Phlebotomy National Certification Exam

What is the Clinical and Laboratory Standards Insitute?

CLSI, global lab that develops standard practices for quality patient care & safety… committed to quality assurance

What us OSHA?

Occupational Safety and Health Administration, responsible for establishing safety regulations in all workplaces

What is quality assurance?

protocol that establishes guidelines defining safe practices and document procedures

What is quality control?

the actual steps/procedures performed to comply with QA program

What is the needlestick safety and prevention act?

OSHA policy to minimize bloodborne pathogen exposure

What is NIOSH?

National Institute for Occupational Safety and Health

What Vaccine does OSHA require all employees in contact with blood take?

Hep B (3 shots)

What is the order of donning ppe?

1. gown

2. mask

3. goggles/face shield

4. gloves

Order for doffing PPE?

1. gloves

2. goggles/face shield

3. gown

4. mask

What is a requisition?

a form used to communicate the providers orders to the lab doing testing

How long is too long to leave a tourniquet on? Why

More than one minute

prevents hemoconcentration (increase blood components due to fluid loss)

What needles do we commonly use?

21 and 22

Straight needle is also called?

Evacuated tube system

What is the correct angle of insertion

15-30 degrees

After throwing the needle away, what do I have to remember to do in front of the patient!

Label the tubes!

How long do i tell the pt to keep the gauze in place to prevent bruising?

30-60 mins

Tips to handle difficult draws

1. warm the site

2. cleanse with a lot of alcohol (cold shrinks skin)

3. tight but not uncomfy tourniquet

4. arm hang down to let gravity help

5. have patient drink water

6. have patient lie down

7. make sure pts legs arent crossed

8. ask for preferred arm

What is different about a draw on someone who had a mastectomy? why?

Can only draw on the opposite site of where the mastectomy was done

bc risk of lymphedema (swelling in an area where lymph nodes were removed)

What are petechiae? What do?

tiny, reddish purple dots below tourqnieut where capillaries burst

stop draw, let them recover and try on the other arm

What is the most common phlebotomy complication?

hematoma (needle punctures side of vein or passes thru it —> blood vessel leakage)

What would a hissing sound come from?

premature needle withdrawl

What would cause vibration of the needle?

hitting a vein valve

What type of needle do we use on PEDS and tube size?

23 G winged infusion set, 2ml pediatric tube

What is the blood draw max for an infant

no more than 1%-5% of their total blood volume within 24 horus

Kg to Lbs

1 kg = 2.2 lbs

Based on weight, what is the equation for max blood you can draw on an infant?

2 times their weight in kg… a 4 kg baby has a max of 8 ml

How is capillary collection done on adults vs kids?

adults: lancet puncture on middle two fingers

kids: heel stick on R & L of the proximal sole of the foot

Capillary Collection tools

1. Microcollection tube- small plastic container

2. Microhematocrit tube- thin glass tube that uses capillary action

3. Point of care testing device- POCT device use test strips to test blood

4. Blood spot collection card- heel sticks, newborn screenings

Microcollection tube vol & fx

hold up to 0.75 ml of blood

place tube against the blood drop, not skin, and allow it to drip into the container

What is order of draw for microcollection tubes?

EHAS (additives for tubes)

E: EDTA

H: Heparin

A: any other additive

S: Serum

What is the dif btwn serum and plasma?

Serum: liquid after blood clots (added to make blood clot)

Plasma: Unclotted liquid blood (added to make blood not clot)

Who do we do heel sticks on?

Capillary draws for infants under one to two years of age

For pre-term infants, what is the max heel puncture depth?

0.85 mm

Fir full-term infants, what is the max heel puncture depth?

2.0 mm

What is newborn screening adn when?

series of tests on neonates in first 28 days of life

What is lab particular about with the blood collection cards?

circles must be filled completely but not overfilled

card must not be placed directly on infants skin

blood must not be smeared/streaked

What body conditions affect blood collection?

bruises, burns/scars, collapsing veins (ETS, small vein), edema (choose site as far as possible), infection, IVs, mastectomy, rashes, rolling veins, tattoos

What are some blood conditions to know?

Anemia- too few RBC

Polycythemia vera- too many RBC

Hemachromatosis- body absorbs too much iron —> abnormal RBC

Leukopenia- too few WBC

Leukocytosis- too many WBC

What is the order of best to worst arm vein for draws?

1. median cubital vein

2. cephalic vein (lateral)

3. basilic vein (medial)

On finger sticks, what is the puncture depth max for children? for adults?

children- 1.5 mm to 2.4 mm

adults- 2.0 mm to 2.4 mm

What is hemostasis? & its phases?

process that stops bleeding

1. vasconstriction

2. platelet plug formation

3. coagulation

4. clot retraction and fibrinolysis

What is EDTA?

an anticoagulant

Proper tube label has?

Pts full legal name

date of birth

date and time of draw

technicians initials

What is order of draw?

Blood cultures/yellow tube —> light blue —> red —> gold/tiger —> light green —> dark green —> lavendar —> pink —> grey —> royal blue

How many times do you invert anticoagulant tubes?

Anticoagulant tubes (Green, Lavender): 8–10 inversions

How many times do you invert serum tubes?

Serum tubes (Red, Gold): 5–10 inversions.

How many times do you invert light blue & blood cultures?

3-4

What test is run using blood cultures? What do they detect?

culture and sensitivity (C&S)

culture- detects pathogens/infection in blood

sensitivity- detects effective antibiotics to use

How much blood collected for a blood culture?

8-10 ml each bottle (aerobic & anaerobic)… 2-4 draws from different body sites several hours apart

Which is drawn first, Aerobic or anaerobic? why?

1- aerobic… BC air that may go through the butterfly needle will not effect the growth of the aerobic bacteria

What additive is in blood cultures? fx?

nutrient broth

• supports microbial growth

What tube alternative can be used instead of BC? What is the additive?

yellow tube top

polyanethol sulfonate (SPS)

How should BCx be stored?

room temp is fine for up to 4 hours

What additive is in Light blue tube? What does it do? And therefore, does it yield plasma or serum?

sodium citrate- anticoagulant

• plasma

What is important about light blue draws because of the additive?

FILL TO THE LINE… need a 1-9 additive to blood ratio

What lab dept is light blue used for? and common tests?

coagulation dept/tests

• PT/INR, PTT, sPTT, D-Dimer

Invert light blue tube how many times?

3-4

What are PT/INR tests?

Prothrombin Time and International Normalized Ratio

• PT test measures the length of time it takes for blood to clot, therefore evaluating the extrinsic pathway of the coagulation cascade

• INR tests assesses level of clotting factors in blood… measured in seconds

What pt would need PT/INR testing?

pt doing anticoagulant therapy

What does a low INR mean vs a high INR?

low= blood clots too quickly

high= blood clots too slow (bleed out)

What is PTT test?

Partial Thromboplastin Time

• evaluates intrinsic pathway of coagulation cascade by measuring length of time for pts blood to clot

Why would a Dr order PTT test?

therapeutic drug monitoring (heparin therapy)

What is the aPTT test?

activated partial thromboplastin time

• same as PTT test, but has more sensitive and standardized results

• it is preferred in clinical settings

What is the D-dimer test?:

rule out the presence of a blood clot

• ie. deep vein thrombosis or pulmonary embolism

OR

evaluating the effectiveness of blood clotting disorders

When can inaccurate readings of elevated D Dimer levels occur?

1. pregnancy

2. heart disease

3. 
   

What is the difference between a glass and plastic red top tube?

glass- contains no additive (discard)

plastic- contains clot activator

What common tests for red top tube?

Therapeutic drug monitoring

• check specific drug levels in bloodstream

• scheduled at intervals to maintain safe/effective dose

In non-STAT orders, what tubes are used for Therapeutic Drug Monitoring? STAT orders?

non-STAT= red or gold (sst)

STAT= light green top

If the red top includes a clot activator, how many times do you invert it? & what do you do after that?

5

allow it to clot for 30-60 mins in upright position, then centrifuge

What additives are in gold top tube aka serum separator tube/tiger top?

silica- rapid clot activator (30-45 mins)

thixotropic gel- separates serum and cells, allowing storage of serum for up to a week

Common tests for SST tubes (gold, tiger top)?

1. CMP (comprehensive metabolic panel)- assesses metabolism (kidney, liver, glucose, electrolytes)

2. BMP (Basic metabolic panel)- simpler (kidney, glucose, electrolytes)

3. Lipid Panel- cholesterol, triglycerides

4. Hepatic function panel- liver health, measures enzymes, proteins, bilirubin

5. Renal function panel- kidney health, measures BUN, creatine, electrolytes

6. Chemistry serum determinations

Invert gold/tiger top sst tubes how many times?

5

What additives in light green top? Each used for what?

lithium heparin- anticoagulant —> STAT Chem testing

or

plasma separator tube (PST)= lithium heparin WITH thixotropic gel separator

Since lithium heparin is an anticoagulant, what is the liquid portion yielded?

plasma

What tests are for light green?

STAT chem tests like:

1. hCG (human chorionic gonadotropin)- present during pregnancy

2. standard electrolyte panel- Na+, K+, Cl-, CO2

3. ionized calcium

4. drug monitoring

How many times should it be inverted?

8

What additive for dark green top tube?

sodium heparin- anticoagulant

What is the most common test for dark green top? details for processing?

Ammonia test, usually STAT bc high levels are toxic

• must be kept on ice/chilled after collection, then place in ice slurry

• sample and cells must be separated within 15 mins

What are ALL the common tests for dark green?

ammonia- liver fx evaluation

Plasma Chemistry determinations

Chromosome studies- aka cytogenetic testing (ID down syndrome)

Invert dark green top how many times?

8

What is the additive in lavender top tube? How does it work?

K2 EDTA- anticoagulant… either liquid or spray dried form

• EDTA binds to calcium in the blood to prevent clotting

How many times to invert lavendar tube?

8

What are the most common tests for lavendar tube? Short description of each

1. CBC (complete blood count)- measures RBC, WBC, platelets, hemoglobin, hematocrit

2. ESR (erythrocyte sedimentation rate- indicates presence of inflammation in body

3. H&H (hemoglobin & hematocrit)- hematocrit is the % of RBC in sample

4. HbA1c (hemoglobin A1c)- used to diagnose & monitor diabetes… reflects average glucose level over past 2-3 months

5. sometimes ammonia

What additional evaluation can be added to a CBC in lavendar top?

differential (diff)- measures percentage of each of the 5 types of WBC

What additive in pink top tube?

K2 EDTA- anticoagulant

How full do lavendar and pink top tubes need to be filled? why?

at least 2/3 full

• to maintain additive-blood ratio

Common tests for pink top tube?

Blood typing and cross matching

• crossmatching: determines blood compatibility btwn donors & recipients

How many times do you invert the pink top tube?

8

What additive is in the gray top tube?

sodium flouride- preservative (3 days)

and

potassium oxalate- anticoagulant… binds to calcium in blood to prevent clotting

Does gray top yield serum or plasma?

plasma

What happens if the gray top is not filled to the top?

oxalate to blood ratio is messed up and hemolysis can occur

What are common tests for gray top tube?

GLUCOSE

lactic acid

blood alcohol concentration (BAC)

For blood alcohol concentration, what step is important in the draw?

use a non alcohol based cleanser (chlorhexidine or povidone-iodine)

What is special about drawing for lactic acid test?

must be drawn without use of a tourniquet

&

must immediately be placed on ice

What do royal blue top tubes test for?

trace elements

What is in the royal blue top with the red stripe? purple stripe? which is drawn first?

1st= red- no additives

2nd= purple- had EDTA (anticoag)

What are common tests for red stripe royal blue top tubes?

1. Selenium- supports immune, thyroid, cognitive fx

2. Copper- immune fx, energy & RBC production, nercve fx

How many times do you invert the red stripe royal blue top?

0

What are common tests for lavendar stripe royal blue top?

1. Zinc- must be centrifuged w/in 2 hours

2. Arsenic- toxic

3. Lead

How many times do you invert the lavendar royal blue top?

8