PREEXAMINATION VARIABLES and outpatient results are being
DIET compared, the physician may request
The ingestion of food and beverages that an outpatient lie down before
alters the level of certain blood sample collection.
components. The tests most affected EXERCISE
are glucose and triglycerides. The effects of exercise depend on the
Serum or plasma collected from physical fitness and muscle mass of
patients shortly after a meal may the patient, the strenuousness and
appear cloudy or turbid (lipemic) intensity of the exercise, and the time
due to the presence of fatty between the exercise and blood
compounds such as meat, cheese, collection.
butter, and cream. Lipemia will Vigorous exercise has been
interfere with many test procedures associated with a
Certain beverages can also affect _______________________________.
laboratory tests. Alcohol consumption Transient short-term exercise and
can cause a transient elevation in prolonged exercise or weight training
glucose levels, and chronic alcohol affect test results differently.
consumption affects tests associated In short-term exercise, muscle
with the liver and increases contents are released into the blood.
triglycerides. Anaerobic glycolysis and metabolic
When a fasting sample is requested, it changes interfere with laboratory
is the responsibility of the results.
phlebotomist to determine whether Short term exercise elevates the
the patient has been fasting for the enzymes associated with muscles
required length of time. (______________) and the ____________
POSTURE because WBCs attached to the venous
Changes in patient posture from a walls are released into the circulation.
supine to an erect position cause The values usually return to normal
variations in some blood constituents, within several hours of relaxation in a
such as cellular elements, plasma healthy person; however, skeletal
proteins, compounds bound to muscle enzymes, aldosterone, renin,
plasma proteins, and high molecular and angiotensin may be elevated for
weight substances. 24 hours.
The large size of these substances Prolonged exercise also increases
prevents their movement between the the muscle-related waste products
plasma and tis sue fluid when body (__________________________), and they
position changes. will remain more consistently
Therefore, when a person moves from elevated.
a supine to an erect position and Well-trained athletes are more
water leaves the plasma, the resistant to exercise related changes
concentration of these substances because of their consistently elevated
increases in the plasma. level of skeletal muscle enzymes.
Tests most noticeably elevated by the STRESS
decreased plasma volume are Failure to calm a frightened, nervous
1. patient before sample collection may
2. increase levels of adrenal hormones
3. (__________ and ___________),
4. _________________, decrease
5. ____________, and markedly affect
6. arterial blood gas (ABG) results.
7. It has been shown that WBC counts
The concentration of these analytes collected from a violently crying
can increase ________________within 10 newborn may be markedly elevated.
minutes after changing from a supine This is caused by the re lease of WBCs
position to standing. attached to the blood vessel walls into
Plasma renin, serum aldosterone, the circulation.
and catecholamines can double in 1 In contrast, WBC counts on early
hour; therefore, patients are required morning samples collected from
to be lying down for _________before patients in a basal state will be
blood collection. decreased until normal activity is
The increase is most noticeable in resumed. Elevated WBC counts return
patients with disorders such as to normal within 1 hour
congestive heart failure and liver For an accurate WBC count,
diseases that cause increased fluid to discontinue blood collection from a
remain in the tissue. When inpatient
crying child until after the child has increasing plasma volume and
been calm for at least 1 hour. influencing its composition.
SMOKING Extensive sweating without fluid
The immediate effects of nicotine replacement, on the other hand, can
include increases in _________________, cause hemoconcentration.
_______, _________, __________________), Environmental factors associated with
_________, and _____________. geographic location are generally
Glucose and BUN can increase by 10 accounted for when reference values
percent and triglycerides by 20 are established.
percent OTHER FACTORS INFLUENCING PATIENT
Chronic smoking increases TEST RESULTS
hemoglobin, red blood cell (RBC) DIURNAL VARIATION
counts, the mean corpuscular The concentration of some blood
volume (MCV) and immunoglobulin constituents is affected by the time of
(Ig) E. ________________________are day. Diurnal rhythm is the normal
decreased, lowering the effective ness fluctuation in blood levels at different
of the immune system. times of the day based on a 24-hour
ALTITUDE cycle of eating and sleeping.
___________ and ___________ and Blood analytes are released into the
___________ levels are increased in bloodstream intermittently.
high-altitude areas such as the _______________________________________
mountains where there are reduced ____________________, estradiol,
oxygen levels. _______________________),
The body produces increased numbers testosterone, bilirubin, hemoglobin,
of RBCs to transport oxygen insulin, potassium, RBC count, and
throughout the body. Normal ranges serum iron levels are highest in the
for RBC parameters must be morning,.
established for populations living at Whereas eosinophil counts, creatinine,
5,000 to 10,000 feet above sea level. glucose, triglyceride, and phosphate
AGE AND GENDER levels are lower.
Laboratory results vary between MEDICATIONS
infancy, childhood, adulthood, and the Administration of medication prior to
elderly because of the gradual change sample collection may affect tests
in the composition of body fluids. results, either by changing a metabolic
Hormone levels vary with age and process within the patient or by
gender. producing interference with the testing
RBC, Hgb, and Hct values are procedure.
higher for males than for females. In general, understanding the effect of
Normal refrence ranges are medications and diagnostic
established for the different patient procedures on laboratory test results
age and gender groups; therefore, the is the responsibility of the health-care
age and gender of the patient should provider, pathologist, or clinical
be present on the requisition. laboratory testing personnel.
PREGNANCY A variety of medications, both
Pregnancy-related differences in prescription and over-the-counter, can
laboratory test results are caused by influence laboratory test results.
the physiological changes in the body Physicians frequently order tests to
including increases in plasma volume. evaluate the effect of certain
The increased plasma volume may prescribed medications on body
cause a dilutional effect and cause systems. In other cases, test results
lower RBC counts, protein, may be affected by over-the-counter
alkaline phosphatase, estradiol, medications not reported to the
free fatty acids, and iron values. physician by the patient.
The erythrocyte sedimentation rate PATIENT COMPLICATION AND
and coagulation factors CONDITIONS
______________________ may be FAINTING (SYNCOPE)
increased. Fainting (syncope) is the spontaneous
TEMPERATURE AND HUMIDITY loss of consciousness caused by
Environmental factors such as insufficient blood flow to the brain.
temperature and humidity can affect Triggers such as the sight of blood,
test values by influencing the having blood drawn, fear of bodily
composition of body fluids. injury, standing for long periods of
Acute heat exposure causes interstitial time, heat expo sure, and exertion can
fluid to move into the blood vessels, cause vasovagal syncope.
Symptoms before fainting or a ___________________- Occasionally, a
syncope episode include patient is allergic to the antiseptic
_______________________________________ used in skin preparation prior to blood
__, a feeling of warmth, or cold, collection. (For example, many
clammy skin. individuals are allergic to povidone–
Apprehensive patients and fasting iodine.) Alternate antiseptics should be
patients may be prone to fainting, and readily available for use in such cases.
the phlebotomist should be alert to PAIN
this possibility. A small amount of pain is normally
According to the CLSI standards, the associated with routine venipuncture
use of ammonia inhalants may be and capillary puncture. Putting
associated with adverse effects and is patients at ease before blood
not recommended. collection helps them relax and can
SEIZURES make the procedure less painful.
If this situation occurs, the tourniquet Warning the patient prior to needle
and needle should be removed, insertion helps avoid a startle reflex.
pressure applied to the site, and help A stinging sensation can be avoided
summoned. by allowing the alcohol to dry
Restrain the patient only to the extent completely prior to needle insertion.
that injury is prevented. Do not DEHYDRATION
attempt to place anything in the Dehydration (decrease in total body
patient’s mouth. fluid), which occurs, for example, with
In both a syncope or seizure situation, persistent vomiting or diarrhea,
notify the designated first-aid–trained causes hemoconcentration, a
personnel immediately condition in which blood components
PETECHIAE that cannot easily leave the blood
Patients who present with small, non stream become concentrated in the
raised red hemorrhagic spots smaller plasma volume.
(petechiae) may have prolonged Blood components affected include
bleeding following venipuncture. RBCs, enzymes, iron (Fe), calcium
Petechiae can be an indication of a (Ca), sodium (Na), and coagulation
_______________, such as a __________or factors.
_________________. JAUNDICE
Additional pressure should be applied Jaundice, also called ________, is a
to the puncture site following needle condition characterized by
removal. _____________(a product of the
ALLERGIES breakdown of RBCs) in the blood,
Patients are occasionally allergic to leading to deposits of yellow bile
alcohol, iodine, latex, or the glue used pigment in the skin, mucous
in adhesive bandages. membranes, and sclerae (whites of the
Necessary precautions must be eyes), giving the patient a yellow
observed by using alternate appearance
antiseptics, paper tape or self- The term icteric means relating to or
adhering wrap (Coban), and nonlatex marked by jaundice and is used to
products. describe serum, plasma, or urine
VOMITING specimens that have an abnormal
A patient may experience nausea or deep yellow to yellow-brown color due
vomiting before, during, or after blood to high bilirubin levels.
collection. HEMATOMA FORMATION AND BRUISING
If the patient vomits, stop the blood Hematoma formation is the
collection and provide the patient with ______________________________It is
an emesis basin or waste basket and caused by blood leaking into the
tissues tissues during or following
ALLERGIES TO EQUIPMENT AND venipuncture and is identified by rapid
SUPPLIES swelling at near or beneath the
Occasionally patients are encountered venipuncture site.
who are allergic to one or more of the A rapidly forming hematoma may
supplies or equipment used in blood indicate that an artery has been
collection accidentally hit. Discontinue the draw
________________ - Some patients are immediately and apply direct forceful
allergic to the glue used in adhesive pressure to the puncture site for a
bandages. One solution is to place a minimum of _______________until active
clean, folded gauze square over the bleeding ceases.
site and wrap it with self-adherent If a hematoma forms during blood
bandaging material collection, the phlebotomist should
discontinue the draw immediately and removal) without first consulting the
hold forceful pressure over the site for patients physicians.
several minutes, and 3 to 5 minutes Lymph node removal which is typically
if accidental arterial puncture is part of the procedure, may cause
suspected _____________(obstruction or stoppage
of nor mal lymph flow).
Applying a tourniquet to or drawing
AREAS TO BE AVOIDED blood from an arm located on the
BURNS, SCARS, AND TATTOOS same side of the body as a recent
Avoid burned, scarred, and mastectomy can be harmful to the
tattooed areas. Veins may be patient and produce erroneous test
difficult to palpate or penetrate in results.
burned and scarred areas. OBESITY
Healed burn sites and other areas with Obese (extremely overweight)
extensive scarring may have impaired patients often present a challenge to
circulation that could lead to the phlebotomist. Veins of obese
erroneous test results. Newly burned patients may be deep and difficult to
areas are painful and susceptible to find.
infection. Proper tourniquet selection and
Freshly tattooed areas may have an application is the first step to a
undetected infection or be more successful venipuncture. Typical strap
susceptible to infection. In addition, tourniquets, which are normally
tattoos may mask problem areas and around 18 inches long, may be too
impair the ability to detect bruising, short to fit around large arms without
rashes, and other reaction to rolling and twisting, and being
phlebotomy. uncomfortably tight
If you have no choice but to draw in an ________________ (longer tourniquets
area with a tattoo, try to insert the nee designed for the obese) should be
dle in a spot that does not contain available. A bariatric or extra large
dye. size blood pressure cuff can also be
DAMAGED VEINS used as long as it is inflated to just
Some patients’ veins feel hard and below the patient’s diastolic pressure.
cord-like and lack resiliency because Most patients who are “difficult draws”
they are occluded or obstructed. know what sites work best.
These veins may be _______________) or To locate the cephalic vein, rotate the
_____________ from the effects of patient’s arm medially, so that the
inflammation, disease, or hand is prone. In this position, the
chemotherapy drugs. weight of excess tissue often pulls
Damaged veins are difficult to downward, making the cephalic vein
puncture, may yield erroneous easier to feel and penetrate with a
(invalid) test results because of needle.
impaired blood flow, and should be A blood pressure cuff may work better
avoided. as a tourniquet when a vinyl or latex
Use another site if possible, or draw tourniquet is too short.
below (distal to) damaged veins. IV THERAPY
EDEMA Frequently, the phlebotomist
Edema is swelling caused by the encounters patients receiving IV fluids
abnormal accumulation of fluid in the in an arm vein. Whenever possible,
tissues. blood should then be drawn from the
It sometimes results when fluid from other arm because the sample maybe
an IV infiltrates the surrounding contaminated with IV fluid.
tissues. Specimens collected from If an arm containing an IV must be
edematous areas may yield inaccurate used for sample collection, the site
test results owing to contamination selected must be below the IV
with tissue fluid or altered blood insertion point and preferably in a
composition caused by the swelling. different vein.
In addition, veins are harder to locate, CLSI recommends having the nurse
the stretched tissue is often fragile turn off the IV infusion for __________
and more easily injured by tourniquet , the phlebotomist then may apply the
and antiseptic application, and healing tourniquet between the IV and the
may be prolonged in these areas. venipuncture site and perform the
MASTECTOMY venipuncture.
Blood should never be drawn from an If a specimen cannot be collected by
arm on the same side as a capillary puncture it may have to be
mastectomy (surgical breast collected from an IV by a nurse or
other specially trained person. Follow and the needle in the tube holder has
facility policy penetrated the tube stopper. Reseat
the tube to make certain that the
needle sleeve is not pushing the tube
HEPARIN AND SALINE LOCKS off the needle.
Heparin or saline locks are winged NEEDLE POSITION
infusion sets connected to a stopcock Insertion of the venipuncture needle
or cap with a diaphragm that can be so that the bevel is correctly
left in a vein for up to 48 hours to positioned within the vein is critical to
provide a means for administering the success of venipuncture
frequently required medications and If the needle or bevel is incorrectly
for obtaining blood samples. positioned, blood may not flow into the
The devices must be flushed with tube or syringe properly or at all. If
heparin or saline periodically and after blood flow is not established or the
use to prevent blood clots from rate of flow is not normal, use visual
developing in the line. cues to help determine if the needle is
The first 5 mL of blood drawn must correctly positioned in the vein.
be discarded from either device. It is
not recommended to collect blood
through these devices for coagulation
testing because residual heparin can
affect test results. Only specifically
trained personnel are authorized to
draw blood from heparin and saline
locks.
CANNULAS AND FISTULAS
Patients receiving renal dialysis have a
permanent surgical fusion of an artery
and a vein called a ________ in one
arm, and this arm should be avoided
for venipuncture because of the
possibility of infection.
Accidental puncture of the area
around the fistula can cause
_____________.
The dialysis patient also may have a
temporary ex ternal connection
between the artery and a vein formed
by a ___________ that contains a special
T-tube connector with a diaphragm for
drawing blood
Be sure to check for the presence of a
fistula or cannula before applying a
tourniquet to the arm, because this
can compromise the patient.
TROUBLESHOOTING FAILED
VENIPUNCTURE
Failure to initially draw blood during a
venipuncture attempt can be caused
by a number of procedural errors.
Being aware of these errors and
knowing how to correct them may
determine whether you obtain blood
on the first try or have to repeat the
procedure.
If you fail to obtain blood after
inserting the needle, stop all needle
movement, remain calm so that you
can clearly analyze and assess the
situation, and correct the problem,
which could be any one of the
following situations.
TUBE POSITION
Tube position is important. Check the
tube to see that it is properly seated