hrs: apply warm compress
98
● Blood leakage into surrounding tissues due to venipuncture complications
● Excessive or blind probing
● Inadvertent arterial puncture
● Fragile vein (too small for the needle size)
● Needle penetrates through the vein
● Needle is partially inserted
● Needle is removed while the tourniquet is still on
● Inadequate pressure applied after venipuncture
Causes of Hematoma
99
Blood loss due to repeated or excessive blood draws
IATROGENIC ANEMIA
100
adverse condition brought by the effects of treatment/procedure
iatrogenic
101
Life is threatened if more than 10% of a patient’s blood volume is removed at
one time
102
Deep or blind probing in the area of the basilic vein (close proximity to the brachial artery) can result in compression injury to a nearby nerve.
Inadvertent Arterial Puncture
103
Rapidly forming hematoma, blood filling the tube very quickly.
Signs of Inadvertent Arterial Puncture
104
Terminate the venipuncture immediately, apply direct forceful pressure to the site for at least 5 minutes until bleeding stops.
Actions of Inadvertent Arterial Puncture
105
Minimized by proper aseptic technique.
Infection
106
- Do not open adhesive tape or bandages ahead of time or temporarily tape them to contaminated objects.
- Do not preload needles onto tube holders.
- Do not touch the site after sterilization.
- Minimize the time between removing the needle cap and performing the venipuncture.
- Remind the patient to keep the bandage on for at least 15 minutes after specimen collection.
Infection Prevention
107
Improper vein selection can lead to
Nerve Injury
108
Extreme pain, burning/electric shock sensation, numbness of the arm, radiating pain.
Signs of Nerve Injury
109
Remove the needle immediately and look for an alternative site.
Action of Nerve Injury
110
flow back into the patient’s vein from the collection tube during the venipuncture procedure.
Reflux of Additive
111
Keep the patient’s arm in a downward position.
Prevention of Reflux of Additive
112
Can result from numerous venipunctures in the same area over time, blind probing, or improper technique when redirecting the needle.
Vein Damage
113
Decrease in fluid content or plasma volume caused by stagnation of normal venous blood flow due to tourniquet application.
Hemoconcentration
114
Increased concentration of RBCs and large molecules (albumin, ammonia, calcium, cholesterol, coagulation factors, enzymes, iron, potassium, total protein).
Effect of Hemoconcentration
115
- Ask the patient to release the fist upon blood flow.
- Do not allow the patient to pump the fist.
- Avoid excessive massaging to locate a vein.
- Do not probe or redirect the needle multiple times.
- Release the tourniquet within 1 minute.
Prevention of Hemoconcentration
116
RBCs are damaged or destroyed, causing hemoglobin to escape into the fluid portion of the specimen.
Appearance:
- Pink (slight)
- Dark pink to light red (moderate)
- Dark red (gross)
Hemolysis
117
serum or plasma appears pink
slight hemolysis
118
dark pink to light red
moderate hemolysis
119
dark red
gross hemolysis
120
- Drawing blood from or through a hematoma.
- Failure to wipe away the first drop of capillary blood (alcohol residue).
- Forceful aspiration of blood during syringe draw.
- Forcing blood from a syringe into an evacuated tube.
- Frothing due to improper needle fit.
- Horizontal transport of tubes.
- Mixing additive tubes vigorously.
- Partially filling a sodium fluoride tube.
- Pulling back the plunger too quickly.
- Rough handling during transport.
- Squeezing the site during capillary blood collection.
- Delay in syringe transfer, forcing partially clotted blood into a tube.
- Using a large-volume tube with a small-diameter butterfly needle.
- Using a needle that is too small in diameter.
Causes of Hemolysis
121
Can affect specimen quality
Partially Filled Tubes (Short Draw)
122
Short-draw serum tubes are
generally acceptable
123
Under-filled anticoagulant tubes
blood-to-additive ratio
124
Never pour two partially filled additive tubes together to fill
one tube
125
Contaminants that can affect specimen integrity.
Specimen Contamination
126
- Alcohol, glove powder, baby powder, or urine from wet diapers.
- Glove powder on blood films (slides).
- Dripping perspiration into capillary specimens.
- Using the wrong antiseptic or not following proper antiseptic procedure.
Sources of Specimen Contamination
127
Use of incorrect or expired tubes affecting specimen integrity.
Wrong or Expired Collection Tube
128
- Additives in expired tubes may not work properly.
- Formation of microclots.
Effects of Wrong or Expired Collection Tube
129
Expiration dates of tubes must be checked routinely, and expired tubes discarded.
Prevention to Wrong or Expired Collection Tube
130
Ensuring proper tube placement for successful blood draw.
Tube Position
131
- Tube is properly seated.
- Needle in the tube holder has penetrated the tube stopper.
- Needle sleeve is not pushing the tube off the needle.
Check in Tube Position
132
Correct placement of the needle within the vein.
Needle Position
133
- Bevel is correctly positioned within the vein.
- Adjust needle slowly and precisely to avoid injury.
Needle Correct Position
134
Occurs when the vein is deeper than normal.
Needle Not Inserted Far Enough
135
Slowly advance the needle forward.
Correction to Needle Not Inserted Far Enough
136
Bevel is not fully under the skin, leading to vacuum loss.
Bevel Partially Out of the Skin
137
- Using superficial/hand veins.
- Steep angle of needle entry.
Causes of Bevel Partially Out of the Skin
138
Discard the tube, advance the needle slowly, then insert a new tube.
Correction to Bevel Partially Out of the Skin
139
Bevel is partly through the upper vein wall, causing slow blood flow.
Bevel Partially Into the Vein
140
Gently push the needle forward into the vein.
Reminder: Partial insertion can cause blood leakage and hematoma formation.
Correction to Bevel Partially Into the Vein
141
The vein rolls slightly due to poor anchoring.
Needle Beside the Vein
142
Needle position is unclear, requiring adjustment.
Correction:
- Remove the tube from the holder.
- Withdraw the needle until the bevel is just under the skin.
- Palpate the arm (not too close to the needle).
- Relocate and anchor the vein, then redirect the needle into it.
Undetermined Needle Position
143
Vein temporarily shuts off blood flow due to excessive vacuum or pressure.
Collapsed Vein
144
-Too much vacuum on small veins.
- Excessive pulling of the plunger.
- Tourniquet tied too tightly or removed too soon.
- Fragile veins (common in elderly patients).
Causes of Collapsed Vein
145
Vein disappears as soon as the tube is engaged or tourniquet is removed.
Clue of Collapsed Vein
146
This happen in a tube preventing blood flow
Tube Vacuum Loss
147
- Shipping and handling issues.
- Tube pushed too far onto the needle before venipuncture.
Causes Tube Vacuum Loss
148
- Try repositioning the needle.
- If unsuccessful, use a new tube.
Correction Tube Vacuum Loss
