National Phlebotomy Certification: Comprehensive Study Notes
CDC Precautions
CDC (Centers for Disease Control and Prevention) enforces standard precautions for all patient care.
Minimum infection prevention practices:
Hand hygiene
Use of personal protective equipment (PPE) such as gloves, lab coats, and masks
Safe injection practices
Safe handling of potentially contaminated equipment or surfaces
Respiratory hygiene/cough etiquette
Maintain awareness of surroundings and keep the workplace clean and organized for a safe environment.
Blood-borne Pathogens and Hazardous Materials
Blood-borne pathogens are pathogenic microorganisms found in human blood that can cause disease (examples: HBV, HIV).
Hazardous materials include: outdated/broken equipment and anything that has contacted contaminated blood.
Sharps container:
Must be puncture-resistant and leak-proof on sides and bottom.
Should be labeled or color-coded red.
Contaminated materials (gloves, gauze, etc.) must be discarded in a biohazard liner or trash bag.
Personal Protective Equipment (PPE)
Employer must provide appropriate PPE at no cost when there is occupational exposure.
PPE includes: gloves, gowns, lab coats, face shields or masks, eye protection, mouthpieces, resuscitation bags, pocket masks, or other ventilation devices.
PPE is "appropriate" if it prevents blood or potentially infectious materials from contacting skin, clothing, undergarments, eyes, mouth, or other mucous membranes under normal use and duration.
Use of PPE when exposure cannot be avoided; employer may document rare cases where PPE use would impede care, and investigate circumstances to prevent recurrence.
Accessibility and fit:
PPE must be readily accessible in appropriate sizes at the worksite or issued to employees.
Hypoallergenic gloves and alternatives (glove liners, powder-free gloves) should be available for those with allergies.
Cleaning, laundering, and disposal:
Employer must clean, launder, and dispose of PPE at no cost to the employee.
If clothing is penetrated by blood or infectious materials, remove promptly.
All PPE removed before leaving the work area and placed in designated storage/decontamination/disposal area.
Repair and replacement:
Employer must repair or replace PPE as needed to maintain effectiveness, at no cost to the employee.
Gloves:
Worn when contact with blood or potentially infectious materials is anticipated, during vascular access procedures, and when handling contaminated items/surfaces.
Disposable gloves (surgical/examination) should be replaced if contaminated, torn, punctured, or compromised; cannot be washed or decontaminated for reuse.
Utility gloves may be decontaminated for reuse if integrity remains intact, but discard if cracked, peeled, torn, punctured, or deteriorated.
Exposure Control Plan:
Written plan to eliminate or minimize employee exposure to blood-borne pathogens and hazardous materials.
Must include: schedule/methods for compliance; HBV/HIV labs and production facilities; hepatitis B vaccination and post-exposure follow-up; hazard communication; recordkeeping.
A copy of the plan must be accessible to employees per applicable standards (e.g., 29 CFR).
Plan should be updated annually and if tasks, positions, or technologies change to reduce exposure.
Employers must solicit input from non-managerial, frontline staff responsible for direct patient care and at risk for needlestick injuries, and document the solicitation in the plan.
Exposure Determination:
List all job classifications with occupational exposure.
List classifications where some employees have exposure.
List tasks/procedures with exposure performed by employees in certain classifications.
This document is prepared without regard to PPE usage.
Universal Precautions and Engineering/Work Practice Controls:
Universal precautions observed to prevent contact with blood or other potentially infectious materials.
In uncertain cases where body fluid types are difficult to differentiate, all body fluids are treated as potentially infectious.
Engineering and work practice controls are used to eliminate or minimize exposure; PPE is used if exposure remains.
Engineering controls should be regularly examined and maintained or replaced to ensure effectiveness.
Understanding how infection spreads:
Infections caused by bacteria, viruses, and other organisms can be spread through various routes:
Stool: pathogens in feces can contaminate hands, food, water, surfaces if hygiene is insufficient; hand washing is the best prevention.
Bodily fluids: saliva, nasal secretions; common colds; hand washing prevents spread.
Contact with blood: small amounts can cause infection; clean and disinfect any exposed objects/equipment.
Direct physical contact: skin-to-skin contact with a sick person can transfer infection; wear gloves/outerwear to minimize exposure.
Contaminated objects: toys, towels, food/water can spread infections; clean/sanitize and use approved food/water sources.
Sterilization, cleaning, and disinfection:
All healthcare workers should wash hands frequently.
When handwashing facilities are not feasible, use antiseptic cleansers with clean cloth/paper towels or antiseptic towelettes.
After using antiseptics, wash hands with soap and running water as soon as possible.
Wash hands and exposed skin with soap and water or flush mucous membranes following contact with blood or potentially infectious material.
Basic Arm Anatomy and Procedures
Blood cell functions:
Red blood cells (RBCs) primarily transport oxygen and carbon dioxide.
Hemoglobin enables oxygen transport; oxygen saturation increases with lung oxygenation, turning blood bright red.
Oxygen release occurs as RBCs perfuse tissues; Hb releases O2 to tissues.
Special considerations for clotting deficiencies:
Patients on blood thinners require careful observation and may not have blood drawn in some cases.
Equipment and Procedure (blood draw):
Equipment checklist:
Safety needles
Butterfly needles
Syringes
Blood collection tubes
Bandage
Gauze
Biohazard sharps containers
Tourniquet
Gloves
Alcohol wipes
Procedure steps:
1) Locate a vein.
2) Clean the area with alcohol.
3) Put on gloves (check patient for latex allergy).
4) Apply tourniquet.
5) Remove cap from needle and inspect needle integrity (no bends, missing parts).
6) Anchor the skin by pulling it taut with the free hand.
7) Insert needle bevel facing up.
8) Collect tubes in order of draw; keep tubes close to free hand for efficiency.
9) After collection, apply gauze over the site without pressing on the needle.
10) Withdraw needle straight out.
11) Apply gauze and bandage.
Order of draw (when applicable):
1) Light blue tube (Sodium citrate) – must be filled completely
2) Red/black tube with gel serum
3) Red tube without gel (serum) or similar
4) Green or tan tube (Heparin)
5) Lavender or tan tube (EDTA)
6) Royal blue tube (EDTA)
7) Grey tube (Glucose) with ACD solution; yellow tube drawn last
Patient Identification (ID) and Preparing the Site
Proper patient identification is crucial in specimen collection; misidentification can lead to under- or over-medication and mismanagement.
Inpatients: steps include asking for full name, address, date of birth or a unique ID; attach identification bracelet to the patient; report problems to supervisor.
Outpatients: steps include confirming full name, address, date of birth or unique ID;compare information with the request form; report problems to supervisor.
Preparing the site for venipuncture:
Locate the vein; prefer larger veins.
Ensure no pulse is present in the antecubital area.
Clean the area with alcohol or iodine.
Wear latex gloves (verify latex allergy).
Tie tourniquet around the arm; ensure clothing or tourniquet is at least away from the venipuncture site.
Remove cap from needle and inspect for manufacturing flaws (bend, missing parts).
Before insertion, anchor the skin by pulling tight with the thumb of the free hand.
Needle bevel should face up during insertion.
Tubes should be near the free hand to minimize interruptions.
After all tubes are filled, place gauze over the site without pressing the needle.
Withdraw needle straight and then apply pressure; bandage as needed.
Checking for errors:
Always double-check patient information and tube labels before and after collection.
Recovering a failed venipuncture:
If no blood flash occurs, consider:
Tube vacuum loss; try a different tube.
Needle position not correct; adjust or rotate to position against a vein wall.
Tube vacuum too strong; use a smaller tube or choose a larger vein.
Site selection for blood collection:
Tighten tourniquet about above the site.
Have the patient make a fist to enlarge veins.
Median vein is usually closest to the skin and best for venipuncture; it is in the middle of the arm and causes the least pain and movement during needle insertion.
If the median vein is not present, consider basilic or cephalic veins.
IV: Capillary blood collection; Site selection for infants
Capillary blood collection involves finger sticks or heel sticks (infants).
Most common test is glucose monitoring.
Finger sticks can be an alternative to venipuncture depending on test and required blood volume.
Finger sticks are the most sensitive and painful even when performed properly.
Puncture devices are spring-loaded, single-use needles designed to retract after use to prevent needlestick injuries; dispose in Sharps container.
Infants 12 months and younger: puncture site is the inner/outer portions of the heel; avoid bruised, broken skin, or rashes.
Finger sticks (age 1+): typically from the third or fourth finger pad; avoid punctures on the thumb side where tissue is thinner.
CLSI Order of Draw; Hematoma and After-care
CLSI order of draw helps prevent cross-contamination of additives between tubes.
If tubes are drawn out of order, test results may be affected.
Hematoma complications:
A hematoma is a raised area under the skin due to blood leakage after venipuncture.
If a hematoma forms, withdraw the needle and apply gauze and pressure to the raised area.
Phlebotomy after-care instructions:
Ensure the patient’s bandage is secure.
Provide a list of home care instructions.
Monitor for adverse symptoms (e.g., fainting, nausea) and check patient status before discharge.
V: Patient Care and Professionalism
Medical professionals have a responsibility to maintain high standards of patient care and professionalism.
Strive to help patients feel they are receiving the best possible care; as a phlebotomist, go the extra mile.
Implementing professionalism:
Poorly trained staff negatively affects patient care; operate professionally and neatly.
You are a representative of your team; actions affect others.
Personal appearance:
Sleep adequately; hair neatly groomed; clothes ironed; maintain high hygiene.
Attitude:
Maintain a positive attitude; support coworkers; be a good example.
Phone etiquette:
Be pleasant, listen, answer questions, and find answers quickly if unsure.
End calls on a good note; avoid long holds.
Patient courtesies:
Address patients by their first name; empathize with nerves and anxiety; adjust conversation to make patients comfortable.
Leadership:
Leaders set examples, take responsibility for actions, correct mistakes, and continuously improve.
VI: Patient Rights, Standards, and Regulations
Patient Rights (American Hospital Association Bill of Rights):
1) Right to considerate and respectful care.
2) Right to information about diagnosis, treatment, prognosis in understandable terms; if not medically advisable, information should be given to an appropriate person.
3) Right to information necessary to give informed consent prior to procedures; information should include procedure specifics, risks, probable duration of incapacitation; alternatives if available; know the person responsible for the procedure.
4) Right to refuse treatment and to be informed of medical consequences.
5) Right to privacy of medical care discussions and confidentiality; non-involved parties require patient permission.
6) Right to confidential handling of communications and records.
7) Right to reasonable hospital response for services; evaluation, service, and referral as indicated; transfer requires complete information and hospital acceptance.
8) Right to obtain information about hospital relationships with other institutions affecting care.
9) Right to be advised about human experimentation affecting care; right to refuse participation.
10) Right to reasonable continuity of care; know appointment times and availability; hospital should inform patient of ongoing care needs after discharge.
11) Right to examine, receive, and understand the bill regardless of payment source.
12) Right to know hospital rules and regulations apply to conduct as a patient; hospital functions include disease prevention, education, and clinical research, all with patient dignity as a priority.Patient identification and obtaining consent
Patient identification requirements before treatment; proof of ID is commonly provided at check-in or prior to informed consent.
Informed consent: physicians are responsible for securing informed consent; responsibility lies with the coordinating physician if not performed personally; hospital rights require information sharing.
Standards of care and potential legal lawsuits
Injury during blood collection does not automatically imply fault by the phlebotomist; phlebotomy is invasive and carries risk.
Common injuries potentially leading to lawsuits:
1) Venous hemorrhage (bleeding from vein)
2) Arterial hemorrhage (arterial puncture) – arterial blood is bright red due to high oxygen content; arteries are near veins in the antecubital region; follow employer work practices and guidelines for artery puncture.
3) Nerve injuries
4) Post-procedure injuries
Venous hemorrhage prevention and response: ensure proper pressure after venipuncture to limit hematoma risk.
VII: HIPAA Laws, Medical Records, and Confidentiality
HIPAA (Health Insurance Portability and Accountability Act) signed into law on August 21, 1996.
Scope: applies to health plans, healthcare clearinghouses, and healthcare providers that electronically conduct healthcare transactions; protects privacy and personal information.
Privacy Rule:
Establishes national standards to protect health information; sets limits on use/disclosures without patient authorization.
Grants patients rights to examine/copy health records and request corrections.
What HIPAA covers?
Any information about a patient’s past, present, or future health, including payment information.
To be HIPAA-covered, medical information must be kept by a covered entity and identifiable with the patient (PHI).
Phlebotomist responsibilities:
Do not discuss patient information outside the workplace; only discuss with the patient or relevant care team.
Patient information includes names, personal information, health issues, and treatment explanations.
Violations can lead to termination and possible legal consequences.
Phlebotomy Key Terms (selected glossary)
ABG: Arterial Blood Gas.
ACD: Acid-citrate-dextrose; an anticoagulant containing citric acid, sodium citrate, and dextrose (formerly used for whole blood preservation; used for plateletpheresis).
AIDS: Acquired Immunodeficiency Syndrome; infection with human immunodeficiency virus.
Anaphylaxis: Life-threatening allergic reaction upon re-exposure to a trigger.
Anemia: Inadequate RBC-mediated oxygen delivery.
Antecubital fossa: The area opposite the elbow on the inner arm.
Anticoagulant: Substance that prevents blood clotting.
Antigen: Substance that elicits an immune response.
Anti-platelet agents: Medications (e.g., aspirin) reducing platelet aggregation.
Antiseptic: Agent inhibiting microbial growth.
Apheresis: Separation and removal of specific blood components with return of the remainder to the donor.
Arteriole: Small artery leading to capillaries.
Artery: Vessel carrying blood away from the heart.
Aseptic: Absence of microorganisms.
Aseptic technique: Practices to keep cultures, instruments, and people free of contamination.
Aspirate: Material drawn with negative pressure (in a syringe).
Autohemolysis: Hemolysis of RBCs caused by the individual's own serum.
Bacteremia: Bacteria present in the bloodstream.
Basal state: Fasting state, typically about 12 hours after last intake.
Basilic vein: Large vein on the inner arm frequently used for collection.
Betadine: Povidone-iodine antiseptic.
Bleeding-time: Test measuring time for small vessels to stop bleeding.
Blood: The fluid containing RBCs, WBCs, platelets, plasma, etc.
Blood-borne pathogens: Disease-producing microorganisms spread via contaminated blood; OSHA defines them accordingly.
Blood clot: Solidification of blood.
Blood clotting factor: Proteins in plasma that help form a clot.
Blood smear: Sample of blood on a slide for microscopic exam.
Blood transfer device: Device used to transfer blood between containers or tubes.
Blood vessel: Duct lined with endothelium through which blood flows.
Bruise/contusion: Subcutaneous bleeding from capillary rupture.
Butterfly needle: Used for multiple sites; often for hand/arm veins.
Citrate: Anticoagulant intermediate in the citric acid cycle; prevents clots.
Clot: Solidified blood.
Coagulate: Clot formation.
Coagulation factors: Plasma proteins (I-XIII) that drive coagulation.
Contamination: Introduction of unwanted material or organisms.
Dialysis: Process of cleansing blood when kidneys fail.
Diaphoretic: Sweating; potential sign of syncope.
Disinfectant: Agent that removes or kills pathogens on surfaces.
Edema: Swelling due to fluid accumulation.
Electrolyte: Conductive ions (Na+, K+, Cl-, Ca2+, PO4^3−, etc.).
Embolus: Moving blood clot.
Epidermis: Outer skin layer.
Fasting: Refraining from eating before tests.
Flash-back: Visible blood in the needle hub during venipuncture.
Gauge: Needle diameter; higher gauge means smaller needle lumen.
Glucose: Blood sugar measured to assess diabetes risk/management.
Hematocrit: RBC volume as a percentage of whole blood.
Hematoma: Localized blood collection under tissue.
Hemoglobin: Oxygen-carrying component in RBCs.
Hemolysis: Destruction of RBC membranes.
Hemostasis: Cessation of bleeding.
Heparin: Anticoagulant produced by the liver; inhibits coagulation factors.
Hepatitis A/B/C: Viral liver infections with distinct transmission modes and clinical features.
HIV: Human immunodeficiency virus.
Hyperglycemia: High blood glucose.
Hypersensitivity: Exaggerated immune response to antigens.
Hypodermic needle: Needle for injections or withdrawals.
Hypoglycemia: Low blood glucose.
Isolation: Procedures to protect patients from infection.
Lancet: Small two-edged blade for incisions.
Medial cubital vein: Main vein used in venipuncture.
Micro-capillary: Capillary blood collection from heel/finger for small samples.
Mononuclear: Cells with one nucleus (monocytes/lymphocytes).
Multi-sample adapter: Device enabling multiple tubes with one puncture.
Nosocomial infection: Hospital-acquired infection.
Order of Draw: Sequence to prevent additive contamination.
Palpate: Feel with the hand to locate a vein.
Peripheral blood: Blood from the circulation away from the heart (e.g., fingertip, heel, antecubital vein).
Phlebotomy: Venipuncture; incision of a vein for blood collection.
Plasma: Liquid portion of clotted blood (contains clotting factors).
Platelet: Blood component aiding hemostasis.
Plateletpheresis: Removal of platelets with return of remaining blood.
Povidone-iodine: Topical iodine antiseptic used when alcohol allergy/intolerance.
QNS: Quantity Not Sufficient.
RBC: Red blood cell.
Serum: Plasma without clotting factors after coagulation.
Stat: Immediate.
Syringe: Instrument for injecting or withdrawing fluids.
Thrombus: Blood clot formed within a vessel.
Tourniquet: Constrictive band used to engorge veins.
Universal (standard) precautions: Treat every patient as potentially infectious.
Vacutainer: System for drawing blood with vacuum tubes.
Vacutainer Holder: Holder for vacutainer tubes/needle.
Vacutainer Needle: Needle used with vacutainer system.
Vacutainer System: The combined holder, needle, and tube assembly.
Vacutainer tube: Tube containing a vacuum to draw blood.
Vein: Vessel carrying blood toward the heart.
Venipuncture: Puncture of a vein to draw blood.
White blood cell: Leukocytes; fight infection.