MEDLAB2

Chapter 1:
Understanding
Phlebotomy

Gladwyn R. Mangubat, RMT

Learning Objectives
At the end of this lecture, the students must be able to:
Describe the evolution of phlebotomy and the role of phlebotomists in today’s
healthcare setting.
 Discuss the traits that form the professional image of the phlebotomists. Explain
the basic concepts of communication as they relate to the healthcare setting.
Distinguish the different types of healthcare settings.
Enumerate the clinical analysis areas of the laboratory and the various types of
laboratory procedures performed in respective areas.

PHLEBOTOMY

Derived from two Greek words “phlebos” which means “vein” and
“temnein” which means “to cut”
▫ Process of collecting blood through the vein by using incision or
puncture methods to draw blood for analysis or as part of therapeutic or
diagnostic measures under the physician’s request; also called
“venesection”

EVOLUTION OF PHLEBOTOMY
Back then, humans used crude tools to cut vessels and drain blood
from the body
▫ 1400 BC – ancient Egyptians practiced phlebotomy as a form of
“bloodletting”
▫ Hippocrates (460-377 BC) – Greek physician; person’s health is
dependent on the balance of the four humors
 3

EVOLUTION OF PHLEBOTOMY (cont.)

Middle Ages – barber-surgeons performed bloodletting as part of the
treatment for some illnesses
17th to 18th century – phlebotomy was treated as a major therapy
Cupping – alternative medicine that helps ease pain, inflammation, or
other health-related concerns; uses special heated suction cups on the
patient’s skin and the incision is made using a fleam (lancet) previously
wiped with a rag
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5
 EVOLUTION OF PHLEBOTOMY (cont.)
Leeching (hirudotherapy) – uses leeches for bloodletting; currently being
used for microsurgical replantation
Hirudo medicinalis (medicinal leech) – introduced to the site after
placing a drop of milk or blood on the patient’s skin; believed to inject local
vasodilator, anesthetic, and hirudin (anticoagulant)
Phlebotomy has evolved from simple bloodletting in the ancient times into

a fundamental diagnostic tool in the healthcare industry today. ▫

Bleeding in form of therapeutic phlebotomy done today for disease
polycythemia vera and hereditary hemochromatosis.

MAIN GOALS OF PHLEBOTOMY

1. For diagnosis and treatment using blood samples
2. For transfusion, to remove blood from the donor
3. For removal of blood for polycythemia or therapeutic purposes 7

TWO MAIN METHODS OF

PHLEBOTOMY
1. Venipuncture – method of blood collection using a needle
 inserted in a vein
2. Capillary puncture – done by puncturing the skin

ROLES OF A PHLEBOTOMIST
Blood sample collection for testing or transfusion
Properly labels blood samples with necessary data for patient
identification
Responsible in delivering or transporting collected samples within
 appropriate prescribed time limits
May also process collected blood samples such as centrifuging or
aliquoting prior laboratory testing
May assist in collection of other specimens, such as urine
Main players in blood-letting activities, such as drawing of blood units
from donors for transfusion to a patient
9

TRAITS OF A GOOD PHLEBOTOMIST

Good manual dexterity
▫ Special communication skills
▫ Good organizational skills
▫ Thorough knowledge of laboratory specimen requirements
▫ Training in phlebotomy skills coupled with standard practice
10
 Verbal Communication Loop in Healthcare Setting
11

PHLEBOTOMY IN HEALTH CARE

 Centralized
Phlebotomist is part of laboratory team and dispatched to hospital
units to collect blood samples
Decentralized
All members of the health care team share responsibility to collect
blood samples.

12

THE HEALTHCARE SETTING

Healthcare facilities are categorized as:
▫ INPATIENT – non-ambulatory; requires patients to stay in the

hospital for at least one night to be serviced by tertiary care

practitioners OUTPATIENT – patients are served by secondary care
specialists on the same day

13

THE HEALTHCARE SETTING

LEVELS OF HEALTHCARE
Primary level – health units in the rural areas and sub-units operated
 by DOH
Secondary level – non-departmentalized hospitals that attend to
patients during symptomatic stages of an ailment
Tertiary level – medical centers and large hospitals with sophisticated
services coupled with highly technical facilities that can address serious
diseases

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THE HEALTHCARE SETTING

OTHER HEALTHCARE SERVICES
Ambulatory care – medical care given to OPD or patients requiring
follow-up check-ups after discharge
▫ Homebound services – procedures, tests, & services done in a
 patient’s home or long-term facility
▫ Public health services – belong to the unit at the local level, under
the jurisdiction of DOH; with little or no charge

15

CLINICAL ANALYSIS AREAS OF THE

LABORATORY
Hematology
Coagulation
Chemistry
Serology/Immunology
Urinalysis
 Microbiology
Blood Bank/ Immunohematology
Histology/Cytology
Molecular Diagnostics

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HEMATOLOGY
(blood and blood forming tissues)

1. Hematocrit (Hct) checks the hemoglobin level and the red cell count.
2. Hemoglobin (Hgb) tests the value to rule out anemia.
3. Red Blood Cell (RBC) count is used to measure the erythropoietic activity. 4. White
Blood Cell (WBC) count checks the leukocyte response 5. Platelet count usually used
to monitor chemotherapy and radiation conditions. 6. Differential White Count (Diff)
monitors changes in the appearance or quantity of specific cell types
7. Indices shows the changes in RBC size, weight and Hgb content 8. Mean
Corpuscular hemoglobin (MCH) gives the weight of the hemoglobin in the cell.
9. Mean Corpuscular volume (MCV) shows the size of the cell.
10. Mean Corpuscular hemoglobin concentration (MCHC) gives information on the
concentration of the hemoglobin per unit volume of RBCs.
11. Red blood distribution width (RDW) measures the size differences of the RBCs

17

COAGULATION
(ability of blood to form and dissolve clots )

1. Activated partial thromboplastin time (APTT) reflects the adequacy of heparin

therapy.
2. D-dimer checks the thrombin and plasmin activity
3. Fibrin split products (FSP) measures if the level is high because it results to FDP
fragments.
4. Fibrinogen tests are performed to check any fibrinogen deficiency. 5. Prothrombin
Time (PT) or International Normalized Ratio (INR) evaluates liver diseases or
deficiency in Vitamin K
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CHEMISTRY
(performs most lab test for plasma, white blood, urine, etc. )

1. Alanine amino transferase (ALT) is used to monitor liver disease. 2.

Alpha-fetoprotein (AFP) checks levels especially for prenatal screening 3. Alkaline
phosphatase (ALP) determines level to check obstructions and bone disease.
4. Ammonia measures the level which could indicate cirrhosis and hepatitis. 5.
Amylase checks the enzyme level which could indicate liver disease, cholecystitis,
etc.
6. Aspartate amino-transferase (AST) measures the level which is indicative of liver
dysfunction.
7. Bilirubin shows the level in the bloodstream that shows red blood destruction 8.
Blood Gases (ABG) evaluates acid-base balance by measuring the pH, partial
pressure of the carbon dioxide and oxygen.
9. Blood Urea Nitrogen (BUN) checks elevated levels which leads to impaired renal
function.
10. B-type natriuretic peptide (BNP) is a cardiac marker for congestive heart failure.

19

CHEMISTRY
(cont.)

1. C-reactive protein High sensitivity (hs-CRP) detects low level of CRP 2.

Carcinoembryonic antigen (CEA) is used for early detection of malignancy in
colorectal cancer.
3. Calcium is used for monitoring effects of the renal failure.
4. Cholesterol (total) indicates risk of cardiovascular diseases.
5. Cortisol shows adrenal hypofunction and hyperfunction.
6. Creatine Kinase (CK) used to check muscle damage.
7. Creatinine checks for cases that indicate renal impairment or muscular dystrophy.
8. Drug Analysis monitors therapeutic range to avoid toxic levels for drugs. 9.
Electrolytes (sodium, potassium, chloride, CO2) shows the sodium values that
determines disorder of the kidney and adrenals.
10. Glucose is used to check diabetic problems, liver disease or malnutrition.
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CHEMISTRY
(cont.)

1. Gamma-glutamyl transferase (GGT) is used for diagnosis of liver specifically

hepatobiliary problems.
2. Hemoglobin A1C determines the Glycohemoglobin level that shows the diabetic
control over the past months.
3. Lactate dehydrogenase checks lung, kidney and liver dysfunction. 4. Lipase shows
the level that could lead to pancreatitis, pancreatic carcinoma 5. Prostate specific
antigen is a test that screens patients for presence of prostate cancer.
6. Total Protein used to check liver and kidney disorders.
7. Triglycerides serves as index to evaluation of atherosclerosis and lipid metabolism
disorder.
8. Troponin-I used for early diagnosis of small myocardial infarcts. 9. Uric Acid tests
are used to check levels that indicates gout and renal problems. [Link] B12 and
folate tests are done to check for anemia and diseases of the small intestine.
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SEROLOGY/IMMUNOLOGY
(serum and autoimmune reactions)

1. Bacterial Studies
Antinuclear antibody (ANA) shows autoimmune disorders such as systematic
lupus erythematosus
Anti-streptolysin O (ASO) titer indicates streptococcal infection
Cold agglutinins checks cases of atypical pneumonia
Febrile agglutinins shows presence of antibodies to specific
organisms FTA-ABS confirms syphilis
Rapid plasma reagin (RPR) when positive it is indicative of syphilis, but it needs
confirmation
Rheumatoid factor (RF) indicates rheumatoid arthritis

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 SEROLOGY/IMMUNOLOGY
(cont.)

2. Viral Studies
Anti-HIV screens Human immunodeficiency virus
Cytomegalovirus antibody (CMV) is a confirmation test
Epstein-Barr Virus checks for presence of heterophile antibody which indicates
infectious mononucleosis
Hepatitis B surface antigen checks for presence of hepatitis antigen in the
surface of the red cells.
3. General Studies
C-reactive protein (CRP) indicates inflammation when levels are increased
Human chorionic gonadotropin (HCG) tests are present when patient is
pregnant

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 URINALYSIS
(test urine specimens)
1. Physical Evaluation
Color indicates presence of blood melanin, bilirubin or urobilin in the urine
specimen Clarity shows presence of fat, chyle, bacteria which affects the turbidity
Specific Gravity suggests renal tubular involvement or ADH deficiency 2. Chemical
Evaluation
Blood - Hematuria could be due to hemorrhage, infection or trauma
Bilirubin - helps differentiate between obstructive and hemolytic jaundice
Glucose - Glucosuria maybe a result of diabetes mellitus, renal
impairments Ketones - uncontrolled diabetes mellitus or starvation
Leukocyte - indicates urinary tract infection if there is a lot of
neutrophils pH - indicates in acid-base balance
Protein - Proteinuria is an indicator of renal dysfunction or disorder
Nitrite - positive results could mean bacterial infection
Urobilinogen - increases in amount when patient suffers from hepatic
issues 3. Microscopic Evaluation
Shows the status of the urinary tract, hematuria, pyuria, etc.
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 BLOOD BANK/IMMUNOHEMATOLOGY (blood
transfusion)

1. Antibody (Ab) screen - agglutination means presence of abnormal antibodies in

the blood
2. Direct antihuman globulin test (DAT) determines transfusion incompatibility
3. Type and RH - shows the blood group (ABO) and type (Rh)
4. Type and crossmatch shows the blood group and screens for antibodies in the
recipient's blood
5. Compatibility testing - detects antibodies and antigen in both recipient's and
donor's blood

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STAT LABS & REFERENCE LABS

 STAT Labs – usually located near the ER of some tertiary care
facilities so that procedures & tests can be done immediately when
needed
▫ Reference Labs – a large and independent laboratory that
provides specialized and confirmatory laboratory tests for blood,
urine, and tissues; offers faster TAT or processing time

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PHASES OF SAMPLE TESTING

Pre-examination - Previously know as preanalytical phase; includes
all processes from collecting the sample to having it ready for testing
Examination - Previously known as analytical phase; includes all
processes done to sample to achieve result
Post-examination - Previously known as postanalytical phase;
process in which the results of the testing are communicated to the
health care provider

27

LABORATORY STAFF
Pathologist
Medical laboratory scientist
Medical laboratory
 technician Phlebotomy
technician Cytotechnologist
Histotechnologist

28

PATIENT RIGHTS
Patient has right to considerate and respectful care
Patient has right to receive understandable information
Patient has right to make decisions about plan of care and refuse
treatment Patient has right to have an advance directive
Patient has the right to privacy
 Patient has the right to confidentiality of his or her medical
records Patient has the right to review records
Patient has the right to expect continuity of care

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PATIENT RIGHTS (cont.)

Patient has right to expect that within its capacity and policies, a hospital
will make reasonable response to the request of a patient for appropriate
and medically indicated care and services
Patient has the right to information regarding hospital business
relationships that might impact his or her care
Patient has the right to consent or decline to participate in proposed
 research studies
Patient has the right to be informed of hospital policies and practices that
relate to patient care, treatment, and responsibilities

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PATIENT RIGHTS (cont.)

Patient has right to expect that within its capacity and policies, a hospital
will make reasonable response to the request of a patient for appropriate
and medically indicated care and services
Patient has the right to information regarding hospital business
relationships that might impact his or her care
Patient has the right to consent or decline to participate in proposed
research studies
 Patient has the right to be informed of hospital policies and practices that
relate to patient care, treatment, and responsibilities

31

PROFESSIONAL ATTITUDE
Everyone must follow professional code of conduct in treatment of
patients
Includes professional approach to all aspects of job and
professional grooming and dress
 32

Advance
Directives
Documents written before
incapacitating illness that give
instructions abouta persons’
health care, if in the future,
they cannot speak for
themselves

33

REGULATORY AGENCIES
The Joint Commission
CAP
State Board of Health
CLSI
CLIA
 OSHA
NAACLS

34

Quality Assurance
Quality is phlebotomist’s responsibility
Result of test sent to physician depends on
quality of sample obtained
Laboratories must have certain levels of
patient satisfaction to continue receiving
payments from insurance companies
Must have quality assurance program, total
quality management program, and
 continuous quality improvement program

35

ACTIVITY NO. 1
ROLE-PLAY ACTIVITY: PHLEBOTOMIST–PATIENT ENCOUNTER
Instructions:
1. You will be group and will receive one scenario involving a patient–phlebotomist interaction.
2. Each group will prepare a 5–7 minute role-play showing:
A. Proper greeting and introduction
B. Patient identification (2 identifiers)
C. Explanation of the procedure
D. Obtaining consent
E. Communication skills and professionalism
F. Respect for patient rights
3. Your group grade will be based on:
 A. Role-play performance
B. Overall presentation

ACTIVITY NO. 1 concepts.

Presentation Rubric
Content Accuracy Information is correct and
aligned with phlebotomy 10 points
Presentation is structured, logical, and
Organization & Flow easy to follow. 10 points
Clear voice, confidence, proper pacing.
Clarity of Delivery understandability, and 10 points
Original, realistic, and keeps the audience
Creativity & Engagement engaged. 10 points

Teamwork All members participate meaningfully and share roles. 5 points

Time behavior and appropriate
Professionalism and Demonstrates respectful conduct.
Fits within the 5–7 minute time requirement. 5 points
THANK YOU

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