Which should the phlebotomist instruct a patient to collect for a urine pregnancy test?
Patient should be instructed on the proper collection of a clean catch midstream urine specimen. Avoid contamination with normal flora from skin, rectum or vagina. If a clean catch urine cannot be obtained from an infant, obtain a bagged specimen: clean area as for a clean catch, attach U-bag, and put collected urine into a sterile container. Show
Clean catch specimen: Have patient urinate into a small clean disposable cup (styrofoam or “Dixie”). Afterward, collection site staff can transfer the urine to the urine culture transport tube using the special collection straw-puncture device designed for use with the Vacutainer® tubes. The numbers of bacteria in a clean unused cup are so few as to be inconsequential when the urine transport stabilizer is added. Thoroughly instruct patient for proper collection of a “clean catch” specimen. Patient must be instructed to thoroughly cleanse skin and collect a midstream specimen. The patient should be instructed to follow the directions provided with the urine collection kit as follows. Catheterized specimen: Refers to an “in and out” catheter that is placed into the bladder solely for collection of the specimen and then withdrawn. Do not collect urine from the drainage bag when an indwelling catheter is in place because growth of bacteria can occur in the bag itself. Rather, clean catheter with an alcohol sponge, puncture with a sterile needle, and collect in sterile syringe. Catheter tips are contaminated by the urethra as they are withdrawn; do not culture them. Male: Wash hands thoroughly with soap and water. Rinse them well and dry with a paper towel. • Tear open the towelette packages so that the towels can be easily removed with one hand as they are needed. Do not touch any of the inside surfaces of the collection cup. • Pull back the foreskin to expose the head of the penis completely. • Wash the head of the penis thoroughly using first one towelette then the other. Discard the used towelettes into the toilet bowl. • Pass a small amount of urine into the toilet bowl, then pass a sample into the container. Do not allow the container to touch the legs or penis. Keep fingers away from the rim and inner surface of the container. Fill the container half full. • The urine specimen should be transferred to the Vacutainer® tube within 10 minutes of collection. Female: Wash hands thoroughly with soap and water. Rinse them well and dry with a paper towel. • Tear open the towelette packages so that the towels can be easily removed with one hand as they are needed. Do not touch any of the inside surfaces of the collection cup. • Remove undergarments and sit on the toilet seat with legs spread widely apart. • With one hand, spread labia apart to expose the vulva. Keep this hand in place during the washing and urinating procedure. • Use one towelette to wash the vulva well passing the towelette only from front to back, not back and forth. Repeat this procedure using the second towelette. Discard the used towelettes into the toilet bowl. • Begin urinating into the toilet bowl then, without stopping the stream, insert the collection cup to collect the specimen. Do not allow the container to touch the legs, vulva, or clothing. Keep fingers away from the rim and inner surface of the container. Fill the container about half full. • The urine specimen should be transferred to the Vacutainer® tube within 10 minutes of collection. BLOOD COLLECTION:ROUTINE VENIPUNCTURE AND SPECIMEN HANDLINGObjectives for the tutorial:
VENIPUNCTURE PROCEDUREThe venipuncture procedure is complex, requiring both knowledge and skill to perform. Each phlebotomist generally establishes a routine that is comfortable for her or him. Phlebotomists are considered to have occupational exposure to blood borne pathogens. The performance of routine vascular access procedures by skilled phlebotomists requires, at a minimum, the use of gloves to prevent contact with blood. Airborne precautions may be considered to provide a level of safety against infectious diseases such as tuberculosis, influenza, and COVID-19. Precautions include a medical grade face mask. With risk for blood spatter a face shield provides protection. A face mask reduces risk for blood culture specimen contamination. Laboratory coats or work smocks are not typically needed as personal protective equipment during routine venipuncture, but an employer must assess the workplace to determine whether certain tasks, workplace situations, or employee skill levels may result in an employee's need for laboratory coats or other personal protective equipment to prevent contact with blood. It is an employer's responsibility to provide, clean, repair, replace, and/or dispose of personal protective equipment/clothing. As part of presenting a professional appearance, an institutional dress code may include wearing of a laboratory coat or smock. Patient identification is critical for safety. At least two patient identifiers, such as name and date of birth, are needed. Label collection tubes after identification of the patient. Interruptions and distractions during medical encounters and procedures should be avoided. Several essential steps are required for every successful collection procedure:
ORDER FORM / REQUISITIONA requisition form must accompany each sample submitted to the laboratory. This requisition form must contain the proper information in order to process the specimen. The essential elements of the requisition form are:
An example of a simple requisition form with the essential elements is shown below: LABELING THE SAMPLEA properly labeled sample is essential so that the results of the test match the patient. The key elements in labeling are:
Automated systems may include labels with bar codes. Examples of labeled collection tubes are shown below: EQUIPMENT:THE FOLLOWING ARE NEEDED FOR ROUTINE VENIPUNCTURE:
ORDER OF DRAWBlood collection tubes must be drawn in a specific order to avoid cross-contamination of additives between tubes. The recommended order of draw for plastic collection tubes is:
NOTE:Tubes with additives must be thoroughly mixed. Erroneous test results may be obtained when the blood is not thoroughly mixed with the additive. Transferring a sample from one collection tube to another or mixing blood from different collection tubes must be avoided. PROCEDURAL ISSUESPATIENT RELATIONS AND IDENTIFICATION: The phlebotomist's role requires a professional, courteous, and understanding manner in all contacts with the patient. Greet the patient and identify yourself and indicate the procedure that will take place. Effective communication - both verbal and nonverbal - is essential. Proper patient identification MANDATORY. If an inpatient is able to respond, ask for a full name and always check the armband or bracelet for confirmation. For an inpatient DO NOT DRAW BLOOD IF THE ARMBAND OR BRACELET IS MISSING. For an inpatient the nursing staff can be contacted to aid in identification prior to proceeding. An outpatient must provide identification other than the verbal statement of a name. Using the requisition for reference, ask a patient to provide additional information such as a birthdate. A government issued photo identification card such as a driver's license can aid in resolving identification issues. If possible, speak with the patient during the process. The patient who is at ease will be less focused on the procedure. Always thank the patient and excuse yourself courteously when finished. PATIENT'S BILL OF RIGHTS: The Patient's Bill of Rights has been adopted by many hospitals as declared by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The basic patient rights endorsed by the JCAHO follow in condensed form are given below. The patient has the right to:
VENIPUNCTURE SITE SELECTION: Although the larger and fuller median cubital and cephalic veins of the arm are used most frequently, the basilic vein on the dorsum of the arm or dorsal hand veins are also acceptable for venipuncture. Foot veins are a last resort because of the higher probability of complications. Certain areas are to be avoided when choosing a site:
PROCEDURE FOR VEIN SELECTION:
PERFORMANCE OF A VENIPUNCTURE:
PHLEBOTOMY PROCEDURE ILLUSTRATED:
PERFORMANCE OF A FINGERSTICK:
FINGERSTICK PROCEDURE ILLUSTRATED:
ADDITIONAL CONSIDERATIONS:To prevent a hematoma:
To prevent hemolysis (which can interfere with many tests):
Indwelling Lines or Catheters:
Hemoconcentration: An increased concentration of larger molecules and formed elements in the blood may be due to several factors:
Prolonged Tourniquet Application:
Patient Preparation Factors:
REASONS FOR CANCELING A LABORATORY TESTA test that has been ordered may be cancelled due to problems unrelated to drawing the specimen, and these are the most common causes for cancellations:
A test may be cancelled due to a technical problem in the specimen collection process:
SAFETY AND INFECTION CONTROLBecause of contacts with sick patients and their specimens, it is important to follow safety and infection control procedures. PROTECT YOURSELF
PROTECT THE PATIENT
TROUBLESHOOTING GUIDELINES:IF AN INCOMPLETE COLLECTION OR NO BLOOD IS OBTAINED:
IF BLOOD STOPS FLOWING INTO THE TUBE:
PROBLEMS OTHER THAN AN INCOMPLETE COLLECTION:
BLOOD COLLECTION ON BABIES:
HEELSTICK PROCEDURE ILLUSTRATED:
PEDIATRIC PHLEBOTOMY:
COLLECTION TUBES FOR PHLEBOTOMY
ReferencesGiavarina D, Lippi G. Blood venous sample collection: Recommendations overview and a checklist to improve quality. Clin Biochem. 2017;50(10-11):568-573. Kiechle FL. So You're Going to Collect a Blood Specimen: An Introduction to Phlebotomy, 13th Edition (2010), College of American Pathologists, Northfield, IL. Dalal BI, Brigden ML. Factitious biochemical measurements resulting from hematologic conditions. Am J Clin Pathol. 2009 Feb;131(2):195-204. Lippi G, Salvagno GL, Montagnana M, Franchini M, Guidi GC. Phlebotomy issues and quality improvement in results of laboratory testing. Clin Lab. 2006;52(5-6):217-30. Lippi G, Blanckaert N, Bonini P, Green S, Kitchen S, Palicka V, Vassault AJ, Mattiuzzi C, Plebani M. Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics. Clin Chem Lab Med. 2009;47(2):143-53. Occupational Safety and Health Administration, United States Department of Labor. https://www.osha.gov/laws-regs/standardinterpretations/2007-10-26 and https://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact03.pdf (Accessed June 13, 2022). Phelan MP, Reineks EZ, Berriochoa JP, Schold JD, Hustey FM, Chamberlin J, Kovach A. Impact of Use of Smaller Volume, Smaller Vacuum Blood Collection Tubes on Hemolysis in Emergency Department Blood Samples. Am J Clin Pathol. 2017;148(4):330-335. Sanders AM, Agger WA, Gray AM, Fischer CM, Kamprud EA. Use of hair nets and face masks to decrease blood culture contamination rates. Diagn Microbiol Infect Dis. 2019;95(1):15-19. doi: 10.1016/j.diagmicrobio.2019.04.001. Uman LS, Birnie KA, Noel M, et al. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2013 Oct 10;(10):CD005179. doi: 10.1002/14651858.CD005179.pub3. Valenstein PN, Sirota RL. Identification errors in pathology and laboratory medicine. Clin Lab Med. 2004;24(4):979-96, vii. World Health Organization. WHO guidelines on drawing blood: best practices in phlebotomy. https://www.ncbi.nlm.nih.gov/books/NBK138650/pdf/Bookshelf_NBK138650.pdf (Accessed June 13, 2022) And for our furry friends: Joslin JO. Blood Collection Techniques in Exotic Small Mammals. Journal of Exotic Pet Medicine. 2009;18(2):117-139. What is the first step a phlebotomy technician performs when drawing blood *?Step 1: Identify The Vein The first step in drawing blood correctly is to identify the appropriate veins to puncture. Which of the following actions should a phlebotomy technician take when performing a venipuncture using an evacuated tube?Which of the following actions should a phlebotomy technician take when performing a venipuncture using an evacuated tube system? The technician should position the needle in the same direction as the vein and at a 30 degree angle with the bevel up. Which of the following is the first step a phlebotomist should take when washing their hands?Antiseptic soap and water: When cleaning your hands with soap and water, first wet your hands with water, then apply the product to your hands, and rub your hands together vigorously for at least 15-20 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Which of the following types of urine specimen should a phlebotomy technician instruct the patient to collect for a pregnancy test?First morning specimens are the best for pregnancy testing because the urine is more concentrated. No special sample preparation is required. Which of the following actions should a phlebotomy technician take when collecting a urine specimen?A phlebotomy technician is collecting a urine specimen from a patient for a pre-employment drug test. Which of the following actions should the technician take? Verify that the specimen contains at least 45 mL of urine. A phlebotomy technician is preparing to draw blood from a patient in an inpatient setting. Which should the phlebotomist instruct a patient to collect for a urine pregnancy test?First morning specimens are the best for pregnancy testing because the urine is more concentrated. No special sample preparation is required. Which of the following actions should a phlebotomy technician take when performing a venipuncture using an evacuated tube?Which of the following actions should a phlebotomy technician take when performing a venipuncture using an evacuated tube system? The technician should position the needle in the same direction as the vein and at a 30 degree angle with the bevel up. Which of the following actions should a phlebotomy technician take to locate a vein using the warming technique?Which of the following actions should a phlebotomy technician take to locate a vein using the warming technique? Encase the warm towel in a plastic bag. A phlebotomy technicia is applying a tourniquet prior to collecting a blood specimen from a patient. How many minutes should the technician allow the serum samples to stand before loading them into the centrifuge?Serum tubes must be placed in an upright vertical position and allowed to clot for a minimum of 30 minutes before centrifuging. After the specimen has been allowed to fully clot, the tube is to be centrifuged within 1 hour of collection and no longer than 2 hours after collection. Which urine specimen is most commonly used to determine pregnancy?II. Specimen:
The urine specimen must be collected in a clean, dry container. Specimens collected at any time are acceptable, however, the first morning urine generally contains the highest concentration of hCG.
Which of the following is a typical instruction to a patient collecting a 24 hour urine specimen?All urine, after the first flushed specimen, must be saved, stored, and kept cold. This means keeping it either on ice or in a refrigerator for the next 24 hours. Try to urinate again at the same time, 24 hours after the start time, to finish the collection process. If you can't urinate at this time, it is OK.
Which of the following tests are collected in a trace element tube?Special Procedures. What will the phlebotomist do to follow the proper technique in preparing a peripheral blood smear?Well-made peripheral smears can be prepared by starting with only a drop of blood at one end of a clean glass slide. The drop is smeared lightly and quickly with a wedge technique so as to leave a thin "feather" edge where all cells may be examined individually, particularly red blood cells.
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