there is no automated system in place, the employee may need to use an a

lternative reference.
Many labo- ratories provide their clients with a book of covered diagnosis codes
for the tests
with limited coverage. Many times the requisitions will be preprinted with the n
ame of the
physician office or practice group. It is still necessary to document which phys
ician within the
practice actually ordered the laboratory test to be performed. If the test was o
rdered as STAT,
it needs to be drawn and processed immediately. It may be necessary to contact a
laboratory
courier to pick up the sample immediately, or to notify the technician that ther
e is a STAT
order. Continued 1899_Ch01_001-024 23/12/11 12:51 PM Page 13 reimbursement for l
aboratory
services. It is specifically used for patients who have Medicare Part B as their
primary
insurance coverage. The purpose of an ABN is to inform Medicare-covered patients
that payment may
be denied for a specific laboratory test and that the patient will be billed for
the full cost of
that test if he or she chooses to have it performed. The ABN al- lows the patien
ts to make an
informed decision about whether they wish to have the tests performed, with the
realization that
they may be responsible for the total cost. The ABN must be verbally reviewed wi
th the pa- tient,
and any questions about potential reimburse- ment must be answered before it is
signed, whether
or not the patient wishes to have the laboratory work per- formed. This process
must occur before
the specimen is collected from the patient. The person collecting the specimen m
ust ensure that
the test ordered has been identified on the ABN form and that there is docu- men
tation of the
anticipated reason for noncoverage. Figure 1-1 shows an example of an ABN. The e
m- ployee filling
out the form also must provide an esti- mated cost in writing so that the patien
t knows what the
financial responsibility may be if he or she decides to have the laboratory test
performed. The
patients decision about having the test performed must be doc- umented on the for
m, along with
the patients signa- ture and that days date. The patient must receive a copy of th
e form after
it is signed, and a copy must also be kept on file with the laboratory. Medicare
coverage for
laboratory tests may be denied for various reasons, including frequency of testi
ng, the diagnosis
provided by the health-care provider for a spe- cific test, or because the test
ordered is
considered exper- imental. Whenever a patient with Medicare coverage has a speci
men collected,
the laboratory employee responsible for the specimen collection must verify whet
her the test
ordered will be covered by Medicare for the reason that the test is ordered. The
regulations
affecting coverage are different for geographical regions across the country, an

d change
frequently. Most laboratories now have a way to verify coverage by using a compu
ter database, but
it can be difficult to keep abreast of changes. It is unlawful to have every Med
icare patient
fill out an ABN just in case; it is the responsibility of those collecting the spe
ci- men to
make their best effort to verify coverage before an ABN is signed. The format fo
r this Advance
Beneficiary Notice of Noncoverage document is defined by the Centers for Medicar
e & Medicaid
Services (CMS), and is updated periodically (CMS document number CMS-R-131). Med
icare bases its
decision for coverage on medical necessity rules, which define those tests that th
e agency
deems medically necessary for specific health conditions, and how frequently the
se tests should
be performed. It is important to remember that just be- cause Medicare has limit
ed coverage on
specific tests, the patient should never be told that the health-care provider g
ave a bad code
or that the test was ordered for the wrong reason. 14 Section I Overview of the L
aboratory
Procedure Rationale 11. Check the requisition for an ICD-9 code for each test to
be performed. If
a code is not present, con- tact the health-care provider or check the chart to
obtain a code.
12. Have the patient wait in a comfortable environ- ment until the sample can be
collected. Place
the requisition in an appropriate location to alert other staff members that a s
pecimen
collection is waiting. An ICD-9 code is necessary for every test for success- fu
l reimbursement.
Sometimes the employee who fills out the requisition is not the same person who
will collect the
sample. Test Your Knowledge 1-7 What is the purpose of an ABN? (Outcome 1-7) Lab
oratory Directory
As discussed, laboratory requisitions often provide in- formation about what typ
e of tube to use
for a blood draw for a specific test by using a code or symbol, but Procedure 11: Completing a
Laboratory Requisitioncontd 1899_Ch01_001-024 23/12/11 12:51 PM Page 14 Chapter 1
The Clinical
Laboratory 15 2692 Millenium Rd. Seattle, WA 98103 425-353-8778 ADVANCE BENEFICI
ARY NOTICE
(ABN) ADVANCE BENEFICIARY NOTICE (ABN) Patients Name: John Smith Identification N
umber: 23995500
ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN) NOTE: If Medicare doesnt pay for
the Laboratory
Test(s) Below you may have to pay. Medicare does not pay for everything, even so
me care that you
or your health-care provider have good reason to think you need. We expect Medic
are may not pay
for the Laboratory Test(s) below. Laboratory Test(s): Reason Medicare May Not Pa
y: Estimated
Cost: PROSTATIC SPECIFIC AG TSH Denied as too frequent Denied for your condition
$50.10 $41.34
WHAT YOU NEED TO DO NOW: Read this notice, so you can make an informed decision
about your
care. Ask us any questions that you may have after you finish reading. Choose an

option below
about whether to receive the Laboratory Test(s) listed above. Note: If you choos
e Option 1 or 2,
we may help you use any other insurance that you may have, but Medicare cannot r
equire us to do
this. OPTIONS: Check only one box. We cannot choose a box for you. OPTION 1. I
want the
Laboratory Test(s) listed above. You may ask to be paid now, but I also want Med
icare billed for
an official decision on payment, which is sent to me on a Medicare Summary Notic
e (MSN). I
understand that if Medicare doesnt pay, I am responsible for payment, but I can a
ppeal to
Medicare by following the directions on the MSN. If Medicare does pay, you will
refund any
payments I made to you, less co-pays or deductibles. OPTION 2. I want the Labor
atory Test(s)
listed above, but do not bill Medicare. You may ask to be paid now as I am respo
nsible for
payment. I cannot appeal if Medicare is not billed. OPTION 3. I do not want the
Laboratory
Test(s) listed above. I understand with this choice I am not responsible for pay
ment, and I
cannot appeal to see if Medicare would pay. Additional Information: This notice
gives our
opinion, not an official Medicare decision. If you have any other questions on t
his notice or
Medicare Billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Sign
ing below means
you have received and understand this notice. You also receive a copy. Signature
: Date: According
to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of
information unless it displays a valid OMB control number. The valid OMB control
number for this
information collection is 0938-0566. The time required to complete this informat
ion collection is
estimated to average 7 minutes per response, including the time to review instru
ctions, search
existing data resources, gather the data needed, and complete and review the inf
ormation
collection. If you have comments concerning the accuracy of the time estimate or
suggestions for
improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA re
ports Clearance
Officer, Baltimore, Maryland 21244-1850. Form CMS-R-131 (03/08) Form Approved OM
B No. 0938-0566
HNL-18 (03/09) WHITE: LAB COPY CANARY: PATIENT COPY CB LABORATORY Figure 1-2 Exa
mple of an
Advance Beneficiary Notice of Noncoverage (ABN). the information provided on the
requisition is
limited at best. The requisition does not include information about how to proce
ss and store the
specimen, or what the minimum volume may be for the test ordered. It also does n
ot include
information about how often the laboratory performs that specific analysis if th
e physician needs
to know this information. This additional information about specimen collection
and handling may
be found in a laboratory directory (Fig. 1-3). 1899_Ch01_001-024 23/12/11 12:51

PM Page 15
Commonly, a laboratory directory is a computer database of specific information
about tests that
are per- formed by that laboratory. The directory may also be provided in a book
format, which
can be consulted by facilities that do not have Internet access. The laboratory
directory (also
known as a directory of services) provides the following types of information: T
he internal
test number used to enter the test order into the database CPT five-digit code u
sed for
reimbursement for that test Related information if there is more than one place
within the
directory where the test is addressed Acronyms or abbreviations that may be list
ed on the
requisition for that test, or perhaps used to order the test in the computer sys
tem for that
laboratory The type of specimen required, and in some cases the type or color of
tubes to use
for the blood draw or identification of the additives that must be present in th
e tubes The
requested specimen volume and the minimum acceptable specimen volume Collection
notes and/or
specific requirements neces- sary for some tests Storage instructions for the sp
ecimen after
collection and during transportation (room temperature, frozen, refrigerated, et
c.) Reference
ranges (also known as normal ranges) for the test ordered Clinical significance
and
interpretation of the test results Testing intervals/frequency and testing locat
ions Once the
specimen requirements have been established, the collection process can continue
. The employee
who is performing the collection must document two unique 16 Section I Overview
of the
Laboratory POINT OF INTEREST 1-1 Advance beneficiary notice of noncoverage If a
laboratory
accepts Medicare assignment, it is not legal to bill Medicare beneficiaries for
laboratory tests
that are covered by Medicare Part B. However, Medicare does not cover all labora
tory tests, so
there are many situations in which the health-care providers may order tests tha
t are not covered
by Medicare but that provide valuable information for patient treatment. The onl
y way that the
laboratory can be reimbursed for these tests is to have the patient complete a v
alid Advance
Beneficiary Notice of Non- coverage, also known as an ABN. This form must be com
pleted and signed
prior to the specimen collec- tion. The ABN form informs the Medicare beneficiary of the test
that has been ordered, and specifies the reason that Medicare may not pay for th
e tests, as well
as providing the estimated cost for the test. The ABN is necessary in these situ
ations: When
the test ordered is not medically necessary in Medicares opinion for the ICD-9 co
de (diagnosis)
that is provided. This situation is also present if there is no ICD-9 code given
for the test
ordered. Many screening tests are not covered by Medicare; these are often not c

overed if there
is no evidence of disease. Tests that are ordered more frequently than what is r
ecommended by
Medicare. Any test that is still considered to be investigational or experimenta
l in nature.
These tests have not yet been approved by the FDA. Often those who work with Med
icare patients
will use the term limited coverage to refer to the rules that govern laboratory
reimbursement.
This means that Medicare will pay for laboratory tests only when they meet certa
in criteria.
These may be national coverage decisions or local coverage decisions. Nationally
, there are
several tests established that have limited coverage (based on the ICD-9 codes,
frequency of
testing, or the investigational status) and regional restrictions may add to the
list that is
established on a national basis. By signing the ABN, the Medicare patient is giv
ing the
laboratory permission to bill him or her directly for the test to be performed.
If the employee
who draws the blood does not get an ABN signed when appropriate, the laboratory
will be
performing the test for free, as it cannot have the ABN signed after the process
is completed. If
the specimen was collected by an employee at a physician office and transported
to the laboratory
for testing, the physician office will often receive a bill for the service from
the laboratory,
because that laboratory cannot be reimbursed in any other way. It is illegal to
have every
Medicare patient fill out an ABN; these forms are to be used only when neces- sa
ry for noncovered
tests. In addition, the laboratory must retain a copy of the ABN and the patient
must also be
given a copy. Advanced Beneficiary Notices of Noncoverage are also used for othe
r medical
services; it is necessary to have a specific one for each type of noncovered ser
vice.
1899_Ch01_001-024 23/12/11 12:51 PM Page 16 Chapter 1 The Clinical Laboratory 1
7 GLYCOHEMOGLOBIN
Order Test GLYCO GLYCO Represents average glucose concentration over a 68 week pe
riod. Synonyms
Specimen Required Container Type Specimen Type Minimum Volume Specimen Processin
g Stability
Alternate Specimens Department CPT Codes Test Schedule Turnaround Time Method Te
st Includes
Reference Ranges HbA1c, % HbA1c 4.06.0 Non-diabetic % The American Diabetes Assoc
iation
considers a result of less than 7% to be the goal of diabetic therapy. HbA1C; He
moglobin A1C
Lavender top tube (EDTA) Whole blood 1 mL Store and transport refrigerated. Room
Temp 24 hours
Refrigerated 7 days Frozen (20C) 2 weeks Sodium flouride/potassium oxalate whole b
lood (grey
top tube). Immunochemistry 83036 Sun-Fri nights 2448 hours HPLC 2692 Millenium Rd
- Seattle, WA
98103 425-353-8778 CB LABORATORY Figure 1-3 Sample of information found in a lab
oratory
directory. Procedure 1-2: Use a Laboratory Directory TASK Use a laboratory direc

tory to clarify
the collection require- ments and processing procedures for a laboratory order.
CAAHEP/ABHES
Standards None CONDITIONS Laboratory requisition Laboratory order from qualified
health-care
professional Laboratory directory book or database including laboratory service
information
Continued 1899_Ch01_001-024 23/12/11 12:51 PM Page 17 18 Section I Overview of
the Laboratory
Procedure Rationale 1. Obtain the laboratory requisition or the laboratory order
from the
health-care provider. Verify the test ordered, especially if it is a test that m
ay be per- formed
on more than one body fluid. 2. Look up the test alphabetically using the comput
er database or
the laboratory directory reference book. 3. Identify the type of specimen to be
collected. 4.
Verify any restrictions on specimen type, or nota- tions of unacceptable specime
ns. 5. Verify the
acceptable minimum volume, if listed. 6. Identify the specimen processing instru
ctions. 7.
Identify the schedule for performance of the test ordered. 8. Prepare the necess
ary supplies to
perform the speci- men collection. Some tests, such as creatinine or total prote
in, are commonly ordered on blood but may also be ordered using a urine specimen. This can
sometimes be
difficult if the test is ordered under an acronym or abbreviation or if there ar
e two names used
for the test, such as Tegretol, which may also be known as carbamazepine. Many l
aboratory
directories will include a cross-reference that may help the user to find the co
rrect entry. The
information may be very straightforward, specify- ing the color of tube to be us
ed. (For example,
lavender-top or green-top tube.) However, some- times the specimen requirements
are described as
heparinized plasma or EDTA plasma. The employee needs to know which type of tube to
use for
this type of specimen. For instance, many tests cannot use hemolyzed sam- ples,
or sometimes
samples that are over 2 hours old cannot be used. There may be a requested volum
e (e.g., 1 mL) as
well as a minimum volume listed. The minimum vol- ume may be important if drawin
g the specimen
from a child or other patient with difficult-to- access veins. Is the specimen s
upposed to be
spun within a certain time after the blood draw? Is the plasma or serum to be fr
ozen? The
processing instructions are very im- portant for the specimen to be acceptable w
hen it arrives at
the testing laboratory. The reference laboratory may list the testing schedule s
o that the
health-care provider will be aware of how long it will take before he or she can
expect the
results for the test. If a specimen must be frozen immediately or kept at a cert
ain temperature,
it is necessary to have the supplies at hand immediately after the specimen is c
ollected. These
should be prepared before proceeding. Procedure 1-2: Use a Laboratory Directoryco

ntd
1899_Ch01_001-024 23/12/11 12:51 PM Page 18 identifiers for the patient, the emp
loyee ID (or
initials), the date of collection, and the time of collection on the requi- siti
on and on the
tube or alternative collection container. This same employee may also be respons
ible for entering
the patient information into the computer database, whereas in other laboratorie
s the specimen
and paperwork may be prepared for transport to another location where the inform
ation will be
added to the database upon arrival. performed, as well as the reference ranges (
also known as
normal ranges) that have been established by the labora- tory for that test. Ref
erence ranges are
the results that are expected in the general healthy population 95% of the time
for a particular
laboratory test. A range is necessary (instead of a specific value) because of d
ifferences in the
population due to age, race, and gender. Geographical locations may also affect
the reference
range, as will the testing methods used by that laboratory. A notation will be p
resent on the
laboratory report for all results that are outside the expected reference range
for that patient,
based on demographics, the testing method, and the test ordered. The gender and
age of the
patient may affect the reference ranges used for interpretation of the results,
so it is critical
that this information is provided whenever a sample is collected. The laboratory
report will also
include the date and time of the specimen collection, the name and identifi- cat
ion number for
the patient, and the name and address of the laboratory where the test was perfo
rmed. The
specimen source is identified, as well as the date and time the report was gener
ated. Chapter 1
The Clinical Laboratory 19 Test Your Knowledge 1-8 Why would a medical assistant
use a laboratory
directory before performing a blood draw? (Outcome 1-8) Laboratory Reports Once
the specimen has
been processed, delivered to the correct department, and tested within the labor
atory, a
laboratory report is generated to transmit the test results back to the health-c
are provider. An
example of a labo- ratory report is presented in Figure 1-4. The laboratory repo
rt document will
list the results for the tests Patient: Sally Seashore DOB: 08/07/1957 Sex: Fe
ID# 774909
Date/Time: 7/20/2012 16:50 Report Status: Final PROCEDURE RESULT VALUES REFERENC
E RANGES Rapid
strep screen Rapid strep screen Dipstick UA only Appearance-UA Color-UA GlucoseUA Ketone-UA UA
spec gravity Occult-blood-UA pH-UA Protein-UA Nitrite Leukocyte esterase Electro
lytes Sodium
Potassium Chloride CO2 Hemoglobin + Hematocrit Hgb HCT Positive Clear Yellow Neg
Neg 1.010 Neg
6.0 Neg Neg Neg 141 4.8 100 25 10.9 33 1.002 1.030 5 7.9 136 145 3.5 5.0 96 106
22 30
12 16 37 48 UNITS mEq/L mEq/L mEq/L mEq/L g/dL g/dL Flags: H = High L= Low A =

Abnormal
Crit = Critical Tests performed at: CB Laboratory, 2692 Millenium Rd., Seattle,
WA 98103 ABN L L
CB LABORATORY Figure 1-4 Sample laboratory report. 1899_Ch01_001-024 23/12/11 12
:51 PM Page 19 20
Section I Overview of the Laboratory Procedure 1-3: Distinguish Between Normal
and Abnormal Test
Results TASK Use a laboratory report to identify normal and abnor- mal test resu
lts for a
patient. CAAHEP/ABHES Standards CAAHEP 2008 Standards II.A.2: Distinguish betwee
n normal and
abnormal test results ABHES Standards None Conditions Laboratory report Pen, pen
cil, or
highlighter Procedure Rationale 1. Examine the laboratory report for all necessa
ry information.
2. Identify the column on the laboratory report where the reference ranges are n
oted for each of
the test results. 3. Compare the patient results to the reference range column.
4. Circle or
highlight the results that are not within the reference ranges. Document High or
Low next to the
values in the provided area. All laboratory reports must include the following:
1. The name of
the patient 2. The patient ID 3. The gender and age of the patient 4. Laboratory
results with
documented reference ranges 5. The name of the ordering health-care provider 6.
The date and time
of specimen collection 7. The date and time that the specimen was tested 8. The
name of the
laboratory where the test was performed This column is usually near the patient
results, and the
data are often listed as a range, except in the case of tests that provide a pos
itive and
negative test result, or in the case of microbiology testing, antibiotic sensiti
vity testing, or
immunology testing. Remember that the reference ranges may take the age and gend
er of the patient
into consideration; the ranges will not necessarily be the same for all patients
tested.
Highlighting or circling these results may bring them to the attention of the pr
ovider. When a
laboratory report is printed in the office (rather than one used in the classroo
m) the High or
Low results are noted on the laboratory report when it is printed. However, the
office protocol
may also include highlighting or circling the results when the report arrives in
the office to
make certain that they are not overlooked. 1899_Ch01_001-024 23/12/11 12:51 PM P
age 20 Laboratory
reports may be hand-delivered to the or- dering health-care provider by a medica
l assistant
within an office or via a courier service from a reference labo- ratory. They ma
y also be faxed,
mailed, or in some cases transmitted via e-mail. In some situations, the laboratory reports may
also be available online through a ded- icated laboratory link so that the provi
der can view the
results on site. These results must be reviewed as soon as possible so that appr
opriate action
can be taken for those outside of the normal reference range. Laboratory reports

are a legal
document that becomes part of the patients health record. the testing process, it
is important
to realize that there are three components, known in laboratory jargon as phases
, associated with
laboratory testing: preanalytical, analytical, and postanalytical. A description
of each phase of
testing is detailed below and summarized in Table 1-3. Preanalytical Phase: The
preanalytical
phase of labo- ratory testing refers to the situations and actions that take pla
ce prior to the
collection, during the collection, and during the processing/storage/transportat
ion of the
specimen. Phlebotomists and medical assistants often participate in this phase o
f laboratory
testing. The im- portance of this phase cannot be emphasized enough. Generally s
peaking, the
majority of problems associated with laboratory tests result from inadequate or
inappro- priate
specimen collection, processing, storage, and transportation (i.e., the preanaly
tical phase of
testing). Analytical Phase: The analytical phase of laboratory testing refers to
the
performance of the tests that have been ordered. This phase also includes mainte
nance and
calibration of laboratory equipment and instru- ments associated with the testin
g and performing
Chapter 1 The Clinical Laboratory 21 Test Your Knowledge 1-9 In which ways are
laboratory
requisitions and labora- tory reports similar? (Outcome 1-9) THREE PHASES OF LAB
ORATORY TESTING
As we begin to understand the way that a laboratory is organized and how informa
tion is
transferred through TABLE 1-3 Identification of, Definition of, and the Personne
l Responsible for
the Three Phases of Laboratory Testing Phase Definition Personnel Responsible Pr
eanalytical
Analytical Postanalytical All procedures/processes that occur before the specimen is actually
tested. Includes patient preparation, accurate paperwork and data entry, appropr
iate specimen
collection, processing, storage and transportation. All procedures/processes inv
olved in the
testing of the specimen. This includes the way the testing instrument was prepar
ed and
maintained, how the testing sup- plies were stored, appropriate training of the
person- nel
performing the test, and quality control to ensure that the testing methods are
working properly.
All procedures/processes that affect how the test results are handled when the a
nalysis has been
completed. These may include review and analysis of the results by the person pe
rforming the
test, appropriate follow- through on extremely high or low results, how the resu
lts are recorded
(in a computer or on paper, etc.) phone calls, report printing, report sorting,
appropri- ate fax
procedures, charting procedures within an office, physician review procedures, c
ontact with
patient if necessary for follow-up. Medical assistant, phlebotomist, CLT or MLT,

other laboratory
profession- als involved in this process Medical assistant, medical laboratory p
rofessional
performing the test, supervisor responsible for training and overseeing the proc
ess, person- nel
performing maintenance on instruments Various laboratory professionals that perf
orm the test,
administrative laboratory support personnel that process the results, medical as
sis- tants or
other physician office personnel who perform charting procedures, physicians and
other
health-care professionals who interact directly with the patients. 1899_Ch01_001
-024 23/12/11
12:51 PM Page 21 quality control (QC) measures, which are in place to validate t
he test
reagents/kits, the testing process, and training of the laboratory personnel per
forming the test.
Postanalytical Phase: The postanalytical phase of laboratory testing includes th
e processes
associated with the recording and reporting of laboratory results, storage and/o
r disposal of
specimens after testing, and provider and patient notification of test results.
Even if the other
two phases of testing occur without any exceptions, if this phase isnt handled ap
propriately,
then the overall experience will not be a positive one, and may negatively affec
t patient
treatment. provide the ordering practitioner with the final test results and ref
erence ranges.
Reimbursement procedures may involve laboratory personnel, so it is important th
at these
individuals understand the processes involved with the necessary documentation o
n a req- uisition
and the use of an ABN. There are three phases of laboratory testing, includ- ing
the procedures
surrounding specimen collection and handling, the actual testing process, and th
e man- ner in
which the results are reported back to the physi- cian. These are the preanalyti
cal phase, the
analytical phase, and the postanalytical phase. All three phases must be handled
correctly for
laboratory results to be as meaningful as possible as part of quality patient ca
re. TIME TO
REVIEW 1. If a patient is asymptomatic, it means Outcome 1-1 that he or she: a.
Demonstrates
specific symptoms of a disease state b. Complains of multiple symptoms c. Does n
ot exhibit
symptoms d. Is not ill 2. True or False: A specimen may be Outcome 1-1 defined a
s a part of
something that demonstrates the characteristics of the whole. 3. What do hospita
l and reference
Outcome 1-2 laboratories have in common? 4. Is urine analyzed only in physician
Outcome 1-2
office laboratories? 5. A medical assisting student needs to Outcome 1-3 have a
blood test
performed to see if she has antibodies to hepatitis B in her bloodstream. This t
est would most
likely be performed in this laboratory department: a. Blood Banking b. Hematolog
y c. Serology d.
Microbiology 6. Which laboratory department is Outcome 1-3 responsible for acces

sioning specimens
into the labo- ratory information system when they arrive at the laboratory? 7.
Mr. Earl has a
laboratory test performed Outcome 1-4 to see if the diet and exercise changes su
ggested by 22
Section I Overview of the Laboratory Test Your Knowledge 1-10 List the three ph
ases of
laboratory testing. (Outcome 1-10) Test Your Knowledge 1-11 If a specimen is col
lected into a
tube with the wrong type of anticoagulant for the test ordered, which phase of l
aboratory testing
has gone wrong? (Outcome 1-11) SUMMARY Laboratory testing is vital to the diagno
sis of patient
disease and implementation of proper patient treat- ment, as it provides critica
l information
that cannot be gathered with a physical examination alone. Testing may occur in
physician office
laboratories, in hospital laboratories, or in large reference laboratories. The
larger
laboratories may be organized by departments as needed for efficient specimen ha
ndling. Various
person- nel perform the testing procedures, and their education and titles will
vary depending on
their responsibilities and the type of testing performed in the respective labor
atory. Medical
assistants play an important role in the laboratory by providing direct patient
interaction,
specimen collection, and processing or performance of laboratory tests. Laborato
ry information,
such as that provided on a requisition, is vital for proper testing procedures,
result
interpretation, and reimbursement for services provided. The exchange of informa
tion begins with
a requisition and may involve the use of a laboratory di- rectory for specimen r
equirements and
other specifics. The process ends with the laboratory reports that 1899_Ch01_001
-024 23/12/11
12:51 PM Page 22 his health-care provider have helped to lower his cholesterol l
evels. Which of
these reasons explains why this test is being ordered? a. Assignment of a diagno
sis b. Ongoing
assessment of the patients progress and treatment c. Prevention or possible early
detection
through screening tests d. None of the above 8. Which of these duties might a me
dical Outcome 1-5
assistant perform in a laboratory setting? a. Urine drug screen collections b. P
hlebotomy c.
Urinalysis testing d. Preparation of microbiology specimens for testing and/or a
nalysis e. All of
the above 9. True or False: A diagnosis code does Outcome 1-6 not need to be inc
luded on a
requisition at the time the laboratory test is ordered. 10. True or False: A req
uisition is used
Outcome 1-6 only for ordering the laboratory tests. 11. The abbreviation ABN sta
nds for: Outcome
1-7 a. Advance Beneficiary Notice of Noncoverage b. Advance Beneficiary Notifica
tion c. Action
Bulletin of Noncoverage d. Advance Bulletin of Noncoverage 12. The laboratory di
rectory will
includeOutcome 1-8 ___________________ instructions for a specimen after collect

ion and during

transportation. 13. True or False: The terms laboratory Outcome 1-9 requisition
and laboratory
report may be used interchangeably. 14. Which phases of laboratory testing Outco
me 1-11 might be
affected by the actions of a medical assistant in his or her various laboratory
roles? Chapter 1
The Clinical Laboratory 23 Case Study 1-1: Potential for growth Cindy Lee, a cer
tified medical
assistant (CMA) working in a gynecology office, leaves early one Friday before h
er office closes.
When she returns on Monday morn- ing, she finds a box containing agar plates for
microbi- ology
specimen growth on the counter in the laboratory area. Cindy notices that the bo
x has KEEP
REFRIGER- ATED printed on the outside, but it appears that the box has been left
out all night,
and the cold packs within the box are at room temperature. Should Cindy be conce
rned about this
situation? Which phase of laboratory testing may be affected by this oversight?
RESOURCES AND
SUGGESTED READINGS American Society for Clinical Laboratory Science Consumer Lab
Testing
Information http://www.ascls.org/labtesting/index.asp Numerous questions and ans
wers on general
laboratory testing. American Society for Clinical Laboratory Science Introductio
n to Laboratory
Testing http://www.ascls.org/labtesting/labintro.asp Introduction to the three p
hases of
laboratory testing; also basic terms referring to analytical aspects of quality
control. Centers
for Medicare & Medicaid Services Overview of Beneficiary Notices Initiative
http://www.cms.hhs.gov/bni Links to various ABN information, including the new a
nd old forms in
use and answers to various commonly asked questions. Good Laboratory Practices f
or Waived Sites
http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5413a1.html An overview of some prob
lems that have
occurred in waived test sites and an introduction to the three phases of laborat
ory testing.
Recommendations for good practices overall. CLIA UpdateJanuary 2010. Division of
Laboratory
Services, Centers for Medicare & Medicaid Services; Laboratories by Type of Faci
lity
(Exempt/Nonexempt combined) http://www.cms.gov/CLIA/downloads/factype.pdf Lists
the number of
different types of laboratories registered with CMS as of January 2010. 1899_Ch0
1_001-024
23/12/11 12:51 PM Page 23 1899_Ch01_001-024 23/12/11 12:51 PM Page 24 25 Chapter
2 Regulations
Governing Laboratory Personnel Constance L. Lieseke, CMA (AAMA), MLT, PBT(ASCP)
CHAPTER OUTLINE
Laboratory Professionals Personnel in the Laboratory Setting Medical Assistants
in the Laboratory
Clinical Laboratory Improvement Amendment of 1988 History of the Regulation Leve
ls of Laboratory
Testing Defined by CLIA Employee Qualifications for Performance of CLIA Testing
Oversight of CLIA
Laboratories Summary Time to Review Case Study Resources and Suggested Readings
2-1 Define the

key terms. 2-2 List the laboratory professionals present in a typical hospital,
reference, or
physician office laboratory. 2-3 Describe the personnel structure of the laboratory settings
presented in the text. 2-4 Explain how the duties of laboratory professionals ma
y vary, depending
on their education and credentials. 2-5 Describe the role of a medical assistant
in the clinical
laboratory. 2-6 Explain the focus of CLIA , 88, and why it was developed. 2-7 De
monstrate
understanding of the levels of laboratory testing designated by CLIA , 88. 2-8 I
dentify the
laboratory professionals qualified to perform the various levels of laboratory t
esting as allowed
by CLIA , 88. 2-9 Identify the agencies responsible for overseeing CLIA , 88 com
pliance. Learning
Outcomes After reading this chapter, the successful student will be able to: CAA
HEP/ABHES
STANDARDS CAAHEP Standards IX.C.5: Discuss licensure and certification as it app
lies to
healthcare providers. IX.C.8: Compare criminal and civil law as it applies to th
e practicing
medical assistant. ABHES Standards 4.b: Medical Law and Ethics: Federal and Stat
e Guidelines 4.f:
Medical Law and Ethics: Health laws and regulations Graduates. f: Comply with fe
deral, state and
local health laws and regulations. 2:17 PM Page 25 M edical assistants are in a
unique situation,
as the diverse training they receive allows them to assume numerous roles in an
ambulatory
setting. A medical assistant may have an opportunity to interact with various he
alth-care
agencies and related entities, such as radiology clinics, insurance companies, p
hysical therapy
offices, specialty physician offices, or pharma- cies. In addition, the duties o
f the medical
assistant will most likely include communication with the laboratory, and many m
edical assistants
also perform laboratory testing in physician office laboratories. It is importan
t to understand
who makes up the workforce of the medical laboratory so that effective communica
- tion may be
established. It is also vital that medical assistants understand the regulations
controlling
labo- ratory testing as they apply to the scope of practice in the physician off
ice laboratory to
remain compliant. This chapter provides an understanding of how to keep the phys
ician office
laboratory operating within the boundaries of the regulations. It will also prov
ide insight into
the clinical laboratory by identify- ing which career paths are available to a m
edical assistant.
LABORATORY PROFESSIONALS Laboratory professionals pay a critical role in quality
health care. The
test results they generate improve patient care by providing information to the
physician that
cannot be discovered in any other way. Even though many processes in the laborat
ory have become
automated, it is important for those performing the testing procedures to have a
dequate

background knowl- edge for appropriate interpretation of the test results. It is

also imperative
that laboratory employees are knowledgeable about the procedures necessary to en
sure quality
testing methods in the laboratory, laws and regulations governing laboratory pro
cesses, and how
all the laboratory departments work together. Personnel in the Laboratory Settin
g The personnel
involved in laboratory testing are classified according to their education and c
redentials. Table
2-1 provides a list of the laboratory professionals that may play a role in labo
ratory testing,
including their creden- tials and education. The basic classifications include t
he following:
Pathologists: These are board-certified physicians who have specialized training
in disease and
laboratory interpretation. A pathologist may function as the laboratory director
for sites that
perform all levels of laboratory testing, and is generally affiliated with hospi
tal and reference
laboratories. Physicians: A physician without any laboratory spe- cialty trainin
g may function
as the laboratory director of a physician office laboratory. Dentists may also s
erve as
laboratory directors if they perform laboratory testing in their clinics. Physic
ians may not
serve as directors for hospital or reference laboratories unless they have addit
ional credentials
specifically qualifying them for this setting. Nurse-practitioners or physician
assistants:
These are known as midlevel health-care providers, and they may function as dire
ctors of
physician office laboratories. Nurse-practitioners have at least 6 years of educ
ation; physician
assistants generally possess at least a 4-year degree, as well as additional foc
used medical
education. These midlevel providers are not usually employed in a reference or h
ospital laboratory. Medical laboratory scientists: Personnel with this title often work in
a reference or
hospital laboratory as testing personnel or as supervisors. They must have at 26
Section I
Overview of the Laboratory KEY TERMS Ambulatory care CLIA , 88 CLIA-waived Cente
rs for Medicare &
Medicaid Services (CMS) COLA Credentialed High-complexity tests Labile Moderatecomplexity tests
Phlebotomist Proficiency testing Provider-performed microscopy procedures (PPMPs
) U.S. Department
of Health and Human Services (HHS) U.S. Food and Drug Administration (FDA) 2:17
PM Page 26
Chapter 2 Regulations Governing Laboratory Personnel 27 tasks they perform are
within their
lawful scope of practice. Medical assistants have completed a medical assisting
program that
included at least an introduc- tion to laboratory procedures. Medical assistants
are not required
to be certified to work in a laboratory, but if they choose to pursue a certific
ation, they may
test through the American Association of Medical Assistants to become a certifie
d medical

assistant (CMA), or through the American Medical Technologists to become a regis

tered medical
assis- tant (RMA). Phlebotomists: A phlebotomist may be a medical assistant, but
there are also
phlebotomists trained in short-term programs, either at technical colleges or on
the job,
specifically to draw blood and process labora- tory specimens. Phlebotomists are
primarily
employed in physician office laboratories and hospital laborato- ries. Phlebotom
ists must have at
least a high school TABLE 2-1 Laboratory professional title, education, and cred
entials
Laboratory Professional Title Education Credentials Pathologist Doctorate with a
t least MD or DO,
board certified as pathologist 8 years of education Physician Doctorate with at
least MD or DO 6
years of education Physician assistant Bachelors degree PA Nurse-practitioner Mas
ters degree NP
or ARNP Clinical laboratory scientist Bachelors or CLS, certified by National Cer
tification
Agency for masters degree Medical Laboratory Personnel (NCA) Medical laboratory B
achelors
degree MLS, certified by the American Society for Clinical scientist Pathology (
ASCP) or MT if
certified by the American Medical Technologists (AMT), or International Society
for Clinical
Laboratory Technology (ISCLT) Medical laboratory technician Associate degree MLT
, certified by
the American Society for Clinical Pathology (ASCP) or American Medical Technolog
ists (AMT)
Clinical or registered Associate degree International Society for Clinical Labor
atory Technology
laboratory technician (ISCLT) Medical assistant 1-year certificate or May be cer
tified by the
American Association of associate degree Medical Assistants (CMA) or registered
by the American
Medical Technologists (RMA) Phlebotomist Varies by state May be nationally certi
fied by various
agencies; not always required; some states may allow training on-the-job with no
formal education
Note: Those with an associate degree or higher are generally required to have ce
rtification
(credentials) to work in the laboratory. Those below this level of education are
not necessarily
required to have formal certification. least a 4-year degree in laboratory medic
ine, and are
credentialed by the American Society for Clinical Pathology. Those qualified wit
h a 4-year degree
may also be known as medical technologists if they received their certification
through the
American Medical Technologists. Medical laboratory technicians: These employees
usually perform
testing procedures in a hospital or reference laboratory. They may also be emplo
yed in physician
office laboratories. Medical laboratory technicians must have completed at least
an associate
degree in laboratory medicine, and are nationally certified through the American
Society of
Clini- cal Pathology or through the American Medical Technologists. Medical assi
stants: Medical

assistants may work in a physician office laboratory, but they can also be emplo
yed in a
reference or hospital laboratory if the 2:17 PM Page 27 diploma (or general equi
valency diploma
[GED]) and have documented training to draw blood. They may become certified nat
ionally, and some
states require additional state certification as well. 28 Section I Overview of
the Laboratory
Test Your Knowledge 2-1 May a physician assistant serve as a laboratory director
? (Outcome 2-2)
Those laboratory professionals that are credentialed have completed the required
education for
their specific classification, and they have also successfully passed a comprehe
nsive assessment
examination as required by their credentialing agency. To keep their credentials
cur- rent, these
professionals must participate in continuous education every year. Some states a
lso require that
labo- ratory personnel pass an additional state examination in order to work in
a laboratory
setting. When entering a clinical laboratory, it may be diffi- cult to tell by o
bservation which
employees have which type of credential, as they are all wearing lab coats and a
ll performing
what appear to be similar tasks. Figures 2-1 and 2-2 are representative of the p
ersonnel
structure in a reference laboratory, a hospital labora- tory, and an ambulatory
care setting
(such as a physi- cian office laboratory). Laboratory testing may be performed b
y a variety of
classifications, such as med- ical laboratory scientists, medical or clinical la
boratory
technicians, medical assistants, or phlebotomists. Test Your Knowledge 2-2 May a
medical
technologist serve as a supervisor in a reference laboratory? (Outcome 2-3) Test
Your Knowledge
2-3 What type of credentials must a phlebotomist possess to work in a laboratory
setting?
(Outcome 2-4) Laboratory Director: Physician, Nurse Practitioner, or Physician A
ssistant Medical
Laboratory Technician Phlebotomist Medical Assistant Laboratory Director: BoardCertified
Pathologist Department or Shift Supervisors: Medical Technologists or Medical La
boratory
Scientists Medical Laboratory Technicians Phlebotomists Medical Assistants Figur
e 2-1 The
personnel structure of the laboratory profes- sionals working in a CLIA-waived p
hysician office
laboratory. Figure 2-2 The personnel structure of the laboratory professionals w
orking in a
hospital or reference laboratory. POINT OF INTEREST 2-1 Name changes When workin
g in a large
laboratory (such as a refer- ence or hospital laboratory), it is possible that y
ou may encounter
various credentials for individuals who are performing the same tasks. This is n
ot unusual, but a
recent merger of credentialing agencies may make this even more confusing! Prior
to 2009 there
were three widely recognized credentialing agencies for laboratory personnel. Th
ey were the Board

of Registry for the American Society of Clinical Pathology (ASCP), the National
Creden- tialing
Agency for Laboratory Personnel (NCA), and the American Medical Technologists (A
MT). In Oc- tober
2009, the NCA and the ASCP credentialing agencies decided to merge. Those who we
re previously
credentialed by the NCA are now part of the ASCP organization, and those who wer
e already part of
the ASCP have not seen very many changes in their cre- dential renewal processes
. The certifying
agency for the ASCP is now called the Board of Certification. What has changed,
however, are the
terms used by these organizations for the various personnel classifications. Bac
calaureate
degreelevel personnel: The ASCP previously used the designation medical technolog
ists to
describe this classification, and the NCA used clinical laboratory scientist. No
w, the new title
for those with a 4-year degree in medical technology that have successfully pass
ed the
examination is that of medical laboratory scientist, with the abbrevia- tion MLS
(ASCP).
Associate degreelevel personnel: The ASCP previously used the designation medical
laboratory
2:17 PM Page 28 Chapter 2 Regulations Governing Laboratory Personnel 29 Test Yo
ur Knowledge 2-4
Are medical assistants only allowed to draw blood in a laboratory setting, or ca
n they perform
other duties? (Outcome 2-5) technician to describe this classification, and the
NCA used clinical
laboratory technician. When the two agencies merged, they retained the designati
on med- ical
laboratory technician for those with a 2-year degree who successfully pass the e
xamination, and
the abbreviation used for their credential is MLT (ASCP). Medical Assistants in
the Laboratory As
introduced in Chapter 1, medical assistants may play numerous roles in the clini
cal laboratory
environment. Their education enables them to draw blood, assist with collection
of other types of
specimens, process specimens for testing, and perform simple or moderately compl
ex test
procedures. They may perform these tasks in the physician office laboratory, in
a hospital
laboratory, or in a reference laboratory. Medical assistants may also work in th
e microbiology or
pathology department within a hospital or reference laboratory assisting with sp
ecimen
preparation, answering phones, or entering specimens into the computer. Some lab
oratory settings,
especially a specialist or hospital laboratory, need their medical assistants to
do more than
draw blood or process specimens. In these set- tings they may be taught how to p
erform arterial
blood draws, and also may learn how to assist with bone mar- row aspirations or
bronchoscopy
specimen collection. In some situations, medical assistants may be running tests
on automated
instruments and performing urine microscopy examinations and manual differential
proce- dures on

normal blood smears. These specialized tasks require additional documented train
ing beyond that
offered in a traditional medical assisting education pro- gram, and the qualific
ations of the
personnel performing these tasks may be regulated by state or local laws. medica
l laboratory
testing, with the exception of those tests performed for research only. It was d
esigned to ensure
that all laboratory tests, regardless of where they are performed, would produce
accurate
reliable results and be performed in a timely manner. History of the Regulation
The original
Clinical Laboratory Improvement Act was enacted in 1967. It affected only privat
e laboratories
(federal and state laboratories were exempt) that received specimens via interst
ate commerce.
This means that the only laboratories affected by the original act were those th
at provided
services across state borders. These laboratories had to be licensed if they pro
cessed more than
100 interstate specimens per year. This act also improved laboratory quality sta
ndards overall by
adding a requirement for proficiency testing to these licensed laboratories. Pro
ficiency testing
is used to ver- ify that the results reported for a certain test are accu- rate.
Because this
Clinical Laboratory Improvement Act had such a small focus, there were many labo
ratories that
were not affected by these requirements, especially physician office laboratorie
s. It was
estimated that of 200,000 laboratories in business in the United States, only ab
out 12,000 were
regulated. In 1987, the Wall Street Journal published two arti- cles expanding o
n the poor
quality of laboratory testing in the United States. At that time, there was very
little
structured supervision of the quality of testing per- formed in laboratories tha
t were not
affected by the Clinical Laboratory Improvement Act of 1967. Specif- ically, the
articles
expanded on several situations in which Papanicolaou (Pap) smear tests showed fa
lse- negative
results, allowing cases of cervical cancer to become advanced before a correct d
iagnosis was
made. The cytology laboratories that were reporting these results were poorly st
affed, and the
technicians were overworked. Both the U.S. House of Representatives and the U.S.
Senate held
hearings to investigate the inaccurate Pap smear reports and other laboratory er
rors. As a result
of these hearings, questions began to form about how laboratories functioned and
about what kind
of quality assurance was in place for the results reported. Therefore, it was de
cided that more
federal oversight was necessary, and on October 31, 1988, the Clinical Laborator
y Improvement
Amendment of 1988 (CLIA , 88) was enacted. Since that time, there have been seve
ral revisions,
allowing more tests to be included in the CLIA-waived category, and giving the U
.S. Food and Drug

Administration (FDA) the CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988 CLIA

, 88 is an
acronym for the Clinical Laboratory Improvement Amendment of 1988. This regulati
on establishes
quality standards for all aspects of human 2:17 PM Page 29 responsibility to det
ermine the level
of complexity for laboratory tests. tests, and mononucleosis testing. Many CLIAwaived tests are
performed in physician office laboratories, but they may also be done in hospita
l or reference
lab- oratories. Table 2-2 lists the types of tests that are CLIA-waived at this
time. This list
has grown signifi- cantly since CLIA 88 first went into effect, and will continue
to change.
Moderate-complexity tests: These tests are more complex than CLIA-waived tests.
The complexity
designation is based on a grading scale that takes into account the difficulty o
f test
performance, the mainte- nance and troubleshooting required for the instru- ment
used for the
test, the amount of knowledge necessary to correctly interpret the results, and
other specific
aspects of the testing process. Some physician office laboratories perform moder
ate-complexity
testing, but there are restrictions on the personnel performing the tests. Emplo
yees must be
properly trained in these more advanced concepts in order to meet the requiremen
ts of the
regulation. These tests also have more requirements for quality control and qual
ity assurance
documentation, and laboratories are required to participate in proficiency-testi
ng programs to
validate their test results. Provider-performed microscopy procedures (PPMPs) ar
e also included
in this classification, which concern the microscopic examination of labile spec
imens in the
office performed by licensed health-care providers. Labile specimens are those t
hat must be
examined shortly 30 Section I Overview of the Laboratory TABLE 2-2 CLIA-waived
tests Test Type
Test Name CPT Code Chemistry Blood glucose by glucose monitoring devices 82962 c
leared by the FDA
for home use Urine and stool testing Fecal occult blood 82270 GO 107 Dipstick or
tablet reagent
urinalysisnonautomated; for bilirubin, 81002 glucose, hemoglobin, ketone, leukocy
tes, nitrite,
pH, protein, specific gravity, and urobilinogen Urine pregnancy tests by visual
color comparison
81025 Ovulation tests by visual color comparison for human 84830 luteinizing hor
mone Hematology
Hemoglobin by copper sulfatenonautomated 83026 Erythrocyte sedimentation ratenonau
tomated 85651
Blood count; spun microhematocrit 85013 Note: This chart recognizes only the ori
ginal CPT codes
and test names listed as waived tests in 1988. There are numerous tests and test
ing methods that
have been added to this list, which can be accessed at
http://www.fda.gov/cdrh/clia/cliawaived.html Test Your Knowledge 2-5 What was CL
IA 88 designed
to ensure? (Outcome 2-6) Levels of Laboratory Testing Defined by CLIA 88 CLIA 88 r

equires that
all laboratories performing tests on human specimens must register with the Cent
ers for Medicare
& Medicaid Services (CMS). The registration process, and title of the certificat
e granted to the
labora- tory, is based on the type of testing performed. The clas- sification of
the testing is
based on the complexity of the testing procedure and the clinical significance o
f the results
from the test, among other factors. This amend- ment classifies all tests into o
ne of three
categories: CLIA-waived tests: These are tests that are so simple and accurate t
hat the
likelihood of misinterpretation is minimal. This classification also requires th
at the tests will
pose no reasonable risk of harm to the patient if the test were accidentally per
formed
incorrectly. CLIA-waived tests also include procedures that have been cleared fo
r home use, such
as glucose testing per- formed by diabetics at home. Examples of CLIA- waived te
sts are
streptococcal screens, urine pregnancy 2:17 PM Page 30 Chapter 2 Regulations Go
verning
Laboratory Personnel 31 after collection because the appearance of the speci- me
n will change
rapidly after collection. Provider- performed microscopy procedures may include
urine microscopic
examinations, semen analysis for the pres- ence or absence of sperm, nasal smear
examinations,
and other types of analysis that need to be performed on fresh specimens. High-c
omplexity
tests: This category of testing is performed almost exclusively in hospital and
reference
laboratories by highly trained laboratory professionals. These tests require sub
stantial
knowledge of the signif- icance of the test results, complex testing procedures,
and stringent
requirements for calibration of instru- ments and quality control procedures to
ensure the
accuracy of the results. Laboratories may perform multiple levels of testing; so
me may perform
only CLIA-waived tests, whereas others may perform high-complexity tests as well
as waived tests.
All laboratories must register and pay a fee to CMS that is based on the complex
ity of the tests
that they perform. Failure to register or follow all the regulations associated
with the
specified level of testing may result in significant fines (thousands of dollars
per day of
noncompliance) and potential closure of the laboratory. manufacturers directions
provided with
the kit used exactly as they are written, and appropriate training for all indiv
iduals performing
the laboratory test must be documented. These tests may be performed by phleboto
mists, medical
assistants, or those with more laboratory education. Moderate-complexity testing
: The minimum
educa- tion requirements are very similar to those of the CLIA-waived category.
Moderate-complexity tests are more complicated to perform, and they may have muc
h more clinical

significance if they are performed or interpreted incorrectly, so the training m

ust be
comprehensive if the individual performing the test has limited formal laborator
y education. This
addi- tional documented training must include numerous areas of the laboratory,
such as quality
control testing procedures, maintenance of the testing instruments, clinical sig
nificance of the
tests, and validity of the test results. In most circumstances, this level of te
sting is
performed by a medical laboratory technician or med- ical technologist, but it i
s possible to
appropriately train a medical assistant to perform at this level as well. High-c
omplexity
testing: In order to perform tests in the clinical laboratory that have been est
ablished as high
complexity by the CLIA standards, the laboratory professional must possess at le
ast an associate
degree in laboratory science. He or she must also have docu- mented training on
site for quality
control procedures, maintenance and troubleshooting of the instruments used for
the procedures,
and more in-depth knowledge of the test parameters. These high-complexity tests
usually comprise
numerous performance steps, and the results have a high level of clinical signif
icance.
High-complexity tests are performed only in larger laboratories such as hospital
and reference
laboratories, and generally are performed by clinical or medical laboratory tech
nicians, clinical
laboratory scientists, or medical technologists. Test Your Knowledge 2-6 Describ
e the minimum
level of education required to perform the following types of laboratory testing
: a. CLIA-waived
tests b. Moderate-complexity tests c. High-complexity tests (Outcome 2-7) Test Y
our Knowledge 2-7
What factors are taken into account when assigning the different levels of compl
exity to the
various laboratory tests? (Outcome 2-7) Employee Qualifications for Performance
of CLIA Testing
The CLIA 88 regulations are very specific about the training necessary to perform
the different
levels of testing that are identified in the amendment: CLIA-waived testing: Min
imum personnel
require- ments include a high school diploma or a GED, and thorough, documented
training for the
processes performed by the individual in the laboratory. Those performing CLIA-w
aived testing
must follow the Test Your Knowledge 2-8 What levels of laboratory testing may a
clinical
laboratory scientist with 4 years of education perform? (Outcome 2-8) Oversight
of CLIA
Laboratories Various agencies are involved with the enforcement of the CLIA 88 re
gulations.
These include the FDA, the CMS, and the U.S. Department of Health and 2:17 PM Pa
ge 31 Human
Services (HHS). The HHS has the overall responsibility for laboratory quality as
surance as designated in CLIA 88, but it has delegated various parts of the process to other agen
cies. The FDA

is responsi- ble for determination of the levels of complexity for the various l
aboratory tests.
After the level of complex- ity has been determined, laboratories that perform t
hese tests must
apply for the appropriate certificate that allows them to perform these tests. T
he laboratory may
qualify only for certain testing procedures based on the qualifications of their
personnel. They
apply to CMS for this certificate, whether it is a Certificate of Waiver (allowi
ng them to
perform CLIA-waived testing only) or another type of certificate that allows the
m to perform
tests of higher complexity. A labora- tory can only begin testing after receivin
g CMS certification. Compliance is monitored by the CMS or, in some situations, by state or
private agencies
that have regulations that are at least as stringent as those of the CMS, and ha
ve an agreement
with CMS to monitor compliance. Some laboratories are affiliated with COLA, an i
ndependent
company that accredits labo- ratories. COLA uses various educational methods to
help laboratories
meet the requirements for CLIA compliance, and CMS recognizes COLA as an accrediting agency. If
a laboratory retains its accreditation with COLA, it will be assumed that that l
aboratory is
meeting the CLIA requirements and will be granted the certificate that is approp
riate for the
level of com- plexity tested without site inspection requirements from the CMS.
COLA is most
commonly associated with physician office laboratories, but the organization is
recognized by
larger laboratories for accreditation purposes as well. The CLIA certificate typ
es are based on
the complex- ity of the tests performed. Here is a summary of the available cert
ificates for
laboratories: Certificate of Waiver: Allows laboratories to perform only CLIA-wa
ived tests.
Certificate of PPM: Allows the licensed health-care providers in an organization
to perform
designated microscopic examinations. Certificate of Compliance or Certificate of
Accreditation:
Allows the laboratory to perform CLIA-waived tests, PPMPs, moderate-complexity t
ests, and
high-complexity tests. These certificates are granted after the laboratory has b
een inspected. If
the inspection was performed by a governmental agency, the laboratory receives a
Certificate of
Compliance. If the inspection was performed by a private accreditation TIME TO R
EVIEW 1. A labile
substance is one that: Outcome 2-1 a. Is not fixed and is easily destroyed b. Is
not fixed but
can be stored for an extended period of time c. Is fixed with some sort of prese
rvative d. Can
easily be transferred to a reference laboratory 2. True or False: Ambulatory car
e Outcome 2-1
refers to the care provided to those transported to the hospital as an emergency
transport. 32
Section I Overview of the Laboratory company, the laboratory receives a Certifi
cate of

Accreditation. SUMMARY Within a typical laboratory setting you will find profess
ionals with
various credentials and educational levels. Those who work in a hospital or refe
rence laboratory may have different qualifications than those who work in a smaller physi
cian office
laboratory. There are regulations that dictate who can perform which type of tes
ting, and what
training and supervi- sion must be involved for each test. CLIA 88, applies to al
l laboratories
in the United States that perform testing on human specimens, except for federal
labo- ratories
and those that perform only research testing. Every testing site must register a
nd pay a fee to
com- ply. This regulation has established three levels of testing: CLIA-waived t
ests,
moderate-complexity tests, and high-complexity tests. The levels have differ- en
t requirements
for testing personnel, quality control procedures, instrument maintenance, and l
aboratory
supervision. The FDA makes the decision about which complexity level each test w
ill have. Medical
assistants with appropriate additional training may perform CLIA-waived or moder
ate-complexity
tests, but those who perform high-complexity testing must have more specialized
laboratory
training in order to be compliant. All laboratories must register with CMS to le
gally perform
laboratory testing at any level. Test Your Knowledge 2-9 Which federal agency as
signs the CLIA
categories to laboratory tests? (Outcome 2-9) 2:17 PM Page 32 3. Which laborator
y settings may
Outcome 2-2 employ a medical assistant? a. POL b. Hospital laboratory c. Referen
ce laboratory d.
None of the above e. a, b, and c 4. True or False: Pathologists serve as Outcome
2-3 directors in
reference laboratory settings. 5. A laboratory professional with an Outcome 2-4
associate degree
in laboratory science may work in which laboratory setting? a. Reference laborat
ory b. Hospital
laboratory c. Physician office laboratory d. None of the above e. a, b, and c 6.
List three
duties that may be Outcome 2-5 performed by a medical assistant in a hospital or
reference
laboratory. 7. CLIA 88 stands for: Outcome 2-6 a. Clinical Laboratory Incident Ac
t #88 b.
Clinical Laboratory Improvement Amendment of 1988 c. Consistent Laboratory Impro
vement Amendment
of 1988 d. Continual Linear Improvement Act of 1988 8. Choose the types of labor
atory testing
Outcome 2-7 that may be performed by a medical assistant. a. CLIA-waived testing
b.
Moderate-complexity testing c. Provider-performed microscopy procedures d. Highcomplexity
testing 9. True or False: Those performing Outcome 2-8 CLIA-waived testing do no
t need to follow
the manufacturers directions; they may write their own procedures as needed. 10.
What role does
the Centers for Outcome 2-9 Medicare & Medicaid Services play in CLIA 88 enforcem
ent? a. It is

not involved b. It inspects each laboratory c. It handles all the laboratory reg
istration
procedures d. It determines the level of complexity for all laboratory tests Cha
pter 2
Regulations Governing Laboratory Personnel 33 Case Study 2-1: CLIA quiz Rose is
starting at a new
job in a physician office laboratory today. As part of her orientation, the phys
i- cian who is in
charge of the laboratory asks her a few questions to test her understanding of t
he laboratory
organization. He asks her to answer the following ques- tions about CLIA 88. How
should she
answer these? 1. Was CLIA 88 created to protect employees or patients? 2. Is it s
till necessary
to be trained in the performance of CLIA-waived test procedures, or can these be
performed
without documented training? 3. Do laboratories have to be formally registered i
n order to
legally perform testing on human specimens? RESOURCES AND SUGGESTED READINGS Ame
rican Medical
Technologists Certifying agency for laboratory professionals http://www.amt1.com
American Society
for Clinical Pathology Membership and certification information for laboratory p
rofessionals, as
well as continuing education information http://www.ascp.org Centers for Disease
Control and
Prevention CLIA-related publications from the Federal Register and the Code of F
ederal
Regulations Excellent reference for the actual CLIA regulations presented in a t
ime line that is
easy to follow http://wwwn.cdc.gov/clia/chronol.aspx Centers for Disease Control
and Prevention
CLIA Subpart A General Provisions Provides various details about CLIA 88, includi
ng compli- ance
requirements http://wwwn.cdc.gov/clia/regs/subpart_a.asp#493.1 Tests waived by t
he FDA from
January 2000 to present List of all CLIA-waived tests. Updated regularly.
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfClia/ testswaived.cfm Inform
ation about the
COLA accreditation services and education products. Also includes online educati
on programs that
may be used to fulfill continuing education requirements. http://www.cola.org 2:
17 PM Page 33
2:17 PM Page 34 35 Chapter 3 Laboratory Safety and Preventing the Spread of Dise
ase Constance L.
Lieseke, CMA (AAMA), MLT, PBT(ASCP) CHAPTER OUTLINE Infection Control and Labora
tory Safety Core
Concepts of Infection Control Microorganisms Types of Microorganisms Microorgani
sm Growth
Requirements Medical Asepsis Chain of Infection Standard Precautions Centers for
Disease Control
and Prevention Hand-Washing Recommendations Acceptable Medical Hand-Washing Proc
edures Proper Use
of Personal Protective Equipment Laboratory Safety Chemical Safety Physical Safe
ty Fire Safety
Electrical Safety Body Mechanics Bloodborne Pathogen Safety Universal Precaution
s Bloodborne
Pathogens Standard Diseases Caused by Bloodborne Pathogens in the Laboratory Set
ting Hepatitis
Human Immunodeficiency Virus Postexposure Follow-Up Procedure Summary Time to Re

view Case Study

Resources and Suggested Readings Learning Outcomes After reading this chapter, t
he successful
student will be able to: 3-1 Define the key terms. 3-2 List the major types of i
nfectious agents.
3-3 Restate the difference between pathogenic and nonpathogenic microorganisms 3
-4 Describe the
various shapes of bacteria presented in the text. 3-5 Compare and contrast bacte
ria and viruses.
3-6 Describe medical asepsis. 3-7 Explain what the chain of infection concept re
fers to, and
describe how the chain may be broken. 3-8 Explain how the CDC Standard Precautio
ns are used in a
laboratory setting. 3-9 Analyze the importance of proper hand-washing procedures
and appropriate
use of personal pro- tective equipment. 3-10 Explain appropriate procedures for
hand sanitization for health-care workers. 3-11 Examine the fundamental concepts included i
n the OSHA Hazard
Communications Standard. 3-12 List the required components on a Material Safety
Data Sheet. 3-13
Explain how a chemical label provides safety information. 3-14 Describe how a la
boratory employee
may protect themselves from other physical dangers in the laboratory. 1899_Ch03_
035-062 26/12/11
3:05 PM Page 35 3-15 Identify who is protected by the OSHA Blood- borne Pathogen
s Standard. 3-16
Interpret the key terms included in the OSHA Bloodborne Pathogens Standard. 3-17
List the
essential components of an exposure control plan. 3-18 Discuss the appropriate u
se and disposal
of sharps in the laboratory environment. 3-19 Define biohazardous waste and expl
ain proper
disposal methods for this type of laboratory waste. 3-20 Compare and contrast th
e major
bloodborne pathogens that are considered to be a threat in the laboratory enviro
nment. 3-21
Detail the appropriate follow-up procedure in case of an accidental bloodborne p
athogens
exposure. 36 Section I Overview of the Laboratory CAAHEP/ABHES STANDARDS CAAHEP
2008 Standards
III.P.4. Perform Handwashing III.C.III.3. Discuss Infection Control Procedures I
II.C.III.5. List
major types of infectious agents III.P.III.2. Practice Standard Precautions X.C.
XI.1: Describe
Personal Protective Equipment X.C.XI.3: Describe the importance of MSDS in a hea
lth- care setting
X.C.XI.4. Identify safety signs, symbols and labels X.C.XI.8. Discuss Fire safet
y issues in a
healthcare environment ABHES 2010 Standards Clinical: Apply principles of asepti
c techniques
and infection control Clinical: Use standard precautions KEY TERMS Aerobic Acqui
red immune
deficiency syndrome (AIDS) Anaerobic Asepsis Asymptomatic Bacilli Bacteria Bioha
zard symbol
Biohazardous waste Bloodborne pathogen (BBP) Bloodborne Pathogens Standard (1910
.1030)
Carcinogenic Carriers CD4 cells Centers for Disease Control and Prevention (CDC)
Cirrhosis Cocci
Contagious Contaminated sharps Diplococci Disinfection Electron microscope Engin

eering controls
Epidemiology Exposure control plan Fecal-oral route Fomites Fungi Hazard Communi
cation Standard
Health careassociated infection Hepatitis Hepatitis A (HAV) Hepatitis B (HBV) Hep
atitis C (HCV)
Hepatitis D Human immunodeficiency virus (HIV) Infection Infection control 1899_
Ch03_035-062
26/12/11 3:05 PM Page 36 INFECTION CONTROL AND LABORATORY SAFETY Pathogens, infe
ction, and
contamination are words that most of us have heard at home or in our communities
. What do they
really refer to? What impact may they have on our laboratory environment, our he
alth, and the
health of our patients? The laboratory setting has strin- gent safety precaution
s that must be
observed in order to keep our health-care workers safe as they perform their dai
ly routines.
Laboratory professionals use various chemicals and equipment that put them at ri
sk for injury. In
addition, specimens taken from the human body pres- ent a unique challenge as th
ey are naturally
infectious, or capable of transmitting disease to others. Infection con- trol is
the term used to
describe the process of protecting health-care workers and the patients they ser
ve from the
infectious agents in our facilities. In addition, because all the hazards faced
in the laboratory
are not from infec- tious agents, further safety methods must be employed to pro
tect our
laboratory professionals. It is imperative that as a medical assistant working i
n a laboratory
environ- ment you understand the hazards you may encounter, the laws that are de
signed to protect
you and the patients you serve, and the appropriate use of the safety equipment
that is available
to you. CORE CONCEPTS OF INFECTION CONTROL In recent years, we all have become m
ore aware of the
infections that may be transmitted through the water, through the air, or with c
asual contact in
our communities. Severe acute respiratory syndrome (SARS), the Asian flu, Escher
ichia coli
outbreaks, and other pathogens such as the monkeypox virus remind us that we are
very vulnerable.
The presence of AIDS and hepatitis C is further proof of how our world has chang
ed in the past 35
years. Be very mindful of the fact that almost any transmissible infection could
find its way
into your laboratory at any moment, as it may be present in your community, and
you wont be
aware of it. An ill patient may come into the office for med- ical services with
an infectious
condition, a specimen may be dropped off that is capable of transmission, or a s
alesperson may
arrive and offer her hand, which is covered with bacteria, for a greeting. Micro
organisms
Diseases that may be encountered in your medical office or laboratory (even with
out any blood
exposure) in- clude varicella (chickenpox), tuberculosis, viral respira- tory in
fections,
conjunctivitis (pinkeye), gastrointestinal Chapter 3 Laboratory Safety and Prev

enting the Spread

of Disease 37 Infectious Material Safety Data Sheets (MSDS) Medical asepsis Micr
oorganisms Mucous
membranes Mycotic National Fire Protection Association (NFPA) Nonintact skin Nor
mal flora
Nosocomial infection Occupational exposure Occupational Safety and Health Admini
stration (OSHA)
Opportunistic pathogen Other potentially infectious materials (OPIMs) Parasites
Parenteral
exposure Pathogens Percutaneous Personal protective equipment (PPE) Postexposure
prophylaxis
(PEP) Protozoa RACE Regulated waste Resident bacteria Sanitization Spirilla Spor
es Standard
Precautions Staphylococci Sterilize Streptococci Surgical asepsis Susceptible Tr
ansient bacteria
Transmissible Universal Precautions Vector Viruses Window period Work practice c
ontrols
1899_Ch03_035-062 26/12/11 3:05 PM Page 37 infections, and measles. Sometimes th
ese infections
affect the personnel, and sometimes they affect other patients within the facili
ty. They are all
caused by microorganisms, living organisms that are too small to be seen without
a microscope.
Most microorganisms are harmless to humans. However, a small percentage of bacte
ria, viruses,
fungi, protozoa, and parasites are capable of causing disease in the human body.
These
disease-causing organisms are known as pathogens. An infection is the invasion o
f the body by
pathogens that then cause disease symptoms. Not all microorganisms are pathogeni
c, and some are
only capable of causing disease when they enter a part of the body where they do
nt normally
reside. A disease is contagious or trans- missible if it can be spread to other
people directly
or indirectly. treatment, identification of the causative agent is often necessa
ry. An initial
step of the identification process is to exam- ine a sample under the microscope
so that the
bacteria can be classified according to one of three basic shapes, as seen in Fi
gure 3-1. Cocci
are round bacteria, which can then be classified further by their appearance whe
n examined
microscopically. Cocci that grow in grape-like clusters are staphylococci, those
that grow in
chains are streptococci, and those that grow in pairs are diplo- cocci. Diseases
caused by cocci
include streptococcal sore throat, pneumonia, abscesses, food poisoning, gon- or
rhea, and
meningitis. Long, slender, rod-shaped (oval) bacteria are called bacilli. These
are especially
prevalent in the soil and the air. Many types of bacilli are able to form spores
, which is a
dormant form of the bacteria that is resistant to changes in heat, moisture, and
disinfectants.
Bacilli cause diseases such as botulism, tetanus, diphtheria, tuberculosis, and
salmonella food
poisoning. E. coli is a normal bacilli that is present on our skin and in our in
- testines, but
if we come in contact with a specific strain, E. coli O157:H7, it may lead to se

rious food
poisoning, and may even be fatal. Spirilla are curve-shaped or spiral bacteria.
This type of
bacterium is less frequently isolated in specimens from the human body, but the
infections may be
quite serious when they occur. Treponema pallidum is a spirillum that causes syp
hilis, and
cholera is caused by another type of spirillum. This category may also be descri
bed as curved
rods and microbiologists may subdivide it further into those bacteria that only
have a slight
curve and those that are tightly wound like a spring. 38 Section I Overview of
the Laboratory
Test Your Knowledge 3-1 Staphylococcus aureus is a type of bacteria that sometim
es functions as a
pathogen. What other types of microor- ganisms may cause disease in humans? (Out
come 3-2) Test
Your Knowledge 3-3 How are staphylococci and diplococci different? (Outcome 3-4)
Test Your
Knowledge 3-2 Do all microorganisms cause disease? (Outcome 3-3) Types of Microo
rganisms
Bacteria. Bacteria are single-celled organisms that have a cell wall in addition
to the cell
membrane that our human cells possess. (This is an important property when ident
ifying different
types of bacteria with special stains, as is discussed in Chapter 10.) Of all th
e bacteria known
to exist, approximately 4% are known to cause disease in humans. Bacterial infec
tions are treated
with medication that will kill the microorganisms or keep them from multiplying,
(antibiotics),
but for effective Coccus Spirillum Streptococci Bacillus Diplococci Staphylococ
ci Figure 3-1
Types of bacteria, including cocci, staphylococci, streptococci, diplo- cocci, b
acilli, and
streptococci. 1899_Ch03_035-062 26/12/11 3:05 PM Page 38 Viruses. Viruses are an
other common type
of patho- genic microorganism. They are the smallest infectious agent, and are n
ot really cells.
Viruses are either made up of RNA or DNA surrounded by a protein capsule, and re
quire a host cell
to survive and replicate. Viruses cannot be observed using a simple microscope s
uch as is found
in most laboratories; they require use of an electron microscope for visualizati
on. They invade
the cells of our body, and use our own structures to make more virus particles.
Viruses cause
many of the diseases for which we are vaccinated, including measles, mumps, and
chickenpox. The
human immunodefi- ciency virus (HIV) is the causative agent of AIDS, and is an e
xample of a
retrovirus. Antiviral medications are available for some viral infections, but b
ecause of the way
virus particles use human cells, the treatment may be quite damaging to the host
as well as to
the virus. Antibiotics are not effective against viruses. Fungi. Fungi are plant
-like organisms
that flourish in an environment that is dark and damp. Yeast is a type of fungus
, and fungal
infections on the body are called mycotic infections. Athletes foot and ringworm

are examples of
fungal infections. Parasites. Parasites are similar to viruses because they requ
ire a living host
to survive. A genus of bacteria known as Rickettsia is parasitic. Parasites take
their
nourishment from the host and require their host cells to reproduce, but they do
not utilize the
human cell in the same way that a virus does. Malaria is an example of a parasit
ic disease; the
malaria parasite actually works into the red blood cells of the host and causes
the patient to
become ill. The word parasite may also be used to refer to larger, multicellular
organisms such
as tapeworms, which live inside the human host and use the body to survive. Prot
ozoa. Protozoa
are complex single-cell microor- ganisms, most of which are nonpathogenic. Howev
er, there are a
few species that can cause very serious infec- tions in humans. Protozoa live in
the soil and
water. Microorganism Growth Requirements Because we have so many microorganisms
present in our
environment, we must find ways to eliminate as many as possible, with an emphasi
s on the removal
of pathogens that could cause harm. However, it is impos- sible and impractical
to sterilize our
environment in the laboratory, which would involve the elimination of all microo
rganisms.
Sanitization reduces the number of microorganisms on a surface with cleaning. He
at or chemicals
are often used for sanitization in the health- care environment. Disinfection is
the process by
which a medical assistant applies a chemical to a surface to kill the pathogenic
microorganisms
that may be present. Sanitization is often performed before an item is disin- fe
cted, so that the
majority of the microorganisms are already removed before the pathogens are targ
eted. Items such
as examination tables, countertops, and equipment are disinfected on a regular b
asis. Skin may
also be disinfected, as it is impossible to sterilize the skin by eliminating al
l the
microorganisms. Seventy percent isopropyl alcohol or povidone-iodine solutions a
re used for skin
disinfection. Work surfaces and equipment are often disinfected in the laborator
y with a freshly
prepared 10% bleach solution. Asepsis means that a surface is without infection.
In the medical
environment, there are two types of asepsis. Surgical asepsis means that all the
pathogenic
organ- isms have been destroyed before they enter the body. Invasive procedures
such as
venipuncture, injections, and urinary catheterization require surgical asepsis t
o be in place so
that pathogenic microorganisms arent intro- duced into the body of the patient. E
quipment used
for these types of procedures must be sterilized, and special care is used to av
oid infection.
Medical asepsis is a term used to describe a procedure or an environment that al
- lows a patient
to be treated without exposure to patho- genic microorganisms. For noninvasive p

rocedures and the

majority of care provided in the medical office, medical asepsis is adequate to
protect the
patients from potential infection. The items that are used for this type of care
are clean and
have been disinfected, but sterility is not necessary. To disinfect the environm
ent appropriately and achieve medical asepsis, we must understand what elements microorganis
ms need for
survival. These include the following: Temperature: The optimum temperature for
each
microorganism will vary. Human pathogens tend to prefer our body temperature, so
they grow best
at approximately 98.6F. pH: A neutral pH is best suited for most microorgan- isms
. This is why
many disinfectants and cleaning Chapter 3 Laboratory Safety and Preventing the
Spread of Disease
39 Test Your Knowledge 3-4 Describe the appearance of bacilli viewed under the m
icroscope.
(Outcome 3-4) Test Your Knowledge 3-5 List two ways that viruses are different f
rom bacteria.
(Outcome 3-5) 1899_Ch03_035-062 26/12/11 3:05 PM Page 39 agents are basic or aci
dic, as they will
kill the microor- ganisms by making their environment inhospitable. Darkness and
moisture: Most
microorganisms like darkness or dim light, and they all need moisture to survive
. Nutrition:
The type of nutrition varies depending on the type of microorganism, but they al
l need something in their environment to use as a food source. Oxygen: Aerobic microorganis
ms need oxygen
pres- ent for survival. Anaerobic microorganisms are best suited for environment
s that have an
absence or low levels of oxygen. Good aseptic practices for the medical setting
will at- tempt to
eliminate the elements necessary for pathogenic microorganisms to survive. These
practices may
include the following: Disinfect work areas (using an appropriate disinfecting a
gent for the
health-care environment) between patients. Take appropriate respiratory precauti
ons while working with patients with potentially infectious respira- tory conditions. Provide
masks and tissues
to the patients, and enforce their use by employees as well. Close the door of t
he treatment or
blood-draw area if possible when an infectious disease is suspected. Limit acces
s of
nonessential personnel and visitors to patient care areas. Keep the laboratory a
nd waiting room
area well lit, well ventilated, and free of dirt and dust. stopped at the source
before it can be
transmitted. The essential parts of the chain include the following: Infectious
agent: A
pathogenic microorganism. This may be a virus, bacteria in the environment, or p
athogens that are
carried in the bloodstream. There may also be microorganisms that are only patho
genic in specific
situations. For instance, if an individual is taking antibiotics for an extended
period of time,
she may develop a yeast infection, because the yeast is taking advantage of the

bodys imbalance
created with the antibiotic use. The yeast would be an opportunis- tic pathogen.
Reservoir
host: Someone who is infected or carry- ing the infectious agent. This may be a pe
rson or an
animal that may or may not have symptoms of the infection. A reservoir host prov
ides the
necessary envi- ronment for the pathogen to grow. Portal of exit: The means by w
hich the
pathogen leaves the host body, either through the eyes, mouth, ears, intestinal
tract, urinary
tract, respiratory tract, reproductive tract, or broken skin. Another portal of
exit may be
through the blood or other body fluids capable of transmitting pathogens. Mode o
f transmission:
This describes how the pathogen moves from one person to another. It may be tran
smission through
the air as moisture droplets after a sneeze or a cough, other direct transmissio
n occurs as one
person touches another or via an insect or other vector. Vectors are living orga
nisms that take
in the pathogen, allow it to live and multiply in or on their bodies, then trans
mit it to another
host without becoming ill with the pathogen during the transport. Dirty hands ar
e a very common
mode of transmission. 40 Section I Overview of the Laboratory Test Your Knowled
ge 3-6 Brittany,
a phlebotomist working in the laboratory, is cleaning up at the end of her shift
. She uses the
disin- fectant provided by her employer and some paper towels to thoroughly clea
n the area where
she has been drawing blood from patients. Is this work area now sterile? (Outcom
e 3-6) Chain of
Infection Figure 3-2 is a representation of the way pathogens are transmitted fr
om person to
person. This is represented as a chain, because all the parts of the circle are
sequential and
linked to one another. To stop the transmission of disease, the chain must be br
oken. A medical
assistant working in a laboratory environment must practice good infection contr
ol techniques to
achieve medical asepsis and break the chain. The potential infection needs to be
Infectious agent
Reservoir host Portal of exit Mode of transmission Portal of entry Susceptible h
ost Figure 3-2
Chain of infection. 1899_Ch03_035-062 26/12/11 3:05 PM Page 40 Pathogens may als
o be transmitted
by inanimate objects, known as fomites. Doorknobs, telephones, countertops, and
writing
instruments are common fomites in the laboratory environment. Contami- nated foo
d or water may
also function as a mode of transmission. Portal of entry: The pathogens enter th
e body in the
same ways that they leave the body. The mucous membranes that line the external
openings of our
bodies are a common portal of entry and exit for path- ogenic microorganisms. Su
sceptible host:
A susceptible host is not protected from the pathogen as it enters his or her bo
dy. The pathogen
to grow and multiply within the susceptible host. Age and illness can affect the

susceptibility
of a patient or an employee. A potential host will protect him- or herself (beco
me less
susceptible) in various ways. Protection may include vaccinations against cer- t
ain viruses or
bacteria, appropriate nutrition, or proper use of personal protective equipment.
In addition to
understanding the chain of infection, it is important to realize how the chain m
ay be broken by
health-care staff members. Appropriate infection control practices and patient e
ducation are
effective means of breaking the chain. Specifics include the following: Infectio
us agent:
Although health-care professionals may not always be able to break the chain at
this link, it is
important to remember that an infectious agent may be eradicated if a patient ta
kes all of his or
her an- tibiotics as directed. Patient education in this area is critical. Reser
voir host:
Health-care personnel are sometimes tempted to go to work when they are ill. The
y are essentially
a reservoir host at this time, and if they are not in the facility when they are
ill, the chain
is bro- ken. In addition, if there is a patient in the waiting room with a suspe
cted illness that
is highly conta- gious, removing the patient from the vicinity of other patients
may break the
chain at this point. Portal of exit: Providing respiratory protection and tissue
s to patients
may contain the infectious agent as it leaves the body. Keeping infected wounds
covered may also
affect this link of the chain. Mode of transmission: The simplest and most impor
- tant action
that health-care personnel can take to break the chain of infection is washing t
heir hands. In
addi- tion, contaminated surfaces should be cleaned immediately after care is pr
ovided, and often
throughout the workday. Patients should be educated about how to protect themsel
ves if they live
in the same household with another family member who is ill. Hand sanitiza- tion
is also critical
for family members and patients to eliminate an opportunity for the pathogens to
be trans- ported
to another susceptible host. Portal of entry: Those who are working with patient
specimens must
wear appropriate protective equip- ment (such as a face shield to provide mucous
membrane
protection, gloves, and a laboratory coat) to protect the common portals of entr
y. Health-care
personnel working with patients who have respira- tory symptoms should protect t
heir own
respiratory passages with a mask. All broken skin should be cov- ered when worki
ng with patients,
and there should be no eating, drinking, chewing gum, or applying makeup in the
area where
specimens are collected or processed. Susceptible host: Health-care personnel sh
ould al- ways
keep their vaccinations up to date to keep them from being susceptible to vaccin
e-preventable
diseases. In addition, a balanced lifestyle with good nutrition and adequate res

t will reduce
susceptibility. Patients should be encouraged to keep vaccinations up to date, a
nd those who have
impaired immune systems should be cautioned about protecting themselves while in
the community.
Chapter 3 Laboratory Safety and Preventing the Spread of Disease 41 Test Your K
nowledge 3-7 How
might a medical assistant break the chain of infec- tion at the mode of transmis
sion link?
(Outcome 3-7) Test Your Knowledge 3-8 Cally Jones just completed a set of vaccin
ations to protect
her from hepatitis A. Where has she broken the chain of infection for this disea
se? (Outcome 3-7)
Standard Precautions We have discovered that there are numerous microorgan- isms
in our
environment that have specific requirements they need to survive. Some of these
microorganisms
are pathogens, meaning that they can cause infection in the human body. A health
careassociated
infection is one that is acquired in a health-care facility, such as a hospi- ta
l, long-term care
facility, physician office, or laboratory. If a patient in an inpatient facility
enters without
any ev- idence of infection, and develops signs of one more than 48 hours after
being admitted,
the infection is then inves- tigated as a health careassociated infection. This t
ype of
1899_Ch03_035-062 26/12/11 3:05 PM Page 41 infection may also be known as a noso
comial infection.
Health careassociated infections are more common in inpatient facilities in which
patients are
in close proximity to one another, but it is also possible to acquire an infecti
on in an
ambulatory care setting. For example, chickenpox is highly contagious and can be
spread from one
person to another via droplets in the air after an infected individual coughs or
sneezes. If a
suscep- tible patient is in the same waiting area for an extended period of time
with someone who
is infected, the patient may develop chickenpox as a health careassociated infect
ion. Health
careassociated infections have become more prevalent, more dangerous, and more ex
pensive to
treat in the past few decades. In response, the Centers for Disease Control and
Prevention (CDC)
has devel- oped a set of Standard Precautions to assist health-care facilities w
ith their
infection control efforts. This stan- dard is based on the premise that every pe
rson is potentially infectious with a microorganism that could be transferred to someone else
in the
health-care setting. Appropriate hand-washing techniques are stressed in the sta
ndard, as it has
been found that this is the most effective action taken by medical staff to stop
the spread of
infection. Appropriate use of personal protective equipment, equipment disinfect
ion, good
respiratory hygiene, appropriate use of sharps, correct disposal of linen, and e
nvironmental
cleaning practices are also addressed in the standard. For those working in inpa

- tient
facilities, the standard includes information about different types of precautio
ns to be taken in
isolation situations. The Standard Precautions expand and enhance the Universal
Precautions
developed in the 1980s, which specifically addressed infections transmit- ted th
rough contact
with blood and other potentially infectious materials. The premise of the Univer
sal Pre- cautions
was that everyone was potentially infectious for bloodborne pathogens and that t
he same care
should be used to treat every specimen. Centers for Disease Control and Preventi
on Hand-Washing
Recommendations Even though research has shown that the hands of health- care pe
rsonnel are one
of the most common modes of transmission for pathogens, there are still issues w
ith hand-washing
compliance. The CDC recognized that this issue needed to be addressed, and the g
uidelines recently released now recommend the use of alcohol-based hand rub for routine deco
ntamination of
the hands in many situations, which may be quicker and easier for health-care pr
ofessionals to
use than washing the hands with soap and water. Either hand washing and decontamination using
alcohol-based hand rubs remove or kill transient bacteria, viruses, or other typ
es of microorganisms that may be present on the hands. Transient mi- croorganisms, which attach
themselves to our
hands dur- ing our day-to-day activities, are responsible for most of the contam
ination and
potential infection as health-care workers move from patient to patient. Residen
t bacteria, or
normal flora, are bacteria living on and in between the deeper layer of our skin
cells, and are
not removed during routine hand cleaning. Here are some of the specific recommen
dations for hand
hygiene: 1. Avoid any unnecessary touching of surfaces sur- rounding the patient
. 2. If your
hands are visibly dirty or contaminated with blood or other materials, wash them
with soap and
water. (It is not important at this point whether it is an antimicrobial soap th
at is used.) 3.
Hands should be washed before eating and after using the restroom. 4. If hands a
re not visibly
soiled, or if they were washed with a soap that was not antimicrobial, it is rec
om- mended that
an alcohol-based hand rub be used. It may be used instead of the soap and water
wash, or in
addition to hand washing after a nonantimicrobial soap is used. 5. Hands should
be decontaminated
(washed or cleansed using the alcohol-based hand rub) in these situations: a. Be
fore and after
direct contact with patients, even if the patient has intact skin b. After conta
ct with blood,
body fluids or excretions, mucous membranes, nonintact skin, or dressings used f
or open wounds c.
If the health-care provider will be going from a contaminated body site to a cle
an body site on
the same patient d. After contact with any objects, such as equipment, in the im

mediate area of
the patient e. After removing gloves 42 Section I Overview of the Laboratory Te
st Your Knowledge
3-10 What is the most effective action a health-care worker can take to stop the
chain of
infection? (Outcome 3-8) Test Your Knowledge 3-9 According to the CDC recommenda
tions for
Standard Precautions, who is to be considered infectious? (Outcome 3-8) 1899_Ch0
3_035-062
26/12/11 3:05 PM Page 42 5. It is also recommended that artificial nails be avoi
ded if the duties
of the health-care provider include direct contact with patients at high risk fo
r infection. Keep
natural nails less than one-fourth-inch long. 6. Minimize jewelry on the hands,
as bacteria may
be present underneath or in jewelry and is not removed during normal hand-washin
g techniques. 7.
Refilling of soap pump dispensers is discouraged. If a refill is necessary, the
dispenser should
be rinsed thor- oughly before more soap is added. Bacterial contam- ination may
be present in the
small amount of soap at the bottom of the container. Acceptable Medical Hand-Was
hing Procedures
The CDC recommendations outline specific practices to be employed when washing o
r disinfecting
hands be- cause this is such an important part of infection control practices. T
hese procedures
are explained in detail in Procedures 3-1 and 3-2. Chapter 3 Laboratory Safety
and Preventing
the Spread of Disease 43 Test Your Knowledge 3-12 Describe three situations in w
hich a
health-care worker should decontaminate their hands. (Outcome 3-10) Test Your Kn
owledge 3-11 What
is an acceptable alternative to hand washing in the laboratory in most situation
s? (Outcome 3-9)
Test Your Knowledge 3-13 Why would a clean, dry paper towel be used to turn off
the water faucets
after hand washing? (Outcome 3-10) Procedure 3-1: Perform Hand Washing TASK Perf
orm hand washing
appropriately, using the recom- mended technique for medical personnel. CAAHEP/A
BHES STANDARDS
CAAHEP 2008 Standards III.P.4. Perform Handwashing ABHES 2010 Clinical Apply pri
nciples of
aseptic techniques and infection control Use standard precautions CONDITIONS Ant
ibacterial
soap Running water Paper towels Manicure brush and stick Procedure Rationale 1.
Remove all
rings, and make certain that lab coats, watches, and bracelets are pushed up abo
ve the wrist
area. 2. Adjust the water temperature until it is warm but not hot. 3. Wet the h
ands and wrists.
4. If using a soap dispenser, use a clean paper towel to dispense the amount of
soap recommended
by the manufacturer. This is usually 35 mL or 12 pumps. If an automatic soap dispe
nser is used,
the paper towel is not necessary. It is not possible to clean appropriately unde
r rings, so they
should be removed. Watches and bracelets need to be moved above the wrists so th
at the wrists can
be cleaned. Hot water leads to skin breakdown, and should be avoided. To provide

the best sudsing

action with the soap, the hands should be wet before applying the soap. A push-t
op soap dispenser
or an automatic dispenser is recommended. If bar soap must be used, the bar of s
oap must be kept
in the hands until they are thor- oughly covered with suds, and a drainable soap
dish must be in
use to avoid pooling of dirty water around the bar of soap. Continued 1899_Ch03_
035-062 26/12/11
3:05 PM Page 43 44 Section I Overview of the Laboratory Procedure Rationale 5.
Rub the hands
together vigorously for at least 1015 seconds. All surfaces of the hands should b
e covered with
soapsuds, as well as between the fingers and up over the wrist area. Keep the ha
nds lower than
the elbows. 6. Avoid touching the lab coat or scrubs on the front of the sink, a
nd avoid touching
the hands to the in- side of the sink while scrubbing. 7. Clean the top of the f
ingernails with
the brush and clean under the fingernails with the manicure stick. 8. Rinse the
hands under the
warm water, keeping the hands lower than the elbows. The friction created helps
to minimize the
amount of bacteria on the hands. The hands must remain lower than the elbows to
avoid having the
water run up to the elbows, causing contamination farther up on the arm. Hand wa
shing with all
surfaces covered with suds, including wrists If the lab coat or scrubs touches t
he front of the
sink, it will become contaminated with dirty water. The in- side of the sink is
considered to be
dirty, so should not be touched during the hand-washing procedure. The cuticle are
a and the
skin surrounding the finger- nails harbor bacteria, so special care needs to be
taken to clean
this area thoroughly. The manicure stick should be used under the fingernails to
remove as much
contamination as possible. The hands need to remain below the elbows to avoid co
ntamination. All
soap must be rinsed from the hands. Rinsing of hands with fingertips pointing do
wnward. Procedure
3-1: Perform Hand Washingcontd 1899_Ch03_035-062 26/12/11 3:05 PM Page 44 Chapter
3 Laboratory
Safety and Preventing the Spread of Disease 45 Procedure Rationale 9. Dry the ha
nds thoroughly
with paper towels. Dispose of the paper towels in an appropriate receptacle. 10.
Using another
clean, dry paper towel, turn off the water faucets. Dispose of the paper towel i
n the appropriate
receptacle. Hands should be dried thoroughly before continuing. Special care sho
uld be given to
the area between fingers. A clean, dry paper towel must be used rather than usin
g the damp one
that was used to dry the hands. The moisture on the paper towel may draw the bac
teria present on
the faucets back onto the clean hands. Procedure 3-2: Sanitize Hands With an Alc
ohol-Based Hand
Sanitizer TASK Sanitize hands using an alcohol-based hand sanitizer. CAAHEP/ABHE
S STANDARDS
CAAHEP 2008 III.P.III.2. Practice Standard Precautions ABHES 2010 Clinical Apply

principles of
aseptic techniques and infection control Use standard precautions CONDITIONS Alc
ohol-based hand
sanitizer containing 60% to 95% alcohol Procedure Rationale 1. Remove all rings,
and make certain
that laboratory coats, watches, and bracelets are pushed up above the wrist area
. 2. Verify that
the sanitizer to be used is alcohol based. 3. Dispense the manufacturers recommen
ded amount of
the product in the palm of the hand. 4. Cover all surfaces of the hands and fing
ers with the
sanitizer solution, and continue to rub these sur- faces until the product is co
mpletely dry.
Dont forget the areas around and under the fingernails, as well as between the fi
ngers and the
wrist area. 5. Allow the hands to air-dry. Do not use a paper towel to dry hands
. It is not
possible to clean appropriately under rings, so they should be removed. Rings co
ntain microorganisms that can cause infection. Watches and bracelets need to be moved above the
wrists so that
the wrists can be cleaned. The CDC recommendations sanction only the use of alco
hol-based
sanitizers. Do not dispense less than is recommended or the hand sanitization wi
ll be incomplete.
Do not apply more than is recommended or the dry time will be in- creased. The s
kin around the
fingernails and cuticles harbors a lot of microorganisms, so pay close attention
to this area. If
the hands are not allowed to air-dry, the sanitization process is incomplete. Th
e microorganisms
will continue to be destroyed while the solution dries on the hands. 1899_Ch03_0
35-062 26/12/11
3:05 PM Page 45 Proper Use of Personal Protective Equipment Later in this chapte
r you will learn
about the Occupa- tional Safety and Health Administration (OSHA) Bloodborne Path
ogens Standard,
which is a compre- hensive policy addressing bloodborne pathogen (BBP) exposure
in health-care
settings. A key compo- nent of this standard, as well as the Standard Precau- ti
ons, is proper
use of personal protective equipment (PPE). Personal protective equipment helps
to protect the
employee from bloodborne pathogens (those pathogens that are transmitted via dir
ect contact with
blood and other infectious body fluids), and in addi- tion it helps to protect t
hem from the
pathogens in their environment that are not bloodborne. In order to be effective
, personal
protective equipment must be worn at appropriate times, removed when not needed,
and disposed of
properly. When considering PPE for a task, the employee must decide what type of
exposure is
reasonably anticipated while performing that task. Policies must be in effect by
the employer to
guide these decisions for PPE use. The most important personal protective equipm
ent in the
medical laboratory is properly fitting gloves (see Fig. 3-3). Employers are resp
onsible for
providing PPE to employees, and gloves are no exception. Most facili- ties no lo

nger use latex

gloves; latex allergies have be- come too widespread to continue with this pract
ice. Latex
alternatives (such as nitrile gloves) are readily available. Gloves should be wo
rn when contact
with blood, mucous membranes, or nonintact skin could be anticipated when perfor
ming a certain
task. Gloves should also be worn when contact with other poten- tially infectiou
s materials
(OPIMs) is anticipated. OPIMs are those that are capable of transmitting bloodbo
rne pathogens. It
is not necessary to wear gloves when touching a patient with intact (unbroken) s
kin for routine
care, such as taking vital signs and helping a patient into the procedure chair.
Hands should be
washed before and after each glove use, and gloves should always be re- moved af
ter caring for a
patient. The same pair of gloves should never be used for the care of more than
one patient. Do
not wash gloves. Gloves should not be worn after patient care when leaving that
immediate area,
as they may be contaminated with unseen mi- croorganisms that will be deposited
on door handles,
telephones, and the like. Also, do not touch your face or hair while caring for
a patient and
wearing gloves. Do not wear the same pair of gloves for a patient if you are goi
ng from a dirty
body site to a clean body site; remove the gloves, wash your hands, and put on a
clean pair.
Remember, gloves cannot prevent a needlestick injury, but they can prevent a pat
hogen from
entering your body through a small break in your skin under the glove, and they
can protect you
from transient microorganisms that you may be exposed to while working in the he
alth-care
environment. Gloves should be removed promptly after use. The method of removal
is critical, as
the gloves may be con- taminated with unseen microorganisms that must not be spr
ead to the
surrounding area. Procedure 3-3 explains the steps involved in aseptic glove rem
oval. Personal
protective equipment also may also include masks, goggles, face shields, or resp
irators (Fig.
3-3). A mask may be worn to protect others from droplets that may be generated w
hen coughing or
sneezing. Masks may be given to patients to wear while they are in the facility,
or health-care
professionals who have an upper respiratory infection or allergies may wear mask
s. Remember to
keep the mask tight to the face so that it is effective. Masks with goggles or f
ace shields may
be worn to protect the employees eyes, mouth, and nasal passages from moisture dr
oplets or
aerosols in the lab- oratory environment. Respirators are required when working
with patients
with pulmonary tuberculosis or when dealing with cer- tain types of specimens co
nsidered
potentially infectious for airborne transmission. Respirators must also be worn
when working with
certain chemicals used as preserva- tives in the laboratory. Respirators must be

fit properly to
the face of the employee to be effective, and the filters must be maintained as
directed. Gowns
may be used when additional protection is re- quired during patient care (Fig. 3
-3). These are
especially important when entering isolation areas of the hospital or when worki
ng in a nursery
environment with new- borns. Care must be taken to keep the interior side of the
gown free of
contamination to protect the employee. Gowns are usually made of light, disposab
le material, and
must be disposed of immediately after use. Generally 46 Section I Overview of t
he Laboratory
Test Your Knowledge 3-14 Marni is working hard to successfully draw blood from a
patient who has
very fragile veins. As she works, the phone keeps ringing. She finally obtains a
sample, and just
as she completes the draw and has the patient put pressure on the site, she reac
hes out with her
gloved hand and answers the phone. What has she done wrong in this scenario? (Ou
tcome 3-9)
1899_Ch03_035-062 26/12/11 3:05 PM Page 46 there is a disposal area just inside
or outside the
room where the gowns were worn. Laboratory coats are also used when there is a p
otential for
splashing or soiling of the clothing worn by laboratory professionals. These sho
uld be OSHA
approved as fluid resistant to offer the best protection. The coats must have ti
ght cuffs, and
should button or snap up to the neckline when worn. Clean laboratory coats shoul
d not be stored
with dirty coats, and employees must not wear their con- taminated laboratory co
ats into eating
areas or the rest- room. Laboratory employees are also not to take their coats h
ome to be
laundered, as this could contaminate their home environment. If laboratory coats
are required at
the facility where an employee works, OSHA regula- tions dictate that the facili
ty is responsible
for providing the coats and cleaning them commercially after use. Chapter 3 Lab
oratory Safety
and Preventing the Spread of Disease 47 Procedure 3-3: Removal of Contaminated G
loves TASK
Properly remove and dispose of contaminated gloves. CAAHEP/ABHES STANDARDS CAAHE
P 2008
III.P.III.2. Practice Standard Precautions ABHES 2010 Clinical Apply principles
of aseptic
techniques and infection control Use standard precautions CONDITIONS Nonlatex gl
oves
Biohazard waste container Procedure Rationale 1. Grasp the palm of the glove on
the nondominant
hand. Keep the gloves away from the body and the hands pointed toward the floor.
2. Pulling on
the palm of the glove, turn it inside out as it is removed from the nondominant
hand. 3. Crumple
up the contaminated glove into the other gloved hand. 4. Insert two of the unglo
ved fingers under
the cuff, against the wrist of the gloved hand. 5. Pulling down with these finge
rs, turn the
second glove inside out over the other glove while slipping it off the fingers.

6. Dispose of the
gloves in a biohazard waste container. 7. Wash hands. Grasping the palm will all
ow a firm hold as
this glove is removed. Keeping the hands away from the body pointed toward the f
loor will
minimize the risk of splatter in the eyes or mucous membranes. If the glove is i
nside out, it
will not be able to contam- inate the bare skin, as the soiled area will be on t
he inside of the
glove. This allows the contaminated glove to be held safely while the other glov
e is removed. Be
careful not to touch the contaminated side of the glove with the bare hand. This
method will
allow the contaminated surfaces to remain inside the glove bundle. Visible conta
mination on the
gloves means that they need to be disposed of as biohazardous waste. Hands must
always be washed
after removing gloves because gloves are not foolproof and hand contami- nation
is still
possible. It also helps to remove any powder residue that may be left behind on
the hands.
1899_Ch03_035-062 26/12/11 3:05 PM Page 47 Laboratory professionals should never
apply makeup,
chew gum, eat, or drink when working with blood or OPIMs. Also, food must never
be stored in the
same refrigerator with specimens or medications, regardless of how it is package
d. LABORATORY
SAFETY The laboratory environment is unique because of the types of hazards pres
ent. As we have
already discussed in this chapter, laboratory professionals are surrounded by po
ten- tial
pathogens as they perform patient care and work with specimens. In addition, emp
loyees are using
or are in the vicinity of chemicals of various types, as well as electrical test
ing equipment.
Laboratory professionals are also ex- posed to bloodborne pathogens, as needle u
se and han- dling
fluids from the human body are part of the daily duties in this environment. All
of these
potential risks make safety in the laboratory workplace somewhat compli- cated.
This chapter has
already provided information about protection from exposure to pathogenic microo
rganisms in the
environment and basic infection control practices. Now we will emphasize chemica
l safety,
physical safety, and bloodborne pathogen safety in the laboratory. Chemical Safe
ty Numerous
chemicals are present in the clinical laboratory. Some of these are used as clea
ning agents or
disinfectants, whereas others may function as preservatives for labora- tory spe
cimens.
Hydrochloric acid (HCl), for example, is often used as a preservative for 24-hou
r urine
specimens, and bleach is used as a recommended method for cleaning surfaces expo
sed to blood and
other potentially infectious materials. Both acidic and alkaline substances can
cause severe
burns, and mixing various chemicals may have dis- astrous effects. To protect th
e employees using
these chemicals, OSHA created the Hazard Communication Standard. This standard g

ives all
employees the right to know about the potential hazards associated with the chem
icals in their
workplace. The required components addressed in this standard include the follow
ing: A hazard
communication program to be developed and used within the facility Current inven
tory of all
hazardous chemicals used in the workplace 48 Section I Overview of the Laborato
ry Test Your
Knowledge 3-15 What type of personal protective equipment should be worn when a
medical assistant
is performing a routine blood draw? (Outcome 3-9) POINT OF INTEREST 3-1 Bloodbor
ne facts The U.S.
Department of Labor, Occupational Safety, and Health Administration (OSHA) has p
ublished a series
of fact sheets that cover various aspects of the Bloodborne Pathogens Standard.
This standard may
be difficult to understand and therefore compliance may be complicated. These fa
ct sheets are
excellent tools for offices that are struggling to develop their plans appropria
tely or for
anyone who is trying to update knowledge of the subject. They cover many subject
s, in- cluding
the hepatitis B virus, vaccine, and postexposure follow-up, and proper use of pe
rsonal protective
equip- ment. Single copies may be obtained by contacting the OSHA Publications O
ffice, Room
N-3101, 200 Constitution Avenue, NW, Washington, DC 20210. Figure 3-3 Medical as
sistant wearing
OSHA-approved laboratory coat, appropriate face protection, and gloves. 1899_Ch0
3_035-062
26/12/11 3:05 PM Page 48 Appropriate labeling of those chemicals designated as h
azardous
Material Safety Data Sheets Documented training for employees The Hazard Communi
cation Standard
establishes comprehensive guidelines for labeling chemicals. These guidelines in
clude the name of
the chemical; contact information for the manufacturer; physical and health haza
rds of the
chemical; safety precautions; and infor- mation pertaining to the storage, handl
ing, and disposal of the chemical. The original container, as well as any transfer container
s for the same
chemical must be labeled in this manner. A Material Safety Data Sheet (MSDS) mus
t also be
available for every hazardous chemical in use. This is a document provided by th
e manufacturer
that provide even more details about the chemical than those printed on the labe
l. A current MSDS
must be kept on file for any chemical in use that is considered potentially haza
rdous, and these
sheets must be accessible to employees at all times (Fig. 3-4). The standard req
uires that the
following information be provided on all Material Safety Data Sheets: Identifica
tion: Must
include the generic and brand name, as well as the name, address, and emergency
phone number for
the manufacturer, and the date the MSDS was prepared. Composition of ingredients
: List of the
ingredients, and how much of the chemical is considered to be safe for exposure.

 Physical and
chemical properties: Includes items such as appearance, odor, boiling point, spe
cific grav- ity,
pH, etc. The last required component of the Hazard Commu- nication Standard is e
mployee training.
All employees who might be exposed to hazardous chemicals at work must be provid
ed information
about the chemicals and their potential hazards prior to the beginning of their
employment in the
area where the chemicals are used, and again whenever the hazard may change with
the ad- dition
of new chemicals or new duties. There must be documentation of each training ses
sion, and the
educa- tion must be continuous; not only offered at the time of initial employme
nt. There must
also be assurance that the employee understood the information presented. The re
quired training
elements include the following: A general overview of the right to know standard
, explaining
all the components involved, where to find the inventory of hazardous chemicals
in use, and where
the written hazard communication pro- gram is kept for that facility Fire and ex
plosion data:
Will this chemical catch fire or explode if used incorrectly? If so, how should
you extinguish
the fire? Reactivity data: How does this chemical react with other chemicals? Wh
at types of
interactions should be avoided? Health hazards: Includes information such as the
route of
entry, signs and symptoms to be aware of in case of overexposure, medical condit
ions that might
be wors- ened when this chemical is used, and acute or chronic health hazards th
at may develop
with regular exposure to the chemical. This section of the MSDS is very im- port
ant to the
health-care professional who uses this chemical as part of his or her daily task
s. There is also
information presented about the carcinogenic (cancer- causing potential) classif
ication of the
chemical. Emergency first-aid procedures: What should you do if overexposure occ
urs as a first
aid measure while help is on the way? Precautions for safe handling and use of t
he chem- ical:
Includes instructions for handling a chemical spill, how to store the chemical,
and how to
dispose of the chemical and or container. Control measures: Includes the persona
l protective
equipment and safety apparatus that should be used when dealing with the chemica
l. Chapter 3
Laboratory Safety and Preventing the Spread of Disease 49 Test Your Knowledge 316 Who is the
OSHA Hazard Communication Standard designed to protect? (Outcome 3-11) Test Your
Knowledge 3-17
The laboratory assistant who is working the evening shift notices that the labor
atory is almost
out of a dis- infectant that staff members use to clean some of the instruments.
He wants to be
sure that the supervisor orders the same product that is now in use. Where can h
e look to find
the name of the manufacturer to tell his supervisor? (Outcome 3-13) Test Your Kn

owledge 3-18 How

many required components must be present on a Material Safety Data Sheet? (Outco
me 3-12)
1899_Ch03_035-062 26/12/11 3:05 PM Page 49 An explanation of what an MSDS is, wh
ere it may be
found in the workplace, and how to use one Identification of the specific chemic
als used in the
work area for that employee, with instructions for the protective measures to be
employed,
including the per- sonal protective equipment that is appropriate for that speci
fic chemical
The meaning of the labels and symbols used on hazardous chemicals Emergency meas
ures to be
taken in case of a spill or exposure To ensure the safe use of chemicals, rememb
er always to wear
the appropriate personal protective equipment and safety equipment for the task
at hand. Also,
never use a chemical in a fashion other than that for which you were trained to
use it. Do not
transfer chemicals to un- labeled containers, and do not reuse containers that h
ave been used
previously. Remember that mixing chemicals may have disastrous effects; adding e
ven water to some
chemicals can be very dangerous. Finally, every employee should know the locatio
n of the eye wash
station and emergency shower in the vicinity of their work area. Physical Safety
As is the case
with any business, there is always the chance that things will go wrong in the l
aboratory. This
could include a chemical exposure, but it could also be a fire, an electrical em
ergency, or other
personal injuries. 50 Section I Overview of the Laboratory Figure 3-4 MSDS info
rmation sheet for
Clorox Bleach. Courtesy of Clorox. 1899_Ch03_035-062 26/12/11 3:05 PM Page 50 A
laboratory
professional needs to be aware of all hazards in the workplace, and also needs t
o be ready to
respond to emergencies appropriately. It is always essential for any business to
have a plan of
action in case of an emergency, but it is even more criti- cal for a health-care
facility such as
a laboratory. Employ- ees are not only responsible for themselves, but also for
the patients in
their presence at the time of the incident. Appropriate training and careful pla
nning may dictate
the difference between a positive or negative outcome of an emergency situation.
This includes
posting of emer- gency numbers (such as 911 or another internal number in a larg
e facility for
emergency response), maps showing the closest exit from various places within th
e building,
employee training on use of fire extinguishers, and haz- ard identification. The
National Fire
Protection Association (NFPA) has developed a labeling system that provides gene
ral information
to employees and rescuers about the health, flammability, or reactivity hazard o
f chemicals.
These categories are represented by blue, red, yellow, and white diamonds, each
containing a
number. The colors of the diamonds represent the different types of hazards, and

the number
contained within each diamond indi- cates the severity of the hazard. The blue d
iamond represents the respective health danger with exposure to the chemical. The red diam
ond indicates
flammability haz- ard, and the yellow diamond indicates the reactivity potential
for the chemical
if exposed to increased heat or other conditions. There is also a white diamond,
which may
include a special symbol, indicating whether a chemical is radioactive or reacts
with water (Fig.
3-5). Chapter 3 Laboratory Safety and Preventing the Spread of Disease 51 Figur
e 3-5 NFPA
chemical fire symbol. Test Your Knowledge 3-19 How do the NFPA fire labels prote
ct employees?
(Outcome 3-14) HEALTH HAZARD 4 - Deadly 3 - Extreme danger 2 - Hazardous 1 - Sli
ghtly hazardous 0
- Normal material FIRE HAZARD Flash Points: 4 - Below 73F 3 - Below 100F 2 - Above
100F, not
exceeding 200F 1 - Above 200F 0 - Will not burn REACTIVITY 4 - May detonate 3 - Sh
ock and heat
may detonate 2 - Violent chemical change 1 - Unstable if heated 0 - Stable SPECI
FIC HAZARD
Oxidizer Acid Alkali Corrosive Use NO WATER Radioactive OX ACID ALK CORR W Fire
Safety In order
to keep themselves and those around them as safe as possible, all employees shou
ld know the
proce- dures to follow in case of fire in their facility. Fire safety basics suc
h as Stop, Drop,
and Roll (in the case of clothing that has caught on fire) are likely familiar c
on- cepts.
However, when in the workplace, there are more aspects to consider: Where are th
e fire
extinguishers? How do I use them? What can I do if there is not one nearby? Wher
e is the nearest
exit? How do I call for help? These are all questions that should be answered in
initial
training, and the procedures should be reviewed on a regular basis. According to
the National
Fire Protection Associa- tion, there are four classifications used to describe f
ires, each of
which has its own type of fire extinguisher to be used. Multipurpose extinguishe
rs are also
available to use for Class A, B, or C fires. Class A: Class A fires involve comm
on household
ma- terials such as wood and paper. Water or a water-based 1899_Ch03_035-062 26/
12/11 3:05 PM
Page 51 solution is needed to put out this type of fire, and these are contained
in a Class A
extinguisher. Class B: Class B fires generally involve flammable liq- uids and/o
r vapors, and
they need to be smothered to be put out. The Class B extinguishers contain chemi
- cals, carbon
dioxide or foam. Class C: Class C fires are related to electrical equip- ment, s
o special care
must be used to extinguish them. If the solution used to extinguish the fire con
ducts
electricity, the fire will not be extinguished. The Class C extinguishers use ch
emicals or other
types of sub- stances that do not conduct electricity. Class D: Class D fires fr

equently lead
to explosions, as they occur with reactive metals such as sodium or potassium. T
hey are very
difficult to control, and there is not a fire extinguisher available in most sit
es to extinguish
this type of fire. Sand or other dry powder agents work best for this type of fi
re. Fast action
is critical when a fire is discovered to keep those in the workplace as safe as
possible. A
common acronym recommended to help those facing a fire remem- ber what to do is
RACE: Rescue,
Alarm, Confinement, Extinguish. Table 3-1 lists the letters and expands on the m
eaning. shock,
remember that you must stay safe in order to help those who have been injured. S
hut off the
source of the electricity immediately, if possible. Do not touch the victim if y
ou are unable to
shut off the source of the electricity. Call for emergency assistance immediatel
y. If the source
of electricity has been eliminated, evaluate the victim and begin cardiopulmonar
y resuscitation
(CPR) if necessary. Body Mechanics As a medical assistant working in a laborator
y environ- ment,
you may be performing numerous venipunctures each shift. These procedures often
require bending
over the patient sitting in the phlebotomy chair, or perhaps in a hospital setti
ng, bending over
the bed of a patient. This bending can cause a great deal of stress to the muscl
es of the back
and neck, resulting in pain. There are addi- tional duties in the laboratory tha
t may require
lifting or carrying equipment trays or supplies. A laboratory pro- fessional may
need to assist a
patient with transfer from a wheelchair to an examination table or other chair.
In all these
situations, it is important to keep your back as healthy as possible. Stretches
and regular
exercise help, as well as staying close to an ideal body weight. Remember to use
the muscles in
your legs when lifting heavy objects, and when carrying heavy objects keep them
close to your
body and avoid twisting motions. Change your position as often as possible; avoi
d sitting or
stand- ing for prolonged periods without a break. If patient transfer is part of
the duties for a
medical assistant in your work environment, appropriate techniques should be par
t of the initial
training for employees. Bloodborne Pathogen Safety Many of you who are reading t
his textbook have
never lived in a world without the presence of HIV and acquired immune deficienc
y syndrome
(AIDS). How- ever, it was not that long ago that these diseases were not yet kno
wn. Prior to
1980, there was not a lot of informa- tion available about potential bloodborne
pathogen exposure in health care. Hepatitis B (HBV) was discovered in 1967, but research on
the methods of
transmission were still in progress for many years. With the discovery of the HI
V in 1983, change
came quickly. It became evident that health-care workers needed to be protected

from the hazards

of working with blood and other potentially infectious materials. Studies perfor
med in the 1970s
showed that the rate of hepatitis B infec- tion for health-care workers was ten
times that of the
general population. A reliable vaccination was 52 Section I Overview of the Lab
oratory TABLE 3-1
RACE: The steps to take in the event of a fire R Rescue individuals in danger A
Activate the
alarm system C Confine the fire by closing windows and doors E Extinguish the fi
re using an
appropriate fire extinguisher Test Your Knowledge 3-20 What is designated by the
different
letters assigned to fire extinguishers? (Outcome 3-14) Electrical Safety We are
surrounded by
electrical equipment in the labo- ratory environment, so that fire and electrica
l shock are
definitely potential hazards. Most hazards can be minimized by appropriate maint
enance and
service of the equipment and the electrical outlets. The use of extension cords
and overloading
of electrical outlets should be avoided. Also, only qualified personnel should s
ervice electrical
equipment. In case of electrical 1899_Ch03_035-062 26/12/11 3:05 PM Page 52 crea
ted and released
to the general public in 1982, but compliance was voluntary, and many health-car
e workers had
already been exposed to the virus. After HIV was identified, data were gathered
to see how many
health-care workers were potentially infected as a result of occupational exposu
re, and although
the numbers related directly to exposure on the job were low, they were too high
to be ignored.
Bloodborne pathogen is a term used to describe any pathogenic microorganism foun
d in human blood
that can cause disease in humans. These diseases are spread through direct conta
ct with the
bloodstream of another individual. This means that there must be a piercing of t
he skin
(parenteral exposure), direct blood-to-blood contact as might occur when noninta
ct skin touches
the blood of another individual, or mucous membrane exposure, as occurs with sex
ual activity or
accidental splashes into the eyes or mouth. These diseases are not carried only
in the
bloodstream of the infected individ- ual. Other potentially infectious materials
include semen,
vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericard
ial fluid,
peritoneal fluid, amniotic fluid, saliva when dental procedures are being perfor
med, and all body
fluids that are visibly contami- nated with blood. If it is impossible to tell w
hich type of
fluid you may be working with, it is also to be assumed that it is a potentially
infectious
material. Tears, feces, urine, sputum, nasal secretions, sweat, and saliva (spit
) are not
considered to be infectious unless they are grossly contaminated with blood. Uni
versal
Precautions Bloodborne pathogen exposure in health care was first addressed by r

ecommendations
from the CDC in 1982, specifically referring to the information about the newly
identified HIV.
In 1985, the CDC published a recommendation to adopt Universal Precautions when
dealing with
blood or other potentially infectious materials. The concept of universal precau
tions recognized the fact that it was impossible to identify all patients who may be infect
ed with HIV or
other blood- borne pathogens by taking a health history and per- forming an exam
ination. The
recommendation was that all patients (and all specimens of an infectious nature)
were to be
considered infectious for HIV and other bloodborne pathogens, and the same preca
utions were to be
taken in all situations. Prior to this, gloves were not mandatory in health-care
settings, mouth
pipetting was still performed in the laboratory, and lab- oratory coats were not
required.
Special precautions were taken only if a specimen or patient was labeled as Bloo
dborne Pathogens
Standard In 1988, OSHA strengthened this recommendation of Universal Precautions
with the
publication of the Bloodborne Pathogens Standard (1910.1030). This standard prov
ided a rigorous
policy to protect health- care workers who had occupational exposure to blood or
other
potentially infectious materials in the work- place. This standard had special s
ignificance for
those who worked in a laboratory environment, because the amount of potential ex
posure was quite
high for this population. This regulation required that all employers with poten
tial occupational
exposure to bloodborne pathogens in their workplace develop an exposure con- tro
l plan. An
exposure control plan must include the following components: Exposure determinat
ion: The plan
requires that all employers determine which classifications of employ- ees have
risk of exposure,
and during what types of duties that the risk exists. Methods of exposure contro
l compliance:
Exposure control compliance means that all employees are to be taught how to pra
ctice universal
precautions by imple- menting appropriate personal protective equipment. It also
required that
the employer use and train the em- ployees to use engineering controls and work
practice controls
to minimize their risk of exposure. Engineer- ing controls are physical devices
(such as needle
safety devices or stationary safety shields) that are used by the employees to m
ake their
environment safer as they perform their duties. Work practice controls are ways
that employees
might alter the manner in which they perform a task to minimize the risk of bloo
dborne pathogen
exposure. These include rules banning eat- ing or drinking in an area where ther
e is potential
exposure, bandaging cuts before application of gloves, wearing gloves and other
PPE
appropriately, wearing close-toed shoes, and disposing of biohazardous waste and

contaminated
sharps correctly. Biohazardous waste is a classification used to describe substa
nces contaminated
with liquid or semiliquid blood or other potentially infectious materials. Conta
minated sharps
Chapter 3 Laboratory Safety and Preventing the Spread of Disease 53 infectious.
Currently, the
CDC standard precautions have expanded universal precautions to include all mean
s of infection.
Test Your Knowledge 3-21 What are some examples of OPIMs? (Outcome 3-16) 1899_Ch
03_035-062
26/12/11 3:05 PM Page 53 are needles or other materials capable of piercing the
skin that have
been used with blood or other poten- tially infectious materials. Hepatitis B va
ccination (or
documented declination of the vaccine by the employee) must be made avail- able
for all employees
with occupational risk of blood- borne pathogen exposure. Communication of hazar
ds to all
at-risk employees, which must occur initially upon assignment, and at least annu
ally. (Retraining
must also occur if there are changes to the procedures or hazards in a specific
area of the
facility.) Records for this training must be kept for at least 3 years. Initial
training must
include: Information about the epidemiology, signs, symp- toms, and methods of t
ransmission of
bloodborne pathogens. Instruction about the specific methods employed by that fa
cility (their
exposure control plan) to protect their employees, as well as general preventati
ve procedures.
Information about the hepatitis B vaccine An explanation of the procedure to fol
low for an
exposure incident safety devices, and no excuse not to use them. Keep in mind th
e following when
considering sharps safety: 1. Always make sure that employees are trained on the
appropriate use
of the needle safety device in use. Many of these devices are designed to be one
handed, and if
the employee tries to use two hands, he or she is at great risk for a puncture w
ith a contaminated needle. 2. Contaminated needles are never to be recapped with the origina
l needle cover,
bent, or broken off. They must be disposed of immediately after use. 3. A biohaz
ard sharps
container should always be within reach when drawing blood or giving injections
so that the
needle can be disposed of immediately. These containers must be rigid and punctu
re-proof, and
should be snapped closed and disposed of when they are three quarters full. 4. I
f contaminated
glassware is broken, use mechanical means to clean up the mess, and then dispose
of the glassware
in a biohazard sharps container. A small dis- posable broom and dustpan may be d
esignated for
this type of situation, or tweezers may be used to pick up the pieces of glass.
Thicker
industrial gloves that are puncture resistant may also be used. Clean the area w
ith an
appropriate disinfectant (10% bleach solution allowed to sit for 20 minutes) to

eliminate
potential bloodborne pathogen exposure. 5. When performing capillary blood draws
from the finger
or foot of a patient, always use a capillary puncture device that recoils into t
he original
holder. Do not try to reuse these devices. 6. Use plastic tubes and other contai
ners instead of
glass whenever possible. 54 Section I Overview of the Laboratory Test Your Know
ledge 3-24 Are
all needle safety devices operated in the same way? (Outcome 3-18) Test Your Kno
wledge 3-22 True
or False: The OSHA Bloodborne Pathogens Stan- dard was created to protect patien
ts. (Outcome
3-15) Test Your Knowledge 3-23 List two key components required in an exposure c
ontrol plan.
(Outcome 3-17) Appropriate Sharps Use and Disposal. Unfor- tunately, more health
-care
professionals are exposed to bloodborne pathogens by contaminated needles or oth
er sharp devices
than through any other route. This means that safety must be considered at all t
imes when using
and disposing of contaminated needles, glassware, or any other instruments that
have come into
contact with infectious materials. In 1999, there was an update to the Bloodborn
e Pathogens
Standard requiring that employ- ers constantly evaluate new safety equipment for
invasive
procedures to be certain that they are using the safest methods and products. Th
e addendum also
requires that employees who actually use the products on a daily basis have inpu
t as to which
product is most efficient and eas- iest to use before the choices are made for w
hich item to
purchase. There are many choices available for needle Regulated Waste and Housek
eeping. In a
health-care setting, there is a need to sort the waste generated by the facility
. Some of the
waste may be dis- posed of in the same way as household trash. Other waste is re
gulated, and
requires special attention for disposal. The OSHA definition of regulated waste
is quite long.
Essentially, the term refers to any liquid blood or other potentially infectious
materials. It
also refers to contaminated items that are soaked with blood to the extent that
the blood could
be released if the item were compressed, or items caked with blood so 1899_Ch03_
035-062 26/12/11
3:05 PM Page 54 that the blood could be released if the item were han- dled. Reg
ulated waste also
refers to contaminated sharps and any other microbiological wastes that may cont
ain blood or
OPIM. Regulated waste must be disposed of in containers that are clearly identif
iable as
biohazardous. The containers (or bags) must either be red or must be marked with
a bio- hazard
symbol (Fig. 3-6). When using bags to collect reg- ulated waste other than sharp
s, care should be
taken to avoid adding items to the bag that are not biohazardous in nature. All
bags must be
closed securely when full, to be enclosed in larger containers for disposal by a

regulated waste
facility. All sharps containers will also be picked up by regulated waste facili
ties for
disposal. Only companies that are licensed to carry biohazardous waste are allow
ed to transport
and incinerate this type of refuse. Other housekeeping guidelines in the laborat
ory include
disinfection of counters at the beginning and end of each shift (at a minimum) w
ith a fresh 10%
bleach solution or an OSHA-approved disinfectant that is designed to kill the he
patitis B virus
and HIV. Also, remember all biohazardous spills must be cleaned up using a spill
kit that is
designed for this purpose. Hepatitis Any discussion of bloodborne pathogens usua
lly in- cludes
the topic of hepatitis. Essentially, hepatitis means inflammation of the liver. Wh
en we discuss
hepatitis in relation to bloodborne pathogens, we are referring to hepatitis tha
t is caused by a
viral infection. There are numerous types of the hepatitis virus that have been
isolated, and not
all of them are bloodborne. The ones that we are most concerned with are hepatitis B and
hepatitis C, as these viruses are bloodborne pathogens, and they can cause serio
us illness. Table
3-2 lists details about the different types of hepatitis and other bloodborne pa
thogens.
Hepatitis B Virus (HBV) Hepatitis B was first identified as a unique virus in 19
67. It was
formerly known as serum hepatitis, because there was a high prevalence of infect
ion with the
hemophiliac population who had received blood products as part of their treatmen
t. The hepatitis
B virus targets the liver, and it is the most serious hazard facing those in the
health-care
industry. HBV may be present in the blood and other potentially infective fluids
of the body.
Unfor- tunately, it may survive on surfaces in dried blood for up to 1 week. Hep
atitis B may be
transmitted in a health- care setting through needlesticks or other contaminated
sharps, by
contact with contaminated surfaces, or through mucous membrane exposure with aer
osols or
splatters created while handling infectious specimens. For those not employed in
health care,
transmission usu- ally is the result of sharing contaminated needles, or through
sexual contact.
Hepatitis B causes flu-like symptoms, and the affected patient may appear jaundi
ced. The symptoms
of infection often do not appear until months after the virus has entered the bo
dy. Most of those
who are infected recover, but approximately 2% of those infected will develop ch
ronic infection,
which causes cirrhosis of the liver or cancer. There are also patients that may
be carriers of
the hepatitis B virus who do not know it. These patients often have had no defin
itive symptoms of
the infection, but they are capable of passing it on to others. Fortunately, a s
eries of
vaccinations may prevent hepatitis B infection. OSHA requires that these vaccina

tions be offered
free of charge to all employees who have bloodborne pathogen exposure in the wor
kplace. There is
also a newly discovered form of hepatitis virus that affects only those who are
already hepatitis
B positive. This appears to be a mutant or variant form of HBV, but it is unique
enough to be
identified as its own Chapter 3 Laboratory Safety and Preventing the Spread of
Disease 55 Test
Your Knowledge 3-25 Is all laboratory waste considered to be biohazardous? (Outc
ome 3-19)
BIOHAZARD Figure 3-6 Biohazard symbol. DISEASES CAUSED BY BLOODBORNE PATHOGENS I
N THE LABORATORY
SETTING The OSHA Bloodborne Pathogens Standard is very comprehensive, and is des
igned to protect
employees who work with blood and other potentially infective body fluids. But w
hat exactly are
the employees being protected from, and how serious are the diseases? 1899_Ch03_
035-062 26/12/11
3:05 PM Page 55 5 6 S e c t i o n
I
O v e r v i e w
o f
t h e
L a b o r a t o r y TABLE 3-2 Comparison chart for various types of vira
l hepatitis and HIV
Method of Symptoms? Long-term Effects? Vaccination or Comments Transmission Prev
ention Hepatitis
A Hepatitis B Hepatitis C HIV Vaccinations avail- able; appropriate personal hyg
iene will
eliminate trans- mission in many situations Vaccinations avail- able; also avoid
ance of high-risk
activities No vaccination available No vaccination avail- able; avoidance of hig
h-risk activities
is essential May spread even in situations with appro- priate personal hygiene i
f drinking water
becomes contaminated Greatest bloodborne pathogen risk for health-care workers d
ue to nature of
the virus Not usually. Symp- toms usually resolve within months A small percenta
ge become
chronically infected; leads to cirrhosis and death Many infected individuals dev
elop chronic
infection; slowly causing permanent liver damage Infection is fatal when the pat
ient develops
AIDS Vomiting, abdominal pain, jaundice, flu-like symptoms Symptoms often delaye
d after initial
infection; include abdominal pain, vomiting, jaundice May be asympto- matic; if
symptoms present,
less obvious than HBV infection and also delayed after initial infection Initial
infection may
produce flu-like symptoms; as dis- ease progresses, symptoms change Fecal-oral r
oute, contaminated food/ water. Not blood- borne Bloodborne Bloodborne Bloodborne 1 8 9 9
_ C h 0 3 _ 0 3

5 - 0 6 2
2 6
/
1 2
/
1 1
3
:
0 5
P M
P a g e
5 6 virus. This is known as hepatitis D. There currently is no vaccinati
on available for
hepatitis D. Hepatitis C Virus (HCV) You may have heard of hepatitis C (HCV) as
the new
epidemic disease of the world. This statement is mis- leading. Although there are
millions of
cases of hepatitis C infection that have been diagnosed over the past decade, th
ese patients did
not necessarily have a recent infection. Hepatitis C infection is usually asympt
omatic, so most
of those who are now being diagnosed with the disease were actually infected mor
e than a decade
ago. For many years researchers knew that there was another form of hepatitis vi
rus that was
different from both HBV and HAV. They just couldnt isolate it as a unique strain
of the virus.
In 1989, technology finally allowed the hepatitis C virus to be identified as an
other cause of
post- transfusion hepatitis. The hepatitis C virus is a blood- borne pathogen, a
nd many of those
who are diagnosed today shared dirty needles for drug use, received blood transf
usions or other
blood products, or had tattoos applied prior to the mid-1980s. If there are any
symp- toms of the
HCV infection, they are usually milder than those of hepatitis B, so are often m
isread as being
symp- toms of the flu. Unlike hepatitis B, in which it is uncom- mon to advance
to the chronic
form of the disease, those with hepatitis C infection usually progress to the ch
ronic stage
(approximately 80% to 85% of patients). Of these, a small percentage develop per
manent liver
damage and/or liver failure. Transmission of the hepatitis C virus in a health-c
are setting
usually requires a larger accidental exposure than would be necessary to transmi
t HBV. There is
no vaccination for HCV. Hepatitis A Virus (HAV) Although the hepatitis A (HAV) v
irus is not a
blood- borne pathogen, it is important to understand how it is transmitted. HAV
attacks the liver
of infected patients and causes inflammation just like the other forms of viral

infections that
we have discussed. The hepatitis A virus is very contagious, and is transmitted
by the fecaloral route. The virus is shed in the feces of infected individuals, often before
they even know
they are in- fected. The fecal material containing the virus can then be passed
on to others
through direct contact (such as touching another individual) or indirect contact
through food,
water, or inanimate objects. Patients with HAV usually show symptoms sooner than
those with HBV
or HCV, and are often initially more severely ill. However, the hepatitis A viru
s rarely
progresses to cause chronic infection or permanent liver damage. There is a seri
es of
vaccinations available to protect against hepati- tis A infection. Chapter 3 La
boratory Safety
and Preventing the Spread of Disease 57 Human Immunodeficiency Virus The human i
mmunodeficiency
virus (HIV) attacks the immune system of our bodies. The HIV infection may event
ually lead to
AIDS. Viruses need the genetic in- formation in our cells to survive and replica
te, and HIV is no
different. It attacks a type of white blood cells in our body known as CD4 cells
. This type of
blood cell fights infection in our bodies. Those infected with HIV are susceptib
le to
opportunistic infections. These infections are caused by microorganisms that wou
ld not normally
infect individuals who have healthy immune systems. HIV infection also makes the
infected
patients more prone to develop certain types of cancer. When patients are infect
ed with HIV, they
undergo several stages. Initially, they may have swollen glands, or they might h
ave slight
flu-like symptoms. This generally lasts from weeks to months. Also, initially, b
ecause the amount
of virus particles in the infected patients body is still low, an HIV test result
would be
negative. HIV tests are designed to detect antibodies to the virus, and in the e
arly stages of
infection, the level of antibodies in an in- dividual are not high enough for de
tection. The
patient is still capable of passing on HIV during this time Test Your Knowledge
3-26 Are all
forms of hepatitis considered to be bloodborne pathogens? (Outcome 3-20) POINT O
F INTEREST 3-2
Pathogenic microorganisms In most situations, the discussion of bloodborne patho
gens focuses on
hepatitis B, HIV, and hepati- tis C. However, the OSHA Bloodborne Pathogens Stan
dard is not only
designed to protect employees from infection with these viruses. The standard ac
tually includes
any pathogenic microorganisms that may be present in blood or other potentially
infectious
materials. Examples of other diseases that may be transmitted by direct contact
with blood of
infected individuals include malaria, syphilis, babesiosis, brucellosis, leptosp
orosis,
Creutzfeldt- Jakob disease, and viral hemorrhagic fever. 1899_Ch03_035-062 26/12

/11 3:05 PM Page

57 through blood-to-blood contact or sexual activity. This is known as the windo
w period of
infection, and may last up to 6 months. The second stage of infection is general
ly asymptomatic. The infected patient may still not know that he or she is HIV positive. T
his stage can
last for months or even years. When patients reach the third stage, they often c
on- tract one or
more opportunistic infections. This can be the first time many patients find out
that they are
HIV positive. Their symptoms will vary, depending on the infection that they are
experiencing.
The final stage of HIV infection is what we know as AIDS. At this stage, the HIV
-positive patient
has been diagnosed with an opportunistic infection or disease that has been clas
sified by the CDC
as an AIDS indi- cator. These diseases include esophageal thrush, cytomegaloviru
s infection, a
type of cancer known as Kaposis sarcoma, and invasive cervical cancer in the HIVpositive
patient. An AIDS diagnosis may be made based on the number of CD4 cells present
in a blood sample
as well. Remember, HIV infection causes AIDS, but an infected patient does not h
ave AIDS until he
or she reaches this final stage and contracts one of the indicator diseases, or
is diagnosed with
AIDS because of the blood count. For many infected individuals worldwide, HIV in
- fection is
fatal. The treatment regime has changed sig- nificantly in the past 25 years, an
d more
HIV-positive patients than ever before are able to live long lives with- out acq
uiring AIDS.
Fortunately, HIV is not a very hearty virus; it dies immediately when it comes i
nto contact with
air, and the amount of virus necessary for an infection to occur from an acciden
tal exposure has
to be quite high. Hepatitis B infection is a much more se- rious risk from accid
ental health-care
worker occupa- tional exposure than HIV infection. Phlebotomy proce- dures are m
ost often
responsible for HIV exposure that occurs in a health-care setting. As of 2000, t
he CDC had
processed 56 claims in which it appeared that a health-care professional had con
tracted HIV from
an accidental exposure. At this time, there is no vaccination for the human immu
nodeficiency
virus, and accidental infection is battled with rapid administration of antiviral medications.
POSTEXPOSURE FOLLOW-UP PROCEDURE You have taken all the appropriate precautions,
read all the
training manuals, worn all the right personal protec- tive equipment . . . but y
our patient jerks
his arm right at the end of the phlebotomy procedure, and you are punctured by a
contaminated
needle. Now what? The Bloodborne Pathogens Standard carefully spells out what ty
pe of follow-up
care employers must offer to their employees (free of charge) if there is an acc
idental exposure to blood or other potentially infectious materials in the workplace. Rememb

er, an exposure
can be percuta- neous (through the skin) as in the scenario above, but it may al
so be a mucous
membrane exposure through a splash in the eyes or in the mouth. Here are the ste
ps to follow if
there is an accidental exposure: 1. Wash the site thoroughly with soap and water
. If it is a
mucous membrane exposure, thoroughly flush the exposed area with water. 2. The i
ncident must be
reported immediately to the ap- propriate manager or other contact person within
your health-care
facility. Many of the antiviral medications used for treatment after an exposure
should be
started within a few hours, so an immediate report is critical. 3. Fill out an i
ncident report
form. The route of expo- sure and the circumstances surrounding the incident are
very important
and are required by law. 4. Identification of the source individual needs to be
determined as
soon as possible. Consent should be obtained for the source individual to be tes
ted for HBV, HCV,
and HIV, unless his or her status is already known for these diseases. If the in
dividual refuses
to consent for the test, the employer must document that a refusal was made. If
allowed by local
law, the test will be performed regardless, so that the employee can be treated
effectively. The
results of these tests will be made available to the exposed employee. A blood s
ample will also
need to be obtained from the exposed employee to test for a baseline level for H
BV, HCV, and HIV.
5. The exposed employee will have the opportunity to seek medical attention as s
oon as possible
after the initial report has been completed. Postexposure pro- phylaxis is most
effective if
initiated rapidly after the exposure. This means that preventive medication (suc
h as antiviral
medicine) should be administered within hours of exposure. The health-care profe
s- sional
providing the follow-up care will be provided with information about how the acc
ident happened,
any laboratory testing results that might be available, 58 Section I Overview o
f the Laboratory
Test Your Knowledge 3-27 What are two characteristics that hepatitis B and HIV h
ave in common?
(Outcome 3-20) 1899_Ch03_035-062 26/12/11 3:05 PM Page 58 and all medical record
s for the
employee that might be relevant (such as vaccination records). The health- care
professional also
must be provided a copy of the Bloodborne Pathogens Standard. 6. The health-care
professional
performing the follow-up care will determine whether postexposure prophylaxis is
necessary for
HBV, HCV, or HIV, depending on the risk evaluation. The route and amount of expo
sure, the
vaccination status of the employee, and the circum- stances of the exposure will
be taken into
consideration. The treatment for the employee often consists of a combination of
drugs for an
extended period of time. 7. Follow-up blood tests are generally performed on the

exposed
employee, at a minimum interval of 6 weeks, 12 weeks, and 6 months. It is possib
le that this
series may be extended up to 12 months. 8. The exposed employee also must be off
ered counsel- ing
and reminded that confidentiality must be retained in reference to the source in
dividual. All
medical follow-up for the employee is also retained confidentially. from chemica
ls in the
workplace, and the Blood- borne Pathogens Standard educates health-care employee
s about the risks
they face from blood- borne pathogens as they perform their duties. Med- ical as
sistants must be
familiar with the details contained in these documents to use safety materials i
n their workplace
and to be prepared for accidents when they happen. TIME TO REVIEW 1. A bacteria
that is aerobic
needs Outcome 3-1 _____________ to survive and replicate: a. Nitrogen b. Oxygen
c. Carbon dioxide
d. Water 2. True or False: A substance that Outcome 3-1 produces or causes cance
r is
carcinogenic. 3. The types of microorganisms listed Outcome 3-2 in this chapter
that may be human
pathogens include: a. Protons, neutrons, and electrons b. Bacteria, viruses, and
parasites c.
Bacteria, viruses, fungi, and parasites d. None of the above 4. True or False: M
ost of the types
of Outcome 3-3 bacteria present in our environment are pathogenic. 5. True or Fa
lse: The presence
of Outcome 3-3 bacteria anywhere in our bodies is always an infection. 6. A roun
d-shaped bacteria
that appears Outcome 3-4 in pairs when viewed under the microscope is known as a
: a. Cocci b.
Spirilla c. Bacilli d. Diplococci 7. Which type of infection is best treated Out
come 3-5 by
antibiotic use? a. Viral b. Bacterial c. Viral and bacterial d. None of the abov
e Chapter 3
Laboratory Safety and Preventing the Spread of Disease 59 SUMMARY The world we l
ive in is a
complex place, with new health hazards constantly emerging. As health- care work
ers, we must
protect ourselves from poten- tial pathogens in our environment, our patients, a
nd our workplace.
There are several government regula- tions that have been designed to protect em
ployees in a
health-care or laboratory environment. Educa- tion concerning these regulations,
and careful
adher- ence to their principles, are essential steps to working safely in this u
nique
environment. Standard Precau- tions have been developed to assist with infection
control efforts.
The Hazard Communications Stan- dard establishes guidelines to protect employees
Test Your
Knowledge 3-28 What should happen immediately if an employee splashes blood in h
er eyes? (Outcome
3-21) Test Your Knowledge 3-29 True or False: All employees who are victims of a
blood- borne
pathogen exposure will be sent to see a health- care provider for follow-up care
. (Outcome 3-21)
1899_Ch03_035-062 26/12/11 3:05 PM Page 59 8. True or False: In a medically asep

tic Outcome 3-6

environment, bacteria may still be present on surfaces. 9. How does the chain of
infection
Outcome 3-7 have to be broken to keep a pathogen from causing disease? a. It mus
t be broken at
multiple points to keep the pathogen from causing disease b. Only vaccinations w
ill break the
chain of infection c. The chain of infection must only be broken at one point to
discontinue the
spread of infection d. The pathogen must be killed before the chain will be brok
en 10. What are
the elements addressed in Outcome 3-8 CDC Standard Precautions document? a. Appr
opriate use of
personal protective equipment b. Equipment disinfection procedures c. Respirator
y hygiene d.
Sharps use e. All of the above 11. True or False: Hand washing is Outcome 3-9 de
signed to remove
the normal (resident) flora from our skin. 12. When using an alcohol-based hand
Outcome 3-10 rub
to disinfect the hands, it is important to: a. Put on gloves while hands are sti
ll damp b. Rub
the solution thoroughly on all parts of the hands and wrists c. Use only a drop
of the solution
d. Always wash the hands first before using 13. The OSHA Hazard Communications O
utcome 3-11
Standard addresses: a. The use of personal protective equipment b. The formal ed
ucation required
by everyone in the laboratory before they can be hired to per- form certain test
s c. What type of
fire extinguisher to use for various types of fires d. The brand of hand sanitiz
er endorsed by
the fed- eral government 14. Which of the following components Outcome 3-12 are
required for any
Material Safety Data Sheet? a. Identification of the chemical b. Color of the ch
emical c. Health
hazards d. a and c e. All of the above 15. True or False: Laboratory employees O
utcome 3-14 may
protect themselves from occupational back injuries by using appropriate bending
techniques when
lifting heavy objects. 16. Why was the OSHA Bloodborne Outcome 3-15 Pathogens St
andard created?
a. To protect employers from lawsuits b. To create a revenue source for OSHA c.
To educate and
protect employees from the hazards of bloodborne pathogens d. To protect patient
s from bloodborne
pathogens 17. What is an example of parenteral Outcome 3-16 or percutaneous bloo
dborne pathogen
exposure? a. A respiratory infection contracted when working with a patient with
pneumonia b.
Touching a patients blood with a bare hand with unbroken skin c. An accidental ne
edlestick with
a needle contam- inated with the blood of a patient d. Splashing urine on the ar
m while pouring a
specimen 18. True or False: The OSHA Blood- Outcome 3-17 borne Pathogens Standar
d requires the
development of an exposure control plan. Part of this plan requires that all emp
loyees who have
occupational exposure to blood or other potentially infectious materials are off
ered an
opportunity to receive a series of hepatitis C vaccinations at no charge. 19. Tr

ue or False: When
using a needle Outcome 3-18 to draw blood, it is okay to lay it down on the tabl
e next to the
drawing chair right after the blood draw, and come back later to activate the sa
fety device and
dispose of it correctly. 20. Who must transport biohazardous Outcome 3-19 waste?
a. Employees of
the laboratory that have been appropriately trained b. The local municipal garba
ge disposal
company c. A certified, licensed biohazardous waste disposal company d. None of
the above 60
Section I Overview of the Laboratory 1899_Ch03_035-062 26/12/11 3:05 PM Page 60
21. What do
hepatitis A, hepatitis B, Outcome 3-20 hepatitis C, and HIV all have in common?
a. They are all
caused by viruses b. They are all caused by bacteria c. They all have vaccinatio
ns to prevent
infection d. None of them have vaccinations to prevent infection. 22. Are blood
tests part of the
follow-up Outcome 3-21 procedure for health-care workers who are are percutaneou
sly exposed to
blood in the workplace? RESOURCES AND SUGGESTED READINGS OSHA Hazard Communicati
on Standard OSHA
regulation for chemical safety in the workplace http://www.osha.gov/SLTC/hazardc
ommunications/
standards.html Small Business Handbook General reference tool to verify that the
OSHA Standards
are in place properly at your worksite http://www.osha.gov/
Publications/smallbusiness/small-business.html#hazsub/ National Fire Protection
Association
National Fire Protection Association website that includes information about fir
e, electrical,
and building safety http://www.nfpa.org Updated directives for OSHA Bloodborne P
athogens
Standards, 1991 Additional information added to the OSHA Bloodborne Pathogens St
andards in 1991
1910.1030- 29CFR http:// www.osha.gov/pls/oshaweb/owadisp.show_document?p_tab
le=standards&p_id=10051 Viral Hepatitis Excellent information about the different
forms of
viral hepati- tis presented by the Centers for Disease Control and Prevention
http://www.cdc.gov/hepatitis/index.htm Hepatitis B Foundation, Meet Dr. Blumberg F
acts
concerning the discovery of hepatitis B, and Dr. Blumberg who was awarded a Nobe
l Prize in 1976
for this discovery http://www.hepb.org/about/blumberg.htm Chapter 3 Laboratory
Safety and
Preventing the Spread of Disease 61 Case Study 3-1: Too tired to think Jackie wa
s really tired.
She had been up all night with her 3-year-old daughter who had an ear infection.
When she
reported to her job at the GI clinic the next morning, she was relieved to find
out that she
would be working in the laboratory, as this meant that she would be on her feet
a bit less than
if she were working as the MA for one of the physicians. It was Friday, which wa
s usually a slow
day in the laboratory. In the middle of the morning, Jackie had drawn three glas
s red-top blood
tubes from Mr. Sifton. She was fighting back a yawn, and when she turned around
to put the blood

in the rack on the counter, she accidentally tapped one of the tubes against the
edge of the
counter with a great deal of force. The tube flew from her hand and broke agains
t the
refrigerator a few feet away. Jackie was flustered. Mr. Sifton had already left,
and she knew
that she would have to call him and ask him to return for another blood draw. In
addition, she
had quite a mess to clean up, as the blood had splattered a great deal. She knew
that the bloody
mess had to take precedence, because other patients would be entering the labora
tory at any time.
Jackie was already wearing her nitrile gloves, so she bent down and started to p
ick up the pieces
of the tube that had broken. Suddenly she felt a sharp pain in her finger, and r
ealized that she
had punctured her glove and her finger with a slice of glass. 1. What are two th
ings that could
have been done to avoid the parenteral exposure to the patients blood? 2. What is
the first
thing that Jackie should do now? What else needs to happen as soon as possible?
1899_Ch03_035-062
26/12/11 3:05 PM Page 61 1899_Ch03_035-062 26/12/11 3:05 PM Page 62 63 Chapter 4
Assuring Quality
Constance L. Lieseke, CMA (AAMA), MLT, PBT(ASCP) CHAPTER OUTLINE Assuring Qualit
y in the
Laboratory Quality Control and Quality Assurance What Is Quality? The Medical As
sistants Role in
Assuring Quality Results Types of Quality Control Specimens What Happens When Th
ings Are Out of
Control? Documentation of Quality Control Results Accuracy and Precision Other Me
thods of
Assuring Laboratory Quality Summary Time to Review Case Study Resources and Sugg
ested Readings
Learning Outcomes After reading this chapter, the successful student will be abl
e to: 4-1 Define
each of the key terms. 4-2 Compare and contrast quality assurance and quality co
ntrol. 4-3
Explain why quality is essential for laboratory testing. 4-4 Describe circumstan
ces when a
medical assistant may need to perform quality control testing in the laboratory.
4-5 Classify the
types of quality control specimens used in the laboratory. 4-6 Explain the conce
pt of
troubleshooting and list various actions that may be taken when quality control
samples are not
in range. 4-7 Demonstrate the ability to correctly log quality control results w
ith appropriate
documentation techniques. 4-8 Provide examples of the ways that quality may be a
ssured with
laboratory testing procedures. CAAHEP/ABHES STANDARDS CAAHEP 2008 Standards I.P.
I.11. Perform
quality control procedures I.A.I.2. Distinguish between normal and abnormal test
results
II.C.II.7. Analyze charts, graphs and/or tables in the interpretation of healthc
are results
II.P.II.2. Maintain laboratory test results using flow sheets ABHES Standards Me
dical Laboratory
Procedures 10.a: Quality Control, and Graduates: a. Practice Quality Control 189
9_Ch04_063-082

21/12/11 2:19 PM Page 63 ASSURING QUALITY IN THE LABORATORY Laboratory results a

re extremely
important to patient diagnosis and treatment. However, the results reported back
to the physician
are only as good as the testing methods themselves. This chapter explains variou
s ways that the
quality of the testing process can be monitored, so that the patient results rep
orted will be
correct. Quality control (QC) and quality assurance (QA) will be covered in deta
il, as well as
documentation techniques and troubleshooting. Other procedures that are part of
overall test
quality assessment will be explored, such as proficiency testing and competency
assessments, and
the rules for quality performance of CLIA-waived tests will be reviewed. QUALITY
CONTROL AND
QUALITY ASSURANCE The terms quality assurance and quality control seem so simila
r; you may be
wondering why it is important to know the difference. Essentially, they are both
part of a plan
to provide excellent quality care to the patients we serve. Quality control is p
art of the
quality assurance process, but with a more specific focus. Try to remember the l
ast time you
visited a health- care provider or laboratory to have your blood drawn and teste
d. How was your
experience? Did you receive the information you needed to prepare for the blood
draw
appropriately? Did you feel that the person who drew your blood was trained adeq
uately? How
confident were you that the testing process was done in a way that accurate and
valid results
were obtained and reported back to your physician? Did your physician contact yo
u in a timely
manner with your results? These impressions, even though they were very personal
to you, are all
part of a quality assurance program at that facility. Quality assurance (QA) inc
ludes all the
policies and procedures necessary to provide excellent quality in laboratory tes
ting. Chapter 1,
introduced the three parts of laboratory testing: preanalytical, analytical, and
postanalytical
processes. A good quality assurance program acknowledges every part of the testi
ng process to
ensure that the laboratory staff members are doing all they can to contribute po
sitively to the
welfare of the patient in a timely manner. Quality assurance may be thought of a
s the big picture
and it may include policies and procedures for collection, patient educa- tion,
training for
those performing the testing, mainte- nance and record keeping of instruments, m
onitoring of
ordering and storage procedures for testing kits or reagents, and monitoring of
turnaround times
for results to be available to the health-care provider. Box 4-1 shows more deta
iled components
of a quality assurance plan. Quality control (QC) practices are used in the labo
- ratory to
ensure the quality of the testing process and the accuracy and precision of the
results. Although

the focus of quality control is specifically on the testing process, these pract
ices are not
limited to the details of how the test was performed. A good quality control pro
gram in- cludes
appropriate employee training, documentation of storage and shipping of reagents
or testing kits
used for testing, adherence to the manufacturers instructions, correct interpreta
tion and
documentation of results, and verification that the results being reported are a
ccurate and
reliable. Quality control focuses on the second part 64 Section I Overview of t
he Laboratory KEY
TERMS Accuracy Analyte Calibration Calibration verification Clinical significanc
e Competency
testing Critical results Electronic quality control devices External quality con
trol specimens
Internal quality control indicators Mean Oncologist Panic results Precision Prof
iciency testing
Qualitative results Quality assurance (QA) Quality control (QC) Quantitative res
ults Reference
ranges Shift Trends Troubleshooting Valid 1899_Ch04_063-082 21/12/11 2:19 PM Pag
e 64 WHAT IS
QUALITY? The laboratory environment is no different from that of any other busin
ess. Customers
are essential to the survival of the laboratory, and the testing provided is a s
ervice that the
customers need. Who are the cus- tomers? This is not quite as easy to answer as
it might seem at
first. The laboratory serves patients; that is pretty clear. The patients may be
varied in age,
socioe- conomic class, race, and gender, but laboratory results are a critical p
art of their
care. However, the laboratory can serve the patients only if the quality of the
labora- tory
performance meets the expectations of the health- care provider who sends the pa
tient (or the
specimens from the patient) to a specific laboratory for testing. Therefore, the
health-care
providers are also laboratory customers. The performance of the laboratory must
be of very high
quality to serve both of these types of customers efficiently. Consider this sce
nario: A new
oncologist opens a practice in your commu- nity. He specializes in providing car
e to patients
with cancer, and is very concerned that the laboratory Chapter 4 Assuring Quali
ty 65 BOX 4-1 QA
processes Preanalytical Phase Requisition appropriately filled out Patient prepa
ration Patient
identification Sample identification; three identifiers must be used Correct sam
ple collection
techniques; venipuncture performed correctly, etc. Correct storage and transport
ation of sample
Correct storage of testing kits and quality control materials Appropriate traini
ng of personnel
Preparation of standard operating procedures and policy manuals for reference Re
tention of
current package inserts for correct instructions Analytical Phase Valid test kit
; not expired and
stored correctly Instrument properly maintained and calibrated Proper mixing/pre
paration of

quality control samples Proper mixing/preparation of patient samples Following m

anufacturer
instructions exactly as written for CLIA-waived tests Proper documentation of qu
ality control
results; verifica- tion of acceptable QC values before patient sample is analyze
d Order/perform
confirmatory tests as recommended by manufacturer Postanalytical Phase Appropria
te documentation
of patient results Appropriate units reported with test results Results transmit
ted to
health-care provider in timely manner All critical results called immediately In
clude correct
reference ranges with laboratory results Report all test results to authorities
as required by
law Properly dispose of used testing materials of the laboratory testing process
: the analytical
phase. Anything that relates directly to the testing process may be part of qual
ity control.
Table 4-1 shows how quality assurance and quality control compare to one another
. Test Your
Knowledge 4-1 List two ways that quality assurance and quality control are alike
. (Outcome 4-2)
TABLE 4-1 Quality assurance versus quality control Quality Assurance Quality Con
trol Addresses
procedures in all phases of laboratory process; includes quality control Compreh
ensive plan
including patients, employees, and employers Plan developed by the employer and
the quality
assurance officer Requires comprehensive and detailed documentation Requires cri
tical thinking
and analysis to design the plan and keep it current Focuses specifically on the
testing process,
or analyti- cal phase of the laboratory process Includes processes performed by
employees and
influenced by policies of employers Policies often established by the manufactur
er; also may be
developed by the employer Requires detailed documentation Requires critical thin
king and analysis
to decide if the patient sample can be reported based on the quality control res
ults
1899_Ch04_063-082 21/12/11 2:19 PM Page 65 testing available will be sufficient
to meet his
needs. Within the first week, he orders several screening tests for ovarian canc
er to be
performed on his patients. The analyzer used to perform these tests breaks down
on Monday, and no
one in the laboratory contacts the physician to let him know of the delay. He fi
nally re- ceives
his screening tests on Friday, and one of the results is positive. He is very up
set about the
time that it took for him to receive this result in his office, and decides to s
end all his
testing requests to another laboratory. This is an example of a breakdown in qua
lity assur- ance.
If the physician had been notified of the expected delay for his results, he may
still have been
upset, but at least the lines of communication would have been open. Another alt
ernative would
have been sending the sam- ples to another laboratory while the machine was ser
- viced; the

delay would most likely have been minimized, and the physician would have receiv
ed his results in
a timely manner. Other examples of poor quality performance are in- correct resu
lts, improper
patient preparation, reporting the wrong reference ranges (a range of expected v
alues for a
healthy individual for a specific test) for a specific patients gender and age, o
r even improper
billing prac- tices. All aspects of the customer experience in the labo- ratory
must be of high
quality, as the test results may have significant impact on the treatment for th
e patient. A
patient may be put on antibiotics when they are not needed because a streptococc
al screen was
incorrectly in- terpreted as positive. Another patient result may show a false e
levation in
potassium levels when a specimen is mishandled, and the physician may change the
ir medica- tion
based on these results. This could be a life threaten- ing situation. It may be
helpful to
consider laboratory quality as a series of Rights: Right result Right time (both s
pecimen
collection and reporting of results) Right specimen Right patient Right referenc
e range for
result interpretation Right price for the services provided The Medical Assistan
ts Role in
Assuring Quality Results Most medical assistants working in a laboratory environ
- ment will be
performing Clinical Laboratory Improve- ment Actwaived (CLIAwaived) tests. These a
re tests that
are very simple to perform with results that are easy to interpret. As introduce
d in Chapter 3 of
this text, lab- oratory tests are categorized under CLIA regulations based on th
e complexity of
the process. Some of the tests are categorized as waived tests because they are ex
empt (or
waived) from many of the regulatory procedures of the laboratory tests that are
more complex in
nature. This does not mean, however, that they are exempt from quality control p
rocedures. Even
before the testing process begins, the medical assistant can be checking the sam
ple collection
devices (such as swabs or blood tubes) for outdates, and participating in necess
ary training to
be ready for the procedure. The first opportunity that a medical assistant might
have to be
involved in quality control is when the testing kit or reagents arrive in the la
boratory. Storage
instruc- tions are printed on the outside of the box, and these need to be follo
wed precisely to
provide accurate test results. Reading the package insert is critical, as the pr
o- cedure
specified by the manufacturer must be followed carefully. When the box is opened
, this package
insert should be stored in a safe place. Many laboratories have a binder for the
se sheets, and it
is the medical assistants responsibility to verify that the insert has not change
d since the
last one was placed in the binder. Laboratories may also keep multiple copies th
at have the date

of receipt documented for reference. Types of Quality Control Specimens When the
kit (or the
reagent) is opened for use, it will be necessary to test a quality control speci
men as recommended on the package insert. Some testing procedures may call for two types of
quality control
specimens to be analyzed. There are three general categories used to describe qu
ality control
specimens: 1. External quality control specimens: This may be a reference soluti
on that comes
with the kit, or a swab that has been treated with material that will cause the
test to read
positive or negative. External quality con- trol materials may also need to be p
urchased separately from the testing materials. Regardless of how the materials are provided,
the most
important con- cept to follow is that of the analysis of the quality 66 Section
I Overview of
the Laboratory Test Your Knowledge 4-2 How do incorrect laboratory results affec
t patient care?
(Outcome 4-3) 1899_Ch04_063-082 21/12/11 2:19 PM Page 66 control specimens exact
ly as directed by
the test man- ufacturer, and the comparison of the results from the specimen to
the data provided
to be sure that the test performance is as expected. These may be qualitative re
sults for tests
that provide a positive or negative re- sult, or they may be quantitative result
s with a range of
expected results. Quantitative tests provide results as numbers indicating the c
oncentration of
certain substances. If the results of the external quality con- trol specimen ar
e not as
expected, the kit or reagent cannot be used to test patient samples until the pr
ob- lem has been
identified and solved. 2. Internal quality control indicators: These are qual- i
ty control
indicators that are part of the individual testing kits. They show that the test
process was
valid, but they do not provide a test result. An inter- nal quality control meas
urement is
usually a color indicator, and in the package insert there will be an explanatio
n of acceptable
performance before a test result can be reported. Internal quality control speci
- mens are most
common in qualitative testing proce- dures. Remember, if the test is not valid (
the indicator
does not develop properly), you may not report the patient test result. Figure 4
-1 shows how an
indicator might appear. 3. Electronic quality control devices: Electronic quality control
devices are reusable, and are used to verify the function of an instrument used
for analysis. The
electronic quality control devices are commonly test strips or cuvettes. The dev
ices come with an
expected numerical range of results, and it is imperative that the results fall
within this range
when tested, or no patient results may be reported until the problem has been id
entified and
solved. Chapter 4 Assuring Quality 67 Positive results Negative result Invalid
results Results

zone Control indicator Results zone Control indicator Results zone Control indic
ator Test Your
Knowledge 4-3 Do electronic QC devices let you know whether a test is valid? (Ou
tcome 4-3) Test
Your Knowledge 4-4 If a medical assistant is using a machine to analyze a blood
sample for a test
result, what type of QC may she be required to use? a. External b. Internal c. E
lectronic d. a
and c (Outcome 4-4) Figure 4-1 Valid and invalid test results. Medical assistant
s may also
perform tests that have been classified as CLIA moderate-complexity proce- dures
. These
procedures may require quality control pro- cedures to be performed with more fr
equency than the
CLIA-waived tests, and there is more training and docu- mentation required for t
he employee who
is performing the tests. Laboratories that perform these moderately complex test
s are required
either to follow the recom- mendations for quality control included in the packa
ge insert from
the manufacturer, or process at least two lev- els of quality control materials
with each
analytical run. The CLIA regulations state that the laboratory must use the more
stringent option
of the two. Tests of moderate complexity utilizing instruments also require cali
bration,
calibration verification, and proficiency testing. These concepts are discussed
later in this
chapter. What Happens When Things Are Out of Control? It is very important to reco
gnize the
importance of qual- ity control specimens as an indicator of the reliability and
accuracy of the
testing method to be utilized for 1899_Ch04_063-082 21/12/11 2:19 PM Page 67 68
Section I
Overview of the Laboratory Procedure 4-1: Documentation of Qualitative Quality C
ontrol Values
TASK Properly perform quality control testing and document qualitative QC values
on a chart.
CAAHEP/ABHES STANDARDS CAAHEP 2008 I.P.I.11. Perform quality control procedures
I.A.I.2.
Distinguish between normal and abnormal test results II.C.II.7. Analyze charts,
graphs and/or
tables in the interpretation of healthcare results II.P.II.2. Maintain laborator
y test results
using flow sheets ABHES Standards Medical Laboratory Procedures 10.a: Quality Co
ntrol, and
Graduates: a. Practice Quality Control CONDITIONS CLIA-waived test kit External
quality
control material Quality control chart Pen Procedure Rationale 1. Open the CLIAwaived test
kit and secure the package insert. 2. Verify which type of quality control speci
men your
laboratory uses for this testing procedure. Find the directions in the package i
nsert for that
type of specimen. 3. Wash hands and apply gloves. 4. Following the directions in
the package
insert, per- form the testing procedure using the positive quality control speci
men. Repeat with
the negative quality control specimen. 5. Verify that the positive and negative
quality control

specimens provide the appropriate results. 6. Remove gloves, dispose of them app
ropriately, and
wash hands. 7. Record the results on the log sheet. Include these factors: a. Da
te and time of
test and employee ID b. Analyte tested (what type of test was performed?) c. Typ
e of quality
control (external); brand name if a commercial control was purchased separately
It will be
necessary to have the package insert available for reference as the quality cont
rol specimen is
analyzed. The quality control specimen may be one that is pro- vided with the ki
t or it may be a
commercial one that is purchased separately. It is important that the correct pr
ocedure be used
for the testing process. Appropriate personal protective equipment should be use
d when testing
quality control materials just as it would be used for testing samples. The perf
ormance of the
testing procedure should be verified with both a positive and negative control s
pecimen as
recommended by the manufacturer. Tests must be valid and the results must be as
expected for the
test kit to be considered in control. Gloves should be removed before documenting
results. All
these factors are very important documentation, and any form should allow for th
e recording of
com- plete information. 1899_Ch04_063-082 21/12/11 2:19 PM Page 68 Chapter 4 As
suring Quality 69
Procedure 4-2: Documentation of Quantitative Quality Control Values TASK Properl
y perform and
document quantitative quality control values on a chart. Determine whether the v
alues are
acceptable according to laboratory protocol. CAAHEP/ABHES STANDARDS CAAHEP 2008
I.P.I.11. Perform
quality control procedures I.A.I.2. Distinguish between normal and abnormal test
results
II.C.II.7. Analyze charts, graphs and/or tables in the interpretation of healthc
are results
II.P.II.2. Maintain laboratory test results using flow sheets ABHES Standards Me
dical Laboratory
Procedures 10.a: Quality Control, and Graduates: a. Practice Quality Control CON
DITIONS
Quantitative testing method External quality control material Quality control ch
art with
established acceptable ranges provided Pen from the kit, and lot number of quali
ty control
material. d. Result (positive or negative) e. Was result acceptable? f. Correcti
ve action taken,
if necessary 8. Put away testing supplies and disinfect work area. Procedure Rat
ionale Procedure
Rationale 1. Consult the instructions for the testing method if necessary before
continuing with
the process. 2. Verify which type of quality control specimen your laboratory us
es for this
testing procedure. 3. Wash hands and apply gloves. 4. Following the directions i
n the package
insert or the laboratory procedure manual, perform the testing procedure using t
he quality
control specimen. Repeat with a second quality control level if recommended by t
he manufacturer.

With automated testing procedures, the manufacturers recommendations usually do n

ot change as
often as they might with the CLIA-waived test kits. However, consulting the inst
ructions is
always appropriate. The quality control specimen may be one that is provided wit
h the testing
method, or it may be a commercial product that is purchased separately. Appropri
ate personal
protective equipment should be used when testing quality control materials just
as it would be
utilized for testing samples. The performance of the testing procedure should be
verified with
both a high and low level quality con- trol specimen as recommended by the manuf
acturer.
Continued 1899_Ch04_063-082 21/12/11 2:19 PM Page 69 70 Section I Overview of t
he Laboratory
Procedure 4-2: Documentation of Quantitative Quality Control Valuescontd Procedure
Rationale 5.
Put away quality control material. 6. Remove gloves, dispose of them appropriate
ly, and wash
hands. 7. Record the results on the log sheet by placing a dot at the line at wh
ich the date and
specimen result intersect. In addition, document the time of the test and your i
dentification.
Verify that the correct con- trol level brand and lot number are on the log shee
t. 8. Verify
whether the quality control is within the established ranges and whether there i
s a pattern
developing that needs attention, such as a trend or a shift in the results. If t
here is a problem
or if the quality control is out of range, do not process patient samples. 9. Re
peat the test if
results are out of range. If the condition persists, begin troubleshooting the p
roblem. Document
the repeat and also if there are troubleshooting steps taken. 10. If the trouble
shooting is not
successful, do not al- low the instrument to be used for patient samples, and co
ntact a
supervisor or the manufacturer for further action. Many quality control specimen
s must remain
refriger- ated, so this should occur immediately after use. Gloves should be rem
oved before
documenting results. All these factors are very important documentation, and any
form should
allow for the recording of com- plete information. Careful documentation of the
results and
observation of any quality control patterns are absolutely neces- sary. Patient
samples cannot be
processed if the sample is out of range or if there is an undesirable pattern fo
rming in the
results. Troubleshooting may include opening a new bottle of quality control mat
erial, cleaning
the instrument, verifying the instructions for performing the test, verifying th
at the quality
control chart is for the correct lot number, etc. It is essential that the probl
em be resolved as
soon as possible to continue with quality patient care. patients. When the QC re
sults are not as
expected, the person running the test or operating the instrument must not repor
t any patient

results until the problem has been solved. The systematic process of identifying
the problem with
the testing procedure is called trou- bleshooting. There are times when the qual
ity control
specimen does not provide a positive result as expected, or when the test result
s appear invalid
when running a pregnancy test QC specimen. The medical assistant per- forming th
e test must
immediately try to identify the problem with the testing procedure before the pr
ocess can
continue. Here are some actions to take when trou- bleshooting a testing process
: 1. Check the
expiration dates of the reagents, kit, and quality control reagents in use. If a
ny of these
supplies are outdated, document the discrepancy, discard the expired item, and p
erform the test
again using materials that are not past their expiration date. 2. Verify how the
specimen, kit,
reagent, or quality con- trol material has been stored. Were the manufacturers re
commendations
followed? If there is evidence that the storage instructions were not followed,
the results
provided by this testing method may be inaccurate. The testing component that wa
s mishandled must
be discarded, with appropriate documentation of the issue. 3. Verify the specime
n type required
for the testing pro- cedure. Sometimes a kit is designed to work only with certa
in types of body
fluids. The acceptable specimen type will be provided as part of the package ins
ert.
1899_Ch04_063-082 21/12/11 2:19 PM Page 70 Tests performed on body fluids not in
dicated as
acceptable may provide inaccurate or invalid results. 4. Was the control materia
l well mixed and
at the cor- rect temperature for the test? The quality control material may requ
ire warming to
room temperature before use or vigorous mixing prior to testing. These instructi
ons must be
followed carefully. 5. Refer to the current package insert. Are you aware of ski
pping a step, or
doing the procedure incorrectly? Has the package insert or instructions changed
since you last
performed the test? 6. If an instrument was used for the test, is it clean? Chec
k the maintenance
documentation, and see if the recom- mended schedule has been followed for routi
ne instru- ment
care. If needed, perform the recommended main- tenance, after which the QC can b
e analyzed again.
7. Read the troubleshooting portion of the manufac- turers instructions. There is
valuable
information here that may help to solve the problem. Usually the problem may be
identified by
following these suggestions. If the problem is still not apparent, a new quality
control specimen
should be obtained for a retest. If it is an internal control and the quality co
ntrol specimen
comes with the kit, open a new kit and try the test again. Finally, documentatio
n of the details
and troubleshooting process is critical. If there seems to be a pattern emerging
, it is

imperative that everyone knows what has occurred, and the steps that have been t
aken to solve the
problem. Details also help while communicat- ing with a manager or supervisor ab
out the problem.
Sometimes the medical assistant may need to contact the manufacturer for advice,
and these
details will be neces- sary to continue the troubleshooting process. Documentati
on of Quality
Control Results Quality control requirements are different for CLIA- waived test
s than they are
for those of moderate or high complexity. Many of the waived tests are qualitati
ve in nature,
which means that the result provided is either positive or negative, rather than
a measurement
reported as a number or percentage. The quality control assess- ment for these q
ualitative tests
may be built in to the in- dividual testing devices or the laboratory may purcha
se other quality
control specimens to verify the perfor - mance quality for the analyte (substanc
e being tested).
Whether the QC is internal or external, it must be doc- umented, and this record
must be kept for
at least two years. As with any document in the laboratory or in a patients chart
, the results
on the quality control chart must be documented in pen, not pencil. This provide
s a permanent
record that is not easily changed. One of the most common sources of laboratory
error is that of
tran- scription; it is very important to carefully document all laboratory data.
Figure 4-2 is an
example of a quality control log sheet to be used for a qualitative test. At a C
hapter 4
Assuring Quality 71 Test Your Knowledge 4-5 Cindy Lou has recently been trained
to perform
pregnancy testing in the physician office laboratory (POL) where she is employed
. She receives a
blood specimen from the physician who asks her to test it to see if a young pati
ent is pregnant.
Cindy follows the pregnancy testing procedure exactly as she was taught, but the
test results
show that it is an invalid test. What are two possible explanations? (Outcome 46) Date and time
of test/ Employee identification Analyte tested Type of quality control specimen
used; external
or internal? For external quality control; brand and quality control lot numbers
Quality control
result Results acceptable? (yes or no) Corrective action taken Figure 4-2 Log us
ed to record
quality control results for a qualitative test. 1899_Ch04_063-082 21/12/11 2:19
PM Page 71
minimum, the documentation should include the following: The date and time of th
e quality
control test. Re- member, the frequency that the QC is tested must be at least a
s often as the
manufacturer recommends. The quality control material lot number and level. If i
t is internal
control, this would be documented as additional information. If the testing devi
ce has a color
change that occurs to verify the validity of the test, this needs to be recorded
as well. The

lot number for the testing kit in use. If this test kit was just opened, the kit
should also have
the date and the initials of the person who opened it written on the test kit bo
x. Results of
the quality control test. This is often just positive or negative for qualitativ
e CLIA-waived
tests. Documentation of whether the kit or test can be used to test patient samp
les. Remember,
this deci- sion is based on whether the quality control results were within the
established
acceptable ranges. Documentation of troubleshooting or corrective action, if req
uired.
Initials or signature of employee performing test. controls, and other informati
on that may be
necessary for that particular laboratory. Levey-Jennings charts will also includ
e the mean
(average) expected value, as well as limits for acceptable QC testing results. I
f an in- dividual
quality control test falls outside of these ranges, patient testing cannot conti
nue until the
prob- lem has been addressed. This type of graph can also be monitored for trend
s in the data,
which show a pro- gressive change in the results from day to day that con- tinue
to move
gradually in one direction. Shifts will also be evident, and can be identified o
n the graph as a
set of results that suddenly move significantly, but still remain within an acce
ptable range.
Sometimes a shift will be evident when the results move from one side of the mea
n to the other,
but a shift may also be evident even if the results remain on the same side of t
he mean. Both of
these situations must be addressed, because they are indicative of a problem wit
h the quality
con- trol procedure, the testing method, the operator, or a combination of these
factors. Figure
4-3 is an example of a quantitative Levey-Jennings quality control chart. 72 Sec
tion I Overview
of the Laboratory Test Your Knowledge 4-6 Why is it important to document the da
te of a quality
control test? (Outcome 4-7) Test Your Knowledge 4-7 Is a Levey-Jennings chart us
ed to document
qualitative QC test results? Why or why not? (Outcome 4-7) Various moderate-comp
lexity tests, as
well as some that are CLIA-waived, will provide quantitative results. This means
that the quality
control results for these testing methods will also be reported as a number, rat
her than merely a
negative or positive result indicat- ing the presence or absence of a substance.
Because the
results reported for these tests are to fall within an es- tablished range, it i
s very important
that the quality control results are monitored closely to verify the methods perf
ormance. A
common tool used to record these quantitative results is a Levey-Jennings chart,
used to monitor
the quality control performance over a set time interval. The acceptable quality
control ranges
are either established by the laboratory before patient samples are analyzed wit
h the kit or

instrument, or they are established by the manufacturer and adopted by the labor
atory. The values
obtained each time the quality control is processed are charted (in pen) accordi
ng to the date
and the value obtained. The chart also has spaces to document the analyte being
tested, the QC
level, the lot numbers of the kit and the quality Accuracy and Precision The Lev
ey-Jennings chart
can be a useful tool to verify whether a testing method is demonstrating accurac
y and precision.
These are very important concepts to keep in mind in the laboratory environment.
Accuracy is a
word used to define how close the result produced for that test is to the real v
alue. This can be
visualized by thinking of a bulls-eye target. The true value for a test procedure
is at the
center of the target. If the test is accurate, then each time the test is perfor
med the results
will be near the center of the target. Precision describes the reproducibility o
f results. This
can also be thought of as a measurement of whether the results are close togethe
r if the test is
run multiple times on the same specimen. Visualizing the bulls-eye target again,
a test shows
good precision if the results are all clustered closely together when the test i
s run multiple
times. A test can be precise but not accurate. This means that the results for a
certain test may
all be close to the same value, but not near the true value for that test. The g
oal for
laboratory testing is to have results that are both 1899_Ch04_063-082 21/12/11 2
:19 PM Page 72
accurate and precise, and quality control measures help to identify problems in
these areas
before they affect the quality of the patient results for that test. OTHER METHO
DS OF ASSURING
LABORATORY QUALITY All laboratory results have clinical significance, mean- ing
that a
health-care provider may change the treatment or assign a diagnosis for a patien
t based on the
laboratory results. In addition, there are established reference ranges for all
laboratory tests.
These are the expected values for patients in a normal population for a certain
analyte. In order
to feel confident that the laboratory results reported are accurate and reliable
, all facets of
quality assurance must be taken into consideration. The best way to understand h
ow these all fit
into patient care is to consider a patient scenario with a negative outcome: Mr.
Butler has
developed an atrial arrhythmia and is being treated with the drug digoxin to hel
p increase the
efficiency of his heart muscle and correct problems with the electrical impulses
that pass
through his heart. Mr. Butler visits the laboratory monthly to have his drug lev
el checked, as
digoxin has serious side effects if the concentration is too high in the bloodstream. When the
laboratory tests the digoxin level, a higher-than-normal level is discovered for
someone being

treated for his condition, and the result is well outside the reference range. W
hen Mr. Butlers
physi- cian receives the report, he calls his patient, verifies his health statu
s, and tells him
that he needs to decrease his digoxin dose for a few days. The physician asks Mr
. Butler to go to
the laboratory to have another specimen drawn at the end of the week. On day thr
ee after
decreasing his dose, Mr. Butler has his drug level rechecked. This second draw i
s extremely low,
well below the reference range. The result is drastically different from what it
was a few days
earlier, and is much lower than it should be with the minor medica- tion adjustm
ent based on the
previous high result. Of course, Mr. Butlers health-care provider is eager to fin
d out how the
results for the digoxin could be so dif- ferent in just a few days. He contacts
Mr. Butler and
confirms that he followed the dosage changes as directed. The physician then con
tacts the
laboratory that per- formed the testing on the first sample. The laboratory staf
f rechecks the
sample, and finds the result is close to the first reading: still high above the
reference range.
However, when their quality assurance officer steps in to resolve the issue, she
finds that the
quality control results for the digoxin test have been slowly reading higher and
higher for a few
days prior to the test date. This trend has gone unnoticed by the personnel perf
orming the tests,
because the results were all within the acceptable range. Chapter 4 Assuring Qu
ality 73 1 2 3 4
5 6 7 9 10 11 13 14 15 16 18 19 20 21 22 23 24 25 26 27 28 17 12 8 175.2 180.2 1
85.2 190.2 195.2
200.2 205.2 210.2 215.2 220.2 C h o l e s t e r o l
m g
/
d L Date/Time/Period LCL CL 181.07 198.75 UCL 216.43 Cholesterol mg/dL +
3s +2s 2s 3s +1s
1s mean Figure 4-3 Levey-Jennings chart used to record quantitative quality contr
ol results.
1899_Ch04_063-082 21/12/11 2:19 PM Page 73 74 Section I Overview of the Laborat
ory POINT OF
INTEREST 4-1 Statistics used for quality control assessment Statistics is a spec
ific branch of
mathematics that deals with the collection, analysis, and interpretation of numerical data. We
use statistics in the laboratory to analyze the quantitative data derived from q
uality control
testing. The entire process is quite complicated, but developing an understandin
g of a few key
terms can benefit the medical assistant as he or she works with these data. To e
stablish
acceptable ranges for qualitative QC testing procedures, the mean, standard devi
ation, and
variance must be established. Mean: The mean is the numerical average of a set o
f numbers. To
calculate the mean, find the sum (total) of a set of values (numbers), then divi
de that sum by

the number of values in the set. For instance, if you were to analyze a specimen
ten times for a
potassium level, you might generate these numbers: 4.5, 4.4, 4.2, 4.6, 4.5, 4.1,
4.3, 4.6, 4.5,
and 4.7 mmol/L. The mean of these values would be calculated by adding them all
together, then
dividing by 10, because there were ten results used for the calculation. The mea
n result for
these numbers would be 4.4 mmol/L. Variance: The variance is a bit more complica
ted to
calculate. It gives a numeric indication of how much the values in the set vary
or deviate from
the mean. The variance is calculated after the mean for the set of numbers has b
een established.
Each number is sub- tracted from the mean, and this difference is squared, which
means to
multiply it by itself one time. The sum of the squares is then established, and
this sum is
divided by the total number of values minus one. (The term used for this calcula
tion is n 1.)
Therefore, for our scenario presented above, we would follow these steps from th
e calculate mean
of 4.4 mmol/L: The sum of the deviations squared is 0.34, and this number divide
d by n 1 (9 in
our example) is 0.036. The variance for this set of numbers is 0.036. 35 25 15 X 15
25 35
Standard deviation: The standard deviation pro- vides a measurement of how the v
alues we are
working with are placed or scattered around the calculated mean for the values.
The standard
devia- tion uses the variance that was calculated in the pre- vious step, and is
calculated by
taking the square root of the variance. For the potassium scenario that we are w
orking with, the
standard deviation would be calculated by calculating the square root of 0.036.
The standard
deviation would be 0.061 mmol/L for this set of potassium results. The previous
calculations are
used to establish accept- able values or allowable standard deviation for their
qualitative
laboratory results. If the potassium values were analyzed for 100 people who wer
e considered to
be of normal health, we would find that their values could be plotted on a graph
to form a
Gaussian curve (see above), which is sometimes known as a bell curve or normal d
istribution
curve. In a normal curve, half of the values are greater than the mean and half
of the values are
less than the mean for that test result. Statistically, it has been shown that 6
8% of the results
in a normal population will be within one standard deviation above or below the
mean, and 95%
will be Potassium Deviation; How Far Deviation Squared; Value from the Mean of 4
.4? Multiplied by
Itself 4.5 0.1 0.01 4.4 0.0 0.00 4.2 0.2 0.04 Potassium Deviation; How Far Devia
tion Squared;
Value from the Mean of 4.4? Multiplied by Itself 4.6 0.2 0.04 4.5 0.1 0.01 4.1 0
.3 0.09 4.3 0.1
0.01 4.6 0.2 0.04 4.5 0.1 0.01 4.7 0.3 0.09 1899_Ch04_063-082 21/12/11 2:19 PM P
age 74 She also

checks the maintenance logs for the instrument used for digoxin testing, and fin
ds that the
machine has not been serviced as recommended by the manufacturer. This is a very
serious
situation, especially because Mr. Butler may not have been the only patient affe
cted by the
instruments performance. The QA officer begins to make a plan to correct the issu
es. The first
part of her plan is to have the overdue maintenance performed on the instrument.
This in- cludes
cleaning the internal components of the machine and changing some tubing and rea
gents. After the
main- tenance has been performed, the machine has to be cali- brated. Calibratio
n is a
standardization of the instru- ment for a specific analyte, meaning that a calib
ration sample
(generally ordered from the manufacturer) is processed using the instrument. If
the reading does
not come out exactly as it should, the instrument is adjusted (according to manu
facturers
instructions) until it does measure the calibration sample at precisely the pred
eter- mined
level. Once the calibration is complete, quality control as- sessment must be pe
rformed again.
This is called cali- bration verification. The calibration and subsequent verifi
cation show that
the testing instrument has been reading the digoxin specimen results several inc
rements higher
than they really were. This caused Mr. Butlers reading to appear falsely elevated
; his specimen
was tested once again after the calibration and verification and found to be at
the high end of
the expected reference range. His dosage should not have been altered. This chan
ge in medication
may have put his health at risk unnecessarily. To follow up on this incident, th
e QA officer
docu- ments all that has occurred. Her follow-up includes reed- ucation of the p
ersonnel
responsible for the quality con- trol and maintenance for the testing instrument
. She develops a
plan to follow up with these employees to see if the intervention and retraining
were successful.
The QA officer also notifies the laboratory director and any other required pers
onnel in the
organization who need to be notified of a testing system problem leading to a ba
d patient
outcome. If the patients health had been negatively affected by the medication ch
ange in
response to the first digoxin test result, the laboratory would be at risk for l
egal action. As a
result of this situation, it is likely that the physician may decide to send his
specimens to a
differ- ent laboratory for analysis. As this scenario draws to a close, the QA o
fficer feels
confident that the digoxin levels reported from that in- strument are now accura
te and reliable.
She also has to go back and follow up on reported results for other patients tes
ted close to the
time that Mr. Butler had his test performed. However, another question still exi
sts: How well do

the digoxin results from this laboratory compare to oth- ers that are performing
the same test
with the same in- strument? This is the final step of assuring quality for the l
aboratory. It is
like taking a standardized assessment to see if the results produced in a certai
n laboratory
compare well to those of others across the country. Proficiency testing is a mea
ns to measure the
performance of a lab- oratory externally. For laboratories performing moderateor
high-complexity testing, federal regulations require that proficiency testing is
performed at
least three times yearly. The laboratories are sent specimens from a provider th
at has been
approved by their licensing agency, and these specimens must be tested exactly a
s a patient
sample would be tested. The laboratories then report their results back to the a
pproved provider,
and they are compared to other laboratories that perform the same test using the
same method. If
a laboratorys results are too different from the others used for the comparison,
that laboratory
may be told that it can no longer offer that specific test until the problem is
identified and
solved. In addition, if a laboratory is not successful with its proficiency test
ing, there will
usually be a site visit per- formed by those who certify or license this laborat
ory for
operation. Chapter 4 Assuring Quality 75 within two standard deviations above a
nd below the
mean. Ninety-nine percent of the results will fall within three standard deviati
ons of the mean.
Normally, when establishing acceptable ranges (also known as confidence limits)
for a laboratory
procedure, the quality control results must fall within a range of two standard
deviations above
or below the mean in order to be an acceptable result. For our potassium scenari
o, if this was a
quality control material that was tested ten times, the results would need to fa
ll within two
standard devi- ations of the mean. The mean was 4.4, and the qual- ity control r
esults would need
to be 4.4 plus or mi- nus 0.122 to be within range. This means that the acceptab
le ranges for
this quality control sample would be 4.28 to 4.52 mmol/L. 1899_Ch04_063-082 21/1
2/11 2:19 PM Page
75 For proficiency testing to be valid, it is important to stress that the sampl
es provided are
to be run precisely the same as patient samples. Laboratories are not allowed to
run the samples
in duplicate unless the patient sam- ples would be treated in this way. Proficie
ncy testing is a
powerful tool, providing verification for a laboratory that their results are co
mparable to
others performing the same test across the region or country. By law, laboratori
es that perform
only CLIA-waived tests are not required to participate in proficiency test- ing.
However, they
may choose to voluntarily partici- pate. The Centers for Medicare & Medicaid Ser
vices (CMS) still

recommends that some sort of external qual- ity verification is performed period
ically, whether
it is through a commercial agency or informally. Informal verification of qualit
y may include
splitting a patient sample and sending some of it to another laboratory to see w
hat its result
is, or asking for another laboratory to share its patients samples for the same r
eason. Many
lab- oratories also perform internal proficiency testing in which they pool pati
ent samples, run
them numerous times to get an acceptable range for the results, and then use the
se to supplement
their commercial quality control materials throughout the day. These patient poo
l speci- mens are
usually separated into small samples and frozen until they can be tested. The in
ternal patient
quality control samples are a nice way to supplement the com- mercial quality co
ntrol in the
laboratory, but they do not help with comparisons to other laboratories unless t
hey are shared.
There is one more recommended method to assure quality in the laboratory. This p
rocess is known
as competency testing. Competency testing actually evaluates the personnel who p
erform the
laboratory tests, by direct observation, or by introducing mock specimens with k
nown values into
the patient load and evaluating the results and documentation after the test is
complete. This
evaluation process can be especially critical with the CLIA-waived tests, as oft
en the person who
performs the test has little or no formal laboratory training, and he or she may
not realize the
significance of cutting corners by not following the procedure exactly as the ma
nufacturer
recommends it to be per- formed. Many laboratories have designed a program in wh
ich competency
testing of some sort is performed annually for each employee, in which a supervi
sor pro- vides
samples of known results for personnel to test. If the documented results do not
fall within the
estab- lished ranges, then additional training needs to be inte- grated into the
laboratory
environment. The CMS has performed site visits at CLIA-waived laboratories acros
s the United
States over the course of the past few years and the results have been very info
r - mative.
Because the regulatory requirements for labora- tories that perform only CLIA-wa
ived tests are
minimal, there is concern for the quality of the services provided by these labo
ratories. The
following is a summary of the issues identified in the site visits: The employee
s performing
the tests were inadequately trained. Training must be provided by a qualified pe
r- son who has
knowledge of the test performance, and the actual performance of the test should
be evaluated as
the trainer observes. There were high turnover rates for testing personnel, espe
cially medical
assistants. CLIA-waived testing sites were performing tests that were not CLIA w
aived, using

personnel who were not adequately educated or trained to perform the proce- dure
s. This could be
a potentially dangerous situation for patients, as the procedures may not be per
formed correctly
and the testing personnel may not be able to identify significant issues with th
e testing process
due to lack of training. Many of the sites did not have the most recent manu- fa
cturers
procedural instructions for the tests they were performing. Approximately 20% of
the sites reported that they did not routinely check the manufac- turers package inserts to s
ee if there
were recom- mended changes in the procedure. There were also cost-cutting measur
es in effect in
some laboratories, in which urinalysis testing strips or fecal occult blood slid
es were being cut
in half to increase the number of specimens tested per kit. This destroys the in
tegrity of the
testing process, and means that the laboratory is noncompliant with the CLIA reg
ulations.
Quality control testing was not performed as specified by the manufacturer by ma
ny of the sites,
and units of measure were incorrectly reported with patient results. 76 Section
I Overview of
the Laboratory Test Your Knowledge 4-8 How is the process of calibration differe
nt from running a
quality control specimen? (Outcome 4-8) Test Your Knowledge 4-9 Is proficiency t
esting required
for all laboratories? (Outcome 4-8) 1899_Ch04_063-082 21/12/11 2:19 PM Page 76 P
roblems were
identified with expiration dates and storage methods for the testing kits, as we
ll as documentation of the lot numbers and control results for the kits once they were ope
ned. There were
also issues with inadequate performance of instrument mainte- nance and calibrat
ion.
Approximately 6% of the laboratories visited did not perform follow-up confirmat
ory tests as
recom- mended by the manufacturer. Some of the sites were testing specimens that
were not
acceptable for that waived method. For instance, some tests are designed to be p
erformed on
urine, but the laboratory was testing plasma instead. In 2005, the Centers for D
isease Control
and Pre- vention (CDC) published a report summarizing the results of site visits
mentioned above.
(You can find the link to the report in the Resources and Suggested Readings sec
tion at the end
of this chapter.) In addi- tion to the summary, the report also includes recommendations for
good laboratory practices for waived testing sites. The majority of these recomm
endations have
been included in this chapter. They include spe- cific considerations for all th
ree parts of the
laboratory testing procedure: preanalytical, analytical and postan- alytical pha
ses. 1. Be
certain that there is a written request or requisi- tion for all tests performed
. 2. Follow the
written instructions for collection meth- ods carefully, and verify what type of
specimen is

needed for the test ordered before collection. 3. Properly identify the patient
and specimen, and
store the specimen properly until the testing process begins. 4. Check the kit e
xpiration date.
5. Know the product insert; be sure that copies are kept current at all times, a
nd refer to them
often. A sample package insert is reproduced in Figure 4-4. 6. Follow the proced
ure provided by
the manufacturer exactly as written. 7. Run controls often, at least as often as
is recom- mended
by the manufacturer. 8. Repeat the test if there is a problem, and trou- bleshoo
t if the problem
continues. Always verify that the test result is valid if there is an indicator
present on the
testing device. 9. Accurately record the results; use the correct units and be s
ure that the
reference ranges reflect the pop- ulation and sample type that you are reporting
. 10. Sign and
date your results wherever they are recorded in your laboratory setting. 11. Not
ify the
health-care provider that ordered the tests in a timely manner. Be aware of pani
c or crit- ical
results. These are test results that are far enough outside of the reference ran
ges that they may
be considered to be life threatening, and must be reported immediately to the or
dering physician
or another appropriate responsible party. When notifying the physicians office of
these results,
document who was notified, what was reported, and when it was reported, and sign
and date this
documentation. Chapter 4 Assuring Quality 77 Test Your Knowledge 4-10 What is t
he most important
step that a medical assistant can take to ensure that he or she is performing a
CLIA- waived test
for mononucleosis correctly? (Outcome 4-8) SUMMARY Quality assurance in the clin
ical laboratory
is like a big umbrella covering numerous aspects of the process. A good QA plan
should address
issues such as education of the providers and patients concerning appropriate pa
tient preparation
before testing, initial and ongoing education of all personnel, written procedur
es, thor- ough
documentation of all testing, quality control and maintenance procedures, and pl
ans for how to
follow up on problems that may develop. Quality control focuses more on the test
ing process
itself, and includes specimen and testing kit or reagent storage, following dire
ctions, and
reporting results appropriately. Other means of assuring quality in the laborato
ry may include
calibration, external proficiency testing, and compe- tency testing. The most im
portant aspect of
all these measures is to assure quality results for the patients we serve so tha
t they can be
cared for appropriately. 1899_Ch04_063-082 21/12/11 2:19 PM Page 77 78 Section I
Overview of the
Laboratory CLIA Complexity: Waived for Whole Blood Non-Waived for Serum or Plasm
a FOR
LABORATORY AND PROFESSIONAL IN VITRO DIAGNOSTIC USE ONLY. INTENDED USE The OSOM
Mono Test is

intended for the qualitative detection of infectious mononucleosis heterophile a

ntibodies in
serum, plasma or whole blood as an aid in the diagnosis of infectious mononucleo
sis. Mono Test
SUMMARY AND EXPLANATION OF TEST The diagnosis of infectious mononucleosis (IM) i
s suggested on
the basis of the clinical symptoms of fever, sore throat and swollen lymph gland
s. The highest
incidence of symptomatic IM occurs during late adolescence (1524 years of age). I
nfectious
mononucleosis is caused by the Epstein- Barr Virus (EBV). (1,2) The laboratory d
iagnosis of IM is
based on the detection of IM heterophile antibodies. These heterophile antibodie
s are directed
against antigens found in bovine, sheep and horse erythrocytes. The OSOM Mono Te
st utilizes an
extract of bovine erythrocytes to give the required sensitivity and speci city. KI
T CONTENTS AND
STORAGE 25 Test Sticks in a container 25 Test Tubes 25 Transfer Pipettes 25 Capi
llary Tubes with
1 Capillary Bulb 1 Diluent (contains buffer with 0.2% sodium azide) 1 Mono Posit
ive Control
(contains rabbit anti-beef stroma in tris buffer with 0.2% sodium azide and 0.05
% gentamycin
sulfate preservatives) 1 Mono Negative Control (contains goat albumin in tris bu
ffer with 0.2%
sodium azide) 1 Work Station 1 Directional Insert 2 Additional test sticks have
been included in
the kit for external QC testing Note: Extra components (tubes, pipettes, capilla
ry tubes and
capillary bulb) have been provided for your convenience. Store the Test Sticks a
nd reagents
tightly capped at 1530C (5986F). Do not use the Test Sticks or reagents after their
expiration dates. MATERIALS REQUIRED BUT NOT PROVIDED Specimen collection contai
ners. A timer or
watch. PRECAUTIONS For in-vitro diagnostic use only. Follow your laboratory safe
ty guidelines
in the collection, handling, storage and disposal of patient specimens and all i
tems exposed to
patient specimens. The Diluent and Controls contain sodium azide which may react
with lead or
copper plumbing to form potentially explosive metal azide. Large quantities of w
ater must be used
to ush discarded Diluent or Controls down a sink. The Capillary Bulb contains dry
natural
rubber. Do not interchange or mix components from different kit lots. SPECIMEN C
OLLECTION AND
PREPARATION Serum, Plasma, or Whole Blood Sample Obtain specimens by acceptable
medical
technique. Collect whole blood samples using a tube containing EDTA or heparin a
s an
anticoagulant. Other anticoagulants have not been tested. Serum and plasma speci
mens may be
refrigerated (28C; 3646F) and tested within 48 hours; serum and plasma specimens held
for
longer times should be frozen (below 10C; 14F) and tested within 3 months. Test who
le blood
specimens within 24 hours. Specimens must be at room temperature (1530C; 5986F) when
tested. Fingertip Whole Blood Hold the capillary tube horizontally while collect
ing the sample.

Touch the end of the capillary tube to the drop of blood on the patients nger. Fil
l the
capillary tube completely. Place the small end of the black bulb onto the capill
ary tube. Place
your ngertip over the opening in the bulb. Squeeze the bulb to dispense the whole
blood sample
into the test tube. QUALITY CONTROL External Quality Control For external QC tes
ting, use the
controls provided in the kit. Add one free falling drop of control to the Test T
ube and then
proceed in the same manner as with a patient sample. Quality Control requirement
s should be
established in accordance with local, state and federal regulations or accredita
tion
requirements. Minimally, Genzyme Diagnostics recommends that positive and negati
ve external
controls be run with each new lot and with each new untrained operator. Some com
mercial controls
may contain interfering additives. The use of these controls is not recommended.
Figure 4-4
Package insert. Courtesy of Genzyme Diagnostics. 1899_Ch04_063-082 21/12/11 2:19
PM Page 78
Chapter 4 Assuring Quality 79 Figure 4-4 Contd EXPECTED VALUES A heterophile ant
ibody response
is observed in approximately 8090% of adults and children with EBV-caused IM. Thi
s percentage
drops to approximately 50% for children under four years of age. (1) While the i
ncidence of IM
re ects wide seasonal, ethnic and geographical variation, a large epidemiological
study noted
that the highest incidence of symptomatic IM occurred during late adolescence (1
524 years of
age) (2) . PERFORMANCE CHARACTERISTICS A total of 439 specimens (183 serum, 176
plasma and 80
whole blood) were evaluated by two clinical labs in a clinical study. Test resul
ts of the OSOM
Mono Test were compared to results obtained with a commercially available latex
particle
agglutination test for the qualitative determination of infectious mononucleosis
heterophile
antibodies. Discrepancies between the results given by the OSOM Mono Test and th
e latex particle
agglutination test were resolved by Epstein-Barr Virus (EBV) speci c serological a
ssays. In these
assays, the speci c antibodies to the EBV capsid antigen (IgM) and EBV nuclear ant
igen-1 (IgM and
IgG) were determined. Serum Specimens: Comparative Test 74 8* 0 101 OSOM Mono T
est *6 out of 8
tested postitive by EBV testing + + Plasma Specimens: Comparative Test 67 15* 0
94 OSOM Mono
Test *8 out of 15 tested postitive by EBV testing + + Whole Blood Specimens: Com
parative Test
30 3* 0 47 OSOM Mono Test *1 out of 3 tested postitive by EBV testing + + All S
pecimens:
Comparative Test 171 26* 0 242 OSOM Mono Test *15 out of 26 tested postitive by
EBV testing + +
When compared to a commercially available latex particle agglutination test for
infectious
mono-nucleosis heterophile antibodies, the OSOM Mono Test showed a sensitivity o
f 100% and a

speci city of 90.3%. The overall agreement was 94.1%. POL Studies An evaluation of
the OSOM Mono
Test was conducted at three physicians of ces or clinical laboratories where testin
g was
performed by personnel with diverse educational backgrounds. Each site tested th
e randomly coded
panel consisting of negative (5), low positive (3) and moderate positive (4) spe
cimens for three
days. The results obtained had 99.1% agreement (107/108) with the expected resul
ts. Fifteen of
the 26 discrepant samples were determined to be recent or acute EBV infections b
y EBV serological
testing, in which case the sample was considered positive. Including the samples
con rmed
positive by EBV serological testing, the overall clinical study speci city of the
OSOM Mono Test
is 95.9% and the overall sensitivity is 100%. LIMITATIONS As with all diagnostic
assays, the
results obtained by this test yield data that must be used as an adjunct to othe
r information
available to the physician. The OSOM Mono Test is a qualitative test for the det
ection of IM
heterophile antibody. A negative result may be obtained from patients at the ons
et of the
disease due to heterophile antibody levels below the sensitivity of this test ki
t. If symptoms
persist or intensify, the test should be repeated. Some segments of the populati
on with acute
IM are heterophile antibody negative. (1) Internal Quality Controls The OSOM Mon
o Test provides
two levels of internal procedural controls with each test procedure. The red Con
trol Line is an
internal positive procedural control. The Test Stick must absorb the proper amou
nt of test
material and be working properly for the red Control Line to appear. A clear bac
kground is an
internal negative procedural control. If the test has been performed correctly a
nd the Test Stick
is working properly, the background will clear to give a discernible result. If
the red Control
Line does not appear, the test may be invalid. If the background does not clear
and interferes
with the test result, the test may be invalid. Call Genzyme Diagnostics Technica
l Assistance if
you experience either of these problems. 1899_Ch04_063-082 21/12/11 2:19 PM Page
79 TIME TO
REVIEW 1. Analyte means: Outcome 4-1 a. A similarity between two things b. A sub
stance being
tested c. A method used for testing samples d. A type of proficiency testing 2.
True or False:
The mean of a set of Outcome 4-1 results is the average of the results. 3. A qua
ntitative testing
procedure Outcome 4-1 provides results as: a. Numbers or measurements b. Positiv
e or negative c.
Descriptive analysis by a pathologist 4. Which concept focuses specifically Outc
ome 4-2 on the
analytical phase of laboratory testing? a. Quality control b. Quality assurance
c. Documentation
d. Personnel training 5. Which of these statements Outcome 4-3 describes how the
details of the

postanalytical phase of laboratory testing affects quality assurance? a. The pos

tanalytical phase
of laboratory testing is not considered to be part of quality assurance b. When
results are
reported promptly to the physi- cian as part of the postanalytical process, pati
ent care is
positively affected c. Postanalytical processes such as appropriate pa- tient ed
ucation are
critical for quality patient care d. Postanalytical processes such as performing
the test
procedures using the manufacturers inserts are critical for quality patient care
6. True or
False: If a medical assistant Outcome 4-4 performs only CLIA-waived testing, wil
l it be necessary for her to perform quality control? 7. When is troubleshooting performed? O
utcome 4-5 a.
Daily b. Quarterly c. As needed d. When directed by the package insert for the t
est kit 8. Please
provide three examples of Outcome 4-6 data that must be documented when logging
quality control
for a qualitative test. 80 Section I Overview of the Laboratory Case Study 4-1:
An unexpected
delay A 3-year-old child is brought into the office with a po- tential urinary t
ract infection.
The mother of the child goes into the restroom and helps with the collection of
a very small
amount of urine to run a urinalysis test. The physician wants the test run as so
on as possible so
that the child can be started on antibiotics, as she is very un- comfortable and
cries whenever
she has to urinate. The medical assistant turns on the urinalysis instru- ment,
and takes out the
quality control material from the refrigerator. While the instrument is performi
ng an inter- nal
electronic check, she notices that the quality control material has a printed ex
piration date
that has already passed, but only by a couple of weeks. 1. Would it be acceptabl
e to use this
quality control material? What are potential outcomes of this decision? 2. What
is one step that
could be taken before inform- ing the physician of the situation? 9. What is the
purpose of
Outcome 4-8 calibration verification? a.Calibration verification is performed to
see if the
internal quality control is working correctly b. Calibration verification is per
formed to see if
calibration is necessary for an instrument c. Calibration verification is perfor
med when a new
reagent lot number is put into use for the first time d. Calibration verificatio
n is performed
after a calibration has been completed on an instru- ment to verify that the cal
ibration was
success- ful and that the instrument is ready for patient testing 10. True or Fa
lse: Competency
testing Outcome 4-7 addresses only test results. 11. Where do laboratories obtai
n Outcome 4-7
samples for proficiency testing? a. From the test kit manufacturer b. From appro
ved providers c.
From the CMS d. From the CDC 1899_Ch04_063-082 21/12/11 2:19 PM Page 80 Chapter
4 Assuring

Quality 81 RESOURCES AND SUGGESTED READINGS CDC Report Assesses the State of Prof
iciency
Testing A summary of a recent report released by the CDC address- ing laboratory
quality
http://www.aacc.org/publications/cln/2008/June/Pages/ cover1_0608.aspx Clinical L
aboratory
Improvement Amendments Overview A written overview of CLIA policies and procedure
s, and numerous
links for more specific information http://www. cms.hhs.gov/CLIA/ CDC Report on G
ood Laboratory
Practices for Waived Testing Sites Summary of site visits to CLIA-waived testing
sites, as well
as recommendations for quality practices. Also available as a printed document.
http://www.cdc.gov/mmwr/preview/ mmwrhtml/rr5413a1.htm Tests Waived by the FDA Fr
om January 2000
to Present List of all CLIA-waived tests. Updated regularly. http://
www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfClia/ testswaived.cfm Laboratory Qua
lity Control
Good information about basic quality control standards
http://www.virology-online.com/presentations/ index.htm Good Laboratory Practice
With Waived
Systems Great information from the WA State Department of Health about laboratori
es that perform
only waived tests http://www.doh.wa.gov/hsqa/fsl/LQA_Home.htm Recommended Element
s of a
Laboratory Quality Assurance Plan Recommendations based on Environmental Protecti
on Agency (EPA)
procedures for development of a QA plan http://www.umass.edu/tei/mwwp/files Abbot
t Diagnostics
Practical Application Quality Control Guide Summary of the practical application
of quality
control principles http://www.abbottdiagnostics.com/Your_Health/ Thyroid/ Testin
g/quality.cfm
Westgard Rules: What Are They? Summary of the Westgard Rules interpretation of Lev
ey- Jennings
QC charts; the Westgard system for defining quality control limits http://www.we
stgard.com/
mltirule.htm 1899_Ch04_063-082 21/12/11 2:19 PM Page 81 1899_Ch04_063-082 21/12/
11 2:19 PM Page
82 83 Chapter 5 Legal and Ethical Issues Constance L. Lieseke, CMA (AAMA), MLT,
PBT(ASCP) CHAPTER
OUTLINE Legal and Ethical Issues in the Laboratory Environment Law and Ethics Le
gal Concepts
Affecting Patient Interactions Consent Release of Information and Patient Rights
and
Responsibilities Tort Law Liability Scope of Practice Health Information Portabi
lity and
Accountability Act The Impact of the Health Insurance Portability and Accountabi
lity Act on the
Medical Assistant Ethics Professional Behaviors Risk Management and the Medical
Assistant Summary
Time to Review Resources and Suggested Readings Learning Outcomes After reading
this chapter, the
successful student will be able to: 5-1 Define the chapter key terms. 5-2 Explai
n the difference
between law and ethics. 5-3 Distinguish between informed and implied con- sent,
and describe when
consent may be refused. 5-4 Express the principles presented in the Consumer Bil
l of Rights and
Responsibilities. 5-5 Explain who has a right to a patients medical in- formation

, and in what
circumstances that right may be waived. 5-6 Compare and contrast intentional and
uninten- tional
torts. 5-7 Describe the liability assumed by a medical assis- tant in the labora
tory, and why
personal malprac- tice insurance is recommended. 5-8 Explain what is meant by sc
ope of practice,
and how these limitations are established for medical assistants. 5-9 Explain th
e acronym HIPAA,
and explain how it affects the daily activities of a medical assistant in the la
boratory
environment. 5-10 Define ethics and explain the difference between personal and
professional
ethics. 5-11 Describe several ways that a medical assistant working in the labor
atory may be part
of risk management for his or her workplace. 1899_Ch05_083-094 21/12/11 2:20 PM
Page 83 84
Section I Overview of the Laboratory a statute. Laws are enforced by appointed
authorities. For
instance, the Occupational Safety and Health Administration has created rules to
uphold the
federal laws developed to safeguard employees. Generally, laws protect the publi
c by prohibiting
activities that may be harmful, and establishing some form of consequences that
would discourage
those that continue to pursue these activities. Health-care laws are designed to
pro- tect the
rights of the patients, the employees, or the employers. Ethics are like laws be
cause they
dictate or deter- mine appropriate behavior for individuals. They are different
from laws because
they are not created by governmental agencies. Personal ethics are behavioral gu
idelines that an
individual develops throughout a lifetime, guided by personal values and morals
, and influenced
by upbringing. Professional ethics are developed by a well-recognized profession
al organization, with the anticipation that those working in that profession will use them
as a guide for
appropriate conduct. LEGAL AND ETHICAL ISSUES IN THE LABORATORY ENVIRONMENT Most
of us understand
that it is important to obey the law and that there may be consequences if we ma
ke the wrong
choices. However, in our daily lives, we realize that there are factors other th
an laws that
affect our ac- tions. These factors may include our personal values and ethics.
In addition, as
health-care employees, medical as- sistants must adhere to a set of professional
laws and ethics
to perform our duties as we should. In this chap- ter, you will learn the differ
ence between law
and ethics, and examine how these concepts define the professional actions of th
ose employed in a
health-care environment. LAWS AND ETHICS Laws are essentially rules of conduct t
hat have been
created by government at the local, state or national level. An established rule
or law may also
be known as CAAHEP/ABHES STANDARDS CAAHEP Standards IX.C.1: Discuss legal scope
of practice for
medical assistants IX.C.5: Discuss licensure and certification as it applies to

healthcare
providers ABHES Standards
#
4: Medical Law and Ethics, b: Federal and State Guidelines, f: Health Laws and Regulations Graduates: f: Comply with federal,
state and local
health laws and regulations KEY TERMS Assault Battery Department of Health and H
uman Services
(HHS) Disclosure Duress Emancipated Ethics Expressed consent Fraud Health Insura
nce Portability
and Accountability Act (HIPAA) Implied consent Informed consent Intentional tort
Laws Liability
Libel Malfeasance Malpractice Misfeasance Negligence Nonfeasance Patient identif
ier Privacy Rule
Protected health information (PHI) Reportable condition Risk management Scope of
practice Slander
Standard of care Statutes Tort Unintentional tort 1899_Ch05_083-094 21/12/11 2:2
0 PM Page 84
LEGAL CONCEPTS AFFECTING PATIENT INTERACTIONS There are numerous laws and statut
es that play a
role in a health-care setting. In addition to feder al laws, each state has a me
dical practice
act that dictates the delivery of health-care services in that state. Medical as
sistants act as
agents of the physician office or labo- ratory where they are employed, which me
ans they have a
responsibility to abide by the laws that dictate their actions as they perform h
ealth-care
procedures and deal with patient information. In order to follow the established
rules, it is
vital to learn some general legal concepts. Consent The law requires that there
is consent, or
permission, given before any treatment occurs. The consent may be given verbally
, in writing, or
nonverbally by behavior. Implied consent means that the patients actions send a m
essage of
agreement to the treatment offered. For instance, when a patient offers his or h
er arm for a
blood draw, the consent for the procedure is implied by this action. Implied con
sent also
dictates care that occurs in an emergency situation. If the patient is not able
to refuse
consent, or if there is no legal document stating that emergency care should not
be offered,
emergency medical assistance may be rendered. It is assumed (implied) that the p
atient would want
to be saved. Informed consent is necessary whenever the treat- ment involved inc
ludes an invasive
surgical procedure, experimental drugs, or any treatment that could be a signifi
cant risk to the
health of the patient. This may also be known as expressed consent. Informed con
sent requires
that the patient is advised of the following details: The name of the procedure
to be performed
and the health-care provider that will perform the procedure Risks of the proced
ure Risks
involved if the procedure is not performed Alternatives to the treatment offered
It is
essential that the patient understand the compo- nents printed on the consent fo
rm, as it is a
legal docu- ment. The patient must sign and date the consent form, and this must

be witnessed. As
in all situations concern- ing consent, the responsibility for explaining the pr
oce- dure and the
risks belongs to the health-care provider (such as a physician or nurse-practiti
oner) but the
med- ical assistant may be asked to verify that the form is filled out correctly
, as well as
witness the signature of the patient. Minors generally are not allowed to sign a
n informed
consent. There are exceptions to this rule, which may vary from state to state.
The exceptions
generally involve requests for birth control or treatment of sexually trans- mit
ted infections.
There are also exceptions for emanci- pated minors, and those in the armed force
s who are still
under the legal age of consent. Emancipated minors have been declared by the cou
rt to be
independent and capa- ble of making their own medical decisions. All other mi- n
ors must have a
parent or legal guardian sign the con- sent form for them. A patient has the rig
ht to refuse
consent at any time. Patients may decline treatment for any reason, based on per
sonal beliefs,
cultural differences, or financial considerations. If consent is refused, the pa
tient should fill
out and sign a form declining the procedure. This documentation can be very impo
rtant if there is
a neg- ative outcome based on the patients decision to refuse treatment. Chapter
5 Legal and
Ethical Issues 85 Test Your Knowledge 5-1 Name one difference between laws and e
thics. (Outcome
5-2) Test Your Knowledge 5-2 When a patient offers an arm for a blood draw, what
kind of consent
is he or she offering? a. Informed consent b. Implied consent c. Deferred consen
t d. None of the
above (Outcome 5-3) Release of Information and Patient Rights and Responsibiliti
es Every patient
who seeks medical care has certain rights and responsibilities. Medical personne
l should always
be conscious of these principles when dealing with patients, so that they can st
ay within
appropriate boundaries in their interactions. Patient responsibilities include p
rovid- ing the
physician with accurate information about his or her medical history and current
condition,
following the physicians instructions for treatment and follow-up care, and provi
ding
appropriate compensation to the health- care provider for services provided. Pat
ient rights have
been addressed numerous times through the years. In 1998, the Presidents Advisory
1899_Ch05_083-094 21/12/11 2:20 PM Page 85 Commission on Consumer Protection and
Quality in the
Health Care Industry issued a Consumer Bill of Rights and Responsibilities. This
document
addresses seven distinct areas of patient care: 1. Information disclosure: Patie
nts have the
right to know the details of their health-care plan, their health-care professio
nals, and the
facilities they may use for care. This means that an interpreter must be provide
d if needed for

understanding. 2. Choice of providers and plans: Patients have the right to eval
uate different
providers and/or health coverage plans to make the best choices for their needs.
3. Access to
emergency services: If an emergency need arises, a patient has the right to rece
ive services
wher- ever needed without prior authorization. (However, this does not mean that
the patient will
not have to pay for these services if they are not covered specifi- cally by the
ir health-care
plan.) 4. Participation in treatment decisions: All patients need to know about
their treatment
options and have the right to participate in decisions about their medical care.
This also means
that they have the right to refuse care if they choose. 5. Respect and nondiscri
mination: All
patients have the right to receive respectful treatment from their health-care p
roviders that is
considerate of their feel- ings and without discrimination. 6. Confidentiality:
Patients have the
right to expect their health-care information to remain confidential. 7. Complai
nts and appeals:
All patients have the right to an objective review of any complaints they have a
bout their
health-care provider or health-care plan. This can include any part of their exp
erience, including billing, accessibility of the building for those with special needs, operati
ng hours, and so
on. Of course, the right to review and appeal also pertains to the quality of ca
re experienced.
Even though patients have the right to expect their health-care information to r
emain
confidential, there are limitations. The physical medical record (where the info
rmation is
documented; also known as the chart) belongs to the health-care provider, but the
information
in the record belongs to the patient. Patients have the right to request their m
edical
information, and they also have the right to control who has access to their med
ical records in
most situations. The information contained in the medical record may be requeste
d by numerous
parties, such as insur- ance companies, family members, and legal representative
s. Later in this
chapter we will learn more about the law which details how personal information
may be protected.
86 Section I Overview of the Laboratory Test Your Knowledge 5-3 Lily Lee is mov
ing to another
city to attend college. She would like to get a copy of her medical records to t
ake with her as
she establishes a new physician relationship in her new home. Does she have the
right to a copy
of her medical record? Is it appropriate for her to take the entire original rec
ord from the
office? (Outcome 5-4 and Outcome 5-5) Test Your Knowledge 5-4 If someone is assa
ulted, was he or
she touched or physically injured? (Outcome 5-1) There are some situations where
the disclosure
(sharing) of the patients information is required, even without consent. For inst
ance, if a

patient is diagnosed with a reportable condition, state and federal laws re- qui
re that the
laboratory or the health-care provider contact the local health department or th
e Centers for
Disease Control and Prevention (CDC). Reportable conditions are diseases or cond
itions that have
been deemed to be dangerous to the general public health. The statistics accumul
ated by the state
or federal agen- cies allow the prevalence of the disease in the population to b
e tracked.
Examples of reportable conditions include HIV infection, Lyme disease, cholera,
hepatitis,
measles, and gonorrhea infection. If a laboratory test is positive for these con
ditions, the
result must be passed on to the appropriate authorities as soon as possible. The
patient does not
have the right to stop this report process, although in some situations he or sh
e may have the
right to request anonymity to protect his or her identity. Tort Law Torts are wr
ongful acts that
are committed against a person or property that result in harm. The harm caused
by the tort may
be physical or emotional. This type of act does not include those that involve v
iolation of a
contract. Torts may be classified as intentional or unintentional. In the case o
f an intentional
tort, it must be apparent that the action was deliberate and intended to cause h
arm. Intentional
torts include the following: Assault: An assault involves threatening an individ
ual, or making
a person fear harm. 1899_Ch05_083-094 21/12/11 2:20 PM Page 86 Battery: Battery
is the act of
touching another with- out that persons permission. A person may be com- mitting
battery even if
the touch does not cause harm. Duress: If a patient is forced or coerced into an
act (such as
signing a consent form or undergoing a procedure against his or her will), that
person may claim
duress. Libel: If a health-care professional makes a false writ- ten statement a
bout a patient
(or someone else), he or she may be accused of libel. This is especially a problem when the
false statement causes a problem with the victims reputation or employment. Sland
er: Slander
is false statement made about some- one else orally. Fraud: Fraud is a dishonest
or deceitful
act that is performed with the intent to hide the truth. Unintentional torts are
situations in
which the harm was the result of an accident. The accuser must believe that the
employee was
performing his or her job in good faith when the patient was harmed, and the inc
ident was not
deliberate. Negligence is often involved in uninten- tional torts, as it means t
hat a
professional did not take reasonable care to prevent harm. The term malpractice
is used if a
health-care professional is shown to be negli- gent in his or her duties. Malpra
ctice accusations
are the most common reason for claims against health-care professionals, and the
legal decisions

are based on the standard of care (minimum safe professional conduct) for a reas
onable
professional with the same training who might be facing a similar situation. Mal
practice may be
classified in one of three ways: 1. Malfeasance: In this situation, the treatmen
t pro- vided was
wrong and unlawful. 2. Misfeasance: If treatment was provided, but it was perfor
med in an
improper manner, it is known as misfeasance. 3. Nonfeasance: When the health-car
e professional
fails to perform a necessary act or delays treatment exces- sively, the act is k
nown as
nonfeasance. their ability. Liability exists in all areas of our lives: driv- in
g a car or while
walking the dog, for example. We are responsible for our actions, and obligated
to drive the car
to the best of our ability, as well as keep our dog on a leash and under control
while on the
walk. For health- care professionals, their liability insurance is actually malp
ractice
insurance, as they may be held responsible for an intentional or unintentional t
ort if they make
a mistake or they dont perform their jobs to the best of their ability. Anyone wh
o works in a
medical office is liable for all interactions with the public, whether per- form
ing an invasive
procedure, taking a blood pressure reading, or participating in a phone call wit
h a patient. A
malpractice suit may be filed against any or all of the employees in an office o
r laboratory. In
most health-care facilities, the malpractice insurance coverage for the physicia
n or health-care
provider gener- ally includes coverage for the medical assistant working for the
m. Many medical
assistants dont pursue their own malpractice insurance coverage. This may be a mi
stake. If a
patient sues the practice (specifically naming each indi- vidual involved), for
malfeasance, for
example, the best outcome for the physician may be to settle out of court. This
means that the
incident will still be on the record for the medical assistant, who was not part
of the decision
to settle in this way. For medical assistants (or other allied health-care profe
ssionals) who
work in the laboratory setting, it is especially important to have appropriate p
ersonal coverage.
Even though the physician may have malpractice insurance that appears to be adeq
uate, it is
possible that when drawing blood or performing labora- tory tests outside of the
direct
supervision of the physi- cian, the medical assistant may be found to be solely
responsible for
malpractice. In addition, if a physician is sued for malpractice because of a ve
nipuncture or
other procedure performed by his or her medical assistant, the physician can eve
n file suit
against the medical assistant for financial damages incurred as a result of the
incident. Chapter
5 Legal and Ethical Issues 87 Test Your Knowledge 5-5 What is the difference be
tween an

intentional and unintentional tort? (Outcome 5-6) Test Your Knowledge 5-6 Is a m
edical assistant
working in a laboratory liable for his or her actions while working with patient
s? Is it possible for him or her to be sued for malpractice? (Outcome 5-7) Scope of Practice
Scope of
practice is a term used to describe the activities that an employee in a specifi
c profession can
and cannot perform. These limitations are different for each of the Liability He
alth-care
professionals assume a certain amount of liability in everything that they do, m
eaning that they
are legally obligated to perform their duties to the best of 1899_Ch05_083-094 2
1/12/11 2:20 PM
Page 87 health-care professionals present in a physician office or laboratory en
vironment. The
scope of practice is dictated by licensure and training, and may vary according
to the state in
which a professional offers his or her services. Medical assistants are not lice
nsed, meaning
that they are required to work under the license of another qualified health-car
e professional,
such as a physician, nurse-practitioner, or physicians assistant. These health- c
are
professionals have a responsibility to train the medical assistant and to establ
ish his or her
duties and limitations within the practice. Many states have statutes in place t
hat limit the
duties that a medical assistant may perform. Although certification is not manda
tory, medical
assistants may take a comprehen- sive examination to become nationally certified
by the American
Association of Medical Assistants or regis- tered through the American Medical T
echnologists. In
addition, some states require very specific certification or registration for al
lied health
professionals who per- form invasive procedures. Educational programs for medica
l assistants
vary. Some may be just a few months in length, whereas other programs offer a 2year associate
degree. In addition, each state may have different laws that dictate the tasks t
hat may be
legally performed by medical assistants. This means that the scope of practice f
or a medical
assistant is based on his or her education and training, as well as the limitati
ons that may be
in effect by the state in which he or she practices. In general, the scope of pr
actice for
medical assistants includes the following limitations: Medical assistants are no
t able to make
independent medical assessments or diagnose, or give advice independently. It is
the
physicians responsibility to be aware of the medical assistants scope of practice,
whether
based on state laws or the medical assistants training. Medical assistants are no
t able
independently to write prescriptions or give out medication samples without spec
ific documented
orders from a qualified health- care professional. Medical assistants cannot ind
ependently

interpret test results or treat patients. In most states, the following are task
s that medical
assistants are allowed to perform: Assisting with various clinical and patient c
are procedures
Carrying out administrative procedures such as answering phones, working with ch
arts, and
perform- ing billing and coding Obtaining medical histories Explaining treatment
procedures
to patients (within the guidelines established by the facility) Preparing and as
sisting with
various routine and spe- cialty examinations Collecting specimens, including ven
ipuncture and
capillary puncture Performing electrocardiograms (ECGs) Administering medication
Assisting
with prescription refills Performing Clinical Laboratory Improvement Act waived l
aboratory
tests or those of moderate complexity Assisting with various disease management
programs, such
as tracking laboratory results for a patient on medication Administering injecti
ons 88 Section
I Overview of the Laboratory Test Your Knowledge 5-7 Is the scope of practice t
he same for
medical assistants anywhere in the United States? (Outcome 5-8) HEALTH INSURANCE
PORTABILITY AND
ACCOUNTABILITY ACT Earlier in this chapter, we discussed the Consumer Bill of Ri
ghts and
Responsibilities. One component ad- dressed the confidentiality of a patients hea
lth record.
This is a very complex issue, and it has been addressed in various ways, as the
protection of
personal health information is one of the most important duties of a health-care
professional. It
is impossible to establish a good working relationship with a patient if there i
s no trust in the
professionals ability to keep private information secure. Patients share informat
ion with those
in health care that they do not divulge to anyone else, and the expectation is t
hat this
information will only be shared if it is absolutely necessary for patient treatm
ent. In the early
1990s, it became evident that there were areas of health care that needed reform
. Congress passed
the Health Insurance Portability and Accountability Act (HIPAA) to provide guide
lines for this
reform. This act was originally designed to improve the efficiency and effective
ness of the
health-care system by focusing on the following areas: Improvement of the health
benefit
options for covered workers who leave or change jobs Standardization of electron
ic health data
1899_Ch05_083-094 21/12/11 2:20 PM Page 88 Creation of unique health identifiers
for the
various entities involved in health-care services Development of security standa
rds for
handling protected health information (PHI), which includes anything in the pati
ents health
record that could be used to identify the patient One of the standardization met
hods for handling
health data was to increase the use of computers for transmission of health info
rmation. This

created more concerns about the unauthorized access to personal information that
may occur with
electronic transmis- sion. To address these confidentiality issues, the Departme
nt of Health and
Human Services (HHS) developed the Privacy Rule, which is an expansion of the or
iginal HIPAA
mandate that applies to confiden- tiality of health information, and the rights
of patients to
control access to their own records. This rule went into effect April 2003, and
it carries
significant mone- tary consequences for noncompliance. This is the first federal
ly mandated set
of rules for the protection of health information. understanding that it may tak
e some time to
process the request and copy the records. 4. Health information cannot be shared
with others
without the patients consent. This does not apply to reporting that may be requir
ed by law. 5.
When any patient information is shared, it is impor- tant that it is limited to
data that are
essential for that situation. This is especially important when dealing with lab
or and industry
claims for injured employees or insurance claims, as the health-care professiona
l should include
only records about a specific treat- ment if it is in question, but not the enti
re chart. 6. The
Privacy Rule also requires every office to have a privacy notice and to train al
l employees about
HIPAA and the Privacy Rule. All patients must receive a copy of the offices priva
cy notice, and
patients must give written consent or permission to disclose their health-care i
nformation. A
privacy or HIPAA compliance officer must be assigned for every institution to ov
ersee the process
within that office. The HIPAA regulations still allow health-care providers to s
hare information
with family members who are directly responsible for the care of a patient, or t
o other providers
or members of the health-care team (such as radiology services, laboratory profe
ssionals, etc.)
when it is necessary for patient care. Also, the regulations recognize that some
times it is
impossible for oral privacy to be assured in all areas of a practice; there has
to be evidence
that this has been addressed to the full extent of the facility. The Impact of t
he Health
Insurance Portability and Accountability Act on the Medical Assistant The privac
y section of the
HIPAA regulations may affect phone conversations with or about patients, discuss
ion of patient
issues within earshot of the waiting area in a clinic, or the visibility of pati
ent information
to visitors in an office. Laboratory requisitions that contain PHI can- not be l
eft where
patients may have access to them, com- puter screens should not be visible to pa
tients as they
walk to and from the treatment area, and patient sched- ules that contain names
should not be
posted where they are visible by those who are being treated. Fax numbers used t
o transmit

laboratory results must be carefully monitored, as these results need to end up

in a secure
location once received. Complications arise when pro- tected health information
is shared via
e-mail, although this method of transmitting information may be more efficient f
or patient care
within a large organization or Chapter 5 Legal and Ethical Issues 89 Test Your
Knowledge 5-8
Does HIPAA impact only confidentiality of medical information? (Outcome 5-9) The
Privacy Rule
outlines very specific precautions that are to be practiced in every health-care
facility. There
are several standard provisions that all medical as- sistants should keep in min
d, regardless of
their specialty of practice: 1. Any document that includes a patient identifier
must be treated
as protected health information. These identifiers include demographic informati
on such as name,
address, and phone number, but also include photos, Social Security numbers, bir
th dates, and
other types of unique information that may be linked back to that specific patie
nt. Documents
must have all patient identifiers removed before they can be discarded, or they
must be destroyed
in such a way that this information is not available after disposal. 2. Patients
have a right to
know how their PHI has been shared, even if it was necessary for treatment. 3. P
atients have a
right to review and/or to request copies of their medical records. This law does
not state that
they have the right to walk out of an office with their physical chart, nor does
the office have
to allow review or copies to be available at any time. A patient can submit a re
quest for the
records, with the 1899_Ch05_083-094 21/12/11 2:20 PM Page 89 between providers.
The need for
electronic security mea - sures is great. Also, many clinics have changed the wa
y they call
patients from the waiting room for treatment; they now call the patients by the
first or the last
name, but not both. It is the responsibility of the designated HIPAA compliance
officer to decide
the specific methods used by an office for compliance with the regulations, and
to ensure that
appropriate training is provided for all employees. It is also illegal to gossip
about patients,
even if it is in a private area where other patients cannot hear. Dis- cussions
about patient
care are to be limited to those that are necessary for providing quality health
care. As
health-care professionals, medical assistants are not allowed to share any prote
cted health
information with family or friends. Sometimes this is difficult, as health- care
professionals
may have knowledge about a family friend or relative that others would want to k
now. It is
illegal to share this information, so care must be taken to keep it private. Ano
ther example of
illegal action is idle searching of the database within a health-care facility t
o see who might

have had services provided. There were recent reports in the news of employees w
ho lost their
jobs and of facilities that were fined significantly when an em- ployee searched
for the records
of a celebrity rumored to be in a certain facility. Even if this information is
not shared with
anyone else, it is a HIPAA violation to per- form the search. It can (and will)
be tracked back
to the responsible individual. ETHICS Most of the information in this chapter is
based on laws
and legal terms that dictate the actions of health-care professionals. But there
are also ethical
decisions that must be made every day in order to interact appropri- ately with
patients,
coworkers, and other members of the health-care team. Ethics are standards that
define our
actions, but they are not created or enforced by govern- mental agencies. As was
explained at the
beginning of this chapter, there are two types of ethics that define our actions
while at work.
We must adhere to a set of per- sonal ethics that are defined by our own sense o
f what is right
and wrong. Professional ethics also define our actions. These are based on the s
tandards of our
profes- sions, and although they are not laws, there are conse- quences to uneth
ical behaviors.
Personal ethics begin to develop in childhood. We generally understand what our
parents and
community define as acceptable behavior by the time we enter grade school. These
are based on our
morals and values, and become refined as we approach adulthood. Per- sonal value
s such as the
desire to help others will make a health-care professional much better at perfor
ming his or her
job. Empathy, honesty, responsibility, and respect for others are also part of o
ur personal
ethics; this is often known as our work ethic. Remember, if there is something t
hat you are doing
at work that you are not proud of, it is probably unethical at the per- sonal le
vel for you.
Professional Behaviors Professional ethics are standards established by the profession, and
usually sponsored by a professional organization that represents the profession.
Physicians have
several codes of ethics that define their actions, such as the Hippocratic Oath
and the Code of
Medical Ethics defined by the American Medical Association. One eth- ical theme
present in both
codes is the show of respect for patients and to show compassion for those serve
d, while staying
within legal limits of practice. By utilizing these standards, physicians may re
mind themselves
why they chose this profession, and also remember what their patients may expect
from them. The
American Association of Medical Assistants also has a code of ethics (Box 5-1).
These guidelines
also include respect for patients and the laws that guide the medical assisting
profession, as
well as ser - vice to the community and lifelong learning. At a min- imum, profe
ssional ethics

for medical assistants must put patients first by honoring their right to confid
en- tiality and
by being honest in all professional situa- tions. If this code is supported by a
strong set of
per- sonal ethics, a medical assistant will be a valuable asset to the professio
n. Remember that
there are ethical dilemmas that de- velop. Many times there may be a situation t
hat arises that
is not illegal, but it is unethical. This may include sit- uations in which the
medical assistant
does not agree with the actions of the employer, even though these actions are n
ot illegal.
Usually these issues involve disrespect for pa- tients or a poor quality of care
due to the
attitude of the physician. The medical assistant will need to make choices about
whether she can
continue employment with this practice. 90 Section I Overview of the Laboratory
Test Your
Knowledge 5-9 List two professional standards included in the AAMA Code of Ethic
s. (Outcome 5-10)
1899_Ch05_083-094 21/12/11 2:20 PM Page 90 Chapter 5 Legal and Ethical Issues 9
1 BOX 5-1
American Association of Medical Assistants code of ethics Members of AAMA dedica
ted to the
conscientious pursuit of their profession, and thus desiring to merit the high r
egard of the
entire medical profession and the respect of the general public which they serve
, do pledge
themselves to strive always to: A. Render service with full respect for the dign
ity of humanity;
B. Respect confidential information obtained through employment unless legally a
uthorized or
required by responsible performance of duty to divulge such information; C. Upho
ld the honor and
high principles of the profes- sion and accept its disciplines; D. Seek to conti
nually improve
the knowledge and skills of medical assistants for the benefit of patients and p
rofessional
colleagues; E. Participate in additional service activities aimed toward improvi
ng the health and
well-being of the community. POINT OF INTEREST 5-1 Medical assisting scope of pr
actice There is a
lot of confusion among medical assistants as well as physicians, nurse-practitio
ners, physician
assistants, and other health-care providers about the scope of practice for the
medical
assistant. The con- fusion is well earned; the scope of practice for each state
differs widely.
For those medical assistants who move from one state to another, it can become e
ven more
difficult to know what they are allowed to do in any given state. Governing Agen
cies Just finding
the regulations for each state can be diffi- cult. A good resource may be the pr
ogram director
for the local CAAHEP or ABHES accredited medical as- sisting programs. These pro
gram directors
should have up-to-date information about the scope of practice for the medical a
ssistants in
their area, and should be able to provide information about which governing body
oversees medical

assistants in their state. In many states the department of health oversees the
unlicensed
members of the health-care teams. In other areas, med- ical assistants may be pa
rt of the state
nursing board. Registration or certification Medical assistants are nonlicensed
members of the
health-care team. There is no license available in any state for medical assista
nts. However,
most states do re- quire some sort of registration process for the medical assis
tants in their
jurisdiction. This may include a test- ing process by which they are registered
and certified to
perform in that state, or the state may require only that the medical assistant
fill out certain
paperwork and submit a fee to become registered. Some states require the medical
assistant to
bear the burden of registration fees, whereas other states require that the medi
cal assis- tant
be registered each time she or he changes employ- ers and the employer is respon
sible for the
fee. Many medical assistants are under the impression that if they become Certif
ied Medical
Assistants through the AAMA or Registered Medical Assistants through the America
n Medical
Technologists that this will cover them regardless of their state of resi- dence
and that these
credentials somehow expand their scope of practice. This is not true. Many state
s will grant
registration (or certification) if the medical assistant is nationally certified
, or they may
require those who are not nationally certified complete a state certification pr
ocess. However,
this varies from state to state, so it is very important to find out what the re
gulations are in
your state of residence. Usually the office manager or physician you are working
for knows the
rules, but occasionally they have decided not to work with the state to register
their medical
assistants. This is not a safe environment to work in, as the medical assistant
may be operating
out- side of his or her scope of practice and unlawfully performing tasks, which
place him or her
at risk for legal actions. Allowable tasks Every state has limitations for the t
asks that can be
performed by the medical assistants. The following are some of the tasks that ma
y be limited:
Invasive procedures: Some states allow medical assistants to draw blood, but thi
s task is still
limited in a few areas. Many states (e.g., New York) do not allow medical assist
ants to
administer medication through any route, including by injection. It is important
to clarify this
before performing injec- tions or venipuncture. Continued American Association o
f Medical
Assistants (AAMA) Code of Ethics 1899_Ch05_083-094 21/12/11 2:20 PM Page 91 RISK
MANAGEMENT AND
THE MEDICAL ASSISTANT After reading through this chapter, it may appear that the
legal aspects of
the medical profession are over- whelming. There is a lot of information to reme
mber, but as a

medical assistant, there are many things that you can do to avoid risk of harm t
o yourself, your
patients, and your practice. This concept is called risk management. These risks
may be legal in
nature, as in a case in which a malpractice suit is filed for poor qual- ity of
care; financial
in nature, as in a case in which a laboratory or physician office chooses not to
accept patients with specific insurance coverage because of the potential for low levels
of reimbursement;
or physical in nature, as in a case in which a medical assistant might not use t
he appropriate
technique to perform a capillary blood draw, or when an office staff doesnt notic
e the puddle
inside the front entrance to the clinic and a pa- tient slips and falls. Because
a medical
assistant may be the member of the health-care team in an office or a laboratory
who spends the
most time with a patient, it is important that he or she keep the following risk
management
techniques in mind to avoid potential harm or legal action: Act within the defin
ed scope of
practice Use all available training to be certain that techniques are performed
with the
highest level of skill possible Use current, up-to-date equipment as available P
erform
regular performance checks on any testing equipment used for patient samples Fol
low the
manufacturers instructions exactly for all laboratory testing performed Consult r
esources
(other employees or reference mate- rials) if you have questions Verify the iden
tity of every
patient before you begin interactions Chart when patients call to inquire for te
st results, and
when they are notified of the results Be certain that all laboratory results are
handled in a
timely manner Practice confidentiality at all times Always practice universal pr
ecautions and
keep your environment medically aseptic Treat all patients with respect and over
come personal
biases to treat them all equally Act as a chaperone when needed for procedures O
btain
informed consent when necessary Be vigilant for potential safety hazards in the
clinic
environment Document promptly and thoroughly Log all phone call correspondence R
emember not
to criticize other members of the health-care team or other health-care provider
s Do not give
advice that has not been approved by the office policy Do not be afraid to ask f
or help if you
are feeling over- whelmed by the number of patients you are assisting or by the
tasks at hand. 92
Section I Overview of the Laboratory IV access: Most states limit the IV access
of nonlicensed health-care personnel. In some areas, the medical assistant is allowed to
stop the IV or
remove the catheter when it is no longer needed, but most areas prohibit much mo
re than this.
Placement of urinary catheters: This is an area where many medical assistants ar
e currently

operat- ing outside of their scope of practice. Most states prohibit the placeme
nt of a urinary
catheter by a nonlicensed health-care professional. Administering oral medicatio
ns: Although
medical assistants are allowed to give injections in most states, the administra
tion of oral
medication may still be limited. Washington State, for example, has a list of or
al medications
that can be administered by health- care assistants, which include medical assis
tants. Working
in a hospital setting: Some states prohibit medical assistants from working in a
hospital or
inpatient setting if they are performing clinical pro- cedures. This decision is
based on the
presence (or absence) of health-care providers in the vicinity while invasive pr
ocedures are
performed. Suture removal: Most states allow medical assis- tants to remove sutu
res, but there
are limitations in a few areas. Botox administration or assisting with other cos
metic
procedures: Medical assistants generally cannot operate laser equipment or admin
ister Botox or
other injections that are not considered to be medications. Test Your Knowledge
5-10 After
drawing the blood from a patient, medical assis- tant Krissy Clark takes the tim
e to document the
blood draw site, the date, and the time of the draw on the laboratory requisitio
n. Is this an
example of risk management? (Outcome 5-11) 1899_Ch05_083-094 21/12/11 2:20 PM Pa
ge 92 SUMMARY The
majority of the time, the relationship between a patient and the health-care tea
m is an amicable
one in which both parties are satisfied with the care provided. However, there a
re unfortunate
situations that may arise as a patient is treated that damage this relationship.
Sometimes these
result in charges of malpractice, and sometimes they may require legal actions b
ecause a member
of the health-care team ignored the legal guidelines that define their scope of
practice. In
order to protect ourselves from these situations, it is important to stay insure
d as a means of
protecting our financial security. It is also important to be aware of the legal
boundaries for
each profession. Ethics play a role as well, as not all inappropriate actions in
a medical office
or labora- tory are illegal. Risk management is a way to pro- vide care defensiv
ely; avoid
problems before they start! TIME TO REVIEW 1. What is a statute? Outcome 5-1 a.
A personal set of
rules dependent on an individ- uals sense of right and wrong b. A law established
by the
legislative branch of a government entity c. Behavioral standards established by
a professional
organization 2. If a newspaper article prints Outcome 5-1 information about a lo
cal physician
that is untrue, what legal term might be used to describe this action? 3. What i
s the meaning of
the acronym Outcome 5-1 HIPAA? 4. Who establishes laws that affect Outcome 5-2 h
ealth-care

organizations? a. Professional organizations b. Governmental agencies c. Local g

roups of
practitioners d. Local health departments 5. The_______________________ Outcome
5-3
_________________ is responsible for explaining the details of a procedure to th
e patient before
the informed consent paperwork is signed. Chapter 5 Legal and Ethical Issues 93
Case Study 5-1:
Too much talk Amy Conner is the receptionist who greets patients at the front de
sk for a family
practice physician. A 17-year-old young man comes in to have his blood drawn a f
ew days after
seeing the physician. He enters the reception area by himself, and gives Amy his
requi- sition.
She notices that in addition to several routine chemistry tests, the physician h
as ordered an HIV
screen to be performed. Amy puts the laboratory orders into the computer system,
and hands the
labels to the medical assistant to perform the blood draw. After the young man l
eaves the
facility, Amy steps into the hallway behind the reception area and starts 6. Whi
ch of these
principles are not Outcome 5-4 addressed in the Consumer Bill of Rights? a. The
right to
insurance coverage b. The right to emergency services when needed c. The right t
o be treated
without discrimination d. The right to an interpreter if needed 7. What is a rep
ortable
condition? Outcome 5-5 8. True or False: It is not necessary for a Outcome 5-7 m
edical assistant
to carry her own malpractice insurance. 9. Referring to the medical assisting Ou
tcome 5-8 scope
of practice explained in this chapter, which of these duties would be outside th
e guidelines? a.
Offering medical advice based on personal experiences b. Documentation of proced
ures performed c.
Assisting with a Pap smear specimen collection d. Scheduling appointments 10. Tr
ue or False: It
is a HIPAA violation Outcome 5-9 to fax medical information to a health-care spe
cial- ist who is
functioning as a consultant for a patients complicated medical condition. 11. Per
sonal ethics
are defined by: Outcome 5-10 a. Professional standards of the profession b. Loca
l statutes c.
Experiences and guidance beginning in child- hood d. HIPAA 12. True or False: Ri
sk management
Outcome 5-11 should be a part of the routine for everyone working in the healthcare environment.
Continued 1899_Ch05_083-094 21/12/11 2:20 PM Page 93 94 Section I Overview of t
he Laboratory a
conversation with the medical assistant. She tells the medical assistant how sad
it is that an
HIV test has to be done on someone so young, and expands her conversation to inc
lude all the
potential ways that he could have contracted HIV. After a few minutes she hears
someone at the
front desk and steps back to her work area. The 17-year-old patient is now at th
e front desk
again, with his mother standing next to him. He appears to be uncomfortable, and
the mother

starts to ask questions about the conversation that Amy was having in the hallwa
y. a. Are Amys
actions in violation of the law? b. Should Amy assume that the mother knows all
about the blood
tests that were ordered for her son? c. How should this situation have been hand
led? RESOURCES
AND SUGGESTED READINGS Office for Civil RightsHIPAA Detailed reference for the HHS
Privacy
Rule http://www.hhs.gov/ocr/Health InformationPrivacy What Is Ethics? Article publ
ished by
Santa Clara University about the meaning of ethics, and how personal and profess
ional ethics
differ http://www.scu.edu/ethics/practicing/decision/ whatisethics.html Quidel Ra
pid Diagnostic
Products Links to the Quidel point-of-care test kits, including CLIA- waived test
s.
http://www.quidel.com/products/product_ list.php?cat=1&by=brand&group=1 Reportabl
e Diseases
Information about reportable diseases that must be reported to the local authori
ties or the
Centers for Disease Control and Prevention http://www.nlm.nih.gov/medlineplus/en
cy/
article/001929.htm 1899_Ch05_083-094 21/12/11 2:20 PM Page 94 95 Chapter 6 Labor
atory Equipment
Constance L. Lieseke, CMA (AAMA), MLT, PBT(ASCP) CHAPTER OUTLINE Laboratory Equi
pment Microscopes
Compound Microscopes Other Types of Microscopes How Do Medical Assistants Use Mi
croscopes?
Centrifuges Centrifuge Maintenance Centrifuge Safety Laboratory Refrigeration In
cubators
Equipment Used for Automated CLIAWaived Testing Testing Methodology Instruments U
sed for
Chemical Testing of Urine Specimens Instruments Used for Coagulation Testing Ins
truments Used for
Chemistry Testing Instruments Used for Hemoglobin Measurements Other Hematology
Instruments
Glassware and Other Miscellaneous Laboratory Equipment Summary Time to Review Re
sources and
Suggested Readings 6-1 Define the key terms. 6-2 Describe the different types of
microscopes
introduced in this chapter. 6-3 Identify the different parts of a compound micro
scope. 6-4
Describe maintenance procedures for a compound microscope. 6-5 Explain how to co
rrectly focus a
microscope to examine a specimen on a slide. 6-6 Explain the role of a medical a
ssistant in a
physi- cian office laboratory that performs microscopic examinations of specimen
s. 6-7 Explain
how to operate and maintain a centrifuge. 6-8 Describe how temperature must be m
onitored for a
laboratory refrigerator. 6-9 Explain why an incubator is sometimes used in a lab
oratory
environment. 6-10 List several advantages of providing CLIA-waived testing in a
physician office
laboratory. 6-11 Demonstrate understanding of the basic principles used for meas
urement in
laboratory instruments. 6-12 Explain why automated urine analyzers are used. 6-1
3 Describe
similarities between the different types of coagulation testing instruments avai
lable for

CLIA-waived testing. 6-14 List several types of instruments used for CLIA waived
chemistry
testing. 6-15 Describe the operation of an instrument used to measure hemoglobin
in a whole blood
specimen. 6-16 List the types of hematology instruments presented in this chapte
r. 6-17 Describe
some of the types of glassware found in the laboratory, and how to correctly mea
sure the liquid
level in glassware. Learning Outcomes After reading this chapter, the successful
student will be
able to: 1899_Ch06_095-117 21/12/11 2:21 PM Page 95 96 Section I Overview of th
e Laboratory KEY
TERMS Agglutination Anemia Aperture Arm Balanced Base Beaker Binocular Centrifug
al force
Centrifuge Cholesterol Coarse adjustment knob Compound microscope Condenser Cove
r slips Cylinder
Diluent Dissecting microscope Electrical impedance Electrolyte Electron microsco
pe Eyepiece Fecal
occult blood Fine adjustment knob Flask Glass slides Glucose Glycosylated hemogl
obin monitoring
Graduated cylinder Hemoglobin Incubator International normalized ratio (INR) Iri
s diaphragm
Laboratory thermometer Light source Lysed Meniscus Monocular Objective lenses Oc
ular lens Oil
immersion lens Pipette Plasma Prothrombin time test Protime Reagent strips Revol
ving nosepiece
Rotations per minute (rpm) Serum Spectrophotometer Stage Stereo microscope Tacho
meter Water baths
LABORATORY EQUIPMENT Laboratories use many types of instruments to process, stor
e, and analyze
specimens. As the complexity and variety of tests offered by a laboratory expand
, so do the
number of instruments in use. Because medical assistants are generally working i
n laboratory
environments performing Clinical Laboratory Improvement Act (CLIA)waived tests, t
hey dont
usually use a wide vari- ety of instruments. This chapter focuses on equipment c
ommonly used for
specimen processing and storage, as well as performance of CLIA-waived testing p
rocedures.
CAAHEP/ABHES STANDARDS None Selected instruments used for laboratory tests of mo
der- ate
complexity are also presented. Microscopes There are several types of microscope
s available.
These vary by the amount of magnification, the manner by which the image is view
ed, and the light
(energy) source used. A typical laboratory setting will use a compound microscop
e, and some
laboratories may also use a dissecting microscope, especially if the laboratory
performs blood
bank procedures. Specialty laboratories 1899_Ch06_095-117 21/12/11 2:21 PM Page
96 Chapter 6
Laboratory Equipment 97 may also have personnel trained to operate an electron m
icroscope to
create three-dimensional images of the specimens. All microscopes provide magnif
ication so that
microscopic structures or organisms that are too small to be seen with the naked
eye can be
identified or quantified in a specimen. Sometimes it is necessary to apply stain
to a specimen

before viewing, and sometimes the specimen is viewed in its natural state. Compo
und Microscopes
The compound microscope is the most common type used in a general laboratory set
ting. The
magnification for this type of microscope is compounded, or increased by two dif
ferent sets of
lenses. The energy source is a replaceable bulb that sits in the base of the mic
roscope and
shines very brightly. Adjustments may be made for the amount of light used for v
iewing, as well
as the strength of the magnification, which makes this micro- scope very versati
le. Compound
microscopes are often used to visualize stained blood smears, urine sediment, an
d various
microbiology specimens. Test Your Knowledge 6-1 What is the most common type of
microscope used
in the clinical laboratory? a. Dissecting microscope b. Electron microscope c. F
luorescent
microscope d. Compound microscope (Outcome 6-2) Figure 6-1 shows a compound micr
oscope with its
component parts identified. It is important that medical assistants working in t
he laboratory
know how to set up a microscope properly, focus a slide for viewing, and maintai
n the microscope
appropriately after the proce- dure. To perform these procedures correctly, the
medical assistant
must be able to identify the parts of the micro- scope. Although at first glance
the microscope
itself may appear complex, its parts may be broken into categories to help you t
o remember their
names and understand their function. Oculars (eyepieces) Objectives Stage clips
Stage Stage
adjustment knobs Light source Base Rotating nosepiece Arm Coarse adjustment knob
Fine adjustment
knob Condenser Figure 6-1 Parts of a compound microscope. 1899_Ch06_095-117 21/1
2/11 2:21 PM Page
97 generally, the denser the specimen, the more light will be needed. In additio
n, as the
magnification increases, there is more need for light, so the condenser and iris
diaphragm need
to be adjusted for better viewing. Magnification The compound microscope has two
dif- ferent
points of magnification. The first magnification is encountered as the light pas
ses through the
specimen from below the stage, and flows into one of the objective lenses. These
lenses are
located on a revolving nosepiece and are identified with their respective power
of magnification: 4X, 10X, 40X, and 100X. The different objectives also vary by rings of d
ifferent colors
on each, and by the length of each objective tube. When using the micro- scope,
the operator
starts with the objective marked with the lowest magnification, and proceeds thr
ough the various levels as needed to view the specimen. If the 100X objective is used, a thin
layer of oil is
placed between the objective and the specimen on the slide to further focus the
light and make
the image as sharp as possible. This objective is known as the oil immersion len
s. The second

point of magnification available in a com- pound microscope is located within th

e eyepiece at the
very top of the microscope. An internal mirror actually reflects the image from
the slide through
this ocular lens (eyepiece) where an additional 10X magnification is accomplishe
d. This means
that if the 100X oil immersion lens is used to examine a specimen, the object is
actually viewed
as 1,000 times larger than it would be without magnification. A binocular micros
cope is one that
has two ocular lenses (or eyepieces), and a monocular microscope is one that has
only one ocular
lens used to view the specimen. Focus on the specimen is achieved by using the c
oarse adjustment
knob and the fine adjustment knob. These knobs project out from the side of the
microscope arm.
The larger of the two knobs is the coarse adjustment, and is used when the speci
men is first
being brought into focus at a low magnification. The fine adjustment is the smal
ler knob, and is
used to fine-tune the focus. The fine adjustment knob is used with the higher ma
gnification
levels. Microscope Maintenance Procedures. A microscope must be handled and main
tained properly
in order to keep it functioning as it should. The following are a few 98 Section
I Overview of
the Laboratory Supportive Structures. The more delicate parts of the microscope
are supported by
a base and an arm. The base sits on the surface (tabletop or laboratory bench) t
o keep the
microscope secure. The microscope arm is a curved metal support, and is to be gr
ipped when it is
being carried. It is important to remember to use two hands whenever moving the
unit; one should
grip the arm, and one should be placed under the base. Another supportive struct
ure is the stage,
which is the surface on which the slide sits for viewing. Most compound microsco
pes have metal
clips that hold the slide securely in place on the stage and allow the slide to
be moved around
for viewing by turning a mechanical control knob, located under the stage. Struc
tures Used for
Specimen Viewing. To view a specimen with the microscope, there are two types of
structures used.
Some of the structures are designed to provide the necessary light to see the sp
ecimen, whereas
others are necessary to provide various amounts of magnification. To visualize t
he specimen as
clearly as possible, it is very important that the light and the magnification a
re both at the
correct setting. Light Sources The light source is located in the base of the mi
croscope. The
bulb can be turned on and off with a switch or knob, which is usually located on
the base toward
the back of the microscope. The bulb should not be touched with the bare hands w
hen changing the
light source, as the natural oils present on the skin may be transferred to the
bulb, and these
will overheat when the bulb is turned on, causing the bulb to shatter. The light
will come up

from the bulb at the base of the micro- scope, through the condenser, then up th
rough the
specimen on the stage and finally through the optical magnification components t
o be viewed. The
condenser is designed to focus the rays of light on the specimen for a clearer i
mage. It may be
raised or lowered, depending on the density of the specimen viewed. The knob to
adjust the
condenser height is on the side under the stage. An iris diaphragmis located on
the front or just
underneath the condenser. The iris diaphragm may be adjusted to increase or decr
ease the amount
of light reaching the slide. The amount of light needed to view a specimen depen
ds on its
density; Test Your Knowledge 6-2 On a compound microscope, what is the name of t
he surface where
the slide is placed for observation? (Outcome 6-3) Test Your Knowledge 6-3 What
is the purpose of
the condenser on the compound microscope? (Outcome 6-3) 1899_Ch06_095-117 21/12/
11 2:21 PM Page
98 Chapter 6 Laboratory Equipment 99 guidelines for handling and maintaining a
compound
microscope that a medical assistant should adhere to: 1. Keep the microscope cov
ered with a
plastic cover when not in use. This protects the delicate microscope and lenses
from excess dust
and potential damage. 2. Always use two hands (as described earlier) to carry a
microscope. 3. Do
not touch the light source or the lenses with your fingers. The light source may
overheat and
burst be- cause of the transferred oils, and fingerprints on the lenses can be v
ery difficult to
remove. 4. The optical lenses and eyepieces should be kept clean at all times. T
hese may be
cleaned only using lens paper, as the glass surfaces are very delicate and will
be scratched if
Kimwipes or other tissues are used. Xylene may be used to assist with removal of
oil or other
buildup. A small amount should be placed on the lens paper before gently rubbing
the lens. 5.
When cleaning the objectives, remember always to clean the 100X optical lens las
t. This one is
used with oil immersion, and if cleaned first, the lens paper used may contamina
te the other
lenses with oil as they are cleaned. Do not apply pressure to the lenses when cl
eaning. 6. Keep
the stage clean between uses. 7. When moving from one objective to another durin
g use or cleaning
procedures, always use the nosepiece to change the powers. Do not push against t
he tubes directly
to move them. 8. Slides should be removed or added to the stage only when the lo
west power
objective is turned down toward the light source. Do not attempt to remove or ad
d slides when the
higher power objectives are in place (pointed down toward the specimen), as the
objective lenses
may be damaged during the process, and/or the slide may be broken. Test Your Kno
wledge 6-4 True
or False: The 100X objective (oil immersion objective) should be cleaned first w
hen performing

maintenance on the compound microscope. (Outcome 6-4) Test Your Knowledge 6-5 Wh
at should be used
to clean the eyepieces on a microscope? a. Kleenex or a similar facial tissue b.
Laboratory
tissues such as Kimwipes c. Lens paper d. None of the above (Outcome 6-4) Proced
ure 6-1:
Microscope Use TASK Correctly use a compound microscope to obtain speci- men foc
us with all
objectives. CAAHEP/ABHES STANDARDS None 1. Wash hands and gather necessary suppl
ies. Apply gloves
if the specimen is infectious and unfixed (without preservative). 2. Remove the
microscope from
storage, if necessary. Be sure to use one hand on the arm and one under the base
of the
microscope. CONDITIONS Compound microscope Lens paper Specimen slide Immersion o
il
Laboratory tissue such as Kimwipes Gloves (if needed) Gloves are not necessary i
f the specimen
is fixed with chemicals that will kill the microorganisms on the slide. If deali
ng with unfixed
specimens (such as vaginal smears or unstained urine) gloves must be applied. Th
e microscope may
be kept on the countertop, or it may be stored in a drawer or on a shelf. Always
support the
microscope with two hands to avoid hitting it against surfaces that could damage
the instrument.
Procedure Rationale Continued 1899_Ch06_095-117 21/12/11 2:21 PM Page 99 100 Sec
tion I Overview
of the Laboratory 3. Plug in the microscope to the electrical outlet. Verify tha
t the excess cord
does not hang over the edge of the counter. 4. Use lens paper to clean the eyepi
eces and the objectives. Start with the eyepieces, after which each objective should be cleaned
starting with
the low- est power and finishing with the 100X objective. Only the optical surfa
ce should be
cleaned with the lens paper. 5. Turn on the light source and adjust the light to
a low level. 6.
Adjust the eyepieces to be the same width as your eyes. With some models, it may
be possible to
adjust the eyepieces individually for a sharper focus. 7. Rotate the nosepiece t
o bring the
lowest power objective straight down where it is pointing at the slide. There sh
ould be an
audible click when this objective is in the proper position. Watch the stage and
objective
closely to avoid touching the stage with the objective. The lowest power objecti
ve may have a 4X
or a 10X printed on it. 8. Using the coarse adjustment knob, move the stage unti
l it is at the
lowest point possible. 9. Place the slide on the stage with the specimen side up
. If the compound
microscope used has stage clips, use these to secure the slide in place. Using t
he stage
adjustment knob, position the slide so that the area on the slide to be viewed i
s directly over
the hole where the light will shine through the specimen. 10. If the microscope
has a condenser,
adjust the con- denser all the way up, using the adjustment knob to the side of
the condenser.

Using the adjustment lever on the diaphragm, open the iris diaphragm to allow th
e maximum amount
of light to be utilized for viewing the specimen. This will be adjusted to a low
er level as you
work through the focusing process. The cord needs to be behind the microscope to
avoid catching
the cord and accidentally pulling the microscope from the counter. The eyepieces
should be
cleaned before the objectives to avoid possible transfer of oil to the eyepieces
from the
objectives. It is also important to remember that the 100X objective should be c
leaned last
because it is used with oil that could be transferred to the other objectives. T
he light should
be at a low level as you begin to focus the specimen. More light will be require
d later as the
objectives are changed to higher levels. Both eyes should be used at the same ti
me when look- ing
through a binocular microscope. This will be best accomplished when the width of
the eyepieces
matches that of your eyes. Focus always starts with the lowest power objective.
Some microscope
models may have a 4X objective, but most will have 10X as the lowest possible ma
gnification. The
coarse adjustment knob is the larger knob at the back of the microscope. Moving
the stage down
will allow space to put the slide in place without poten- tially touching the ob
jective with the
slide. If the slide is not faceup, it will be very difficult to reach optimum cl
arity when
viewing the specimen. It is especially important to center the slide where the s
pecimen viewing
area is focused over the hole where the light comes through when the specimen co
vers only a small
area on the slide. As the specimen focus process begins, it is essential to have
as much light as
possible available. The con- denser may be moved farther from the specimen, and
the diaphragm may
be adjusted as the specimen is brought into closer focus. Procedure 6-1: Microsc
ope Usecontd
Procedure Rationale 1899_Ch06_095-117 21/12/11 2:21 PM Page 100 Chapter 6 Labor
atory Equipment
101 11. While looking through the eyepieces, slowly turn the coarse adjustment k
nob until the
specimen comes into approximate focus. It may not be possible to bring the speci
men into complete
focus using only the coarse adjustment knob. 12. Without moving the slide or the
objective, use
the fine adjustment knob to bring the specimen into complete focus. 13. Adjust t
he amount of
light entering the specimen by moving the condenser down and by adjusting the di
aphragm until the
specimen appears in crisp, clear focus. 14. Use the stage adjustment knob to mov
e the object
viewed directly into the center of the field of vision while looking in the micr
oscope. 15. Use
the nosepiece to swing the next objective so that it is pointing directly down a
t the slide. As
before, the objective should click into place. 16. Use the fine adjustment knob
to bring the

object into focus. It may be necessary to adjust the amount of light entering th
e specimen to see
the object clearly. 17. If desired for the type of specimen viewed, continue thi
s process, using
the fine focus and adjusting the available light as the objectives are changed t
o higher levels
of magnification. 18. If the oil immersion lens (the lens marked with the 100X a
nd a
symbol) is
to be used, it will be necessary to place one or two drops of immersion oil on t
he slide before
rotating the objective into place. a. Use the nosepiece to move the current obje
ctive out of the
way, but do not lower the 100X objective until the oil has been added. b. Keep t
he slide as it
was with the previous objec- tive and place the drop(s) of oil on the slide righ
t over the light
source. c. Then, use the nosepiece to lower the 100X lens into place and adjust
the focus as
needed with the fine adjustment knob. The coarse adjustment knob allows for an a
pproximate focus.
The fine adjustment knob is to be used only after approximate focus has been acc
omplished with
the coarse adjustment knob. Too much light at a low magnification may cause the
specimen to
appear washed out, and some of the formed elements may be overlooked. Too little
light does not
allow for enough contrast to identify some of the structures. If this step is no
t performed, you
may not be able to find the object again after changing to the next level of mag
nification,
especially if the specimen only covers a small portion of the slide. Always watc
h the objective
as you move it into place to avoid touching anything with the objective lens. Wi
th the objectives
above 10X, do not use the coarse adjustment knob for focus. Some specimens do no
t require higher
levels of magni- fication if the structures can be identified at the lower level
s. Resist the
urge to make more room for this objective before moving it into place. This obje
ctive will be
very close to the slide; it will appear that it is going to touch the slide, but
if the
proceeding steps were performed correctly, it will not touch the slide. The oil
will seal the
objective with the slide to keep the light focused on the specimen with clarity.
Procedure
Rationale Continued 1899_Ch06_095-117 21/12/11 2:21 PM Page 101 102 Section I O
verview of the
Laboratory Test Your Knowledge 6-6 Which adjustment knob should be used first wh
en the specimen
on the microscope is initially brought into focus? (Outcome 6-5) 19. After the s
pecimen has been
analyzed as needed, lower the stage to the lowest possible point, and remove the
slide from the
stage clips. 20. Using the nosepiece, adjust the objectives so that the lowest p
ower is pointing
down toward the stage. 21. Turn off the light source, and clean the eyepieces an
d objectives
using lens paper. Remember to clean the 100X objective last, if applicable. Xyle
ne can be used on

the lens paper if needed for exces- sive soiling of the lenses. 22. Wipe off the
stage and the
rest of the microscope using a laboratory tissue such as Kimwipes. Mois- ten the
tissue if
necessary to remove dust. The stage should be disinfected periodically by using
an alcohol wipe.
23. Unplug and secure the electrical cord, and put the plastic cover back on the
microscope. Be
certain to move the microscope to the appropriate storage area as directed by of
fice policy. 24.
Discard the slide or place it in the appropriate storage area as dictated by off
ice policy. 25.
Remove gloves (if used for the procedure) and wash hands. The stage should alway
s be at the
lowest point during storage to avoid potentially damaging the objectives. This a
llows the
focusing to start appropriately when a new slide is put on the microscope, and a
lso helps to
avoid potential damage to the objectives. Only lens paper should be used for thi
s, as any other
type of tissue will scratch the sensitive lenses. If the 100X objective is clean
ed first, the
rest of the lenses may be contaminated with oil. If xylene is used, be sure to f
ollow appropriate
protec- tive measures as described by the manufacturer and the workplace. The sl
ides, specimens,
and oil can easily soil the stage. Be sure to use two hands when transporting th
e microscope.
Stained specimens are often stored for a period of time for future study. Slides
should be
treated as a sharp and disposed of in a puncture-resistant biohazard container. Ha
nds should be
washed before and after each proce- dure in the laboratory setting. Procedure 61: Microscope
Usecontd Test Your Knowledge 6-7 Is the microscope stage moved when objectives are
changed for
higher magnification of a specimen? (Outcome 6-5) Other Types of Microscopes A d
issecting
microscope may also be utilized in the laboratory to view specimens that need to
be seen in their
natural state without compression or those that are too thick to be viewed effec
tively with the
compound microscope. This type of microscope may also be known as a stereo micro
scope because the
microscope is designed to allow a slightly different view from each of the eyepi
eces, providing
an image with depth and dimension. The light source for this type of microscope
is not focused in
the same way that the compound microscope is focused; it is diffused or reflecte
d onto the
Procedure Rationale 1899_Ch06_095-117 21/12/11 2:21 PM Page 102 image rather tha
n shone directly
through it. The magni- fication ability of the dissecting microscope is not as e
xtensive as that
of the compound microscope, as it is usually only capable of enlarging the speci
men by 40 or 100
times its normal size. Dissecting microscopes are often used for blood bank proc
edures when the
technol- ogist is examining different serum and cell combinations to look for ag
glutination of

the specimen. Dissecting microscopes may be used for a variety of other purposes
in the clinical
laboratory when fine, detailed work needs to be performed with some magnificatio
n. An electron
microscope allows for much greater mag- nification of specimens, and also provid
es a three dimensional image. Electrons are utilized to excite the speci- men, and the resulting i
nteraction
with the atoms present in the specimen will produce an image to be recorded and
studied. This
image is more of a picture that is defined by the properties of the specimen, ra
ther than a true
image seen by the eyes while viewing the specimen. The image created by the exci
tation of the
sample is stored and viewed on a computer. Electron microscopes may be used to v
isualize
specimens that are far too small to be seen with a compound microscope, such as
viruses and the
interior structures of cells. This type of microscope is not routinely found in
clinical
laboratories, as the user requires specialized training to operate it and interp
ret the images
created with examination. How Do Medical Assistants Use Microscopes? The majorit
y of the time, a
medical assistant will not perform microscopic examinations for diagnostic purposes. There are
a few microscopic procedures that have been classified as CLIA moderately comple
x procedures, and
these can be performed by medical assistants with appropriate documented trainin
g. These include
urine microscopic analysis (see Chapter 22) and normal blood cell differential c
ounts (see
Chapter 12). These are the exceptional cases in specialized offices such as uro
logy offices or
physician office laboratories with minimal staffing. Most commonly, a medical as
sistants use of
a microscope is limited to focusing the specimen for the health-care provider, a
s well as
performing maintenance procedures. It is of great benefit for a medical assistan
t to Chapter 6
Laboratory Equipment 103 Test Your Knowledge 6-8 What type of microscope may be
used to see
viruses? a. Compound microscope b. Electron microscope c. Dissecting microscope
d. Fluorescent
microscope (Outcome 6-2) be capable of focusing the microscope, as this allows t
he health-care
providers valuable time to be spent examin- ing the specimen rather than performi
ng the original
setup process. Medical assistants may be focusing stained blood smears, urinalys
is sediment
specimens, vaginal smears, nasal smears, Gram-stained microbiological specimens,
and microscopic
examinations for the pres- ence of fungal elements on the microscope for examina
- tion. Remember,
if the health-care provider does per- form microscopy examinations, the laborato
ry must register
as a CLIA site that provides this type of service. Centrifuges A centrifuge is a
n instrument used
to prepare blood (or other liquid specimens) for transport or testing. Blood is
made up of cells

that are suspended in a liquid substance called plasma. Chemical analysis is oft
en performed on
the plasma, and in order for the results to be accurate, the cells must be remov
ed from the
liquid portion of the blood as soon as possible after the specimen is obtained.
A centrifuge is
used to force the separation of the cells from the fluid portion of the blood (p
lasma). If a
blood specimen is allowed to sit for an extended period of time in a tube, gravi
ty causes the
cells to settle to the bottom of the tube, as they are denser (heavier) than the
surrounding
fluid. A centrifuge creates a pow- erful artificial gravity source, called centrif
ugal force.
The force is formed as the specimen spins around an axis hundreds to thousands o
f times per
minute. When a specimen is processed by a centrifuge, the separation of the diff
erent components
of the blood is accelerated; the cells are pushed to the bottom of the tube with
in minutes. This
allows the plasma to be removed from the cells in a timely manner so that chemic
al analysis can
be performed. Urine specimens may also be centrifuged to bring the suspended ele
ments (such as
blood cells, bacteria, etc.) to the bottom of the tube so that they can be exami
ned under a
microscope. There are various types of centrifuges available for use in a labora
tory. Some of the
benchtop models are designed to spin 8 to 10 samples at a time for a maxi- mum o
f 10 minutes each
cycle. Others are units the size of a dishwasher, capable of processing hundreds
of tubes in each
cycle for extended periods of time. The decision about which type of centrifuge
to use is based
on several Test Your Knowledge 6-9 Is a medical assistant properly trained to pe
rform microscopic
identification procedures? (Outcome 6-6) 1899_Ch06_095-117 21/12/11 2:21 PM Page
103 104 Section
I Overview of the Laboratory factors, including the volume of samples to be pro
cessed, the
requirements for the liquid portion of the blood after separation, and the amoun
t of separation
required. The decision may also be based on the recommended maintenance procedur
es for the
centrifuge model of choice, as well as cost. Some centrifuges generate a lot of
excess heat as
they operate, due to the rapid turning of the unit around the axis. These models
require built-in
refrigeration to decrease the temperature to keep the specimens from becoming ov
erheated.
Centrifuge Maintenance Maintenance of all centrifuge models is similar. It is im
portant that the
interior and exterior of the machine stay clean and that there is nothing impedi
ng the rotation
of the unit around the axis. The rotations per minute (rpms) must also be checke
d at least
quarterly using a tachometer. If the rotations have changed significantly since
the last check,
the instrument should be serviced, as there may be a problem that needs to be ad
dressed. Many

centrifuge models have a brushed drive motor, and these brushes must be changed
at intervals
recommended by the manufacturer. All metal components of the centrifuge should b
e checked for
cracks at least once a month. As with all electrical equipment, the electrical c
ord should also
be checked for wear periodically. Centrifuge Safety All medical centrifuges shou
ld have a cover
that must be locked in place when in operation. Figure 6-2 shows an example of a
centrifuge. The
cover keeps the operator safe from potential aerosol formation or splashing that
may occur if a
specimen breaks or if a tube becomes uncovered during the cycle. It is also impo
rtant that the
centrifuge is balanced before starting. This means that for every tube inserted
into the
centrifuge, a tube with the same weight of fluid must be placed directly across
from it in the
unit. This additional tube may be filled with the same fluid as the specimen (an
other blood tube
filled to the same level, for example), or it may be a balance tube that is fill
ed with the same
amount of water. This is a crit- ical step, no matter what type of specimen is t
o be centrifuged.
If the unit is not balanced, it is possible that the centrifuge will rock while
operating (like
an off-balanced washing machine), fall off the counter- top, and break the speci
mens as they are
spinning. Be certain that all specimens are capped securely before starting the
centrifuge.
It is very important to follow the manufacturers recommendations concerning lengt
h of cycles and
specific maintenance. Remember never to open the centrifuge before it stops spin
ning
completely. Never use your hand to try and slow down the final spin; this can be
very dangerous.
Test Your Knowledge 6-10 List two maintenance procedures to be performed on a ce
ntrifuge.
(Outcome 6-7) Figure 6-2 The inside (A) and outside (B) of a typical benchtop ce
ntrifuge. A B
Test Your Knowledge 6-11 What does it mean to balance a centrifuge? (Outcome 6-7
)
1899_Ch06_095-117 21/12/11 2:21 PM Page 104 Chapter 6 Laboratory Equipment 105
Procedure 6-2:
Operating the Centrifuge TASK Use a benchtop centrifuge to successfully separate
plasma from
cells in a blood specimen. CAAHEP/ABHES STANDARDS None 1. Wash hands and gather
necessary
supplies. Apply gloves. 2. Verify that the centrifuge is plugged into an elec- t
rical outlet.
Open the lid and verify that all the slots in the centrifuge are empty. 3. Pick
up the blood
specimen and hold the tube at eye level. Fill the balance tube with water until
the two tubes
have an equal volume of fluid. 4. Verify that the original rubber cap is on the
blood tube
securely. The balance tube should also be capped with the original rubber cap. 5
. For some
centrifuge models, it may be necessary to place a rubber spacer or adapter in th
e cen- trifuge

slot to accommodate the size of tube spun. Consult the manufacturers recommendati
ons. 6. Place
the two tubes in slots within the centrifuge that are across from each other. Th
e centrifuge can
be operated if the other slots are empty, as long as the two tubes are across fr
om each other. 7.
Close the lid securely. Turn on the timer on the centrifuge to the appropriate t
ime for spinning
a blood specimen. This will be indicated on the front of the centrifuge or in th
e manufacturers
insert. CONDITIONS Gloves Benchtop centrifuge Blood specimen in tube Balance tub
e
Spacers to go inside slots in centrifuge if necessary Water and transfer pipette
Test tube
rack Disinfectant wipe Hands should be washed before and after performing any pr
ocedures in the
laboratory, and gloves must be worn whenever handling blood specimens. Occasiona
lly the previous
user will have left a tube or a spacer in one of the slots within the centrifuge
, which can cause
it to become unbalanced while processing the specimen. Care should also be taken
to verify that
there is no liquid in the bottom of the receptacles in the centrifuge, as this c
ould also cause
the centrifuge to become unbalanced. The tubes must have the same fluid volume f
or the centrifuge
to be balanced. This can also be accom- plished with two tubes of blood that are
the same and are
filled to the same level. To avoid aerosol formation, all specimens processed in
the centrifuge
should be securely capped. The spacer or adapter will allow the blood tube to re
main high enough
in the centrifuge to be removed after spinning, and it may also allow for a tigh
ter fit within
the slot to avoid the breakage from vibration that is possible when the tube doe
s not fit
securely. Balance is essential to keep the centrifuge from vibrat- ing excessive
ly while
operating. An unbalanced cen- trifuge can cause the tubes to break, and it also
can cause the
centrifuge to fall off the countertop due to the excessive motion. Larger tubes
may require a
higher rate of centrifugation or a longer time in the centrifuge to achieve the
desired
separation of cells and plasma. Procedure Rationale Continued 1899_Ch06_095-117
21/12/11 2:21 PM
Page 105 Procedure Rationale 106 Section I Overview of the Laboratory 8. Monito
r the centrifuge
for at least 20 to 30 seconds after it has been turned on to see if the instrume
nt is vibrating
excessively. If so, turn off or unplug the centrifuge immediately. 9. Do not att
empt to open the
centrifuge until it has come to a full stop. 10. When the centrifuge has come to
a complete stop,
open the lid and carefully remove the tube of blood. Place the blood in a rack f
or further
processing. 11. Remove the balance tube and the spacers and adapters if used. Th
e balance tube
may be discarded or reused for another specimen. The spacers and adapters are to
be stored for

use with the next centrifuge load. 12. Use a disinfectant wipe to wipe down the
exterior and
interior of the unit. 13. Remove gloves and wash hands. An unbalanced centrifuge
can be dangerous
if it vibrates on the countertop and moves from its original position. Opening t
he centrifuge
prematurely or placing a hand into the unit while it is still spinning can be ve
ry dangerous.
Care needs to be taken when removing the tube of blood so that the plasma and ce
lls do not become
mixed. Some laboratories keep a set of balance tubes close at hand to be used fo
r additional
centrifugation. Be sure that the tube cap is securely fastened if using the bala
nce tube again.
If excessive contamination is evident, it may be neces- sary to clean the unit t
o a greater
extent. In many units, the slots in which the tubes are placed are removable so
that they can be
washed if necessary. Hands should be washed before and after performing any proc
edures in the
laboratory. Procedure 6-2: Operating the Centrifugecontd POINT OF INTEREST 6-1 Sall
y
Centrifuge In many areas of the world health-care providers do not have access to
electricity or
funds for purchasing traditional instruments used for diagnosis. The pres- ence
of anemia
contributes significantly to the diag- nosis and subsequent treatment of disorde
rs such as
malnutrition, HIV/AIDS, tuberculosis, and malaria. Blood specimens collected fro
m the patients in
these areas must be shipped to larger health-care facilities for testing, which
is expensive and
time consuming. In 2010, two Rice University college students cre- ated an inexp
ensive centrifuge
that allows the cells to be separated from the plasma in microhematocrit tubes i
n 10 to 20
minutes without the use of electric- ity. Lauren Theis and Lila Kerr created the
centrifuge as a
class project, using materials that included combs, yogurt containers, and a sal
ad spinner. The
centrifuge cost approximately $30 to build, and it can process 30 samples of 15
microliters each
at one time. The cen- trifuge must be pumped by hand for 10 to 20 minutes, at wh
ich point it
reaches speeds of approximately 950 rotations per minute and successfully separa
tes the blood
cells from the plasma in the tubes. The tubes then can be compared to a referenc
e chart to obtain
the hematocrit result, used to diagnosis the presence of anemia. These students
are part of a
Rice University pro- gram, Beyond Traditional Borders. As part of this program,
the students used
the centrifuges in several remote locations during the summer of 2010 to test th
eir ability to
withstand traditional use in a health- care setting. If successful, Sally Centrif
uge could have
a profound impact on the ability to deliver affordable, timely health care in ma
ny locations
across the globe. 1899_Ch06_095-117 21/12/11 2:21 PM Page 106 Laboratory Refrige
ration Many

specimens must be maintained at reduced temper- atures to provide reliable test

results when
analyzed. The instructions for specimen collection and processing for a particul
ar test may
include refrigeration of the specimen, or possibly freezing of the plasma or ser
um. To ensure
that the specimens are at the correct temperature, the re- frigerators or freeze
rs in the
clinical laboratory should be monitored each day; in large laboratories with mul
tiple shifts,
they may be monitored more than once a day. A laboratory thermometer is used to
obtain accurate,
reliable temperature readings. Laboratory thermometers are usually made of a mea
surement device
that has the end designed to register the temperature while submersed in a conta
iner filled with
liquid. The employee who is monitor- ing the temperature will open the door of t
he refrigerator
or freezer, read the temperature on the thermometer, and record the result on a
log sheet nearby.
To keep the temper- ature as stable as possible, the door for the refrigerator o
r freezer should
be opened only long enough to read the thermometer. Some thermometers are design
ed with sys- tems
that allow them to be monitored by a device that is outside of the refrigerator.
This is
advantageous because it is not necessary to open the door of the unit to take th
e temperature. In
either case, a range of acceptable readings for each refrigerator or freezer mus
t be established,
and if the results fall outside this range, corrective action must be taken imme
diately. The
specimens in the unit must be transferred elsewhere until the temperature readin
g is within the
acceptable range again. In laboratory situations in which refrigeration tem- per
ature is
especially critical, an alarm system may be installed that sounds whenever there
is a fluctuation
in the temperature readings. Blood bank facilities have a very small range of ac
ceptable storage
temperatures for units of blood, and must have processes in place for critical m
onitoring of all
their refrigeration units. These special refrigerators often have battery backup
s that activate a
cooling system in case of power failure, as well as remote monitoring systems an
d audible alarms.
The temperature for these units must be monitored more frequently than other ref
rigerators; often
there is a continuous recording of temperatures. Some refrigerators and freezers
in physician
office laboratories may be used to store specimens as well as vac- cines or othe
r medications.
These products will have very specific storage requirements, so monitoring of th
e tem- perature
used for storage will be especially critical. If the unit falls outside the acce
ptable storage
ranges, the med- ication and vaccines may need to be discarded. Quality control
materials may
also be stored in refrigerators or freezers with specimens, and these materials
will also have

specific storage requirements that must be followed. It is imperative that all r

efrigeration or
freezer units in a laboratory setting are properly maintained to avoid excessive
moisture or ice
buildup. The refrigeration coils at the back of the unit should be kept free of
dust buildup, and
the interior and exterior of the unit should be kept as clean as possible. No fo
od or drink is to
be stored in laboratory refrigerators where specimens are kept. This is a safety
precaution
designed to protect employees from potential contamination of their food, as wel
l as an
Occupational Safety and Health Administration (OSHA) regulation that must be fol
lowed. Incubators
When microbiology specimens are collected from a human for analysis, the pathoge
ns that may be
present are reproducing at body temperature. This temperature is approximately 2
5 to 27 Celsius
or 95 to 99 Fahrenheit. To keep these pathogens alive until they can be identified
, it is
necessary to keep them at this temper- ature for a few days. A laboratory incuba
tor is used for
this purpose. The temperature for an incubator must be monitored at least daily,
and the results
must be documented on a log sheet. Much like a laboratory refrigeration unit, th
ere is a limited
acceptable range for these temperature readings, and if the incubator falls outs
ide of that
range, the unit must be serviced. In addition, water baths or other types of hea
ting units may be
used in a laboratory. Water baths may be used to heat specimens as part of speci
fic testing
proce- dures. Other heating units may be used to fix a speci- men to a slide, or t
o sterilize
inoculation devices in the microbiology laboratory. EQUIPMENT USED FOR AUTOMATED
CLIAWAIVED
LABORATORY TESTING Many medical offices choose to perform automated CLIA-waived
tests in their
own laboratory on site. Performance of these tests in the office environment Cha
pter 6
Laboratory Equipment 107 Test Your Knowledge 6-12 If specimens are to be kept at
a certain
reduced temperature, how often should the refrigerator temperature be monitored?
What other
precautions should be in place? (Outcome 6-8) 1899_Ch06_095-117 21/12/11 2:21 PM
Page 107 rather
than in a reference laboratory may benefit the patient in various ways: On-site
testing may
assist the health-care provider to assign a definitive diagnosis quickly. This a
llows a plan of
treatment to be established before the patient leaves the office. The patient an
d health-care
provider can discuss the plan, and an opportunity is provided for face-to-face c
ommunication.
This can be especially critical for patients who are acutely ill and those with
chronic health
conditions requiring frequent labora- tory testing to monitor the progress of th
eir treatment.
CLIA-waived tests performed in the physicians office may be less expensive for th
e patient. Many

times insurance coverage is limited for laboratory testing, so a reduced charge

is definitely a
benefit. Performance of testing on site may allow patients to minimize visits; t
hey can have
their specimen collected and tested at the same location that they see their hea
lth-care
provider, without going to a separate destination for collection and/or testing.
This helps
improve patient compliance rates. CLIA-waived automated testing may also be performed in larger
laboratories for tests that do not require more advanced methods of analysis. Th
ese laboratories
may employ medical assistants or phlebotomists to per- form these testing proced
ures with
appropriate oversight by other laboratory professionals. Automated methods for C
LIA-waived tests
include chemical urinalysis, chem- istry testing, and hematology testing. Testin
g Methodology
Chemistry analyzers may test the liquid portion of the blood (plasma) or the who
le blood
specimen. Hematology instruments are designed to perform various measure- ments
on the cells
present in the specimen. Automated analyzers used for CLIA-waived hematology, co
agulation,
urinalysis, and chemistry testing (as well as advanced instruments used in more
complex testing
procedures) are often used to provide quantitative results of substances or cell
s present in the
specimens. Other testing instruments may provide qualitative results, such as th
ose used for
fecal occult blood testing or urine drug screening. In this case, the presence o
r absence of a
specific analyte provides the necessary information for the health-care provider
to develop a
plan of action. Most of the CLIA-waived chemistry testing methods explained in t
his textbook use
reagents that change color when they are exposed to the chemicals present in the
specimen. This
color change is measured by a spec- trophotometer, an instrument that measures l
ight inten- sity.
A specific wavelength of light enters a sample, and depending on the amount of c
olor change, a
certain amount will continue through the sample to be measured on the other side
. The measurement
of the intensity of the light at the end of the process is directly related to t
he concentration
of the chemical substances present in the solution. The light intensity measurem
ent may be
changed by absorption of the light by the specimen, or by reflecting or scatteri
ng the light so
that it is not measured directly at the end of the reaction. Hematology testing
often uses
electrical imped- ance, a process for counting cells in the whole blood specimen
and
differentiating them by size. For this type of test, whole blood specimens are a
dded to a diluent
(a liquid used for dilution of a specimen) that is capa- ble of conducting elect
ricity. An
electrical current is applied to the mixture of specimen and diluent as it passe
s through a small

opening, called an aperture. Because the blood cells do not conduct electricity,
they break the
current between the electrodes on either side of the aperture. The amount of imp
edance (interference of the electrical signal) caused by a certain cell will allow the instrumen
t to count the
cell and approximate the size and other physical properties. A similar type of m
easurement uses
the amount of light scattered by a specimen to measure the cell numbers and cell
sizes in a
hematology specimen. Hematology instruments (such as those that test only hemogl
obin) may also
use spectrophotometers to measure a specific substance. In this case, the cells
must be broken,
or lysed prior to the testing procedure, so that the hemoglobin present inside t
he cells may be
measured. When using an instrument to perform any of these tests, it is imperati
ve that the
manufacturers instructions are followed concerning frequency and extent of qualit
y control
testing and calibration of the instrument. These procedures must be performed as
directed to
verify that the instrument is operating as it should before patient samples are
analyzed. The
reagents used with the analyzers often have storage requirements and expiration
dates that must
be monitored as well, and quality control samples must be prepared and processed
as directed to
produce meaningful results. 108 Section I Overview of the Laboratory Test Your
Knowledge 6-13
List one advantage of performing automated CLIA-waived tests in a physician offi
ce laboratory.
(Outcome 6-10) 1899_Ch06_095-117 21/12/11 2:21 PM Page 108 Instruments Used for
Chemical Testing
of Urine Specimens Urine specimens are analyzed in various ways. One of the meth
ods used to
evaluate the specimen is a chemi- cal analysis to detect and/or quantify the pre
sence of
substances in the urine specimen that may indicate disease. Quite often, this an
alysis will be
performed manually in a physician office laboratory, but this analysis may also
be performed
using an instrument and reagent strips that are imbedded with small squares desi
gned to change
color when exposed to specific chemicals present in the urine specimen. Although
the exact number
and types of chemicals analyzed in the specimen may vary according to the manufa
cturer of the
unit, common chemical substances detected include the following: pH levels prote
in glucose
blood leukocytes specific gravity bilirubin glucose ketone urobilinogen nitri
The process of reading the reagent strips is time and color sensitive. The chemi
cal measurements
are based on changes in color that develop in response to the presence of certai
n chemicals.
These changes do not all occur at the same rate, which means that the reagent pa
ds on the strips
must be read at specific time intervals after the strip has been exposed to the
urine specimen.
Automated urine analyzers are designed to move the strip through the measuring d

evice with the

appropriate speed to read these reagent pads at the correct time. A similar proc
edure is used for
testing urine using any of these machines. Essentially, the reagent strip is imm
ersed in the
urine specimen, blotted to remove excess specimen, then applied to a tray that f
eeds the reagent
strip into the instrument for analysis. The instru- ment times the advance of th
e strip
appropriately for the different reagent pads to be analyzed for color changes. T
he amount of
color change is directly related to the concentration of the chemical substances
in the urine,
and once analyzed, the results are printed on a strip that may be kept as a perm
anent record.
Some of the instru- ments are also capable of transmitting the results directly
to a computer so
that they may be stored electronically. Urine analyzers are quick and easy to us
e, and eliminate
the need for the employee to monitor the reaction of the different areas of the
reagent strip for
the full time needed for color development. Common urine analyzers include the C
linitek Urine
Analyzer, manufactured by the Bayer Corpora- tion, and the Urisys 1100 Analyzer,
manufactured by
Roche. Henry Schein also manufactures the One Step Plus Analyzer (Fig. 6-3). The
automated
chemical analysis testing that is performed with these instruments is CLIA-waive
d, as long as the
manufac- turers directions are followed exactly as printed. Quality control and m
aintenance for
this type of equipment may include the use of commercial quality control specime
ns of different
levels, calibration of the instrument, and cleaning of the instrument at reg- ul
ar intervals.
Some general aspects to keep in mind Chapter 6 Laboratory Equipment 109 Test Yo
ur Knowledge 6-14
Electrical impedance is a common term used to describe how the number of cells i
n a specimen are
measured. What process occurs to allow the cells to be counted by the instrument
? (Outcome 6-11)
Figure 6-3 One Step Plus Urine Analyzer. Courtesy of Henry Schein, Inc. 1899_Ch0
6_095-117
21/12/11 2:21 PM Page 109 when performing urine testing with an automated instru
ment include the
following: Reagent strips do outdate. Always check the expiration date before us
ing the strips.
Reagent strips must be protected from moisture, so the bottle must be closed imm
ediately after
removing the necessary strips for testing. Automated urinalysis instruments may
produce erroneous results in situations in which the urine is discol- ored by medications or
dyes used for
diagnostic pur- poses. The employee performing these tests must keep this in min
d and follow the
manufacturers recommen- dations and the office policy for confirmatory testing be
fore reporting
results on discolored specimens. As with all testing procedures, documentation o
f the quality
control and maintenance procedures is critical, as well as the appropriate docum

entation of all
patient results. Instruments Used for Coagulation Testing Coagulation testing is
used to screen
patients for blood clotting issues. It may also be used to monitor patients who
have been placed
on anticoagulant therapy, such as warfarin (Coumadin). As presented in more deta
il in Chapter 15,
coagulation testing is commonly performed as a CLIA-waived test in the physician
office
laboratory environment. The most common test used for screening or monitoring is
the prothrombin
time test. This test is more commonly known as a protime, and it measures the le
ngth of time
necessary for a blood specimen to form a clot when reagents are added. The resul
t is reported in
seconds. Protimes may also be performed in larger laboratories using testing met
hods that are not
CLIA-waived. When the protime test is performed, an international normalized rat
io (INR) is
usually reported in addition to the test result. The INR is a calculation provid
ed by dividing
the protime result for the patient by the normal control value for the lot of re
agents currently
in use for that system. Protime testing on the CLIA-waived instruments is accomp
lished by
inserting a reagent strip or cartridge into the instrument, then adding one or m
ore drops of
blood to the designated area of the strip. The blood specimen is usually obtaine
d from a
capillary punc- ture, and a drop is placed directly onto the testing device or t
ransferred from
the finger using a capillary transfer device. There are specific timing and quan
tity
requirements, and if the operator does not follow these guidelines, an error cod
e will result and
the test must be repeated with a fresh specimen. Some of these coagulation analy
zers provide a
printout, others can be connected to an external printer for result documenta- t
ion, and still
other instruments may be interfaced to the computer for the results to be stored
electronically.
The units do have a display screen where the operator can read the result. Vario
us CLIA-waived
methods and instruments may be used to perform the protime test. These include t
he ITC ProTime-3
as well as Roche Diagnostics CoaguChek S, XS, and XS Plus. Other CLIA-waived prot
ime systems
include the Hemosense Inratio system, and several products produced by the Lifes
can Corporation. Figure 6-4 shows a Roche CoaguChek S with reagents and necessary to perfor
m a protime test.
Each type of instrument has instructions that are a little bit different, but al
l the testing
systems share some of the following characteristics: All CLIA-waived or home use
systems have
test strips that are packaged individually so that one test is performed at a ti
me. Each lot of
test strips has a unique product code that must be entered into the machine to p
erform the test.
Some products have a computer chip with the product code, and this must be inser

ted into the

analyzer prior to the sample testing process. All instruments have quality contr
ol procedures;
some are built-in internal controls that run automatically during the testing pr
ocess, while
other instruments use liquid commercial control materials that are run as 110 Se
ction I Overview
of the Laboratory Figure 6-4 Roche CoaguChek S Plus with reagents and quality co
ntrol materials.
1899_Ch06_095-117 21/12/11 2:21 PM Page 110 patient samples. As always, the qual
ity control (QC)
values must be documented and interpreted as recom- mended by the manufacturer.
The reagents
all have specific storage requirements, although these vary from brand to brand.
All
CLIA-waived methods require whole blood samples for testing, and the test is des
igned to be run
on capillary blood. A lancet is used to pierce the skin for the sample. Many of
the testing
methods recommend use of a microcapillary tube with a bulb or a collection cup t
o assist with
obtaining adequate sample volume. The blood sample is applied directly to the re
agent strip for
all methods; generally there is a window or circle that must be covered complete
ly with blood.
The instruments require very little maintenance. Most have batteries and some al
so have A/C
adapters. The batteries must be changed periodically, and should be removed from
the device if it
will not be used for an extended period of time. The analyzers should also be ke
pt clean. The
instrument (especially the sample application area) may be cleaned with a cotton
-tipped
applicator moistened with isopropyl alcohol or a 5% bleach solution. None of the
instruments
should be immersed in water or any other liquid. All manufacturers instructions f
or the
testing process must be followed exactly as written. Instruments Used for Chemis
try Testing
CLIA-waived automated chemistry testing procedures are now available for a varie
ty of analytes.
Some of the most common tests performed in the physician office laboratory are g
lucose
measurements and glycosylated hemoglobin monitoring for diabetes screening and t
reatment. Cholesterol studies and electrolyte measurements are also quite common. Many instrumen
ts now have the
capability of performing chemistry panels that include three or more tests, prov
iding the
health-care provider a more compre- hensive set of information to work with as t
hey develop a
treatment plan. The test results are usually available within an hour of the tes
t onset, and many
of the instruments are capable of transmitting these results directly to a compu
ter for
documentation. Calibration of these analyzers may be performed internally or wit
h an external
cartridge, and many methods include an internal method of quality con- trol that
eliminates the
need to purchase separate liquid controls. Also, because the CLIA-waived status

for these
instruments applies to whole blood specimen testing, most of the instruments req
uire only a few
drops of blood, which can be accomplished with a capillary blood draw. There are
more CLIA-waived
glucose testing methods than any other type of chemistry analyzers. Many of the
glucose
instruments used in the physicians office labora- tory are also in use as home te
sting devices.
These instru- ments have become more technologically advanced, and use even less
blood for
analysis than in the past. It is no longer required to use fingertips for all sa
mples; innovative lancets and reduced specimen volume requirements have allowed the sites for
specimen
collection to vary. Devices used at home and in the office allow for test result
s to be stored,
and some also may interface directly with a computer system to allow for closer
monitoring and
better communication with the health-care provider. Glucose analyzers utilize re
agent strips or
cassettes that are inserted into the instrument. A capillary blood specimen is o
btained and a few
drops are placed directly onto the appropriate area of the reagent strip. The st
rip may be
advanced into the instrument, or the specimen may be analyzed through the applic
ation area at the
front of the instrument. The analyzer includes a display screen on which the ope
rator may view
the results, and (as is the case for the other instruments already covered in th
is chapter) the
analyzer may be capable of printing results or transmitting them directly to a c
omputer for
electronic storage. Some instruments are even capable of charting or graphing pa
tient data to
provide a historical overview of results over a period of time. Glucose analyzer
s found in the
physician office lab- oratory may include the Roche Diagnostics Accu- Chek, the
Abbott iStat, and
the Hemocue Glucose 201 Microcuvette. There are many CLIA-waived glucose analyze
r methods, and
more information may be found for any specific type by visiting the website for
that
manufacturer. It is important to remember that each brand of analyzer has unique
reagent strips
and quality control materials; these are not interchangeable. Chapter 6 Laborat
ory Equipment 111
Test Your Knowledge 6-15 What type of specimen is needed for handheld coagulatio
n instruments? a.
Plasma b. Serum c. Urine d. Whole blood (Outcome 6-13) Test Your Knowledge 6-16
Are results for
CLIA-waived coagulation testing available at the completion of the test? (Outcom
e 6-13)
1899_Ch06_095-117 21/12/11 2:21 PM Page 111 Other chemistry tests may be perform
ed using CLIAwaived automated testing procedures in a physician office setting or other small
laboratory.
These include measure- ments for electrolytes, blood urea nitrogen (BUN), trigly
cerides,
cholesterol, and calcium. Instruments used for testing these analytes use indivi

dual testing
cartridges, which are self-contained. A capillary blood sample may be obtained i
n some
situations, or in others the entire tube of blood collected by venipuncture may
be placed in the
instrument to be sampled. Because each testing car- tridge is self-contained, th
e blood sample is
added to every cartridge individually. The addition of the sample may be perform
ed within the
instrument using an auto- mated method, or the person performing the test may ad
d the sample to
each cartridge by hand. Results are usu- ally available within 30 minutes, even
if the patient
has several tests performed at once. The results are printed out on a slip that
may be added to
the patient record, and many models are also capable of transmitting the information
electronically to a computer system. The CLIA-waived automated chemistry instrum
ents that use
individual cartridges are more expensive to operate per test than the large chem
istry analyzers
found in reference and hospital laboratories, because of the high cost of the in
dividual
cartridges. Larger instruments have reagents that cost less per assay, but they
are not CLIA
waived for operation. The low sample volume and limited variety of testing proce
dures ordered in
a physi- cian office laboratory are served well by the instruments that use the
self-contained
individual cartridges. The Abbott iStat Chem 8 Cartridge analyzer is a common CLI
A-waived
chemistry instrument that may be used for point-of-care testing in an emergency
room, at the
bedside of a patient in the hospital, or in a physi- cian office laboratory. It
uses whole blood,
and can be used to produce results for a variety of tests. Cholesterol testing m
ay be performed
using the Cholestech LDX, but this instrument may not be used for very many othe
r types of tests.
The Abixis Piccolo Xpress blood chemistry analyzer has a good deal of flexibilit
y, uses tubes of
whole blood, and doesnt take up very much space on a coun- tertop. A comprehensiv
e list of the
CLIA-waived auto- mated chemistry testing instruments may be found on the U.S. F
ood and Drug
Administration (FDA) website listed in the Resources and Suggested Readings sect
ion at the end of
this chapter. Instruments Used for Hemoglobin Measurements Hemoglobin is the mol
ecule within the
red blood cells that carries oxygen to the tissues of the body. Iron is necessar
y to build this
molecule, so the hemoglobin level of the blood is directly related to the oxygen
-carrying
capacity of the cells, as well as the iron levels of the individual. Hemo- globi
n (Hgb) is
commonly performed as a screening test for anemia, and it may also be ordered as
a test to
monitor progress when a patient is being treated for anemia. Because hemoglobin
is part of the
red blood cell structure, the cells must be broken or lysed before the hemoglobi

n level can be
measured. In CLIA-waived automated hemoglobin testing instruments, the cells are
lysed within the
individual cuvette when the blood is added. For instance, in the HemoCue hemoglo
bin test- ing
method, the inside of the individual cuvette used for the test is coated with a
chemical (sodium
deoxycholate) that destroys the red blood cell membranes, allowing the hemoglobi
n to be measured.
Regardless of the type of instrument used, hemoglo- bin testing is always perfor
med using whole
blood. CLIA-waived systems use capillary samples, and the blood is usually appli
ed directly to
the cuvette (or testing device such as a strip) from the capillary puncture site
. Proper
capillary technique must be used to provide an appropriate specimen. One test is
performed at a
time, and the individual testing device may be placed in the instrument after th
e blood has been
added, or it may be necessary to place it in the machine prior to the addition o
f the sample.
(Check the manufacturers recommenda- tions for details.) The instruments will hav
e a display
screen on which the progress of the test may be moni- tored once the blood has b
een added;
generally the re- sults are available within one minute. Some of the instru- men
ts may be capable
of printing the results, whereas others may also be able to send the results ele
ctronically to a
computer system for documentation. The CLIA-waived hemoglobin systems are equipp
ed with
electronic calibration methods. The HemoCue system has a standardized cuvette wi
th known values
that should be checked at regular intervals to be certain that the instrument is
operating
correctly. The ITC Hgb Pro has an internal calibration that is performed every t
ime a test is 112
Section I Overview of the Laboratory Test Your Knowledge 6-17 What is a common
chemistry
analyzer used in small laboratories to test cholesterol levels? (Outcome 6-14) T
est Your
Knowledge 6-18 Is hemoglobin measured from intact red blood cells? (Outcome 6-15
)
1899_Ch06_095-117 21/12/11 2:21 PM Page 112 performed. If the internal calibrati
on process does
not show that the instrument is working correctly, an error will result and the
instrument cannot
be used for patient test- ing until the calibration is successful. Liquid commer
cial quality
control specimens may also be utilized to verify that any hemoglobin instrument
is operating
appropriately. Other Hematology Instruments Many physician office laboratories u
se hematology
instruments that have been classified as moderately complex according to CLIA re
gulations. Common
manufacturers are Beckman Coulter and Abbott. Remember, when performing tests of
moderate complexity, it is necessary to perform quality control and calibration procedures m
ore frequently,
and there are more regulations for personnel training. Glassware and Other Misce

llaneous
Laboratory Equipment Physician office laboratories dont have as much glassware as
larger
laboratories, and in many cases, glassware is now replaced by plastic disposable
containers.
However, there are a few standard items that may be found in the labora- tory se
tting, regardless
of the size of the facility: Pipettes: Pipettes are used to move liquid from one
place to
another. It is similar to the turkey baster that you may find in your kitchen. S
ome pipettes are
designed to measure small amounts of liquid very accu- rately. Others are used j
ust to transfer
liquids from one place to another, without measurement. Pipettes come in varied
sizes, and are
often plastic and disposable. Beakers and flasks: Beakers and flasks are both co
ntain- ers that
may be used to store, transfer, or heat liquids. Beakers generally are wide at t
he top and have a
flat base, whereas flasks have a narrow opening at the top and a rounded bottom
that is much
larger than the top. Glass slides and cover slips: Glass slides are still used i
n the
laboratory, even though many items are now made of plastic. Slides made of glass
are still the
best item to use when viewing items under the microscope, as they do not distort
the view in the
manner that some plastic slides may. Slides may be completely clear, or they may
be frosted
partially or completely for special- ized uses. Some slides may have a depressio
n in the center
for certain types of specimens. Cover slips are small panes of glass or plastic
placed on top of
liquid specimens on the glass slides before viewing. Cover slips are often used
when the specimen
is viewed in a natural state without any preservative or staining. Cylinder: A c
ylinder is a
slim, round container that is used to measure liquids. A graduated cylinder is m
arked with
specific units to allow for accurate measurement. Because glassware is often use
d to accurately
measure liquid in the laboratory setting, it is important to know the correct wa
y to read the
amount of liquid present. Liquid in a glass container is not completely flat at
the top, because
liquid is attracted or pulled up or down the sides of the container to form a curv
e. This
curved surface of the liquid is known as the meniscus. In a nar- row container,
the meniscus will
be more curved than it will be in a wide container. When measuring liquid in gla
ssware, always
perform the measurement at the lowest or highest point of the meniscus; this pri
nciple applies
whether removing liquid to obtain a certain volume, or adding liquid to a contai
ner. Figure 6-5
shows how to measure liquid correctly in glassware using the meniscus. SUMMARY V
arious types of
automated instruments may be found in the clinical laboratory. These instruments
may be used to
process samples for analysis, examine specimens under the microscope, or analyze

body fluids
utilizing CLIA-waived automated testing techniques. Medical assistants need to k
now the correct
way to use and maintain equipment for specimen processing, focus microscopes, an
d perform
automated testing appropri- ate to their level of training. It is also important
that medical
assistants familiarize themselves with the other equipment used in the laborator
y setting, such
as refrig- erators, incubators, and various types of glassware. Care should be t
aken to maintain
all equipment appro- priately, and follow the manufacturers directions to perform
testing
procedures exactly as directed. Chapter 6 Laboratory Equipment 113 Test Your Kn
owledge 6-19 Is a
glucometer an example of an instrument used for hematology testing? (Outcome 6-1
4) Test Your
Knowledge 6-20 The curved area at the top of a column of liquid in a glass cylin
der is called
the: a. Photometer b. Diaphragm c. Flask d. Meniscus (Outcome 6-17) 1899_Ch06_09
5-117 21/12/11
2:21 PM Page 113 TIME TO REVIEW 1. What disorder might be monitored Outcome 6-1
by performing
periodic glycosylated hemoglobin tests? a. Diabetes b. Hypertension c. Hyperlipi
demia d.
Hypokalemia 2. A device used to transfer small Outcome 6-1 quantities of liquids
is a: a. Pipette
b. Cuvette c. Cylinder d. Beaker 3. True or False: A tachometer is a Outcome 6-1
type of
thermometer used to measure temperatures in the laboratory environment. 4. True
or False: The
objective is a Outcome 6-1 device that can be adjusted to control the amount of
light that enters
a specimen on a microscope. 5. How many eyepieces does a Outcome 6-1 binocular m
icroscope have?
a. One b. Two c. Three d. Four 6. True or False: Centrifuges are Outcome 6-7 use
d to process all
laboratory specimens before testing. 7. What are two tasks that a Outcome 6-6 me
dical assistant
may be asked to perform with a microscope? a. Maintenance and cleaning of the mi
croscope b.
Prepare and focus specimens on the microscope for examination by the health-care
provider c. With
appropriate training, examination of urine sediment d. All of the above 8. True
or False:
Automated urine Outcome 6-12 analyzers are used to test for bacteria and other s
uspended objects
in urine specimens. 9. What are two types of Outcome 6-14 CLIA-waived chemistry
instruments
presented in this chapter? 10. Which company is mentioned Outcome 6-16 in the te
xt as a common
manufacturer of hematology instruments? a. Bayer b. Dimension c. Beckman Coulter
d. Piccolo 11.
Why is a cover slip used? Outcome 6-17 a. To view specimens that have been prese
rved with an
additive b. To view specimens in their natural state c. To view large specimens
without the use
of a slide d. To view chemical reactions 114 Section I Overview of the Laborato
ry 15 16 17
Figure 6-5 Reading the liquid volume using the meniscus. Many liquids curve at t

he edges of glass
containers because of the attraction of the molecules to the glass. This curvatu
re at the top of
the liquid is called the meniscus. The level is to be measured at the horizontal
center of the
curvature. Some liquids curve upward instead of downward from the edges of the c
ontainer, in
which case the liquid level is to be read at the top of the curvature. Always ho
ld the container
at eye level when measuring. 1899_Ch06_095-117 21/12/11 2:21 PM Page 114 Chapter
6 Laboratory
Equipment 115 Case Study 6-2: Lack of focus Lucille has been working in the labo
ratory at the
local obstetrics and gynecology office for several years. She routinely performs
blood draws and
several different CLIA-waived laboratory tests. The providers in the office have
decided that
they want to start performing microscopy procedures in the office to better serv
e their patients.
To perform the microscopy procedures, the providers in the office ask Lucille to
demonstrate how
well she can focus the microscope. Lucille has not worked with a microscope sinc
e she was in
medical assisting school, but she does her best to remember the steps involved.
She is successful
with the initial focus using the 10X objective, but cant seem to bring the specim
en into focus
when she switches to the 40X objective. 1. What are two possible explanations fo
r the lack of
focus with the 40X objective? Case Study 6-1: This test wont work! The manager fo
r the internal
medicine office where Cindy Lou is employed as a medical assistant is on vacatio
n. In her
absence, the lead medical assistant has placed a few orders for laboratory suppl
ies, including
some test strips for the glucometer used for glucose testing. On Tuesday morning
, Cindy knows
that a patient is scheduled for diabetes monitoring. This usually involves a blo
od glucose level
to be performed during his visit. Cindy decides to process the quality control s
pecimens for the
glucometer first thing in the morning so that she can be ready for the patients a
rrival. Cindy
turns on the instrument, allows it to perform the internal verification that it
always goes
through, and inserts a test strip to process the quality control specimen. The t
est strip seems
to fit in the instrument a bit differently from the way it has before, but she c
on- tinues with
the process. After inserting the strip and adding the QC material, the display s
creen flashes an
ERROR code, and no result is displayed for the test. Cindy removes this strip an
d inserts another
one, but receives the same result. She checks the QC material to see if it might
be expired, and
finds that it is not. Once more Cindy attempts to process a QC specimen of a dif
ferent level
(high glucose level) but receives the same code. 1. What is the most probable ex
planation for the
ERROR code? 2. Can Cindy Lou process a patient specimen despite the ERROR codes?

RESOURCES AND
SUGGESTED READINGS US Centrifuge Systems: Frequently Asked Questions Frequently as
ked questions
about how a centrifuge works, and types to choose from http://www.uscentrifuge.c
om/ faq.htm The
Clinical Laboratory Improvement Act and the Physicians Office Laboratory Various e
ducational
modules and mini quizzes for CLIA waived hematology and chemistry tests http://w
ww.
medicine.uiowa.edu/CME/clia/default.asp Tests Waived by the FDA From January 2000
to Present
List of all CLIA waived tests; updated regularly http://www.
accessdata.fda.gov/scripts/cdrh/cfdocs/cfClia/testswaived.cfm Principles of Spect
rophotometry
Great explanations about how spectrophotometry works
http://www.ruf.rice.edu/~bioslabs/methods/protein/ spectrophotometer.html Welcome
to HemoCue
Information about the various products manufactured by HemoCue http://www.hemocu
e.com Glossary
of Microscope Terms Explanations for many of the terms used with microscope use
http://www.microscope-microscope.org/basic/ microscope-glossary.htm 1899_Ch06_09
5-117 21/12/11
2:21 PM Page 115 1899_Ch06_095-117 21/12/11 2:21 PM Page 116 117 Section I Overv
iew of the
Laboratory What Does It All Mean? The purpose of this section is to introduce yo
u to global
aspects associated with the clinical labora- tory and laboratory testing. As thi
s section clearly
in- dicates, laboratory testing is crucial to the diagnosis and monitoring of pa
tient diseases
and conditions, as well as to rule out any diseases and conditions. This being s
aid, an alert
medical assistant will have a comprehensive understanding of these aspects. Furt
her, the medical
assistant will use appropriate corresponding techniques and procedures to ensure
proper
laboratory sample collection for testing by appropriately trained and educated i
ndividuals. Our
Case in Point for this section explores some of these important concepts and ser
ves as a review
of the section content. Case in Point As noted in this case, during the first we
ek of your
student practicum you are introduced to the clinical laboratory by your clinical
instructor,
Doris. Your patient, Mr. Hershey, presents to Maple Grove Clinic for evaluation.
After examining
Mr. Hershey, Dr. Pueblo determines that he requires laboratory testing to determ
ine his
condition. This situation gives you and Doris a wonderful opportunity to dis- cu
ss important
concepts associated with both the clinical laboratory and laboratory testing. Hi
gh- lights of
this discussion follow for your review and consideration. There are numerous way
s in which
laboratories are structured and organized based on a number of fac- tors, includ
ing the
environment in which the laboratory exists (it may be a small rural hospital or
large commercial reference laboratory). Each laboratory determines what tests it will run, w
hat instrument it

will use for the tests, and the values considered as normal for the typical pati
ent population
the laboratory serves. There are three phases of laboratory testing: preanalytic
al, analytical,
and postanalytical. Every laboratory test passes through all three phases. An er
ror in any of the
three phases may adversely affect the laboratory results generated. Most of the
problems
encountered in laboratory testing occur during the preanalytical testing phase b
ecause of a
variety of issues, for example, collecting the sample on an individual other tha
n the targeted
patient. Laboratory tests are categorized based in part on the difficulty of the
procedure
required to obtain the results. Health-care support individuals, including medical assistants,
are allowed under government regula- tions to perform select testing under stric
t guidelines.
Handling every sample using universal precautions is an important point to empha
size, as doing
this con- tributes to the validity of the test results obtained. In ad- dition t
o running the
laboratory tests, quality control samples must also be tested on a regular basis
to ensure that
the test is working properly. Laboratory test results can only be released (in l
aboratory jargon
this is called turned out) to the patients chart if the qual- ity control samples t
est
properly. In the event that qual- ity control results are not in range, investig
ation and
resolution of the problem must occur before patient results can be considered va
lid. Individuals
vary in many ways. Variations in laboratory test values (as well as quality cont
rol samples) are
no exception. Because of this, laboratory test results considered as being norma
l fall within a
range of values. In conclusion, laboratory tests provide physicians and other pr
imary care
providers with valuable infor- mation. In fact, many sources have reported that
some 70% to 80%
of diagnosis and treatment deci- sions are based on laboratory results. As this
section clearly
suggests, there are many important aspects to laboratory structure and testing,
all of which contribute to the bottom line: accurate laboratory tests performed in a timely mann
er.
1899_Ch06_095-117 21/12/11 2:21 PM Page 117 118 On the Horizon It has been widel
y documented that
as many as 70% to 80% of all patient treatment decisions are based on laboratory
test results.
Similarly, there is strong evi- dence to support the fact that laboratory test r
esults are only
as good as the sample from which the test- ing occurs. Specimen collection and p
rocessing, also
known as the preanalytical phase (meaning the steps before actual analysis occur
s) of testing, is
thus a very important factor that contributes to the reliability of the laborato
ry test results
obtained. Results from such samples collected and/or processed improperly can- n
ot be considered

valid and thus are of no benefit to the patient. There is widespread evidence th
at most
laboratory testing errors occur in during the collection and processing of speci
mens. Relevance
for the Medical Assistant (Health-Care Provider) Medical assistants and other he
alth-care support
per- sonnel are often called upon to assist in the collection of, perform the co
llection of,
instruct patients on the collection of and process samples for laboratory testing. To ensure
the most reliable results for the patient, an in-depth understanding of specimen
collection and
processing is of paramount importance. Case in Point After a relatively smooth m
orning, your
first patient after lunch is Wilma F., a 70-year-old woman. After reviewing Wilm
as file, you
notice that she was seen and treated 3 weeks ago, on what just happened to be on
your day off,
for a urinary tract infection. As you help Wilma get onto the scale to weigh her
and then again
when you place the blood pressure cuff on her arm, you notice that she is very h
ot to the touch.
Your suspicions are confirmed when you take her temperature and it is 101.5F! You
ask Wilma to
identify all symptoms she has been experi- encing. She tells you that in additio
n to feeling hot
all the time, she has a burning sensation and pain during urina- tion. You docum
ent these details
and tell Wilma that the doctor will be in to see her shortly and you leave the e
xamining room.
After the doctor examines Wilma, he asks you to collect her blood and assist Wil
ma in collecting urine for urinalysis and culture. Questions for Consideration: What special
considerations
must be addressed to col- lect the blood in an appropriate manner in this case?
What special
equipment do you need to collect this blood sample? What type of urine sample sh
ould you assist
Wilma to collect? How is this type of urine sample collected? Why are the blood
and urine
collection processes so important to implement in this case? 1899_Ch07_118-132 2
1/12/11 2:22 PM
Page 118 119 Section II Specimen Collection and Processing As one might imagine,
there are many
things that must be considered in this situa- tion to ensure that laboratory spe
cimens are
properly collected and processed. That being said, this section is divided into
four chapters,
each with a targeted focus. Chapter 7: Overview of Specimen Collection and Proce
ssing consists of
an in-depth dis- cussion of the proper ordering and documentation associated wit
h specimen
collection. The name of the labor atory test(s) being ordered, methods of collec
tion, patient
prepa- ration, and proper information for specimen labeling are all addressed. S
pecimen
collections that involve a process known as the chain of custody are identified
and described.
Chapter 8: Collection and Processing of Blood Samples explores the anatomy and p
hysiology of the

cardiovascular system as well as body sites both suitable and unsuitable for the
collection of
blood. The equipment and procedures for successful venipuncture and capillary pu
ncture specimens
and the process of creating periph- eral blood smears is detailed. Chapter 9: Co
llection and
Processing of Urine Samples introduces the reader to the most common types of ur
ine samples,
including but not limited to catheterized, midstream-clean catch, first morning
collection, and
timed collection. The purpose of each specimen type is identified. Chapter 10: C
ollection and
Processing of Samples for Microbial Studies covers the general requirements for
proper collection
of samples for microbial studies. Samples described include throat swabs for str
ep screen and
culture, sputum, urine, blood (using aseptic technique), wounds, and stool. Samp
les for saline
wet preps and KOH preps are also described. Processing supplies, particularly me
dia and techniques used to support growth of microorganisms, are covered. 1899_Ch07_118-132
21/12/11 2:22 PM
Page 119 1899_Ch07_118-132 21/12/11 2:22 PM Page 120 121 Chapter 7 Overview of S
pecimen
Collection and Processing Constance L. Lieseke, CMA (AAMA), MLT, PBT(ASCP) CHAPT
ER OUTLINE
Specimen Ordering Required Items for All Laboratory Tests Test Specifics Medicar
e-Approved Panels
Standing Orders Reflexive Testing Patient Identification Verification of Patient
Identity
Acceptable Patient Identifiers Electronic Bar Codes Patient Preparation Specimen
Collection at
Home Items That Must Be Documented With Specimen Collection Labeling Information
Chain of Custody
Summary Time to Review Resources and Suggested Readings Learning Outcomes After
reading this
chapter, the successful student will be able to: 7-1 Define each of the key term
s. 7-2 List the
required items necessary for ordering any laboratory test. 7-3 Compare and contr
ast organ- or
disease-specific panels that are approved by the Centers for Medicare & Medicaid
services (CMS)
to custom panels created by some laboratories. 7-4 Explain how standing orders a
re used in the
laboratory. 7-5 Describe reflexive testing and explain how it may benefit patien
ts. 7-6 Describe
acceptable methods used to verify patient identity. 7-7 Demonstrate understandin
g of the
importance of proper patient preparation prior to specimen collection. 7-8 Instr
uct patients in
how to fast for a laboratory test. 7-9 Explain the importance of timing for peak
and trough
medication levels. 7-10 Explain why thorough documentation of speci- men sources
is so important.
7-11 Describe what to include when documenting specimen collection. 7-12 Describ
e appropriate
labeling procedures for laboratory specimens. 7-13 Describe the critical aspects
involved in a
speci- men collection that requires a chain of custody. 1899_Ch07_118-132 21/12/
11 2:22 PM Page

121 122 Section II Specimen Collection and Processing CAAHEP/ABHES STANDARDS CA

AHEP Standards
Met IV.P. Psychomotor Skills, Concepts of Effective Commu- nication, #6: Prepare
a patient for
procedures and/or treatments. ABHES Standards 10. Medical Laboratory Procedures,
Specimens KEY
TERMS 1 or 2 hr postprandial (1 or 2 hr pp) Chain of custody Fasting First morni
ng void Glucose
challenge Glucose tolerance test Peak collection level Random specimen Reflexive
testing Standing
orders Trough collection level P roper specimen collection and processing are cr
itical components
of laboratory testing as part of the pre- analytical phase. As introduced in Cha
pter 1, certain
fac- tors in the collection and processing of specimens are universal: clear, co
ncise patient
preparation instructions, verification of patient identification, labeling proce
- dures, and
source documentation are all utilized for specimen collection procedures, regard
less of the
speci- men source. To have a positive impact on patient treat- ment and outcomes
, health-care
employees who collect specimens or instruct patients to prepare for specimen col
lection must be
knowledgeable about the techniques required for quality procedures. SPECIMEN ORD
ERING Laboratory
testing begins with orders for specimens to be collected. Sometimes this step ma
y ambiguous.
Commu- nication from the health-care provider may be unclear for various reasons
. Examples of
potential problems include verbal orders that are misunderstood, the use of nons
tan- dardized
abbreviations, and handwritten orders that are difficult to read. It is imperati
ve that everyone
involved with the process understand how critical the initial data used to order
a test may be.
Required Items for All Laboratory Tests A laboratory requisition form is used to
order specific
laboratory testing procedures, but the requisition is also used to provide infor
mation needed for
reimbursement for these procedures. In addition, the test ordered must always be
documented in
the patients chart. Laboratory requisition forms may vary; some are or- ganized w
ith the tests
listed in alphabetical order, whereas others may be organized with the tests lis
ted in
categories. Regardless of the organization of the laboratory requisi- tion form,
there are
certain items that are essential for the collection process to be carried out ap
propriately. Many
of these items are introduced in earlier chapters in the textbook. At a minimum
the requisition
form should include the following: 1. Complete demographic information for the p
atient. This
includes the full name and birth date, the patients gender, and the billing infor
mation. 2. Name
of ordering health-care professional and docu- mentation of any other additional
agencies or
health- care professionals that should receive copies of the laboratory report.
3. Date for the

test collection. A specific date may be a critical factor, or there may be a bit
more flexibility
for the collection date. For instance, sometimes a lab- oratory test will be ord
ered to be
checked for a med- ication blood level after the patient has been on that partic
ular medication
for several days; this date should be noted on the requisition form so that the
patient knows
when to have his or her blood drawn. 4. Specific documentation for the tests ord
ered. Each test
must be marked carefully and completely with an X or a circle around the test. E
ach test will be
accom- panied by a current procedural terminology (CPT) 1899_Ch07_118-132 21/12/
11 2:22 PM Page
122 code (printed on the requisition form next to the test), which may help with
definitive
choices when a provider is unsure of which test to order. 5. Diagnosis codes (in
the form of an
ICD-9 code) must be included with all laboratory tests ordered. Each test must h
ave a diagnosis
code specifically assigned to it, rather than one or two codes written randomly
on the
requisition form, as they may not apply to all the tests ordered. A diagnosis co
de is required
for reimbursement. 6. If a test may be performed on more than one type of body f
luid, it is very
important to specify which fluid is to be used for the analysis. For instance, c
ortisol levels
may frequently be performed using serum or urine; if the source is not documente
d correctly, then
the patient may be required to return to resubmit the specimen. 7. When a medica
tion level is
ordered, the time of the last medication dose should be included on the req- uis
ition form, or
the time of the requested blood draw should be specified. This may be critical f
or appropriate
interpretation of the results. 8. If a wound culture is required, the source mus
t be documented
carefully. Specimen processing for microbiological specimens will vary depending
on the site of
the collection and the type of sample. 9. Medicare-Approved Panels Health-care p
roviders must be
careful when ordering panels, especially for those patients who have Medicare co
verage for their
payment source. The Centers for Medicare & Medicaid Services (CMS) has adopted s
ev- eral organor disease-specific panels that were designed by the American Medical Associatio
n (AMA). These
panels will be the same no matter which laboratory uses them. These are the only
panels that are
always covered by Medicare without the need of an Advanced Benefici- ary Notice
of Noncoverage
(ABN), even though some of the tests included in the panel have limited Medicare
coverage. Care
must be taken, however, to ensure that all the tests in the panel are really nec
essary for the
treat- ment of the patient. If there is no documentation in the patients chart to
show necessity
for the entire panel, the health-care provider may be held responsible for fraud
u- lent ordering

practices. The Medicare-approved organ- or disease-specific panels are the follo

wing: Basic
Metabolic Panel(s); with or without ionized Calcium Electrolyte Panel Hepatic Pa
nel
Hepatitis Panel Comprehensive Metabolic Panel Renal Function Panel Lipid Panel L
aboratories
must follow strict reimbursement rules for tests that are included in panels. Th
e total cost of
the panel may not exceed the totals of the separate tests included in the panel.
Table 7-1
itemizes the tests included in the CMS-approved panels. Chapter 7 Overview of S
pecimen
Collection and Processing 123 Test Your Knowledge 7-1 List three items that must
be present on a
laboratory requisition form when ordering a specimen collection. (Outcome 7-2) T
est Specifics
Laboratory tests may be ordered in several ways. If a health-care provider feels
that only one
analyte needs to be tested to assist with diagnosis and treatment, he or she wil
l order a single
test, such as a glucose level for a patient who is being screened for diabetes,
a potassium level
for someone who is taking diuretics, or a hematocrit test for someone who is bei
ng treated for
anemia. However, it is often beneficial for the health-care provider to order a
group of tests
that have been designed to enable providers to make more accurate diagnoses. The
se groups of
tests may be custom panels that have been designed by a spe- cific laboratory or
specialty. A
thyroid panel, for instance, may include three different tests that measure diff
erent aspects of
thyroid function. These custom panels are not universal in nature; what is inclu
ded in a custom
panel by one laboratory will not necessarily be the same as those included in a
panel by the same
name with another laboratory. TABLE 7-1 Medicare-approved panels Test Name CPT C
ode Comprehensive
Metabolic Panel (CPT 80053) Albumin 82040 Bilirubin, total 82247 Calcium 82310 C
arbon dioxide
82374 Chloride 82435 Creatinine 82565 Glucose 82974 Alkaline phosphatase 84075 C
ontinued
1899_Ch07_118-132 21/12/11 2:22 PM Page 123 Standing Orders Frequently health-ca
re professionals
will establish a set of standing orders for a patient, meaning that the patient
is to have a
specific test performed at a certain time interval for a period of time. For ins
tance, a patient
may need to have a potassium level checked every 3 months to monitor progress wh
ile on a certain
medication. To set up the standing order, the physician will submit a requisitio
n form to the
laboratory with the initial potassium level ordered, but the requisition form ma
y also include
additional orders to repeat this test every 3 months. Some laboratories may also
have a separate
form used to transmit information about standing orders, rather than using the i
nitial
requisition form. Standing orders may not be continued for more than a year with
out a new order

being written by the health-care provider. Recently, the practice of using stand
ing orders has
been questioned. In 2007, there was a change to the Physician Fee Schedule updat
e, which
specified a need for a separate order for every blood glucose test performed for
patients in
certain set- tings; the rule emphasized that a standing order was not sufficient
for
documentation of necessity for these patients. Even though this ruling addressed
only blood 124
Section II Specimen Collection and Processing TABLE 7-1contd Medicare-approved pa
nels Test
Name CPT Code Potassium 84132 Total protein 84155 Sodium 84295 Transferase, alan
ine amino (ALT,
SGPT) 84460 Transferase, aspartate amino (AST, SGOT) 84450 Blood urea $$ 84520 H
epatic Function
Panel (CPT 80076) Total protein 84155 Albumin 82040 Alkaline phosphatase 84075 T
ransferase,
aspartate amino (AST, SGOT) 84450 Transferase, alanine amino (ALT, SGPT) 84460 B
ilirubin, total
82247 Total protein 84155 Basic Metabolic Panel With Ionized Calcium (CPT 80047)
Glucose 82974
Potassium 84132 Sodium 84295 Blood urea nitrogen 84520 Calcium, ionized 82330 Ca
rbon dioxide
82374 Chloride 82435 Creatinine 82565 Basic Metabolic Panel With Calcium (CPT 80
048) Glucose
82974 Potassium 84132 Sodium 84295 Blood urea nitrogen 84520 Calcium 82310 Carbo
n dioxide 82374
Chloride 82435 Creatinine 82565 Renal Function Panel (CPT 80069) Glucose 82974 P
otassium 84132
Sodium 84295 Blood urea nitrogen 84520 Calcium 82310 Carbon dioxide 82374 Chlori
de 82435
Creatinine 82565 Phosphorus 84100 Lipid Panel (CPT 80061) Cholesterol, total 825
65 Triglycerides
84478 Electrolytes (CPT 80051) Potassium 84132 Sodium 84295 Carbon dioxide 82374
Chloride 82435
Current Procedural Terminology 2011 American Medical Association, All Rights Res
erved. Test
Your Knowledge 7-2 How are custom panels similar to the Medicare- approved panel
s? (Outcome 7-3)
1899_Ch07_118-132 21/12/11 2:22 PM Page 124 Reflexive Testing Another practice t
hat may be used
in a clinical labora- tory is reflexive testing. In this situation, additional t
est- ing is
automatically performed in response to certain ab- normal results. An example of
reflexive
testing is the antibiotic sensitivity testing performed on culture sam- ples. If
a culture
specimen has a positive result, an antibi- otic sensitivity is automatically per
formed to provide
the physician with additional knowledge about the best way to treat the infectio
n. Without this
reflexive option, it would be necessary to contact the physician and request a s
eparate order for
this sensitivity to be performed, which would delay patient treatment. The addit
ion of reflexive
tests allows the ordering physician to receive additional information in a timel
y manner rather
than waiting until the initial sample result is transmitted back to the physicia
n and another

order is placed for a new sample to be collected. In order for reflexive testing
to be performed
within the guidelines necessary for reimbursement, it is essential that the orde
ring physician is
made aware of the tests included in the reflexive testing panel, and it is also
necessary that
the physician be offered the opportunity to order these secondary tests separate
ly without the
reflexive option if needed. These reflexive tests are to be documented clearly o
n the requisition
form. Verification of Patient Identity Whenever a patient presents for specimen
collection, it is
imperative that the person performing the collection verify the identity of the
patient. This is
the most impor- tant procedure in the specimen collection process. A minimum of
two unique
identifiers must be used to verify patient identification. Incorrect identificat
ion of the
patient may result in specimen collection on the wrong patient, and misdiagnosis
of the patient
because of incorrect laboratory values. Drawing the wrong patient may even have
fatal
consequences if the treat- ment plan developed is incorrect. Acceptable Patient
Identifiers
Name: It is always best to ask the patient to state his or her name; do not ask,
Are you Mrs.
Smith? as many patients may say Yes without actually hearing or understanding what
was asked.
Ask the patient to state his or her name, and spell the last name. Birth date: T
he patient must
also state his or her birth date. It is possible to have two patients with the s
ame first and
last name, but improbable that they will also share the same birthday. Social Se
curity number
or patient ID: The use of the Social Security number is no longer recommended in
most cases, with
the exception of those who are receiv- ing care in a government facility. A pati
ent ID may have
been assigned to the patient (especially in the case of managed care clients or
hospital
settings) and this may serve as a unique identifier. Drivers license or other pic
ture
identification: For legal specimens or those that are associated with employment
, a picture ID is
necessary for definitive identification. It is an acceptable means of identifica
- tion in all
situations, but not always necessary. In many office settings, the picture ID is
part of the
patients permanent health record. In hospitals or other settings in which the pat
ient may not be
able to converse with the collector, it is especially important that the identit
y of the patient
is established before the specimen is collected. Never use the name written or p
rinted above the
bed as that of the patient. If the patient has an armband that has been placed o
n the wrist, this
may be used if the patient is not capable of verifying his or her identity verba
lly. Never use an
armband for identification if it is not securely placed on the patients arm. If t
he patient is

not wearing appropriate identification, it will be neces- sary to locate the hea
lth-care
professional responsible Chapter 7 Overview of Specimen Collection and Processi
ng 125 Test Your
Knowledge 7-3 A standing order for a theophylline drug level is written so that
the patient is to
have her medication level tested monthly for 18 months. Is this order acceptable
? Why or why not?
(Outcome 7-4) Test Your Knowledge 7-4 List one way that reflexive testing benefi
ts patients.
(Outcome 7-5) PATIENT IDENTIFICATION As presented in Chapter 1, the medical assi
stant or
phlebotomist responsible for collecting samples for analysis plays a critical ro
le. Appropriate
patient identi- fication and documentation of the collection proce- dures used a
re very important
components of this preanalytical process. glucose, it does serve as a warning fo
r future policy
changes in reference to standing orders. 1899_Ch07_118-132 21/12/11 2:22 PM Page
125 for this
patient (usually one of the nursing staff ) and ask him or her to reband the pat
ient and provide
defin- itive ID before collecting the specimen. In this situa- tion, be sure to
document the name
of the person who provided the identification. Electronic Bar Codes Most likely,
not many of us
remember a time when we didnt have bar codes on our groceries and other items tha
t we purchase
in retail stores. Bar codes allow for more specific identification of the produc
t purchased, and
pro- vide an efficient way to update prices and product inven- tory. The healthcare industry has
also found that the use of electronic bar codes helps to streamline the process
of ordering
laboratory tests. Using labels with electronic bar codes on the individual tubes
and specimen
containers helps to assure specimen identification and patient confi- dentiality
, and allows for
automated sorting and distribu- tion of the specimens in large laboratory settin
gs. It is
especially important to verify identification in situations in which bar codes a
re used, because
the individual spec- imen containers do not necessarily include the patients name
. The
individual specimens may only be identified with the bar code or specimen ID lab
el that
represents that patient in the electronic system. PATIENT PREPARATION In additio
n to the
verification of patient identity and de- mographic information, the medical assi
stant responsible for specimen collection must also verify whether the patient prepared approp
riately for the
test ordered prior to collection of the specimen. The reference ranges for labor
atory tests are
based on specific parameters, and if these were not in place for the patient bei
ng tested, their
results may appear to be abnormal. Examples of specific preparation procedures i
nclude the
following: Fasting: A fasting specimen may be required for tests such as blood g
lucose levels

or lipid testing. Fasting means that the individual must go without food and any
liquid other
than water for 12 hours prior to the blood draw. The patient usually can take me
dication that has
been prescribed if it poses a health risk to skip or postpone a dose until after
the period of
fasting. If the patient did take medication during this fasting pe- riod, it mus
t be documented
on the requisition form. 1 or 2 hr postprandial: A 1 hr pp or 2 hr postprandial
(1 or 2 hr pp)
blood draw means that the specimen is collected 1 or 2 hours (respectively) afte
r the individual eats a meal. These pp samples are usually used for blood glucose testing. Gl
ucose
challenge: When patients are screened for diabetes (especially for pregnant wome
n) a glucose
challenge may be ordered. In this situation the patient is given a drink that co
ntains 50 g of
glucose to ingest. One hour after the sweetened drink is con- sumed, the patient
has his or her
blood drawn again for a glucose test. Glucose tolerance test: A glucose toleranc
e test has
several steps, and is usually only ordered if the fasting blood sugar, postprand
ial blood sugar,
or glucose chal- lenge results are abnormal. In this situation, a blood sample i
s drawn from the
fasting patient. (The patient usually provides a urine specimen as well.) The pa
tient is then
asked to drink a solution that contains 100 g of glucose. Subsequent blood draws
are performed
every half hour for a period of 3 to 6 hours. (This process is presented in more
detail in
Chapter 17.) Timed drug levels: Reference ranges for blood medica- tion levels a
re based on the
rate at which different drugs are metabolized. Some types of medication peak in
the bloodstream
relatively quickly after ingestion, while others are slow acting. The medical as
sistant or
phlebotomist needs to verify (and document) when the patient last took their med
ication before
perform- ing the collection. Some drugs may have therapeutic ranges that are ver
y close to the
levels where the drug may harm the body, and the timing of the draw is essential
to determine
whether the dosage should be changed. Drugs may also be ordered as peak or troug
h collection
levels. These terms mean that the specimen is to be drawn when that particular d
rug is at the
high- est level (peak) and/or the lowest level (trough) in the bloodstream. Beca
use each
medication is absorbed and cleared from the body differently, the time after the
last dose of the
medication for the peak and trough draw will vary. The peak levels are generally
obtained 1 to 2
hours after a drug is given; the trough levels are usually just before the next
dose is due. With
peak and trough levels, if the medical assistant does not verify the time of the
last dose, the
result may appear to be abnormal when in actuality the specimen was just drawn a
t the wrong time.

 Restricted diets for specimen collection: Some labora- tory tests performed on b
lood, stool,
and urine 126 Section II Specimen Collection and Processing Test Your Knowledge
7-5 Should an
armband taped on the side of a hospital bed not be used for patient identificati
on? (Outcome 7-6)
1899_Ch07_118-132 21/12/11 2:22 PM Page 126 require that the patient restrict hi
s or her diet
before and/or during collection. Examples may be avoidance of rare meat for a fe
w days before the
collection of a stool specimen for fecal occult blood testing, or avoidance of c
ertain foods
during the collection time for a 24-hour urine specimen. Random specimens: Rando
m specimens do
not re- quire special preparation before collection. The con- centration of many
chemical
substances and cellular components present in the bloodstream does not change th
roughout the day,
and can be collected at any time. This term is also used to describe urine specimens used for
basic urinalysis testing, as well as many microbiology specimens. First morning
void: During
sleep, the body continues to create urine as the blood circulates through the ki
dneys. The first
morning void specimen may be requested for specific urine chemistry tests, as th
e concentration
of the analyte will be elevated in this specimen because it has been in the blad
der all night. A
microalbumin test is an example of a test that is often ordered as a first morni
ng void specimen.
remain protected from light, whereas other specimens need to be added to contain
ers with
preservatives imme- diately after collection. It is the responsibility of the me
dical assistant
who accepts these specimens from the patient to verify that the collection and p
rocessing have
been performed correctly. Prior patient education is critical for quality specim
ens. ITEMS THAT
MUST BE DOCUMENTED WITH SPECIMEN COLLECTION Documentation does not end with the
collection of the
specimen. It is essential that details about the collection are recorded on the
requisition form,
as these details help to provide critical information that may affect the test r
esults. Who?
The initials (or other unique identification, such as an employee ID) for the pe
rson who
collected the specimen must be documented on the requisition form. This informat
ion may be
critical if there are any problems with the specimen. This information is also p
laced on the
blood tube after collection while in the presence of the patient. What? What typ
e of specimen
was collected? For blood specimens, there should be documentation of the type of
specimen
collected because venous, arterial, and cap- illary samples may have different r
eference ranges
for a specific analyte. Reimbursement for the collection may also vary with the
type of blood
specimen. For urine specimens, there should be documentation as to whether the s
ample is a random

or timed urine collec- tion, and the method used for the collection process. (Th
is is further
clarified in Chapter 9.) Body fluids (such as amniotic fluid or synovial fluid)
are especially
difficult to identify by sight, so clarification of the spec- imen type is essen
tial at the time
of collection; reference ranges are very different for each type of body fluid.
When?
Documentation of the date and time of collec- tion is critical. The time must in
clude a.m. or
p.m., or military time may be used. Many chemical analytes change drastically wi
th time once the
blood has left the body, and these natural postcollection changes may be misiden
tified as part of
a disease process if the specimen is not processed in a timely fashion. For time
d collections, it
is essential. The date and time of collection are added to the requisition form
as well as the
tube after a blood draw is complete. Where? The site of collection must also be
docu- mented.
For blood draws, this does not need to be absolutely specific; a general locatio
n such as right
Chapter 7 Overview of Specimen Collection and Processing 127 SPECIMEN COLLECTIO
N AT HOME Urine,
stool, and microbiology specimens are often col- lected by patients in the priva
cy of their homes
and delivered to the laboratory soon after. With this type of collection, specia
l care must be
taken to educate the patient properly in reference to specimen collection and st
orage.
Information for patient use should be offered verbally and in writing to ensure
understanding and
compliance. Collection and storage techniques should be verified again before ac
cepting the
specimen at the laboratory. For instance, a urine specimen collected at home sho
uld be collected
using a sterile container, and the specimen must be refrigerated and transported
to the
laboratory as soon as possible after collection. In contrast, stool specimens co
llected for
culture are not to be refrigerated, but should arrive at the laboratory within 2
hours of
collection. Some specimens must Test Your Knowledge 7-6 Mr. Rider comes in for a
blood draw as
part of his annual physical. The physician has ordered a fasting blood glu- cose
level. Just as
the medical assistant begins to prepare for the blood draw, she notices that the
patient has a
cof- fee mug in his hand. What should she ask him before she begins the draw? (O
utcome 7-8)
1899_Ch07_118-132 21/12/11 2:22 PM Page 127 hand or left arm will do. This docum
entation can be
very helpful if there are complications at the draw site. For culture specimens,
documentation of
the collec- tion site should be as specific as possible, because the normal flor
ae present in
different areas of the body are not the same. The physical location of the cultu
re collection
site needs must be specified (right arm, left leg, opening of fistula, etc.) as
well as the type

of wound or collection procedure used. A superficial wound sample is different f

rom that
collected from a deep puncture wound, and a specimen collected by aspiration is
different from a
specimen collected by squeezing a pustule. For instance, bacteria that are commo
n on the surface
of the skin are not part of the normal florae in a deep wound, even if the speci
mens are both
taken from the right great toe. LABELING INFORMATION All collection containers m
ust be labeled
immediately after collection, meaning that the specimen must be labeled in an ou
tpatient setting
while in the presence of the patient and before another outpatient requisition f
orm is accepted.
In an inpatient setting, the specimen labeling process must be complete before t
he phle- botomist
leaves the patients room. Labeling may in- volve writing with an indelible pen di
rectly on the
preaffixed label on the tube after collection, or by apply- ing a label that has
been generated
by a computer and adding a few items. Computer-generated labels often include ba
r codes that may
be read by the instruments used for testing. Tubes should never be prelabeled be
fore specimen
collection, as this can lead to incorrect patient identification if the collecti
on is
unsuccessful and the tubes are not discarded, or if there is more than one patie
nt present in a
blood drawing area at the same time. Specimens that are mislabeled can potential
ly cause serious
harm to patients when inaccurate patient results are generated. The specimen lab
el must include
the following information: The name of the patient and a unique identifier number. The ID
number is generated by the computer CHAIN OF CUSTODY Sometimes blood or urine is
collected in
situations in which the test results may be used as legal evidence. Blood may be
collected for
DNA analysis or blood alcohol level readings, whereas urine may be tested for dr
ugs of abuse. The
tests may be ordered in preemploy- ment situations, in the case of on-the-job ac
cidents or
suspected drunk driving, or for some athletes. In these situations, it is impera
tive that medical
assistants follow their facilitys guidelines very carefully as they perform their
duties. The
specimens that are collected must have written documentation for their processin
g and storage
from the point of collection through the testing and reporting process. It must
be evident that a
respon- sible individual had possession of the specimen, or had secured the spec
imen at every
step of the process. The record of the individuals who have access to the specim
en is called the
chain of custody. A chain of cus- tody is a physical object: a form that is fill
ed out and signed
each time that the specimen changes hands. An at the time of the blood draw, or
it may be part of
the requisition form available as a small peel-off label. If the patient number
is not available,

the date of birth may be used instead. Two patient identifiers are required. Dat
e and time of
collection Initials (or other unique ID) for the person who per- formed the spec
imen collection
Other required information may include documen- tation of a peak or trough draw,
or at what
time a specimen is taken for a glucose tolerance test. Even though the time of t
he draw should
indicate which specimen is in the tube, it is a good idea to docu- ment this in
more than one way
to avoid any confusion. For patients who collect their specimens at home, the pe
rson who accepts
the specimen at the laboratory must verify that the specimen is labeled appropri
ately while in
the presence of the patient. If a patient drops off a specimen that is not label
ed and no one is
present to accept the specimen, it will need to be recollected. 128 Section II
Specimen
Collection and Processing Test Your Knowledge 7-7 Why is it important to documen
t that a blood
specimen was obtained from a capillary puncture rather than a vein? (Outcome 7-1
0) Test Your
Knowledge 7-8 List two items that must be included on the label after a blood sp
ecimen is
collected. (Outcome 7-12) 1899_Ch07_118-132 21/12/11 2:22 PM Page 128 example of
a chain of
custody form may be found in Figure 7-1. Critical components of the process incl
ude the
following: 1. Identification of the patient: This is the most impor- tant part o
f the process.
Sometimes patients are not willing participants in the process, as they may have
been placed
under arrest, or may have been involved in some sort of incident at their place
of work. If the
patient is not able (or willing) to show appropriate identification, the arresti
ng officer or
supervisor must identify the patient and it must be documented on the form. 2. E
xplanation of the
process and witnessed signed con- sent form. 3. Secure collection area and stand
ardized process:
Especially in the case of urine specimens, there are very specific procedures th
at must be
followed to eliminate the opportunity for patients to add water or other substan
ces to the
specimen, or to substitute a specimen that they may have brought from out- side
the premises. For
instance, the patient is not allowed to take any coats or purses into the restroom during the
collection. The handles of the faucet in the collection area may be secured with
tamper-evident
tape, or the water supply may be shut off from outside the room. In addition, th
e toi- let water
always has a bluing agent added to avoid an opportunity to take water from the t
oilet unnoticed. The specimen temperature is documented immediately when the collection is
complete as a
means of quality assurance. 4. Assignment of a sample number: Legal specimens sh
ould not be
identified by name after the initial col- lection process. This helps to protect
the patients

confidentiality, and also limits the opportunities for someone to tamper with a
specific
specimen. 5. Securing the specimen and protecting against tam- pering: The speci
men has a
tamper-evident seal that is affixed at the time of collection. The patient and t
he collector
initial this seal and the specimen is sealed in the presence of the patient. If
this seal is broken when the sample is accessed for testing, the chain of custody is invalidated
. 6.
Documentation of processing: The specimen must remain in a secure location at al
l times. The
chain of custody form provides an opportunity to docu- ment where the specimen w
as stored, and
who placed it in that location at each step of transfer. Legal specimens must be
kept in a locked
location with limited authorized access until they are tested. The documentation
continues until
the time that the specimen is disposed of. There may be times when the medical a
ssistant is
called to testify about the collection process of a legal specimen. If the chain
of custody
process is followed carefully, there should be no problem with testifying regard
ing the specimen
processing. Poor documentation may be reason for dismissal of a legal case, and
could have
serious repercussions. Chapter 7 Overview of Specimen Collection and Processing
129 Test Your
Knowledge 7-9 What are two methods used to protect a legal specimen from potenti
al tampering?
(Outcome 7-13) POINT OF INTEREST 7-1 DOT drug screening Urine may be tested for
drugs of abuse
for many rea- sons. The test is a common part of preemployment screening for man
y corporations.
Most of the large retail store chains now require drug screening as a preemploym
ent procedure,
and some of them also use random drug screens as well. There are also times when
the federal
government requires drug screen testing. The Omnibus Trans- portation Employee T
esting Act of
1991 set a stan- dard that requires drug and alcohol testing for employees who a
re employed in
professions that the government has designated as safety-sensitive. This regulatio
n potentially
affects more than 10 million individuals. These employees may be working in the
following areas:
Those in the trucking industry Railroad workers Bus drivers or other mass-transi
t employees
Pilots and other aviation employees Employees in other types of public transport
ation Those
who work on public pipelines The U.S. Department of Transportation (DOT) has set
standards
concerning who will be tested, as well as the policies and procedures to be foll
owed for these
individuals. The collection process is even more critical in these situations, a
nd the laboratory
testing may be performed only at laboratories that have been approved by the DOT
. Special chain
of custody forms are used for the collection process, and the procedures for pro
cessing of the

paperwork are very specific. 1899_Ch07_118-132 21/12/11 2:22 PM Page 129 130 Sec
tion II Specimen
Collection and Processing NON FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM 1829
0 SPECIMEN ID No.
STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE STEP 2: COMPLETED BY C
OLLECTOR REMARKS
RECEIVED AT LAB: STEP 5a: PRIMARY SPECIMEN TEST RESULTS - COMPLETED BY PRIMARY L
ABORATORY STEP
5b: SPLIT SPECIMEN TEST RESULTS - (IF TESTED) COMPLETED BY SECONDARY LABORATORY
STEP 3: Collector
affixes bottle seal(s) to bottle(s). Collector dates seal(s). Donor initials sea
l(s). Donor
completes STEP 5 on Copy 2 (MRO Copy) STEP 4: CHAIN OF CUSTODY - INITIATED BY CO
LLECTOR AND
COMPLETED BY LABORATORY A. Employer Name, Address, I.D. No. B. MRO Name, Address
, Phone and Fax
No. ABC Temporary Employment Agency 1 Main Street, Hollywood, NY 11111 C. Donor
Name D. Reason
for Test: E. Drug Tests to be Performed: G. Collection Site Address: Donor SSN o
r Employee I.D.
No. Pre-employment Return to Duty Random Follow-up Reasonable Suspicion/Cause Ot
her (specify)
Post Accident John A. Smith, Jr. Hair 5 Drug Panel Urine 5 Drug Panel Other (spe
cify) 1 Main
Street Hollywood, NY 11111 123888 x x Read specimen temperature within 4 minutes
. Is temperature
between 90 and 100F? Yes No, Enter Remark Specimen Collection: Split Single Non P
rovided
(Enter Remark) HEAD HAIR URINE BODY x X X X X AM PM SPECIMEN BOTTLE(S) RELEASED
TO: I certify
that the specimen given to me by the donor identified in the certification secti
on on Copy Z of
this form was collected, labeled, sealed and released to the Delivery Service no
ted in accordance
with applicable Federal requirements. John Doe John Doe 2:00 PM 01/31/2012 Date
(Mo, Day, Yr)
Date (Mo, Day, Yr) Time of Collection Signature of Collector (PRINT) Collectors
Name (First, MI,
Last) (PRINT) Accessioners Name (First, MI, Last) UPS Next Day Delivery Name of D
elivery Service
Transferring Specimen to Lab Signature of Accessioner SPECIMEN BOTTLE(S) RELEASE
D TO: Primary
Specimen Bottle Seal Intact Yes No, Enter Remark Below NEGATIVE DILUTE REJECTED
FOR TESTING
POSITIVE for: PCP COCAINE METABOLITE MARIJUANA METABOLITE CODEINE MORPHINE AMPHE
TAMINE
METHAMPHETAMINE ADULTERATED SUBSTITUTED 6-ACETYLMORPHINE INVALID RESULT REMARKS
TEST LAB (if
different from above) I certify that the specimen identified on this form was ex
amined upon
receipt, handled using chain of custody procedures, analyzed, and reported in ac
cordance with
applicable Federal requirements. (PRINT) Certifying Scientist (First, MI, Last)
Signature of
Certifying Scientist Date (Mo, Day, Yr) Laboratory Name Laboratory Address Sign
ature of
Certifying Scientist (PRINT) Certifying Scientist (First, MI, Last) Date (Mo, Da
y, Yr)
RECONFIRMED FAILED TO RECONFIRM - REASON I certify that the split specimen ident
ified on this

form was examined upon receipt, handled using chain of custody procedures, analy
zed, and reported
in accordance with applicable Federal requirements. C. Doyel 6291 Park Ave, Holl
ywood, NY 11111
Figure 7-1 An example of a chain of custody form. The top copy contains the name
of the patient,
but this copy does not follow the specimen as it progresses to the testing phase
. The copies that
are used with the specimen after it is input into the computer are designated on
ly by the
specimen ID number. 1899_Ch07_118-132 21/12/11 2:22 PM Page 130 SUMMARY Specimen
collection and
processing are critical com- ponents of the laboratory testing. Care must be tak
en to fill out
the request for testing in the proper man- ner, educate the patient appropriatel
y for necessary
preparation, and thoroughly document the collec- tion procedure. It is also nece
ssary to label
the speci- men using recommended procedures so that there are no potential probl
ems with
identification as the testing process continues. The type of collection, the typ
e of specimen,
and the date and time of collection are critical components that must be logged
on the
requisition form after collection. In legal situations, care must be taken to fo
llow established
procedures to ensure that specimens are kept safe from tamper- ing until they ar
e tested and the
results are reported. This process uses a chain of custody form, which must be f
illed out by
anyone who has access to the specimen during and after collection. TIME TO REVIE
W 1. When is a
trough blood level drawn? Outcome 7-1 2. Which of these items does not need to O
utcome 7-2 be
included on a complete laboratory requisition form? a. ICD-9 code(s) b. Ordering
physicians name
c. Cost of tests d. Demographic information for the patient 3. How are CMS panel
s different from
Outcome 7-3 custom panels created by independent laboratories? a. The custom pan
els include fewer
tests b. The CMS panels have been approved by the AMA c. The reimbursement rates
are better for
the cus- tom panels d. They are essentially the same 4. True or False: Reflexive
testing causes
Outcome 7-5 excessive time to be spent before results are available to the order
ing health-care
provider. 5. True or False: All medication is Outcome 7-9) absorbed and used by
the body at the
same rate. 6. List three items that must be Outcome 7-11 documented on the requi
sition form after
a specimen is collected. 7. True or False: It is acceptable to use Outcome 7-12
a
computer-generated label on a tube after collection as long as it includes the b
asic required
information. Chapter 7 Overview of Specimen Collection and Processing 131 Case
Study 7-1:
Standing orders Mr. Johnson comes into the laboratory to have his potassium leve
l checked. He has
a standing order to have this test performed every 3 months because of a medicat
ion that he takes

for a heart disorder. When he arrives at the laboratory, the phlebotomist checks
the records for
Mr. Johnson in the computer system. He informs Mr. Johnson that he cannot draw h
is blood today
because his standing order has expired. 1. What does the phlebotomist mean by st
ating that the
standing order has expired? 2. What needs to occur before Mr. Johnson can have h
is blood drawn
for the potassium test? Case Study 7-2: Labeling Cassy Jones is a medical assist
ing student who
is training in the laboratory. She is trying very hard to get all the informatio
n correct for
every situation, and she tells her trainer that she is working on anticipating t
he needs of the
practice so that she can be better organized. When her trainer returns from lunc
h one afternoon,
she finds that Cassy has labeled blood tubes for the expected blood draws for th
e afternoon.
Cassys trainer tells her that although she can see that her intentions were good,
this is an
unacceptable practice. 1. Why is the prelabeling of the tubes an unacceptable pr
actice?
1899_Ch07_118-132 21/12/11 2:22 PM Page 131 132 Section II Specimen Collection
and Processing
RESOURCES AND SUGGESTED READINGS University of Washington Laboratory Testing Poli
cies Very
specific information about testing and collection processes designed for use by
practitioners
http://depts .washington.edu/labweb/PatientCare/Policies/index.htm Errors in Labo
ratory
Medicine Information about common laboratory errors including all phases of the t
esting process
http://www.clinchem.org/cgi/ content/abstract/48/5/691 Laboratory Test Ordering a
nd
Documentation; List of Dos and Donts http://www.cap.org/apps/docs/pt_checkup/
pol_library/laboratory_test_ordering.pdf 1899_Ch07_118-132 21/12/11 2:22 PM Page
132 133 Chapter
8 Collection and Processing of Blood Samples Constance L. Lieseke, CMA (AAMA), M
LT, PBT(ASCP)
CHAPTER OUTLINE Anatomy and Physiology of the Cardiovascular System The Heart Bl
ood Vessels
Arteries Veins Capillaries Site Selection Most Commonly Used Veins Appropriate C
apillary Puncture
Sites Contraindications and Areas to Avoid Scars and Tattoos Mastectomy Consider
ations
Intravenous Fluids Bruises and Hematomas Varicose Veins Central Lines and Fistul
as Edematous
Areas Obese Patients Venipuncture Equipment Tourniquets Gloves Sharps Biohazardo
us Waste
Containers Alcohol and Gauze Pads Needles Additional Supplies Methods Used for V
enipuncture
Evacuated Tube System Syringe Method Winged Infusion or Butterfly Method Blood C
ollection Tubes
Color Coding of Tubes Types of Additives Order of Draw for Venipuncture Capillar
y Punctures Order
of Draw for Capillary Puncture Preparation for Blood Collection Specimen Process
ing Obtaining
Serum for Testing Obtaining Plasma for Testing Whole Blood Specimens Unacceptabl
e Specimen Types
Potential Negative Outcomes of Venipuncture and Capillary Puncture Inability to

Draw Blood
Fainting Patients Rolling Veins Hematoma Formation Collapsing Veins Nerve Damage
Infection Other
Processing Procedures Preparation of a Peripheral Blood Smear for Staining Wrigh
ts Stain
Procedure Summary Time to Review Resources and Suggested Readings 1899_Ch08_133194 21/12/11 2:23
PM Page 133 134 Section II Specimen Collection and Processing CAAHEP/ABHES STAN
DARDS CAAHEP
Standards: I.C.I.4: List major organs in each body system I.C.I.5: Describe the
normal function
of each body system I.P.I.2: Perform Venipuncture I.P.I.3: Perform Capillary Pun
cture I.A.I.1:
Apply critical thinking skills in performing patient assessment and care III.P.I
II.3: Select
appropriate barrier/personal protective equipment (PPE) for potentially infectio
us situations
ABHES Standards Medical Office Laboratory Procedures: Collect, label and process
specimens:
Perform venipuncture Medical Office Clinical Procedures: Apply principles of ase
ptic techniques
and infection control Medical Office Clinical Procedures: Use Standard Precautio
ns 8-1 Define
the key terms. 8-2 Explain the route used as blood moves through the heart. 8-3
Compare and
contrast the qualities of veins and arteries. 8-4 Examine the ways that capillar
ies differ from
veins and arteries. 8-5 Locate the most commonly used veins for draw- ing blood
specimens, and
explain why they are the best choice for this procedure. 8-6 Describe where capi
llary blood draws
may be safely performed. 8-7 List the major contraindications for blood draws, a
s well as areas
to be avoided. 8-8 List and describe the supplies necessary to per- form success
ful venipuncture
and capillary punc- tures. 8-9 Differentiate when the different methods of venip
uncture
(evacuated tube system, syringe system, or butterfly system) might be used. 8-10
Describe the
significance of the tube stopper col- ors when drawing blood. 8-11 Explain the o
rder of draw for
specimen collec- tion, and describe how it may be different with the various col
lection
techniques. 8-12 Analyze techniques to be used with different age groups when pe
rforming
venipuncture or capil- lary puncture. 8-13 Explain why capillary punctures may b
e pre- ferred as
a blood draw technique in some circum- stances, and provide examples. 8-14 Summa
rize appropriate
preparation techniques for blood draw procedures. 8-15 Successfully perform veni
puncture and
capillary puncture procedures using the process outlined in the textbook. 8-16 D
emonstrate the
ability to create a blood smear on a slide that would be suitable for staining,
and explain why
staining is important for examina- tion of blood samples. 8-17 Explain how to pr
ocess samples for
various labo- ratory tests ordered. 8-18 Analyze the differences between serum a
nd plasma. 8-19
Provide examples of inappropriate specimens, and describe how these issues may b

e avoided. 8-20
Describe how negative outcomes may be avoided when drawing blood. Learning Outco
mes After Reading
this Chapter, the Successful Student will be able to: 1899_Ch08_133-194 21/12/11
2:23 PM Page 134
Chapter 8 Collection and Processing of Blood Samples 135 KEY TERMS Antecubital
area
Anticoagulants Arteries Arterioles Basilic vein Bevel Butterfly system Capillari
es Capillary
action Capillary puncture Capillary tubes Cardiovascular Cephalic vein Clot acti
vators
Contraindications Edema Evacuated tube system Flanges Gauge Hematoma Hemoconcent
ration Hemolysis
Interstitial Lipemia Lumen Mastectomy Median cubital vein Microcollection contai
ners Morphology
Multi-sample needle Palpation Plasma Plasma separator tubes (PST) Quality not su
fficient (QNS)
Serum Serum separator tubes (SST) Sharp Short draw Syringe system Tourniquet Vac
uum Vasodilation
Vasovagal syncope Veins Venules Winged infusion set T he majority of laboratory
testing is
performed on blood specimens. As part of the preanalytical process, medical assi
stants and
phlebotomists are responsible for greeting and identifying patients, verifying p
atient identification, making appropriate site selections for collection, using correct colle
ction procedures,
and processing speci- mens prior to the testing stage. It is essential that the
health-care
professional who performs these duties under- stands how to execute them correct
ly, as the
potential impact of these processes is profound if they are per- formed improper
ly. This chapter
provides details about how to collect and process various blood specimens, inclu
ding necessary
knowledge of the anatomy and phys- iology of the cardiovascular system, an intro
duction to the
various tools used for obtaining blood, and information about how to avoid negat
ive outcomes
during the collec- tion process. Procedures for processing specimens after colle
ction are also
presented. ANATOMY AND PHYSIOLOGY OF THE CARDIOVASCULAR SYSTEM In order to consi
der the various
methods used to obtain blood specimens, it is important to understand the anatom
y and physiology
of the cardiovascular system. Essentially, all the body systems are connected, o
r linked, by the
cardiovascular system, because it offers a means of transportation to and from a
ll the cells of
the body. Homeostasis is a state in which the body is healthy and in balance. Fo
r homeostasis to
be maintained in our bodies, the cardiovascular system must transport water, nut
rients, waste
products, chemicals, and hormones everywhere within the body. The immune system
is also dependent
on the function of the cardiovascular system. In addition, circulation of the bl
ood helps to keep
the bodys temperature within normal limits, contributing to homeostasis. 1899_Ch0
8_133-194
21/12/11 2:23 PM Page 135 136 Section II Specimen Collection and Processing The

Heart The heart

is the beginning and the end of the cardiovas- cular system, and is approximatel
y the size of a
closed fist. It is made of very strong cardiac muscular tissue. Within the struc
ture of the heart
are four chambers. The upper two chambers of the heart are the atria and the low
er two chambers
of the heart are the ventricles. The two sides of the heart are separated by a w
all (called the
septum) and the atria and the ventricles on each side of the heart are separated
by valves, which
keep the blood from flowing backward within the structure. Figure 8-1 allows us
to follow the
path of the blood flow through the heart and lungs. 1. Oxygen-poor blood flows i
nto the right
atrium through two large veins known as the superior vena cava and inferior vena
cava. 2. As the
heart contracts, the blood flows through the tricuspid valve (which separates th
e chambers) into
the right ventricle. 3. From the right ventricle, the blood passes the pul- mona
ry semilunar
valve and enters the right and left pulmonary arteries. These arteries take the
blood into the
lungs for oxygenation. (These are the only arter- ies in the body that do not ca
rry oxygenated
blood.) 4. Once the blood has passed through the lungs, where it exchanges oxyge
n for carbon
dioxide, the blood flows back onto the left atria through the right and left pul
monary veins.
(These veins are the only veins in the body that carry freshly oxygenated blood.
) 5. From the
left atria, the blood passes through the bicuspid valve and enters the left vent
ricle. The left
ventricle is the part of the heart where the muscular walls are the thickest, as
the left
ventricle is responsi- ble for pumping the blood out of the heart into the arter
ial system to
circulate through the body. 6. The blood passes through the aortic semilunar val
ve, finally
exiting the heart through a very large artery, known as the aorta. Pulmonary art
ery Pulmonary
artery Pulmonary veins Pulmonary veins Superior vena cava Inferior vena cava Aor
ta Right atrium
Right ventricle Left atrium Left ventricle Interventricular septum Apex Mitral v
alve Aortic valve
Tricuspid valve Pulmonary valve Figure 8-1 The pathway followed by the blood as
it circulates
through the heart, lungs, and vessels. Reprinted with permission from Eagle S, B
rassington C,
Dailey C, and Goretti C: The Professional Medical Assistant: An Integrative, Tea
mwork-Based
Approach. Philadelphia: FA Davis, 2009. 1899_Ch08_133-194 21/12/11 2:23 PM Page
136 Chapter 8
Collection and Processing of Blood Samples 137 7. In a single heartbeat, the hea
rt goes through
two stages: systole (the contraction of the heart muscle) and diastole (the rela
xation of the
heart muscle). During ventricular systole, the blood pressure increases, push- i
ng the blood
through the arterial system and adding pressure to the walls of the arterial ves

sels, causing
them to expand. The diastolic (relaxation) phase allows the blood pressure to de
crease and the
arterial walls to adjust back to their normal size. We feel this increase and de
crease in the
blood pressure as a patients pulse in the arteries of the body. Blood Vessels The
re are three
types of blood vessels that make up the cardiovascular system: arteries, veins,
and capillaries.
Each type of vessel has unique characteristics that enable it to perform specifi
c tasks. Blood
specimens may be col- lected from any of these vessels. Figure 8-2 shows the relationship
between the types of blood vessels that make up the cardiovascular system. Test
Your Knowledge
8-1 What organs and/or body systems make up the cardio- vascular system? (Outcom
e 8-1) Pulmonary
vein Pulmonary artery Superior vena cava Right atrium Right ventricle Left atriu
m Left ventricle
Lungs Aorta To organs To trunk and legs To head and arms Arteries Arteries are t
he vessels that
carry oxygenated blood away from the heart. Arterial walls are quite muscular an
d have more
elasticity than do venous walls, and as the blood flows through the arteries (ex
panding and
relaxing the vessels) it is felt as a pulse. There are three layers that make up
the walls of
both arteries and veins, but the walls of the arteries are thicker and stronger
than those of the
veins, and the arterial walls have more flexibility. Arteries get smaller and sm
aller as they
branch through the body away from the heart. Smaller arterial vessels branch int
o arterioles,
which then lead into capillaries. The blood that travels through arteries is bri
ghter red than
that which travels through the veins or capillaries due to the high level of oxy
gen present in
the arterial red blood cells. Veins Veins carry blood back to the heart from the
systemic
circulation. Because this is not a process that actually follows the laws of gra
vity, the venous
vessels have one- way valves that help to keep the blood from pooling in the ext
remities. The
walls of the veins are made up of Figure 8-2 The relationships between the arter
ies, veins, and
capillaries. Reprinted with permission from Eagle S, Brassington C, Dailey C, an
d Goretti C: The
Professional Medical Assistant: An Integrative, Teamwork-Based Approach. Philade
lphia: FA Davis,
2009. 1899_Ch08_133-194 21/12/11 2:23 PM Page 137 three layers, but the layers a
re thinner and
less muscular than are those of the arterial system. Veins require skele- tal mu
scle movement to
propel the blood back to the heart. Veins are smallest where they are attached t
o the
capillaries; these tiny vessels are called venules. The veins become larger and
larger as they
approach the heart. The blood that travels through the veins has less oxygen tha
n that in the
arterial or capillary system, and is darker red in color. Veins do not have a pu

lse, and when

palpated, veins feel less rigid than arteries. Capillaries Capillaries are so sm
all that they can
be seen only with a microscope. The walls of capillary vessels are made up of a
single layer of
epithelial cells. They are designed to link the arterial vessels to the venous v
essels, and the
blood that flows through the capillaries is a mixture of venous and arterial blo
od. As blood
travels through the arteries to the arterioles, there is less and less room for
the entire volume
of blood to make it through the vessels. As the vessels get smaller, more fluids
are pushed out
of the vessel and into the interstitial spaces between the cells surrounding the
blood vessels.
By the time that the blood makes it to the capillaries, the size of the blood ve
ssel has often
reduced to the point that there is room for only one red blood cell at a time to
make it through.
The capillary beds are the only place in the body where exchange of nutrients, g
ases, and other
molecules may occur, because the liquid portion of the blood is in direct contac
t with the cells
around the vessels. As the capillaries join back with the venous system, they be
gin to get larger
in diam- eter, and the vessels become venules, which gradually increase in diame
ter to become
veins. Due to their small size, capillaries do not cause a pulse that can be fel
t. 138 Section II
Specimen Collection and Processing The most common area for venipunctures to be
performed is the
antecubital area of the arm, which is the area imme- diately in front of (the an
terior side of )
the elbow. Most Commonly Used Veins There are several veins in the antecubital a
rea that may be
successfully used for withdrawing blood. The median cubital vein (Fig. 8-3) is b
est for
venipuncture because it is usually large and well anchored. This means that the
median cubital
vein doesnt usually move when the needle is inserted. The cephalic vein, which is
located on the
thumb (lateral side) of the antecubital area, and the basilic vein, on the littl
e finger (medial
side) of the antecubital area, may also be acceptable for venipuncture. If it is
nec- essary to
consider these two alternative venipuncture sites, the median cubital vein is th
e first choice;
if this vein can- not be felt, the second choice would be the cephalic vein. The
basilic vein is
the last choice in the antecubital area because of its close proximity to the br
achial artery and
median nerve. The basilic vein is also not anchored as well as the other antecub
ital veins, so it
has more of a tendency to move, or roll away, during the puncture. When performi
ng phlebotomy,
finding a vein is one step that requires practice and experience. Applying a tou
rniquet may allow
the vein to be more prominent. Palpation, which uses touch to feel for a vein, m
ay be used with
or without the tourniquet application to de- termine whether a vein is suitable

for a blood draw.

Sight may be helpful initially, but if a vein cannot be felt, that vein should n
ot be used for a
blood draw. Palpation is performed by using the tips of the gloved fingers (neve
r the thumb) in a
pushing manner as the fingers are moved across the arm. An acceptable vein shoul
d have some
bounce, like a soft rubber tube, when palpated. A tendon will feel flatter and har
der than a
vein, without Test Your Knowledge 8-2 What is one way that veins are different f
rom arteries?
(Outcome 8-3) Test Your Knowledge 8-3 Are capillaries approximately the same siz
e as arteries and
veins? (Outcome 8-4) SITE SELECTION Appropriate site selection for venipuncture
procedures is
essential to obtain a blood sample that is acceptable for testing, and to avoid
negative outcomes
for the patient. Basilic vein Median cubital vein Cephalic vein Basilic vein Fig
ure 8-3
Antecubital area with vein selection; identifi- cation of the median cubital, ce
phalic, and
basilic veins. 1899_Ch08_133-194 21/12/11 2:23 PM Page 138 Chapter 8 Collection
and Processing
of Blood Samples 139 any elasticity, and an artery will feel like a taut rubber
band. Veins may
be differentiated from arteries because of the pulse that is felt in an arterial
vessel. While
feeling for the vein, it is important to establish the depth and size of the ves
sel, as well the
direction of the vein. When the needle is inserted into the arm, it must follow
the di- rection
of the vein, and be inserted to the correct depth at which it will be in the vei
n rather than
resting above or piercing through the vein. The angle of insertion is also very
important to
allow for the blood to enter the vein when it is pierced. Venous patterns vary f
rom person to
person, as the anatomy of each patient is unique. In addition, some patients hav
e vessels that
are much more prominent in one arm than in the other. A venipuncture should not
be attempted if
the health-care professional is not sure whether the vein is suitable for the pr
ocedure or until
the other arm has been checked for potential sites. If there is no suitable vein
identified in
the antecubital area of either arm, the back of the hand may also be considered
for obtaining a
sample. It is especially important to anchor the blood vessels of the hand befor
e inserting the
needle, as these vessels are located close to the surface of the skin and often
roll away when
the needle is inserted. The hand veins are also more prone to bruising and hemat
oma formation.
Venipunctures should not be performed on the inside (or underside) of the wrist
because of the
presence of various nerves, tendons and ligaments, the close prox- imity of the
radial artery,
and the small size of the veins present in this area. If an acceptable vein cann
ot be located, it
may be nec- essary to encourage the vessels to become more promi- nent before ve

nipuncture is
attempted. To encourage vasodilation, a warm compress may be applied to the area
, or the desired
site may be massaged. Slapping, thumping, or flicking the draw site is not recom
mended. Lowering
the arm down below the level of the heart may also allow the veins to become mor
e evident.
Tourniquet application is definitely beneficial, but it is important to remember
that a
tourniquet may stay on for a maximum of only 1 minute before it should be remove
d. A blood
pressure cuff (stand-alone type) set at 40 mm Hg of pres- sure may also be usefu
l in coaxing the
veins to become more prominent. Appropriate Capillary Puncture Sites Capillary b
lood draws (also
known as dermal or skin punctures) may be used for blood collection when the req
uired volume of
blood needed for testing is small. The capillary beds in the fingers and heel ar
e the sites
generally used in the laboratory. The fingers are often used as sites for capill
ary punctures for
adults and chil- dren over the age of 1 year. The puncture should be made on the
fleshy central
surface on the palmar side of the finger. Capillary draws should never be perfor
med right on the
tip of the finger, or on the extreme lateral side(s) near the fingernail, becaus
e of the close
proximity to the bone. The capillary device should be oriented so that the punct
ure into the skin
is perpendicular to the fingerprints; doing so means that the blood wont pool int
o the lines of
the fingerprint during the collection process. Figure 8-4 shows where it is safe
to perform a
capillary puncture on a fingertip. For infants (children below the age of 1 year
) capillary blood
draws are performed on the heel of the foot. The fingers on infants should not b
e used for
capillary punc- tures, as there is not enough tissue to make this a safe choice
while avoiding
potential damage to the bone. The central area of the infants heel, the arch of t
he foot, the
ball of the foot, and the toes should never be used for blood draws. The capilla
ry draw should be
done only on the most medial and lateral section of the bottom of the heel. Figu
re 8-5 shows the
safe areas for capillary punc- tures on an infants heel. The bone of the foot may
be damaged if
the procedure is performed incorrectly and osteomyelitis (inflammation and/or in
fection of the
bone and bone marrow) may result. In all capillary draw situations, it is impera
tive that the
site is warmed thoroughly before the process begins. It is also helpful if the h
and or foot is
held below the level of the heart. Massage may also benefit the process, as it T
est Your
Knowledge 8-4 What area of the arm should be the first choice for venipuncture?
(Outcome 8-5)
Figure 8-4 Locations for capillary draws for fingers. 1899_Ch08_133-194 21/12/11
2:23 PM Page 139
140 Section II Specimen Collection and Processing POINT OF INTEREST 8-1 Newborn

screening Each
state provides newborn screening to detect dis- orders that would cause irrevers
ible damage or
death if undetected for an extended period of time. These disorders (for the mos
t part) are not
visible at birth; the babies appear to be healthy until the damage has already o
ccurred.
Irreversible neurological or muscu- loskeletal damage will result if these disea
ses are not
detected. Most states require that the babies be tested prior to discharge from
the hospital,
with a recom- mendation for a second screening 7 to 14 days later. Examples of d
isorders that may
be detected with screening include the following: Phenylketonuria Maple syrup ur
ine disease
Carnitine uptake deficiency Congenital hypothyroidism Cystic fibrosis Various
hemoglobinopathies Galactosemia The specimen collection usually includes a capil
- lary sample
taken from a heel stick. Blood may also be drawn from the veins on the back of t
he hand and
applied to the collection paper. Special filter paper is used for the collection
process, and the
sample must be handled appropriately to avoid erroneous results or rejection of
the specimen.
Test Your Knowledge 8-5 Are capillary draws always performed on the fingers? (Ou
tcome 8-6) Figure
8-5 Locations for capillary draws in the heel of an infant. will help to increas
e the blood
supply to the area. When a capillary specimen is submitted for testing, it is im
por- tant to
document that the specimen came from a capil- lary draw rather than a venipunctu
re because the
refer- ence ranges for capillary blood samples are not the same as those for ven
ous blood. Blood
used for capillary samples should be free flow- ing. It is important that the ar
ea immediately
adjacent to the puncture site is not squeezed to increase the blood flow, as thi
s will
contaminate the sample with interstitial fluid. This fluid from between the cell
s has a different
concentration of many chemical substances and will dilute the cell counts for he
matology
specimens. Massaging the finger well above the puncture site will help increase
the blood flow.
Specimens drawn from the heel may benefit from gentle pressure applied to the ca
lf and ankle
area. CONTRAINDICATIONS AND AREAS TO AVOID When considering an appropriate site
for venipuncture,
it is the responsibility of the health-care professional to use best judgment to
avoid harming
the patient unnec- essarily. Also, as part of the preanalytical process, it is i
mportant to
remember that any substances that may contaminate the specimen during the blood
draw must be
avoided. To accomplish these goals, there are certain contraindications and prec
autions for
venipuncture to keep in mind. Scars and Tattoos Excessively scarred skin (as in
the case of a
burn) should not be used for venipuncture. Scarred areas are more sus- ceptible
to infection and

often have reduced circulation; further, the veins underneath the scarred skin m
ay be difficult
to palpate and anchor. Skin that has been tattooed is also more prone to infecti
on, and the dyes
used in coloring the tattoo may cause test interference if they make their way i
nto the specimen.
Mastectomy Considerations If a patient has had a mastectomy, venipuncture should
not be performed
on the arm on the same side of the body as the procedure. Mastectomy procedures
involve the
removal of breast tissue. In addition, the lymph nodes surrounding the breast an
d under the arm
also may be removed. The absence of these nodes can cause a decrease in the flow
of the lymph
fluid in the area, which puts the patient at an increased risk of lymphedema 189
9_Ch08_133-194
21/12/11 2:23 PM Page 140 Chapter 8 Collection and Processing of Blood Samples
141 (accumulation
of lymph in the tissues) and infection, even if the blood draw is not performed
and only a
tourniquet is applied. The opposite arm should be used for the blood draw. If a
patient has a
double mastectomy, the health-care professional who ordered the blood draw shoul
d be consulted to
see what alternative sites may be used for blood collection. Intravenous Fluids
Intravenous
fluids are a potential source of contamina- tion when drawing blood. In situatio
ns in which the
patient is receiving IV fluids, it is preferable to use the opposite arm for ven
ipuncture. If it
is not possible to draw from the other arm, the IV flow must be discontin- ued (
turned off ) for
at least 2 minutes (depending on the substance being infused) by a physician or
other quali- fied
health-care provider before the blood draw is attempted. After the IV fluid drip
has been turned
off, the tourniquet may be applied below the IV insertion site, and the blood dr
aw may be drawn
from below the IV site. Even with these precautions, the first 5 to 10 mL of blo
od withdrawn must
be discarded to avoid potential contamination with IV fluid. If a coagulation te
st is part of the
blood draw order, an additional 5 mL of blood should be drawn and discarded befo
re this tube used
for the coagulation testing is collected. Veins that have been used for IV thera
py are often
irritated and damaged, even after the IV has been dis- continued. Ideally, these
sites should be
avoided for venipunctures for at least 1 or 2 days after the catheter has been r
emoved to allow
for the vein to recover. Phlebitis (inflammation of the vein) may result if the
area is not
allowed to heal before venipuncture procedures are performed. Bruising and Hemat
omas Bruises and
hematomas may occur as complications of venipuncture or IV therapy, and these si
tes should be
avoided for subsequent blood draws. A bruise and a hematoma are similar in that
each is a visible
sign of damage to a vessel in which blood has escaped and entered the surroundin
g tissues.

Hematomas result from damage to larger vessels such as veins and arteries, where
as a bruise may
be the result of injury to a capillary Test Your Knowledge 8-6 Is IV therapy alw
ays a
contraindication for venipuncture? Why or why not? (Outcome 8-7) or a small bloo
d vessel. A
hematoma is often hard and swollen, and may be quite painful for the patient. If
a blood draw is
attempted in a bruised area or a hematoma site, it may cause additional discomfo
rt for the
patient and the integrity of the sample may be affected because of the pooling o
f old, dead cells
in the area. Drawing from this area may also include the risk of infection due t
o inflammation of
the tissues. If it is absolutely necessary to draw from an area with excessive b
ruising or a
hematoma, the venipuncture should be performed below the injured site. Varicose
Veins A varicose
vein is one that is twisted and enlarged and very visible near the surface of th
e skin. These
veins have lost their natural elasticity and integrity, and are prone to inflamm
ation and blood
clot formation. Varicose veins should not be used for venipuncture, as the blood
flow through
these areas has been adversely affected, increasing the chance for infection and
bruis- ing.
These veins are also not very stable and will often roll away during the venipun
cture. Central
Lines and Fistulas Intravenous lines are used commonly to administer medication,
fluids, or blood
products, especially when there is a need for continued access for an extended p
eriod of time.
There are times when a phlebotomist or medical assistant may be asked to withdra
w blood from a
central venous catheter or a peripherally inserted central catheter (PICC line).
The central
venous catheters are inserted into one of the major veins of the body, such as t
he subclavian,
superior vena cava, or jugular vein. There is a piece of tubing extending out of
the vein through
the skin that is covered with a dressing. The central venous catheter is often l
eft in place for
an extended period of time to be used for administration of medication directly
into the
bloodstream. A PICC is inserted into the cephalic or basilic vein of the arm or
hand. These
peripherally inserted catheters are fragile, as they are not inserted into a lar
ge vessel. Blood
withdrawal from either of these devices generally requires injection of saline a
nd/or a heparin
solution into the catheter to clear the line before and after the blood is taken
. It is essential
to remember that anyone who withdraws blood from these types of lines must have
specialized
training, and in some states it is unlawful for a nonlicensed person to perform
this function. In
states where this is allowed, each facility must establish its own policy and tr
aining
procedures. 1899_Ch08_133-194 21/12/11 2:23 PM Page 141 Medical assistants and p
hlebotomists in

most states are not allowed to perform this type of draw. Another type of venous
access device
that may be in use is a cannula. This is a flexible tube that is used to gain ac
cess to the veins
for dialysis treatment for those who have advanced kidney disease. The cannula i
s placed under
the skin, and has a special port that is designed for insertion of a needle to w
ithdraw blood for
dialysis or for testing. A fistula is similar to a cannula, except that the devi
ce has been
implanted in a way that it joins the arterial and venous system for hemodialysis
procedures. The
fistula is also under the surface of the skin, so it re- quires the skin to be p
unctured for
access. It is recom- mended to use the other arm, rather than one contain- ing t
he fistula. Blood
draws should never be attempted from these implanted devices unless the practiti
oner has received
specialized training. In many states, only li- censed health-care providers may
perform this
proce- dure. In addition, a tourniquet should not be applied to the arm that con
tains a fistula
or cannula. Edematous Areas In some clinical situations, patients may accumulate
fluid in the
intercellular spaces of the tissues. This accu- mulation of fluid is called edem
a. The presence
of excess fluid may be widespread as a result of heart and/or renal failure, or
it can be more
localized from trauma or fluid leakage from an IV site. It will be very difficul
t to palpate a
vein in edematous areas, because of the additional fluid in the tissues. If poss
ible, these areas
of the body should be avoided for venipuncture, because of the increased opportu
nity for
infection and potential for contamina- tion of the specimen with the additional
fluids. If the
edema is widespread, the medical assistant may need to apply gentle pressure to
the site until
the edema is displaced, then perform the venipuncture as quickly as possible. If
this is not
successful and alternative sites are not obvious, the phlebotomist or medical as
sistant who is
drawing the specimen should notify the physician. Capillary collection procedure
s are often not
an option 142 Section II Specimen Collection and Processing POINT OF INTEREST 8
-2 Arterial blood
draws Respiratory emergencies (such as advanced chronic obstructive pulmonary di
sease [COPD] or
pul- monary edema) may require an arterial blood gas analysis for appropriate tr
eatment to be
started. In these situations the oxygen and carbon dioxide levels may be far out
side the
reference ranges, and the arterial blood pH may be increased or decreased to a l
ife-threatening
level. Arterial blood draws are similar to venipuncture procedures in that the s
ite must be
stabilized and cleansed properly before the needle is inserted. The angle of ins
ertion, site
selection options, and the way the blood enters the syringe are different from t
hose of a

venipuncture. Arterial blood gases are commonly drawn from the radial artery; as
a second choice,
the brachial artery may be used as long as the patient is not being treated with
anticoagulant
drugs. The radial artery is easy to identify and secure because it is so near th
e surface of the
body. To choose a site for an arterial blood draw, the health-care professional
must palpate
until the pulse is felt strongly. The site needs to be cleansed thoroughly, and
the specimen
needs to be drawn into a special heparinized syringe designed for this type of c
ollection. A cup
of wet ice also needs to be on hand, as the sample needs to be placed on ice imm
ediately after
the draw is complete. The health-care provider should have his or her index fing
er on the pulse
of the artery. The needle is inserted at an angle of approximately 45 degrees. T
he skin is
pierced right next to the index finger. When the artery is entered, the blood wi
ll pump out
through the lumen of the needle because of the pulse pressure. A flash is appare
nt immediately at
the end of the needle attached to the syringe as the artery is pierced, and the
blood will
continue to fill the syringe without pulling on the plunger. (The plunger is pul
led back before
the needle is inserted to allow room for the blood in the syringe.) When the syr
inge is full, the
safety device must be activated immedi- ately on the needle. The needle will be
removed and the
end of the syringe will be plugged with a rubber stopper. The sample must be pla
ced on ice
immedi- ately after labeling of the specimen. Firm pressure must be applied to t
he puncture site
for a minimum of 5 minutes after the blood draw, or until the blood stops flowin
g from the site.
Due to the potential for arterial damage or nerve damage with arterial blood dra
ws, intensive
training is required for health-care professionals who perform this as part of t
heir job.
Training includes careful observation and supervised performance, as well as ide
ntification of
risk factors associated with the process. Some states restrict this procedure to
licensed
personnel such as respiratory therapists or RNs. 1899_Ch08_133-194 21/12/11 2:23
PM Page 142
Chapter 8 Collection and Processing of Blood Samples 143 when edema is present
because of the
excessive amount of fluid contamination. Obese Patients Excessive body fat can m
ake venipuncture
very challeng- ing. It may be very difficult to palpate veins in obese patients,
and sometimes it
is even necessary to use longer than normal needles to successfully reach the ve
ins under the
surface of the skin. Obese patients may be quite apprehensive about the blood dr
aw process
because of past experiences with unsuccessful venipunctures. The anxious attitud
e may make it
even more difficult to carry out a successful blood draw. If the patient suggest
s a site where

others have had success, it is best to attempt this site if there are no other p
rominent veins.
Adipose tissue may also be displaced in some situations by applying gentle press
ure with the
fingers to move the tissue out of the way until the draw site has been established
.
VENIPUNCTURE EQUIPMENT There are various methods used to obtain blood from a vei
n. Each type of
blood draw requires unique supplies and procedures. Blood may be withdrawn from
a vein using the
evacuated tube system, the syringe system, or the butterfly method. Regardless o
f the method
chosen, tourniquets, gloves, sharps containers, alcohol and gauze pads, needles,
and adhesive
materials to be applied after the blood draw are necessary for the process. Tour
niquets A
tourniquet is a flexible band that is placed around the arm of the patient to ma
ke the veins more
promi- nent. Most tourniquets found on the market today are stretchy and made of
a nonlatex
material. They are approximately 1 in. wide, and approximately 15 in. in length.
Tourniquets are
designed to apply pressure, which causes distention of the veins. The tourniquet
must be placed
approximately 3 in. above the site to be used for venipuncture. If it is placed
closer, the ends
of the tourniquet may interfere with the procedure. Remember, tourniquets are on
ly a tool to help
the vein to become more visible; there are times when it is not necessary to use
a tourniquet,
and some laboratory tests prohibit the use of a tourniquet for the specimen coll
ection.
Tourniquets should not be applied too tightly; this can cause pain for the patie
nt, and may cause
hemoconcen- tration in the veins because of the restricted blood flow. Hemoconce
ntration occurs
when excessive pressure builds up in the veins below the tourniquet application
site. The
increased pressure in the veins will force water and small molecules out of the
vessels into the
surrounding tissues. Larger formed elements and molecules will remain in the ven
ous blood, and
become more concentrated. White blood cells, red blood cells, platelets, calcium
, cholesterol,
triglycerides, and bilirubin levels may all be affected by this venous concentra
tion. Tourniquets
that are left on for more than a minute may also cause hemoconcentration; theref
ore, the
phlebotomist needs to remain aware of this as the venipuncture site is prepared.
Extended
tourniquet application time may also cause pain for the patient. When applying a
tourniquet, keep
in mind that it should be applied in a way that it can easily be released with o
ne hand.
Tourniquets do not need to be applied to bare skin; they can be applied over the
sleeve. Open
wounds, scars, and bruises should be avoided when applying the tourniquet. Some
tourniquets are
dispos- able, and these should be discarded after each use. Others are designed
to be used for

multiple patients, and should be disinfected at least daily, and discarded if th

ey are visibly
soiled or lose elasticity. Gloves The Occupational Safety and Health Administrat
ion (OSHA)
regulations designed to protect health-care em- ployees specify that gloves are
to be worn when
collect- ing blood. After a blood draw, the gloves are removed, and the employee
must sanitize
his or her hands. For effective palpation and dexterity during the collection pr
ocess, gloves
should fit snugly. Except in very specific circumstances, it is not necessary fo
r the gloves used
for phlebotomy to be sterile. Most health-care settings no longer use latex glov
es, due to the
increase in latex sensitivity issues. A common substitute for latex gloves, nitr
ile gloves work
well for phlebotomy. Vinyl gloves may also be worn, but they are not advised in
all situa- tions
because of their tendency to break down when exposed to certain chemicals. Sharp
s Biohazardous
Waste Containers A sharp is anything that has been exposed to blood (or other po
tentially
infectious materials) that has corners, edges, or sharp projections that are cap
able of cutting
or Test Your Knowledge 8-7 Why is it important to avoid edematous areas when per
forming
venipunctures? (Outcome 8-7) 1899_Ch08_133-194 21/12/11 2:23 PM Page 143 144 Sec
tion II Specimen
Collection and Processing piercing the skin. In venipuncture, sharps include nee
dles and
capillary puncture devices. Glass slides may also be classified as sharps becaus
e they have sharp
cor- ners that may be hazardous. Sharps must be disposed of in a waste container
that is
specifically designed to be puncture resistant, leakproof on the sides and botto
m, and labeled as
biohazardous waste. These containers should be placed close to the site where th
e venipuncture is
performed so that contaminated sharps may be dis- posed of immediately. Sharps w
aste containers
come in various sizes, and should never be overfilled. If a sharps container is
filled past the
marked fill line, it is possible for injury to occur when an employee adds conta
mi- nated sharps
to the container. Alcohol and Gauze Pads Seventy percent isopropyl alcohol is ge
nerally used for
cleaning the venipuncture site. It may be applied by using a presoaked commercia
l square that is
individually wrapped and packaged. Alcohol may also be applied by using a gauze
pad that has been
saturated just prior to use. Isopropyl alcohol is an effective antiseptic that c
an help to
eliminate most transient and surface resident bacteria from the venipuncture sit
e. The alcohol
used to cleanse the site must be allowed to dry completely before the procedure
is performed. If
liquid alcohol is still pres- ent when the needle is inserted, it can cause a st
inging sensation
and irritation to the skin and/or the vein. Alcohol may also cause hemolysis of
the red blood

cells if it is introduced into the specimen. When additional cleanliness is esse

ntial during the
collection process (such as when blood cultures or arterial punctures are ordere
d), iodine or
chlorhexidine gluconate may be used. Chlorhexidine gluconate is ideal for those
who are allergic
to iodine. Procedures used for drawing blood cultures are presented in more deta
il in Chapter 10.
Clean 2 x 2 gauze squares are recommended for venipuncture procedures. The gauze
is applied after
the needle has been removed from the arm and the collec- tion is completed. Cott
on balls should
not be used because their excess fibers tend to stick to the wound and can cause
bleeding to
recur when the cotton ball is removed later. Needles Needles used to withdraw bl
ood are always
disposable and used only once. They are generally 1 to 1.5 in. in length. Figure
8-6 describes
the different parts of a needle. The slanted part of the needle that creates the
sharp tip is
called the bevel. This slant helps the needle to enter the skin with a minimum a
mount of trauma
and pain. There is a hole in the bevel where the blood enters the interior hollo
w portion of the
needle, called the lumen. The gauge of the needle refers to the diameter of the
lumen: the larger
the needle, the smaller the number used to describe the gauge. Needles used for
venipunc- ture
are generally 20 to 23 gauge. Needles that are smaller than 23 gauge will cause
hemolysis
(breaking of the red blood cells with release of hemoglobin) as the blood cells
are broken when
they enter the small hollow cylinder that forms the lumen. Conversely, if the ne
edle used is too
large, hemolysis may also result because of the force at which the blood enters
the tube or
syringe through the large opening. When removing the cap from a needle to prepar
e for
venipuncture, it is important to inspect the needle for any defects such as burr
s or a blunt tip.
If there are problems present, the needle must be discarded immediately into a s
harps container
and a new one used for the procedure. Needles used for the evacuated tube system
are also known
as multi-sample needles. They have sharp tips at both ends; the end with the bev
eled tip is
designed to be inserted into the vein; the shorter, blunt tip at the opposite en
d is covered with
a rubberized sleeve. The needle is designed to be screwed into a hard plastic ho
lder that holds
the tube and the needle. The needle Test Your Knowledge! 8-8 List three items th
at are needed for
all venipuncture procedures, regardless of which technique used. (Outcome 8-8) H
ub Shaft Point
Bevel Figure 8-6 Identification of the different parts of a needle. 1899_Ch08_13
3-194 21/12/11
2:23 PM Page 144 Chapter 8 Collection and Processing of Blood Samples 145 or th
e holder must be
equipped with a safety device to protect the employee upon completion of the blo
od draw. A

multi-sample needle and holder are shown in Figure 8-7. When performing venipunc
ture utilizing
the sy- ringe system, a needle of similar length and gauge as that for the evacu
ated tube method
is used (Fig. 8-8). These needles are designed to screw directly onto the syring
e, so the needle
only has one pointed end; the other end has a hub that attaches directly to the
sy- ringe. The
needles or the syringe must be equipped with a safety device to protect the empl
oyee after the
blood draw is completed. Examples of safety mecha- nisms include a cover that is
pushed over the
needle and locked in place after the draw, or a retractable needle that moves ba
ck into the
syringe once the specimen is obtained. The butterfly system, or winged infusion
system, consists
of a short needle with wings (Fig. 8-9). When used for venipuncture, the needle is
generally 23
gauge, and is attached to a piece of plastic tubing that is approx- imately 12 i
n. long. The
wings are held by the fingers while the needle is inserted into the vein. Butter
fly nee- dles are
used for fragile veins (such as those in the hand) or pediatric draws. The butte
rfly tubing may
be attached directly to a syringe, or an adapter may be used to attach the butte
rfly setup to a
plastic evacuated tube holder. Proper activation of the safety devices included
with the
butterfly system is critical, as there are more accidental needlesticks attribut
ed to the use of
butterflies than there are in either of the other two systems. Safety needles ar
e required for
all methods of venipuncture. The various safety devices are designed to be easil
y activated,
using either a needle that withdraws into the device while still in the skin, or
one hand activation of the safety device. Figure 8-10 shows various safety devices for evacua
ted tube systems,
syringe nee- dles, and butterfly needles. It is essential that the medical assis
tant performing
venipuncture become comfortable Safety device Tube advancement mark Evacuated tu
be holder Figure
8-7 Multi-sample needle and holder with identifi- cation of parts. Plunger Luer
lock tip Bevel
Barrel Needle hub Shaft Figure 8-8 Syringe with identification of the various p
arts. Figure 8-9
Butterfly assembly. Test Your Knowledge 8-9 Are the needles used for all venipun
cture techniques
the same? (Outcome 8-8) 1899_Ch08_133-194 21/12/11 2:23 PM Page 145 146 Section
II Specimen
Collection and Processing with the safety devices available to him or her so tha
t the device can
be activated quickly and safely for protection. Additional Supplies Blood spill
cleanup supplies
should be available near every phlebotomy station, and staff should be trained r
egularly on their
use. In addition, because every tube should be identified while in the presence
of the patient,
it is important to have at least one functional pen avail- able to identify the
tube and document

the blood draw information on the requisition. It is also necessary to have back
up tubes and
needles within reach for use when the procedure does not go as planned. METHODS
USED FOR
VENIPUNCTURE Evacuated Tube System The most common and most efficient method of
performing
venipuncture is the use of the evacuated tube system. As described earlier in th
e chapter, blood
is col- lected directly into an evacuated tube through a needle that has two poi
nted ends. This
method is advantageous because there is no need to transfer the blood from one c
ontainer to
another after the draw, and also because multiple tubes of blood may easily and
quickly be drawn
with one skin puncture. The needle to be used with the evacuated tube system is
screwed into an
evacuated tube holder that is made of semirigid plastic. These tube hold- ers ar
e designed to be
used only once; if the medical assistant tries to use them more than once, the n
eedle may not
screw in securely. The rubber cover covering the shorter, posterior end of the n
eedle is pushed
back to expose the sharp needle as the evacuated tube is pushed on during the bl
ood draw.
Evacuated tubes have the air removed to create a vacuum, so as soon as the tube
cap is pierced
with the needle, the blood is pulled into the tube. When the blood draw is compl
ete, the safety
device for the needle must be activated, and the evacu- ated tube holder with th
e needle attached
must be dis- posed of directly into a biohazardous sharps container. The plastic
evacuated tube
holder has flared sections at the bottom, which are known as flanges. These are
de- signed to be
pushed against as the medical assistant changes tubes during the blood draw proc
ess. The flanges
help to keep the venipuncture setup stable during the process of drawing blood.
There is also a
line marked on the tube holder; this is a safe mark that shows how far the tubes c
an be
advanced into the holder before the vac- uum will be affected. Some health-care
personnel prefer
to advance the tube to this mark before they begin the blood draw process, where
as others do not.
If the tube is ad- vanced past this mark, the vacuum will be affected and the tu
be may not fill
as desired once the needle is in the vein. Syringe Method Health-care personnel
may prefer to use
the syringe method for venipuncture in patients having small or frag- ile veins.
Use of a syringe
to withdraw blood allows for more control of the vacuum used to withdraw blood f
rom the vein, as
the individual performing the venipuncture can control the speed and force used
to pull on the
plunger of the syringe. Syringe draws also allow the person performing the venip
uncture to see
the blood in the hub of the needle as the vein is entered, which can be reassuring when
attempting a blood draw on a vein that is diffi- cult to palpate or locate. This
return of blood

into the hub of the needle is called a flash of blood. Syringes are made of a holl
ow plastic
barrel with graduated measurements in cubic centimeters (cc) or milliliters (mL)
printed on the
side. Inside the barrel of the syringe is a plunger that is designed to fit tigh
tly enough to
create suction when the plunger is pulled backward. The sizes of syringes used f
or venipuncture
may vary from 3 mL to 20 mL, with 5-mL or 10-mL syringes most commonly used. Any
size needle may
be attached to the syringe, but 20- to 23-gauge, 1-in. needles are most commonly
utilized for
venipuncture. Safety devices for the blood draw may be attached to the needle, o
r the syringe may
be safety enabled. One disadvantage of using syringes for venipuncture is that t
he blood must be
transferred into tubes for further processing and testing after the blood draw.
This must occur
quickly so that the blood does not clot in the syringe. Transfer devices should
be used to add
the blood from the syringe to the necessary tubes (Fig. 8-11). Figure 8-10 Safet
y devices for use
with the evacuated tube system and syringe draws. 1899_Ch08_133-194 21/12/11 2:2
3 PM Page 146
Because the amount of blood obtained with one venipuncture is limited to the siz
e of the syringe
used, this must be taken into consideration before choosing the syringe method f
or blood
collection. It may not be advantageous to use a syringe when there is an order t
hat requires more
than 10 mL of blood, as the sample may clot in the syringe before it can be succ
essfully transferred to the correct blood tubes. Winged Infusion or Butterfly Method Winged in
fusion sets (also
known as butterfly systems) are made up of a beveled needle that is attached to
a length of
tubing with a luer adapter on the opposite end. Just below the needle on the but
terfly system are
two wings that are made of hard plastic. The medical assistant will grasp these wi
ngs and use
them to guide the insertion of the needle into the vein. Butterfly systems are o
ften used for
venipuncture in patients having very fragile veins, such as those in the hands.
They are also
used for many pediatric blood draws, small fragile veins in areas other than the
hand, and
sometimes for uncooperative patients. Butterfly sets are preferred in these situ
ations because
the needle can be maneuvered easily to gain venous access because of its decreas
ed length. The
angle used to enter the vein is smaller when using a butterfly setup. This can b
e especially
important when attempting a blood draw from a superfi- cial small vein, such as
those in
children. The attached flexible tubing allows for multiple tubes to be collected
without danger
of moving the needle in the vein. Butterfly systems may be used directly with ev
acuated tubes
(utilizing a Luer adapter for this purpose), or they may be attached to a syring
e when there is a

desire to use very gentle pressure during the blood draw. Venipuncture with a bu
tterfly system
has a higher risk of an accidental needlestick if the safety device is not activ
ated properly
before the medical assistant attempts Chapter 8 Collection and Processing of Bl
ood Samples 147
to process the specimen after the blood draw. Becton, Dickinson has a product wi
th a push-button
activation that withdraws the needle into a plastic reservoir before it is remov
ed from the skin.
Other products require acti- vation of the safety device after the needle is rem
oved from the
patient, and it is imperative that the health-care professional performing the v
enipuncture
follow direc- tions for activation to avoid potential bloodborne pathogen exposu
re. BLOOD
COLLECTION TUBES Evacuated tubes used for blood collection are available in seve
ral sizes, and
are made of plastic with rubberized stoppers. (Glass collection tubes may still
be available, but
they are not recommended due to the potential for breakage and blood exposure fo
r health-care
personnel.) Evacuated tubes vary by diameter, length, and the addi- tives presen
t in the tubes.
They are each designed to hold Figure 8-11 Transfer device. POINT OF INTEREST 83 Minimizing
risks for employees and patients while collecting samples The collection of bloo
d samples is a
very important part of the laboratory testing process. It is important to rememb
er that safety
precautions must be followed at all times to protect both the employee and the p
atient. The
appropriate personal protective equip- ment will offer a layer of protection for
the employee,
but safety does not stop there. It is very important to follow instructions for
the use and
activation of all safety devices in order for them to provide protection. It is
also important to
focus your full attention on the task at hand when performing invasive procedure
s; it only takes
a moment of inattention to provide an opportunity for bloodborne pathogen exposu
re. Patient
safety is also very important. Invasive procedures can be very traumatic for som
e patients
because of prior experiences or fear of the unknown. Use of phlebotomy chairs wi
th padded support
on the arms and across the chest will help to keep the patient comfortable and s
afe during the
process. Careful observation of the patients response to the invasive procedure w
ill help the
employee anticipate fainting or other adverse reactions. All patients should be
treated with
compassion and care, and the collection process should be completed as quickly a
nd efficiently as
possible. 1899_Ch08_133-194 21/12/11 2:23 PM Page 147 148 Section II Specimen C
ollection and
Processing a specific amount of blood and vary from 2-mL tubes that may be used
for pediatric or
geriatric blood draws, to 15-mL tubes that are used when a high volume of blood
is necessary for

a particular assay. The medical assistant or phlebotomist drawing the blood will
choose the tube
size according to the age of the patient, the integrity of the vein, and the amo
unt of blood
needed for the test ordered. The different colors used for the stoppers are code
d according to
the additive contained within the tube. These tubes are evacuated because the ai
r within the tube
has been removed to create a vacuum. This vacuum has been artificially created a
nd calibrated by
the manu- facturer so that a very specific amount of blood will be drawn into th
e tube. The tube
will never fill completely to the top, as they are not calibrated to hold that v
olume of blood.
As long as the vacuum is still present within the tube, blood will continue to f
low. If there has
been a loss of vacuum in the evacuated tube, blood will not enter the tube, or i
t will fill
incompletely. This is known as a short draw and often will require the specimen
to be redrawn.
Short draws are sometimes caused by dropping a tube prior to the venipuncture, p
ushing the tube
too far onto the double-ended needle used for evacuated tube draws prior to the
blood collection,
or by acciden- tally pulling the needle out of the vein during the venipuncture
process. All
blood tubes have an expiration printed on the label. There is an expectation tha
t the vacuum and
additives in the tube will function as expected until this date. The health-care
worker who
performs the blood draw is responsible for checking the expira- tion date on all
tubes before
they are used, and at the same time examining the tube for any obvious defects o
r breaks. Any
tubes that are near expiration should be removed from the shelves before the pri
nted date has
passed. Color Coding of Tubes Evacuated tubes are all sealed with a colored stop
per. These
closures are made of rubber and/or plastic and are designed to ensure the vacuum
within the tube
and pro- vide a barrier to the blood once the tube is filled. Some tubes availab
le on the market
have a rubber stopper with an outside plastic cap of the same color. The plastic
cap provides
protection for the employee when opening the tube, because the additional plasti
c cap hangs over
the outside of the tube and forms a barrier to any aerosol formation from the bl
ood in the tube.
An example of this type of tube is the Hemogard tube, manufactured by Becton, Di
ckinson. See
Figure 8-12 for an example of the Hemogard tube. The stopper colors on evacuated
tubes are color
coded and used to indicate whether additives are present in the tubes, and if so
, what types are
present. Additives may function as anticoagulants, or clot activators. The additives may
sometimes serve as preservatives of the integrity of the specimen. Anticoagulant
s will keep the
blood from clotting in the tube so that the cells remain suspended in the plasma
. Without the

addition of anticoagulants, the blood will begin to clot in the tube immediately
, and a visible
solid clot will form within an hour. Clot activators, such as glass beads or sil
icone, are
designed to speed up the clotting process so that the blood can be spun in the c
entrifuge within
a shorter period of time after collection. Tubes may also contain a thixotropic
separating gel
that is designed to form a barrier between the blood cells and the liquid portio
n of the blood
after it is centrifuged. The gel in these serum separator tubes (SST) or plasma
sep- arator tubes
(PST) is in the bottom of the tube when the blood is collected, but as the tube
is centrifuged,
the cells move to the bottom of the tube and the gel travels up in the tube to f
orm a barrier
between the cells and the liquid. Figure 8-13 shows how the gel separates the sa
mple after
centrifugation. The colors used for tube stoppers are similar from brand to bran
d, providing a
uniform reference for the different types of additives. The type of anticoagulan
t present in the
tube is printed on the label, along with the expiration date and the blood volum
e for the Test
Your Knowledge 8-10 Why are tubes used for blood collection called vacuum tubes?
(Outcome 8-8)
Figure 8-12 Vacuum tubes with Hemogard caps presented in the appropriate order o
f draw.
1899_Ch08_133-194 21/12/11 2:23 PM Page 148 Chapter 8 Collection and Processing
of Blood Samples
149 tube. When using reference materials (such as laboratory requisition forms o
r laboratory
directories) the specimen collection instructions will reference the stopper col
or needed for the
test ordered or the additive present in the tubes. Each laboratory may have diff
erent tube
require- ments for a given test based on its testing methodology, so it is alway
s best to verify
the necessary tube before drawing the blood. Types of Additives Types of anticoa
gulants and/or
additives present in the most common evacuated tubes are listed here with their
respective color
stoppers and summarized in Table 8-1. Yellow: Sterile tubes used for blood cultu
res. There are
also specific yellow top tubes that contain a red blood cell preservative called
acid citrate
dextrose (ACD), and these are used for special blood bank procedures. The steril
e yellow tubes
for blood cultures are by far more common. Light blue: Contains sodium citrate a
s an anticoagulant. Light blue top tubes are primarily used for coag- ulation studies. The rat
io of blood to
anticoagulant is critical for these tubes and they must always be filled complet
ely to prevent
potential dilution and erroneous results. Red: Glass red top tubes are sterile a
nd contain no
additives. Plastic red top tubes contain a clot activator. Red top tubes are use
d for a variety
of tests in which serum is the preferred specimen. Red/gray (tiger top) or gold:
Contains a

silica clot activator that increases platelet activity and decreases the time ne
cessary for a
clot to form in the tube. Also contains thixotropic gel that separates the cells
from the serum
when the specimen is centrifuged. Used for chemistry and immunology testing in w
hich serum is the
preferred specimen. Black: Special tubes used only for Westergren sedimentation
rates. Contain
sodium citrate, but in a different concentration (blood to anticoagulant liquid
4:1) than the
light blue top tubes. These tubes are not to be used for coagulation studies. Gr
een: Contains
heparin combined with sodium, lithium, or ammonium as an anticoagulant. These tu
bes are preferred
for chemistry tests in which plasma is suitable for testing and the results must
be obtained
quickly, as the specimen does not need to clot before the sample may be spun in
the centrifuge.
Light green Hemogard tubes and those with green and black mottled stoppers conta
in thixotropic
gel in addition to the anticoagulant, which separates the plasma from the cells
after
centrifugation. Gray: Contains sodium fluoride, which acts as a glucose preserva
tive (called an
antiglycolytic agent) keeping the glucose levels stable in the specimen for a pe
riod of time
after collection. Also contains an anticoagulant; either potassium oxalate or so
dium EDTA. Gray
top tubes are not appropriate for general chemistry testing, but are used for gl
ucose testing, as
well as blood alcohol determinations. Lavender: Contains potassium EDTA (dipotas
sium
ethylenediaminetetraacetic acid) as the anticoagulant. Prevents the use of calci
um in the
clotting process to prevent blood clotting and keep the blood cells suspended in
plasma. Lavender
top tubes are used for hematology testing because this preservative preserves th
e integrity and
shape of the individual cells better than any of the other anticoagulants. Figur
e 8-13 The tube
on the left shows whole blood before centrifugation. The tube in the middle show
s plasma sitting
on top of clotted blood cells. The tube on the right is a tube with serum separa
tor gel that has
been spun in a centrifuge and shows serum sitting on top of clotted blood cells.
Reprinted with
permission from Eagle S, Brassington C, Dailey C, and Goretti C: The Professiona
l Medical
Assistant: An Integrative, Teamwork-Based Approach. Philadelphia: FA Davis, 2009
. Test Your
Knowledge 8-11 What is the significance of the different stopper colors used for
the vacuum
tubes? (Outcome 8-10) 1899_Ch08_133-194 21/12/11 2:23 PM Page 149 150 Section II
Specimen
Collection and Processing this is no longer necessary. An exception is when a bu
t- terfly system
is used to draw a light blue top tube; in this case, a red top tube is used as a
clear tube
because of the excessive air present in the tubing of the butter- fly. The blue
top tubes must be

filled as far as the vac- uum allows, and if the excess air from the tubing is i
n- troduced into
the light blue top tube, the tube will not fill adequately. 3. Red top, tiger to
p, or gold top
tubes with or with- out clot activator: These tubes are used when serum is the s
pecimen of
choice. 4. Green top tubes: These are both tubes that have gel separator and tub
es that do not.
They may be mint green or dark green. These are to be drawn before the EDTA tube
s to reduce the
risk of crossover that may increase the potassium levels when analyzed. 5. Laven
der top tubes:
These have potassium EDTA as the anticoagulant, and are primarily used for whole
blood testing.
6. Gray top tubes: Gray top tubes are used for glucose testing, as well as a few
other tests.
They need to be drawn after the EDTA tubes because the additives present in the
gray top tube
could cause abnormal changes in the red blood cells to be analyzed if there is c
rossover. The
gray top tube must be drawn after the tubes used for other chemistry testing, be
cause the
potassium oxalate present in the gray top tube could cause falsely elevated pota
ssium results if
the specimens were contaminated by the anticoagulant and this test was to be per
formed on the
sample. CAPILLARY PUNCTURES Most blood collections are performed by puncturing a
vein. However,
there are times when a capillary punc- ture is a more appropriate method. During
a capillary
puncture, an incision is made in through the skin, which passes through the epid
ermis into the
dermal layer. It is critical that the puncture reaches the dermal layer, as this
is where the
blood supply exists. Remember, the blood present in the capillary beds of the bo
dy is a mixture
of venous and arterial blood. There is actually more arterial blood represented
because of the
increased arterial pres- sure forcing this blood into the capillary vessels. Bec
ause of the way
that the skin layers are punctured, capillary samples may also include additiona
l fluid from the
space between the tissues and cells surrounding the capillary vessels. This is w
hy it is very
important to document the source of the blood specimen when collecting a capilla
ry sample, as the
reference ranges will be different from those used for venous blood. TABLE 8-1 T
able of common
tube colors and additives Tube Stopper Color Additives Red top None Tiger top/ C
lot
activators/thixotropic gel speckled top/ gold top Green top Heparin Mint green t
op Heparin and
thixotropic gel Light blue top Sodium citrate Lavender top Potassium EDTA Gray t
op Sodium
fluoride and potassium oxalate ORDER OF DRAW FOR VENIPUNCTURE The Clinical and L
aboratory
Standards Institute (formerly known as NCCLS) has recommended a specific order o
f draw for
venipuncture specimens using the evacuated tube system, syringe collection metho
d, or butterfly

draws. There is a different recommended order of draw for capil- lary specimens.
These
recommendations were developed because of potential problems with additive carry
over from one
evacuated tube to another. Reports showed significant increases in potassium and
some other
analytes when a lavender top tube (containing potassium EDTA for an anticoagulan
t) was drawn just
prior to the tube used for chemistry testing. Other potential carryover issues w
ere also
identified. The recommended order of draw for the six most commonly used tubes:
1. Blood culture
specimens: These may be yellow top tubes or a set of bottles used for blood cult
ures. They must
be drawn first to avoid potential for contamina- tion of the draw site. 2. Light
blue top citrate
tube: This tube is primarily used for coagulation studies, so it is important th
at ad- ditive
crossover is avoided because of potential interac- tions. Previous recommendatio
ns always called
for a red top tube to be drawn before the light blue top tube, but with the curr
ent CLSI
recommendations, Test Your Knowledge 8-12 Why is the order of draw so important?
(Outcome 8-11)
1899_Ch08_133-194 21/12/11 2:23 PM Page 150 Chapter 8 Collection and Processing
of Blood Samples
151 Capillary samples are never appropriate when the test ordered requires a lar
ge amount of
blood, or if there are problems with the circulation for the patient. This techn
ique should also
be avoided if the patient has edema, as the excessive fluid may dilute the sampl
e and cause
erroneous results. CLIA-waived tests require very little blood, so capillary pun
ctures are often
performed for these tests. Some patients who are undergoing can- cer treatment o
r dialysis may be
better suited for capil- lary blood draws to allow their blood levels to remain
stable. Capillary
punctures are also appropriate for most children, some geriatric patients with f
ragile veins, and
infants. Capillary punctures should always be performed us- ing retractable nonr
eusable lancets
for the safety of the patient and the employee performing the puncture. These de
vices are
calibrated to provide a uniform depth for the puncture, and they lock in place o
nce the puncture has occurred so that they cannot be reactivated. The devices used for capil
lary punctures
are color coded according to the depth of the blade. They vary from those used f
or infants, which
must be less than 2.0 mm (to avoid potentially touching bone), to adult depths u
p to 3 mm,
primarily used for finger punctures. Lancet devices that may be used for home te
sting or perhaps
for an individual CLIA-waived test procedure usually will not provide a puncture
that is feasible
for collecting enough blood to fill a microtube for analysis. All punc- ture dev
ices must be
disposed of in a biohazardous sharps container. During a venipuncture, a tourniq
uet is used to

aid in the palpation and visualization of an appropriate draw site. Capillary dr

aws do not
require the use of a tourniquet, but it is very important that the site to be us
ed is as warm as
possible to help increase the blood circulation. This may be accomplished by soa
king the
appendage in warm (not hot) water; by using a warm, wet compress; or with use of
a commer- cial
hand warmer held on the skin until it is warm to the touch. The capillary punctu
re also requires
the use of clean gauze (usually at least two sets), 70% isopropyl alcohol to cle
an the site, and
a bandage to be used after the puncture. The employee who is performing the capi
llary puncture
should also prepare the site under the patients hand or foot by draping the area
with an
absorbent cloth or sheet to absorb any excess blood. Capillary samples may be co
llected in
various ways. Microcollection tubes may be utilized, which are smaller versions
of the evacuated
tubes used for venipuncture. These tubes are color coded in a way similar to the
evacuated tubes,
and many contain anti- coagulants or other additives. Capillary tubes may also b
e used,
especially for hematocrit testing. Capil- lary tubes are long, thin, hollow tube
s designed to
hold blood. The tubes are held horizontally with one end touching the drop of bl
ood created by
the capil- lary puncture. The tube fills with blood via capillary action. These
tubes may be made
of glass or plastic. They may be coated internally with heparin to keep the bloo
d from clotting
as it is collected, in which case the tube will have a red ring around it. Other
capillary tubes
do not include anticoagulant, and these plain tubes will have a blue ring around
their diameter.
Capillary tubes may also be part of a microcollection container setup, where the
capillary action
pulls the blood into the container. Figure 8-14 includes exam- ples of devices u
sed for capillary
punctures. Order of Draw for Capillary Puncture The order of draw for the variou
s microcollection
con- tainers using a capillary technique is different from the order used for ve
nipuncture. The
order is not the same because the capillary blood clots faster than the blood ta
ken from a vein
and because the potential for carryover Test Your Knowledge 8-13 Why is it impor
tant to document
that a sample was capillary rather than venous? (Outcome 8-13) Figure 8-14 Devic
es used for
capillary punctures. Reprinted with permission from Eagle S, Brassington C, Dail
ey C, and Goretti
C: The Professional Medical Assistant: An Integrative, Teamwork-Based Approach.
Philadelphia: FA
Davis, 2009. 1899_Ch08_133-194 21/12/11 2:23 PM Page 151 152 Section II Specime
n Collection and
Processing is not as high. For capillary draws, the order of draw is as follows:
1. Lavender
(EDTA) tubes are filled first. It is impera- tive that these are well mixed duri
ng the process to

avoid blood clot formation. 2. Other additive tubes, such as green top tubes or
those with
heparin and thixotropic gel, are collected next. Microcollection tubes are not u
sed for coagulation studies, so there are no sodium citrate tubes to be filled. 3. Nonadditive
tubes are drawn
last, and will usually clot within 6 or 7 minutes. Test Your Knowledge 8-14 Is t
he order of draw
the same for capillary draws as it is for venipuncture specimens? (Outcome 8-11)
POINT OF
INTEREST 8-4 Waste reduction considerations Unfortunately, specimen collection g
enerates a lot of
waste. Current practice prohibits reusing most items that are exposed to bloodbo
rne pathogens
because of the danger of exposure for subsequent patients. The contaminated wast
e must be
disposed of and processed appropriately by a licensed biohazardous waste handler
. The waste is
packaged according to federal specifications, transported in a standardized mann
er, and finally
incinerated. However, not all the waste in the laboratory setting is contaminate
d. Lids from
needles, plastic and paper packaging, and alcohol prep pad packages need to be a
dded to the
regular trash, not treated as biohazardous materials. Some of the packaging may
be recyclable;
this option should be employed when- ever possible. Any paper may include protec
ted personal
information and so needs to be shredded before disposal to protect patients priva
cy. Some
recycling programs will process shredded paper. To minimize waste, do not open s
terile packaging
until you are certain that you will be using a specific device for specimen coll
ection. Many
phlebotomists will set up all the sterile supplies before they palpate the vein
of the patient.
This may be a mistake, as it may become apparent that a different device is need
ed for the blood
draw. The sterility has been compromised for the devices that were set out, so t
hey will all need
to be discarded, in addition to the devices actually used for the blood draw. Be
come aware of
recycling options in the laboratory setting, and make use of this service whenev
er possible.
PREPARATION FOR BLOOD COLLECTION Several steps are required in the blood collect
ion process prior
to the actual puncture of the skin. Specific proce- dures are utilized regardles
s of the method
used to collect the sample. These critical aspects include the following: A prof
essional
atmosphere: A collection site where phlebotomy is performed should be clean, org
anized, well lit,
and tidy. Many times this collection site is the only contact that the patient w
ill actually have
with the laboratory where the testing will be performed, and if they feel as if
this is a
professional environment, the patient will have more confidence with the testing
process to
follow. Appropriate introductions: When first approaching a patient, the healthcare employee

must identify him- or herself. Proper identification should also be worn, such a
s a name tag
and/or uniform so that the patient feels in the presence of a qualified professi
onal for the
procedure. Patient identification: This is the most critical aspect of the colle
ction
procedure. The health-care employee should ask for the patient to give his or he
r entire name and
birth date for verification of identification. This information should be checke
d against the
requi- sition form for accuracy. It is important that the pa- tient actually say
s, I am Sally
Smith, rather than the health-care employee asking, Are you Sally Smith? Many times
patients
will answer yes to such a ques- tion, even though they did not hear or understan
d the name given.
If drawing blood from a patient in an in- patient setting, armbands may be used
for identification, but in addition, the patient identity also needs to be verified in another
way. The
phlebotomist must document who provided the verification of the patient identity
if it is not the
patient. Verification of orders and patient preparation: The medical assistant o
r phlebotomist
needs to verify what tests were ordered before continuing with the collec- tion
procedure. This
can be accomplished by looking carefully at the requisition form or labels provi
ded for the blood
draw. The medical assistant is also responsi- ble to see if patients are prepare
d properly for
the test 1899_Ch08_133-194 21/12/11 2:23 PM Page 152 Chapter 8 Collection and P
rocessing of
Blood Samples 153 ordered; for instance, if the test is a fasting blood sugar, t
he medical
assistant must ask patients if they have been without food and drink (except wat
er and necessary
medications) for 12 hours. If the preparation was not followed appropriately, th
e specimen is not
to be drawn. When drawing blood to test for a therapeu- tic drug level, the medi
cal assistant
needs to ask when the medication was last taken, and verify if that is an approp
riate time
interval for this particular test. Hand sanitization: The medical assistant must
wash his or
her hands (if they are visibly soiled from a previous procedure) or use hand san
itizer appropriately before touching the patient. Gloves must be worn during the venipuncture p
rocess and should
not be applied until the hands are totally dry. Site selection: The medical assi
stant should
always start in the antecubital area when looking for an appropriate venipunctur
e site. The first
choice is the median cubital vein, the second choice is the cephalic vein, and t
he last choice in
this area is the basilic vein. The medical assistant should always check the vei
ns in both arms
to make the best choice. The back of the hand may also be used for venipuncture
if there are no
suitable sites in the antecubital area. For a capillary draw on an adult, the mi
ddle finger or

ring finger is used, and part of the preparation may be warming the site. Prepar
ation of
necessary supplies: It is not possible to prepare fully for the venipuncture bef
ore the site selection has been performed, because the choice of which method to use for the bl
ood draw will be
de- pendent on the integrity and size of the veins to be used for the blood draw
. Once the site
selection is complete, the medical assistant can prepare an evacu- ated tube set
up, a syringe for
the blood draw, or a but- terfly setup. The tubes to be used should also be chec
ked for
expiration and/or defects, and laid out in order of draw close to the patient so
that they can be
easily reached during the procedure. Gauze and alco- hol should be within reach
as well. Supplies
may vary depending on the age and gen- eral health of the patient. An infant usu
ally does not
have venipuncture performed for most laboratory tests. Small children may need v
enipuncture, but
a smaller volume of blood may be drawn using a but- terfly and a 2- or 3-mL tube
. Those patients
who are over the age of 60 often present veins that collapse or roll easily, and
due to complex
health issues, it may be necessary to withdraw smaller volumes of blood for thes
e populations. A
syringe draw or butterfly setup will often be necessary. Cleansing and support o
f the site:
Once the site has been selected, it must be cleaned. Seventy percent iso- propyl
alcohol is
usually used to clean the site, and it is applied in a circular motion with the
draw site at the
center of the circle. The alcohol must be allowed to dry completely before the b
lood draw is
performed. The site should not be repalpated after the alcohol has been used. If
repalpation is
absolutely necessary, the site should be cleaned again after being touched. The
venipuncture site
should be well supported by using a chair that has arms or a cross support desig
ned for
blood-drawing procedures. It may be helpful to have the patient make a fist with
the oppo- site
hand and place this under the elbow, which helps to expose the antecubital area
fully for
inspection and offers additional support. For inpatients, the patients arm should
be settled on
a pillow or rolled-up towel to help make the veins more accessible. Support of t
he site may be
complicated for small children. It may be necessary to ask the adult who ac- com
panied the child
to assist with the process by hold- ing the child and securing the childs upper b
ody for safety.
A staff member may also be asked to assist in the process. The medical assistant
should be ready
for the blood draw as quickly as possible in this situation, and should not allo
w the child to
see the needle for an excessive period of time before the venipuncture. Patient
communication:
Whenever the skin is to be punctured, remember to be honest with the patient abo
ut what will

occur. Never tell a patient that the pro- cedure wont hurt, or chastise the patie
nt for expressing fear or discomfort with the procedure. Assure the patient that the procedure
is necessary,
and that it will be completed in as little time as possible. Try to adapt to the
age of the
patient by making appropriate small talk. Allowing the child to blow away the pai
n may be
beneficial; the act of saying ow and blowing out may help to distract him or her f
rom the
process. Test Your Knowledge 8-15 What is the most important aspect of patient p
reparation for
blood collection procedures? (Outcome 8-14) SPECIMEN PROCESSING Once the blood s
pecimen is
collected, it may require fur- ther processing before it can be used for testing
. The analysis
may call for serum, plasma, or whole blood for (Text continues on page 180) 1899
_Ch08_133-194
21/12/11 2:23 PM Page 153 154 Section II Specimen Collection and Processing Pro
cedure 8-1:
Venipuncture Using the Evacuated Tube System The evacuated tube system is the me
thod used most
commonly for obtaining blood. It is fast and relatively safe, and allows for mul
tiple tubes to be
filled with one invasive procedure. TASK Successfully perform a venipuncture usi
ng the evacuated tube system. The process must be completed within 5 minutes. CONDITIONS Han
d-washing
supplies and/or alcohol-based hand sanitizer Disposable gloves Tourniquet 70% is
opropyl
alcohol Double-pointed multi-sample needle Evacuated tube holder Laboratory requ
isition
form or labels with specified test Evacuated tubes 2 x 2 gauze pads Adhesive ban
dage or
wrap Test tube rack Biohazardous sharps container Biohazardous disposal bag CAAH
EP/ABHES
STANDARDS CAAHEP Standards I.P.I.2: Perform Venipuncture I.A.I.1: Apply critica
l thinking skills
in performing patient assessment and care III.P.III.3: Select appropriate barri
er/personal
protective equipment (PPE) for potentially infectious situations ABHES Standards
Medical Office
Laboratory Procedures: Collect, label and process specimens: Perform venipunctur
e Medical
Office Clinical Procedures: Apply principles of aseptic techniques and infection
control
Medical Office Clinical Procedures: Use Standard Precautions Procedure Rationale
1. Gather the
requisition form and/or labels for the blood draw, and greet the patient. Identi
fy your- self
appropriately. 2. Wash hands (if they are visibly soiled) or apply hand sanitize
r. Allow hands to
dry completely. 3. Verify the identity of the patient by asking for his or her n
ame and at least
one other unique identi- fier (such as the patients birth date). Compare this inf
ormation to the
requisition form or labels. 4. Verify whether dietary restrictions were followed
, and time of
last medication dose, if needed. 5. Have the patient sit in the phlebotomy chair
with appropriate

arm support, and extend his or her arm to expose the antecubital area. The requi
sition or labels
are necessary to collect the correct type of specimen. It is always correct prac
tice to identify
yourself to the patient. Clean hands stop the spread of infection. Hands should
be completely dry
before attempting to apply gloves, or it will be difficult to put the gloves on
the wet hands.
Patient identification must always be verified using at least two unique factors
. Many laboratory
tests require fasting specimens or other dietary restrictions. Drug dosage times
are es- pecially
important for appropriate interpretation of the laboratory results. The arm shou
ld be supported
for the venipuncture process, and the antecubital area will be the first area th
at is considered
for the blood draw. 1899_Ch08_133-194 21/12/11 2:23 PM Page 154 Chapter 8 Colle
ction and
Processing of Blood Samples 155 6. Apply gloves. 7. Apply the tourniquet approxi
mately 3 in.
above the antecubital area (or above the wrist if a hand draw is necessary) and
select an
appropriate draw site using palpation. Use the tips of the ring finger and middl
e finger in a
gentle probing motion as the antecubital area is examined. An appropriate vein w
ill feel flexible
and firm. Do not allow the tourniquet to remain on the arm for more than 1 minut
e. 8. While
palpating, have the patient make a fist, but do not allow the patient to pump hi
s or her hand. 9.
If an appropriate site is not identified on the first arm, examine the other arm
. If the
antecubital area is not appropriate on either arm, examine the back of the hands
for other
opportunities. 10. Once an appropriate site is selected, determine the direction
of the vein; is
it running straight up and down or at an angle across the arm? Establish a visib
le landmark (a
mole or dimple in the skin, etc.) for reference. 11. Have the patient open the h
and to relax the
fist until the tourniquet is reapplied. 12. Remove the tourniquet. Gloves are re
quired for
procedures in which there is reasonable anticipation of exposure to blood or oth
er potentially
infectious materials. The tourniquet needs to be placed high enough that it will
not block the
venipuncture site. Only blood vessels that can be palpated should be used for ve
nipuncture; just
looking at them is not sufficient. The thumb should never be used to feel for a
vein, as there
may be a pulse felt from the thumb that can be misleading. The thumb is also not
as sensitive as
the fingers. Procedure Rationale Pumping the hand can cause erroneous test resul
ts due to
hemoconcentration. It is important to choose the best site before inserting the
needle. If the
first arm examined doesnt provide a vein that is appropriate, check the other arm
. If necessary,
the back of the hands may be con- sidered as a blood draw site. The needle must
be inserted in

such a way that it follows the direction of the vein for the best chance of succ
ess. A landmark
is helpful so that the chosen venipuncture site can be identified after cleaning
the area.
Relaxing the hand will help the blood to flow normally as the site is prepared.
A tourniquet may
not stay on the arm for more than 1 minute, or hemoconcentration may result. Con
tinued
1899_Ch08_133-194 21/12/11 2:23 PM Page 155 156 Section II Specimen Collection
and Processing
13. Apply 70% isopropyl alcohol to the area in a circular motion with the draw s
ite at the center
of the circle. Allow the site to air-dry. 14. As the alcohol is drying, assemble
the necessary
supplies. a. Choose a needle of appropriate size and attach it to the evacuated
tube holder. Do
not remove the cap that covers the long end of the needle until right before the
skin is to be
punctured. b. Arrange the necessary tubes for the tests ordered within easy reac
h of your
nondomi- nant hand, and have them set up in the correct order of draw. c. Verify
that the tubes
are not expired and that the anticoagulant is placed away from the rub- ber stop
per within the
tube. (You may need to shake the tube lightly to get the anticoagulant to move a
way from the
stopper.) Check for any obvious defects in the tubes. 15. Verify that gauze pads
and an adhesive
bandage are within reach. Extra tubes should also be close by so that they can b
e used if
necessary. 16. Once the alcohol is dry, reapply the tourniquet. Do not repalpate
the venipuncture
site, or if absolutely necessary, clean the end of the gloved finger with alcoho
l before touching
the site. 17. Have the patient make a fist. 18. Remove the cap to expose the end
of the needle to
be inserted into the arm. Do not allow this needle to touch anything before pier
cing the skin.
70% isopropyl alcohol will kill most of the bacterial contaminants on the surfac
e of the skin.
Never blow or fan the site to speed up the drying process, as this recontaminate
s the clean area.
Supplies need to be close by for ease of use and patient safety. This should alw
ays occur in the
presence of the patient so that he or she is assured that the needle is sterile.
The cap should
not be removed until it is ready to be used to minimize the risk of contamina- t
ion or possible
injury. Needle sizes may vary according to the needs of the patient and the poli
cy of the
facility. The tubes may be laid out on the counter near the pa- tient, or a smal
l tube rack may
work well for this purpose. Use of an expired tube may result in a loss of vacuu
m and an
unsuccessful blood draw. Potential crossover of anticoagulant from one tube to a
nother should be
minimized as much as possible. Defective (such as cracked or chipped tubes) shou
ld be discarded
im- mediately. The gauze pads and adhesive bandages need to be ready for use imm
ediately when the

needle is removed from the skin. If the phlebotomist feels that there may be a c
hance that the
vacuum is exhausted in the first tube, using a second one that is nearby may all
ow the
venipuncture to be successful. If the site is touched after cleansing, it will n
eed to be cleaned
again before the venipuncture can begin. Forming a fist may help with the visual
ization of the
veins once the tourniquet is reapplied. Touching this needle to any surface befo
re it pierces the
skin will cause contamination and possible introduction of bacteria into the vei
n. Procedure 8-1:
Venipuncture Using the Evacuated Tube Systemcontd Procedure Rationale 1899_Ch08_13
3-194
21/12/11 2:23 PM Page 156 Chapter 8 Collection and Processing of Blood Samples
157 19. Stabilize
the chosen vein by anchoring it with the thumb of the nondominant hand about 2 i
n. below the draw
site, and/or off to the side. Make sure that the skin is pulled taut over the ve
in. 20. As you
prepare to pierce the skin with the needle, it is good practice to warn the pati
ent by saying
something like, Here we go; you will feel a stick. 21. Insert the needle at an ang
le of
approximately 15 degrees, with the bevel up. The actual inser- tion site is appr
oximately 1
/
4 to 1
/
2 inch below the identified draw site so that the needle is actually ins
erted into the vein
at the chosen site. 22. The needle needs to be inserted quickly, with one smooth
gentle motion.
As the insertion is accom- plished, follow the direction of the vein that was pr
eviously
identified; if the vein is running at an angle across the arm or hand, this is h
ow the needle
should be directed into the vein. Approximately a third of the needle is usually
below the
surface of the skin when the insertion is complete. It is important to stabilize
the vein, but if
the thumb is placed too close to the draw site, it will be in the way of the nee
dle insertion and
could cause interference with the angle used for the process and result in an un
successful blood
draw. If the patient is not expecting the skin to be pierced, he or she may be s
tartled and move
the arm or hand, causing an unsuccessful venipuncture. If the angle is significa
ntly less or more
than 15 degrees, it may slide just above the vein or puncture through both sides
of the vein
rather than just entering the vein. The bevel facing upward allows the blood to
enter the needle
with minimal trauma. Smooth insertion minimizes the trauma to the patient. It is
important to
follow the direction of the vein as the needle is inserted; this allows a better
opportu- nity
for the blood to enter the needle without obstruction. The needle needs to be in
serted far enough
to enter the vein, but not so far that it punctures both sides of the vein. Proc

edure Rationale
Continued 1899_Ch08_133-194 21/12/11 2:23 PM Page 157 23. While keeping the need
le firmly seated
in the vein, push the first tube into the needle holder, with the label facing d
ownward. Use the
index and middle fingers of the nondominant hand by placing them on either side
of the flared
edge at the bottom of the evacuated tube holder. Place the thumb of the nondomin
ant hand on the
bottom of the tube, and squeeze or pull the thumb toward the fingers, pushing th
e tube into the
holder. If the needle is placed appropriately in the vein, blood should start to
enter the tube
as soon as the needle has pierced the stopper. 24. If only one tube is necessary
for the tests
ordered, release the tourniquet once the blood has started to enter the tube. If
there is more
than one tube necessary, the tourniquet may stay in place until the last tube ha
s been inserted,
as long as the length of time has not exceeded 1 minute since the tourniquet was
applied. 25. If
it is necessary to use more than one tube for the blood draw, push against the f
langes to remove
the tube from the holder. Be careful not to disturb the needle placement as the
tube is removed.
Insert the next tube needed for the tests ordered, follow- ing the appropriate o
rder of draw. 26.
As each tube with additive is removed from the holder, invert the tube gently at
least one or two
times. This may be accomplished while the next tube is filling. 27. As the last
tube is filling,
ask the patient to relax the fist. Verify that the tourniquet has been re- lease
d, and remove the
last tube from the holder. The hand used to hold the evacuated tube holder shoul
d rest firmly
against the arm to keep the needle in place. If the label on the tube is facing
upward, it is
difficult to see the blood as it enters the tube. 158 Section II Specimen Colle
ction and
Processing The tourniquet must not stay on longer than 1 minute. It is always ne
cessary to
release the tourniquet before the needle is removed from the arm to avoid bleeding from the
venipuncture site and introduction of air into the last vacuum tube used. It is
important to keep
applying gentle pressure on the arm of the patient with the back of the fingers
that are
supporting the evacuated tube holder while removing and inserting tubes to keep
the needle in
place within the vein. It may be necessary to change tubes more than once when t
here are multiple
tubes necessary for the tests ordered. Tubes with anticoagulant added must be in
verted sufficiently to mix the sample with the additive or the blood will clot and the spe
cimen will need
to be redrawn. This is important to avoid a potential bruise or hematoma at the
draw site, and
also to avoid intro- duction of excess air into this last tube. Procedure Ration
ale Procedure
8-1: Venipuncture Using the Evacuated Tube Systemcontd 1899_Ch08_133-194 21/12/11

2:23 PM Page
158 28. As the needle is removed from the skin, place gauze over the site withou
t applying
initial pressure. The needle is to be removed quickly, and at the same angle as
the insertion. Do
not apply pressure to the site with the gauze until the needle has been removed
completely from
the skin, as this will cause pain for the patient. 29. Ask the patient to apply
pressure to the
site for 3 to 5 minutes. Do not allow the patient to bend his or her arm. 30. On
ce the needle has
been removed from the arm, immediately activate the needle safety device and dis
card the entire
setup in the biohazardous sharps container. Do not remove the needle from the ev
acuated tube
holder before disposal. Never recap contaminated needles. The gauze placed over
the site will
minimize bleeding as the needle is removed. Chapter 8 Collection and Processing
of Blood Samples
159 The pressure should be adequate to stop any bleeding before the patient leav
es the drawing
area. Bending the arm increases the risk for bleeding and bruise formation. The
evacuated tube
setup is designed to be used one time and discarded without removing the needle
before disposal.
Recapping contaminated needles increases the risk of needlestick accidents and p
otential exposure
to bloodborne pathogens. Procedure Rationale A Continued 1899_Ch08_133-194 21/12
/11 2:23 PM Page
159 31. As the patient is applying pressure to the draw site, gently invert the
blood specimens
containing anticoagulant 5 to 10 times. 32. Label the tubes, including the full
name of the
patient, birth date (or other unique identifier assigned by the health-care prov
ider), the date
and time of collection, and the initials of the person who drew the sample. 33.
Use the
requisition form or the labels to verify that all the necessary tubes were drawn
for the specimens ordered. Insufficient mixing of the anticoagulant with the specimen will re
sult in clotted
blood and a sample that must be discarded. All samples must be labeled using at
least two unique
identifiers. The date and time provide additional information that may be necess
ary for
interpretation of the results. 160 Section II Specimen Collection and Processin
g Procedure
Rationale Procedure 8-1: Venipuncture Using the Evacuated Tube Systemcontd B Ident
ification of
the phlebotomist may be helpful if there are questions about the procedure or th
e spec- imens
collected. Verifying the details of the blood draw once more in the presence of
the patient
allows for a redraw to be performed immediately if something is missing. 1899_Ch
08_133-194
21/12/11 2:23 PM Page 160 34. Observe any special handling instructions for the
specimens. 35.
Monitor the patient for any signs of distress from the procedure. 36. Once the t
ubes have been
labeled, check the draw site for bleeding. If it has not stopped bleeding, apply

pressure for
another few minutes, and if the bleeding is still present, contact a physician.
37. If the
bleeding has subsided, apply an adhesive bandage, but leave the gauze in place t
o allow for
additional pressure. 38. Advise the patient to avoid heavy lifting or exces- siv
e exercise of the
arm used for venipuncture for at least 1 hour. 39. Assist the patient to stand (
if necessary) and
thank him or her for being cooperative. 40. Discard all trash, and place the tub
es in an appropriate vessel for processing. Never touch full tubes of blood without wearing gl
oves. 41. Remove
gloves and sanitize hands. Some types of specimens must remain at room temper- a
ture, whereas
others may need to be put on ice immediately. This should be information that is
ascertained
before the procedure starts. These may include pallor, perspiration (especially
on the upper lip
or forehead), increased anxiety, or light-headedness. If the patient is exhibiti
ng any of these
symptoms, it is best to have him or her lie down if possible. This may be easily
accomplished if
the patient is in a chair that can recline. If not, a cold compress on the foreh
ead and/or the
back of the neck may help. Continue to converse with the patient and move the bl
ood out of sight.
Ask for assistance if you feel that your patient is feeling faint. If the patien
t loses
consciousness, it may be necessary to lower him or her to the floor from the phl
ebotomy chair. It
is important to look under the gauze for 2 or 3 seconds before applying the adhe
sive bandage to
be certain that the site has actually stopped bleeding. Self-adhesive bandages (
such as Coban)
may be wrapped around the site rather than applying an adhesive to the skin dire
ctly.
Self-adhesive bandages may be especially effective for those patients who are on
anticoagulant
therapy. Heavy lifting or exercise could cause the site to resume bleeding. Pati
ents may be a bit
light-headed, and assistance may be needed when he or she first stands up. Touch
ing the tubes of
blood without wearing gloves offers potential opportunities for exposure to bloo
dborne pathogens.
Hands must always be sanitized after removing gloves. Chapter 8 Collection and
Processing of
Blood Samples 161 Procedure Rationale Continued 1899_Ch08_133-194 21/12/11 2:23
PM Page 161 42.
Document the procedure in the patients chart as well as on the requisition form.
Include the
date and time of collection, what was collected, and if there were any circumsta
nces that were
out of the ordinary. Also document where the vein was accessed (such as right ar
m, left hand,
etc.). The documentation should include the type (color) of tubes drawn, as well
as the identity
of the person who collected the sample. All patient interactions must be careful
ly documented.
The site used for vein access should always be writ- ten in the chart or on the

requisition form
so that if there are any negative outcomes associated with the procedure, the si
te has been
noted. 162 Section II Specimen Collection and Processing Date 1/18/2020: Phlebo
tomy performed in
right antecubital area for CMP and CBC. Tiger top and lavender top tube drawn.
1100 a.m.
Connie Lieseke, CMA (AAMA) Procedure Rationale Procedure 8-1: Venipunctu
re Using the
Evacuated Tube Systemcontd Procedure 8-2: Venipuncture Using a Syringe A syringe a
nd needle may
be used for venipuncture in situations in which the available veins are prone to
move during the
blood draw, or when the vein may not be capable of supporting the vacuum exerted
from an
evacuated tube. This may be the case if the vein is small, or if it lacks bounce w
hen palpated.
Syringe draws are an excellent choice in the antecubital area when the veins are
not quite
suitable for a blood draw using an evacuated tube system setup. TASK Successfull
y perform a
venipuncture using a syringe. After the blood has been obtained, transfer it suc
cess- fully into
the necessary tubes for analysis. The process must be completed within 5 minutes
. CONDITIONS
Hand-washing supplies and/or alcohol-based hand sanitizer Disposable gloves Tour
niquet 70%
isopropyl alcohol Syringe (5- to 15-mL capacity) 21- to 23-gauge safety enabled
needle
Transfer device Laboratory requisition form or labels with specified test Evacua
ted tubes 2
x 2 gauze pads Adhesive bandage or wrap Test tube rack Biohazardous sharps conta
iner
Biohazardous disposal bag CAAHEP/ABHES STANDARDS CAAHEP Standards I.P.I.2: Perfo
rm Venipuncture
I.A.I.1: Apply critical thinking skills in performing patient assessment and car
e III.P.III.3:
Select appropriate barrier/personal protective equipment (PPE) for potentially i
nfectious
situations ABHES Standards Medical Office Laboratory Procedures: Collect, label
and process
specimens: Perform venipuncture Medical Office Clinical Procedures: Apply princi
ples of aseptic
techniques and infection control Medical Office Clinical Procedures: Use Standar
d Precautions
1899_Ch08_133-194 21/12/11 2:23 PM Page 162 Chapter 8 Collection and Processing
of Blood Samples
163 Procedure Rationale 1. Gather the requisition form and/or labels for the blo
od draw, and
greet the patient. Identify yourself appropriately. 2. Wash hands (if they are v
isibly soiled) or
apply hand sanitizer. Allow hands to dry completely. 3. Verify the identificatio
n of the patient
by asking for his or her name and at least one other unique iden- tifier (such a
s the patients
birth date). Compare this information to the requisition form or labels. 4. Veri
fy whether diet
restrictions were followed, and time of last medication dose, if needed. 5. Have

the patient sit

in the phlebotomy chair with appropriate arm support, and extend his or her arm
to expose the
antecubital area. 6. Apply gloves. 7. Apply the tourniquet approximately 3 in. a
bove the
antecubital area (or above the wrist if a hand draw is necessary) and select an
appropriate draw
site using palpation. Use the tips of the ring finger and middle finger in a gen
tle probing
motion as the antecubital area is examined. An appropriate vein will feel flexib
le and firm. Do
not allow the tourni- quet to remain on the arm for more than 1 minute. 8. While
palpating, have
the patient make a fist, but do not allow the patient to pump his or her hand. 9
. If an
appropriate site is not identified on the first arm, examine the other arm. If t
he antecubital
area is not appropriate on either arm, examine the back of the hands for other o
pportunities. 10.
Once an appropriate site is selected, determine the direction of the vein; is it
running straight
up and down or at an angle across the arm? Establish a visible landmark (a mole
or dimple in the
skin, etc.). for reference. The requisition or labels are necessary to collect t
he correct type
of specimen. It is always correct practice to identify yourself to the patient.
Clean hands stop
the spread of infection. Hands should be completely dry before attempting to apply gloves, or
it will be difficult to put the gloves on the wet hands. Patient identification
must always be
verified using at least two unique factors. Many laboratory tests require fastin
g specimens or
other dietary restrictions. Drug dosage times are es- pecially important for app
ropriate
interpretation of the laboratory results. The arm should be supported for the ve
nipuncture
process, and the antecubital area will be the first area that is considered for
the blood draw.
Gloves are required for procedures in which there is reasonable anticipation of
exposure to blood
or other potentially infectious materials. The tourniquet needs to be placed hig
h enough that it
will not block the venipuncture site. Only blood vessels that can be palpated sh
ould be used for
venipuncture; just looking at them is not sufficient. The thumb should never be
used to feel for
a vein, as there may be a pulse felt from the thumb that can be misleading. The
thumb is also not
as sensitive as the fingers. Pumping the hand can cause erroneous results becaus
e of
hemoconcentration. It is important to choose the best site before inserting the
needle. If the
first arm examined doesnt provide a vein that is appropriate, check the other arm
. If necessary,
the back of the hands may be considered as a blood draw site. The needle must be
inserted in such
a way that it fol- lows the direction of the vein for the best chance of success
. A landmark is
helpful so that the chosen venipuncture site can be identified after cleaning th

e area. Continued
1899_Ch08_133-194 21/12/11 2:23 PM Page 163 11. Have the patient open the hand t
o relax the fist
until the tourniquet is reapplied. 12. Remove the tourniquet. 13. Apply 70% isop
ropyl alcohol to
the area in a cir- cular motion with the draw site at the center of the circle.
Allow the site to
air-dry. 14. As the alcohol is drying, assemble the necessary supplies. a. Open
the sterile
package holding the syringe b. Pull back and push forward the plunger of the syr
inge several
times to verify whether it moves smoothly. Be certain that the plunger is pushed
forward as far
as it goes before continuing with the process. c. Remove the needle from the ste
rile wrapper. Do
not take off the cap covering the end of the needle until just before insertion
into the
patients arm. d. Attach the needle to the syringe tip. e. Place gauze pads and ad
hesive bandage
within reach of the nondominant hand for use at the end of the venipuncture. f.
Organize tubes
needed for analysis and unwrap transfer device. Place within easy reach. g. Veri
fy that the tubes
are not expired and that the anticoagulant is placed away from the rub- ber stop
per within the
tube. (You may need to shake the tube lightly to get the anticoagulant to move a
way from the
stopper.) Check for any obvious defects in the tubes. 15. Once the alcohol is dr
y and the
supplies are assem- bled, reapply the tourniquet. Do not repalpate the venipunct
ure site, or if
absolutely necessary, clean the end of the gloved finger with alcohol before tou
ching the site.
Relaxing the hand will help the blood to flow normally as the site is prepared.
A tourniquet may
not stay on the arm for more than 1 minute, or hemoconcentration may result. 70%
isopropyl
alcohol will kill most of the bacterial contaminants on the surface of the skin.
Never blow or
fan the site to speed up the drying process, as this recontaminates the clean ar
ea. Supplies need
to be close by for ease of use and patient safety. Syringes should remain steril
e until the time
of use. Exercising the plunger in this way allows for smooth movement when pulling
back the
plunger to allow blood to enter the syringe. If the plunger does not move smooth
ly or is too
loose within the barrel of the syringe, it should be discarded. The needle must
remain sterile
until just prior to inser- tion. It cannot touch other surfaces before piercing
the skin of the
patient. Verify that this is a secure connection so that blood will not leak out
around the
needle during the venipunc- ture process. Supplies to be used during the venipun
cture process
should be within easy reach of the nondominant hand to avoid reaching over the s
ite where the
nee- dle is inserted in the arm. When the venipuncture procedure is finished, it
is nec- essary
to transfer the blood into the tubes quickly to avoid clot formation in the samp

le. Organization
of supplies before the process is critical. Use of an expired tube may result in
a loss of vacuum
and an unsuccessful blood draw. Potential crossover of anticoagulant from one tu
be to another
should be minimized as much as possible. Defective (such as cracked or chipped t
ubes) should be
discarded immediately. If the site is touched after cleansing, it will need to b
e cleaned again
before the venipuncture can begin. 164 Section II Specimen Collection and Proce
ssing Procedure
Rationale Procedure 8-2: Venipuncture Using a Syringecontd 1899_Ch08_133-194 21/12
/11 2:23 PM
Page 164 16. Have the patient make a fist. 17. Remove the cap to expose the end
of the needle to
be inserted into the arm. Do not allow this needle to touch anything before pier
cing the skin.
18. Stabilize the chosen vein by anchoring it with the thumb of the nondominant
hand about 2 in.
below the draw site, and/or off to the side. Make sure that the skin is pulled t
aut over the
vein. 19. As you prepare to pierce the skin with the needle, it is good practice
to warn the
patient by saying something like, Here we go; you will feel a stick. 20. Insert th
e needle at
an angle of approximately 15 degrees, with the bevel up. The actual insertion si
te is
approximately 1
/
4 to 1
/
2 inch below the identified draw site so that the needle is actually ins
erted into the vein
at the chosen site. 21. The needle needs to be inserted quickly, with one smooth
gentle motion.
As the insertion is accom- plished, follow the direction of the vein that was pr
eviously
identified; if the vein is running at an angle across the arm or hand, this is h
ow the needle
should be directed into the vein. Approx- imately a third of the needle is usual
ly below the
surface of the skin when the insertion is complete. Forming a fist may help with
the
visualization of the veins once the tourniquet is reapplied. Touching this needl
e to any surface
before it pierces the skin will cause contamination and possible intro- duction
of bacteria into
the vein. It is important to stabilize the vein, but if the thumb is placed too
close to the draw
site, it will be in the way of the needle insertion and could cause interference
with the angle
used for the process and result in an unsuccessful blood draw. If the patient is
not expecting
the skin to be pierced, he or she may be startled and move the arm or hand, caus
ing an
unsuccessful venipuncture. If the angle is significantly less or more than 15 de
grees, it may
slide just above the vein or puncture through both sides of the vein rather than
just entering
the vein. The bevel facing upward allows the blood to enter the needle with mini

mal trauma.
Smooth insertion minimizes the trauma to the patient. It is important to follow
the direction of
the vein as the needle is inserted; this allows a better opportu- nity for the b
lood to enter the
needle without obstruction. The needle needs to be inserted far enough to enter
the vein, but not
so far that it punc- tures both sides of the vein. Chapter 8 Collection and Pro
cessing of Blood
Samples 165 Procedure Rationale Continued 1899_Ch08_133-194 21/12/11 2:23 PM Pag
e 165 22. When
using the syringe technique, there may be a flash of blood visible in the hub of t
he needle as
soon as it is inserted in the vein. Gently pull back on the plunger of the syrin
ge to create a
vacuum and pull the blood into the syringe. 23. Continue to pull back slowly on
the plunger and
monitor the volume of blood entering the syringe. Keep gentle pressure on the ar
m of the patient
with the back of the fingers holding the syringe. 24. When the required amount o
f blood has
almost been obtained, release the tourniquet and have the patient open his or he
r fist. 25. As
the needle is removed from the skin, place gauze over the site, without applying
initial pressure. The needle is to be removed quickly, and at the same angle as the insertio
n. Do not apply
pres- sure to the site with the gauze until the needle has been removed complete
ly from the skin,
as this will cause pain for the patient. 26. Ask the patient to apply pressure t
o the site for 3
to 5 minutes. Do not allow the patient to bend his or her arm. It is important t
o pull back
relatively slowly because if the plunger is pulled back too fast, it can cause h
emolysis. It is
also possible that if the vein is small, it will collapse with the pressure appl
ied by pulling
the plunger back too quickly. The medical assistant must continue to pull back o
n the plunger so
that the blood will continue to enter the syringe. To keep the needle from movin
g during the
process, pressure should be applied with the back of the fingers holding the syr
inge. 166 Section
II Specimen Collection and Processing The tourniquet must not stay on longer th
an 1 minute. It
is always necessary to release the tourniquet and have the patient open the fist
before the
needle is removed from the arm to avoid bleeding from the venipuncture site. The
gauze placed
over the site will minimize bleeding as the needle is removed. The pressure shou
ld be adequate to
stop any bleeding before the patient leaves the drawing area. Bending the arm in
creases the risk
for bleeding and bruise formation. Procedure Rationale Procedure 8-2: Venipunctu
re Using a
Syringecontd 1899_Ch08_133-194 21/12/11 2:23 PM Page 166 27. Once the needle has b
een removed
from the arm, immediately activate the needle safety device. Grasp the needle at
its base, and
remove it from the syringe. Discard the needle in the biohaz- ardous sharps cont

ainer. Never
recap contaminated needles. 28. Screw the transfer device onto the end of the sy
ringe filled with
blood. 29. While holding the syringe upright, insert each evacuated tube into th
e open end of the
transfer device. Follow the recommended order of draw. 30. Dispose of the transf
er device and
syringe in a biohazardous sharps container. 31. Gently invert the blood specimen
s containing
anticoagulant 5 to 10 times. 32. Label the tubes, including the full name of the
patient, birth
date (or other unique identifier assigned by the health-care provider), the date
and time of
collection, and the initials of the collector. The needle must be removed from t
he syringe so
that the transfer device can be applied. Recapping con- taminated needles increa
ses the risk of
needlestick accidents and potential exposure to bloodborne pathogens. Make sure
this is a secure
seal so that the blood will flow adequately. Holding the syringe upright will mi
nimize the opportunity for anticoagulant crossover as the transfer device is used. Chapter 8 Co
llection and
Processing of Blood Samples 167 There is a needle within the transfer device, so
this must go
into a sharps container. Insufficient mixing of the anticoagulant with the specimen will result
in clotted blood and a sample that must be discarded. All samples must be labele
d using at least
two unique identifiers. The date and time provide additional information that ma
y be necessary
for interpretation of the results. Identification of the phlebotomist may be hel
pful if there are
questions about the procedure or the specimens collected. Procedure Rationale Co
ntinued
1899_Ch08_133-194 21/12/11 2:23 PM Page 167 33. Use the requisition form or the
labels to verify
that all the necessary tubes were drawn for the speci- mens ordered. 34. Observe
any special
handling instructions for the specimens. 35. Monitor the patient for any signs o
f distress from
the procedure. 36. Once the tubes have been labeled, check the draw site for ble
eding. If it has
not stopped bleeding, apply pressure for another few minutes, and if the bleedin
g is still
present, contact a physician. 37. If the bleeding has subsided, apply an adhesiv
e bandage, but
leave the gauze in place to allow for additional pressure. 38. Advise the patien
t to avoid heavy
lifting or exces- sive exercise of the arm used for venipuncture for at least 1
hour. 39. Assist
the patient to stand (if necessary) and thank them for their cooperation. 40. Di
scard all trash,
and place the tubes in an appro- priate vessel for processing. Never touch full
tubes of blood
without wearing gloves. 41. Remove gloves and sanitize hands. Verifying the deta
ils of the blood
draw once more in the presence of the patient allows for a redraw to be performe
d immediately if
something is missing. Some types of specimens must remain at room temper- ature,

whereas others
may need to be put on ice immediately. This should be information that is ascert
ained before the
procedure starts. These may include pallor, perspiration (especially on the uppe
r lip or
forehead), increased anxiety, or light-headedness. If the patient is exhibiting
any of these
symptoms, it is best to have him or her lie down if possible. This may be easily
accomplished if
the patient is in a chair that can recline. If not, a cold compress on the foreh
ead and/or the
back of the neck may help. Continue to converse with the patient and move the bl
ood out of sight.
Ask for assistance if you feel that your patient is feeling faint. If the patien
t loses
consciousness, it may be necessary to lower him or her to the floor from the phl
ebotomy chair. It
is important to look under the gauze for 2 or 3 seconds before applying the adhe
sive bandage to
be certain that the site has actually stopped bleeding. Self-adhesive bandages (
such as Coban)
may be wrapped around the site rather than applying an adhesive to the skin dire
ctly.
Self-adhesive bandages may be especially effective for those patients who are on
anticoagulant
therapy. Heavy lifting or exercise could cause the site to resume bleeding. Pati
ents may be a bit
light-headed and assistance may be needed when he or she first stands up. Touchi
ng the tubes of
blood without wearing gloves offers potential opportunities for exposure to bloo
d- borne
pathogens. Hands must always be sanitized after removing gloves. 168 Section II
Specimen
Collection and Processing Procedure Rationale Procedure 8-2: Venipuncture Using
a Syringecontd
1899_Ch08_133-194 21/12/11 2:23 PM Page 168 42. Document the procedure in the pa
tients chart as
well as on the requisition form. Include the date and time of collection, what w
as collected, and
if there were any circumstances that were out of the ordinary. Also document whe
re the vein was
accessed (such as right arm, left hand, etc.). The documentation should include
the type (color)
of tubes drawn, as well as the identity of the person who collected the sample.
All patient
interactions must be carefully documented. The site used for vein access should
always be written in the chart or on the requisition form so that if there are any negative ou
tcomes associated
with the procedure, the site has been noted. Chapter 8 Collection and Processin
g of Blood
Samples 169 Date 1/18/2020: Phlebotomy performed in left antecubital area for H&
H. Lavender top
tube drawn.
1100 a.m.
Connie Lieseke, CMA (AAMA) Procedure Rationale Procedure 8-3: Venipunctu
re Using the
Butterfly (Winged Infusion) System The butterfly system is often used for obtain

ing blood from

patients with small, fragile veins. It is the system of choice when performing b
lood draws from
the hand of patients. When utilized for venipuncture, 23-gauge needles are usual
ly used. TASK
Successfully perform a venipuncture using a butterfly (winged infusion) system.
The process must
be com- pleted within 5 minutes. CONDITIONS Hand-washing supplies and/or alcohol
-based hand
sanitizer Disposable gloves Tourniquet 70% isopropyl alcohol Butterfly needle (w
inged
infusion set) Evacuated tube holder and luer adapter, or syringe and transfer de
vice
Laboratory requisition or labels with specified test Evacuated tubes 2 x 2 gauze
pads
Adhesive bandage or wrap Test tube rack Biohazardous sharps container Biohazardo
us disposal
bag CAAHEP/ABHES STANDARDS CAAHEP Standards I.P.I.2: Perform Venipuncture I.A.I
.1: Apply
critical thinking skills in performing patient assessment and care III.P.III.3:
Select
appropriate barrier/personal protective equipment (PPE) for potentially infectio
us situations
ABHES Standards Medical Office Laboratory Procedures: Collect, label and process
specimens:
Perform venipuncture Medical Office Clinical Procedures: Apply principles of ase
ptic techniques
and infection control Medical Office Clinical Procedures: Use Standard Precautio
ns Continued
1899_Ch08_133-194 21/12/11 2:23 PM Page 169 Procedure Rationale 1. Gather the re
quisition and/or
labels for the blood draw, and greet the patient. Identify yourself appropriatel
y. 2. Wash hands
(if they are visibly soiled) or apply hand sanitizer. Allow hands to dry complet
ely. 3. Verify
the identification of the patient by asking for his or her name and at least one
other unique
identifier (such as the patients birth date). Com- pare this information to the r
equisition or
labels. 4. Verify whether dietary restrictions were followed, and time of last m
edication dose,
if needed. 5. Have the patient sit in the phlebotomy chair with appropriate arm
support, and
extend his or her arm to expose the antecubital area. 6. Apply gloves. 7. Apply
the tourniquet
approximately 3 in. above the antecubital area (or above the wrist if a hand dra
w is necessary)
and select an appropriate draw site using palpation. Use the tips of the ring fi
nger and middle
finger in a gentle probing motion as the antecubital area is examined. An approp
riate vein will
feel flexible and firm. Do not allow the tourniquet to remain on the arm for mor
e than 1 minute.
8. While palpating, have the patient make a fist, but do not allow them to pump
his or her hand.
9. If an appropriate site is not identified on the first arm, examine the other
arm. If the
antecubital area is not appropriate on either arm, examine the back of the hands
for other
opportunities. 170 Section II Specimen Collection and Processing The requisitio

n or labels are
necessary to collect the correct type of specimen. It is always correct practice
to identify
yourself to the patient. Clean hands stop the spread of infection. Hands should
be completely dry
before attempting to apply gloves, or it will be difficult to put the gloves on
the wet hands.
Patient identification must always be verified using at least two unique factors
. Many laboratory
tests require fasting specimens or other dietary restrictions. Drug dosage times
are especially
important for appropriate interpretation of the laboratory results. The arm shou
ld be supported
for the venipuncture process, and the antecubital area will be the first area th
at is considered
for the blood draw. Gloves are required for procedures in which there is reasona
ble anticipation
of exposure to blood or other potentially infectious materials. The tourniquet n
eeds to be placed
high enough that it will not block the venipuncture site. Only blood vessels tha
t can be palpated
should be used for venipuncture; just looking at them is not sufficient. The thu
mb should never
be used to feel for a vein, as there may be a pulse felt from the thumb that can
be misleading.
The thumb is also not as sensitive as the fingers. Pumping the hand can cause er
roneous results
because of hemoconcentration. It is important to choose the best site before ins
erting the
needle. If the first arm examined doesnt provide a vein that is appropriate, chec
k the other
arm. If necessary, the back of the hands may be considered. Procedure 8-3: Venip
uncture Using the
Butterfly (Winged Infusion) Systemcontd 1899_Ch08_133-194 21/12/11 2:23 PM Page 17
0 10. Once an
appropriate site is selected, determine the direction of the vein; is it running
straight up and
down or at an angle across the arm? Establish a visible landmark (a mole or dimp
le in the skin,
etc.) for reference. 11. Have the patient open the hand to relax the fist until
the tourniquet is
reapplied. 12. Remove the tourniquet. 13. Apply 70% isopropyl alcohol to the are
a in a circu- lar
motion with the draw site at the center of the circle. Allow the site to air-dry
. 14. As the
alcohol is drying, assemble the necessary supplies. Start by opening the sterile
package holding the butterfly setup and uncurling the tubing by gently stretching it. Option
1. Butterfly
System With a Syringe a. Open the sterile package holding the syringe b. Pull ba
ck and push
forward the plunger of the syringe several times to verify whether it moves smoo
thly. c. Attach
the end of the butterfly tubing to the syringe. d. Open a transfer device and pl
ace within reach.
Option 2. Butterfly System With Evacuated Tube Holder a. Verify that the butterf
ly system has a
luer adapter to be used with the evacuated tube holder. b. Screw the butterfly t
ubing with the
adapter attached into the evacuated tube holder. The needle must be inserted in

such a way that

it fol- lows the direction of the vein for the best chance of success. A landmar
k is helpful so
that the chosen venipuncture site can be identified after cleaning the area. Rel
axing the hand
will help the blood to flow normally as the site is prepared. A tourniquet may n
ot stay on the
arm for more than 1 minute, or hemoconcentration may result. 70% isopropyl alcoh
ol will kill most
of the bacterial contaminants on the surface of the skin. Never blow or fan the
site to speed up
the drying process, as this recontaminates the clean area. Supplies need to be c
lose by for ease
of use and patient safety. The butterfly system should remain sterile until just
before use. If
the tubing stays tightly curled, it is difficult to use it effectively. Syringes
should remain
sterile until the time of use. Exercising the plunger in this way allows for smoot
h movement
when pulling back the plunger to allow blood to enter the syringe. If the plunge
r does not move
smoothly or is too loose within the syringe, it should be discarded. This tubing
needs to be
attached securely to allow the blood to enter the syringe. There is a limited am
ount of time
allowed to transfer the blood from the syringe to the tubes before it clots, so
it is important
to have the transfer device ready. The luer adapter has a needle covered with a
rubber sleeve
that pierces the tubes when using the evacu- ated tube holder. The tubing and th
e holder must be
securely attached to one another to allow the blood to flow appropriately into t
he tubes. Chapter
8 Collection and Processing of Blood Samples 171 Procedure Rationale Continued
1899_Ch08_133-194
21/12/11 2:23 PM Page 171 Procedure Rationale 15. Place gauze pads and adhesive
bandage within
reach of the nondominant hand for use at the end of the venipuncture. 16. Organi
ze tubes needed
for analysis and place within easy reach. 17. Verify that the tubes are not expi
red and that the
anticoagulant is placed away from the rubber stopper within the tube. (You may n
eed to shake the
tube lightly to get the anticoagulant to move away from the stopper.) Check for
any obvious
defects in the tubes. 18. Once the alcohol is dry and the supplies are assem- bl
ed, reapply the
tourniquet. Do not repalpate the venipuncture site, or if absolutely necessary,
clean the end of
the gloved finger with alcohol before touching the site. 19. Have the patient ma
ke a fist. 20.
Remove the cap to expose the end of the needle to be inserted into the arm. Do n
ot allow this
needle to touch anything before piercing the skin. 21. Stabilize the chosen vein
by anchoring it
with the thumb of the nondominant hand about 2 in. below the draw site, and/or o
ff to the side.
Make sure that the skin is pulled taut over the vein. 22. As you prepare to pier
ce the skin with
the needle, it is good practice to warn the patient by saying something like, Her

e we go; you
will feel a stick. 23. Grasp the butterfly needle with the wings on either side.
The textured
area of the plastic wings is designed to be against the fingers; this allows the
bevel of the
needle to face upward. Supplies to be used during the venipuncture process shoul
d be within easy
reach of the nondominant hand to avoid reaching over the site where the nee- dle
is inserted in
the arm. To allow for the blood collection process to proceed smoothly, it is ne
cessary organize
the supplies before getting started. Use of an expired tube may result in a loss
of vacuum and an
unsuccessful blood draw. Potential crossover of anticoagulant from one tube to a
nother should be
minimized as much as possible. Defective (such as cracked or chipped tubes) shou
ld be discarded
immediately. If the site is touched after cleansing, it will need to be cleaned
again before the
venipuncture can begin. Forming a fist may help with the visualization of the ve
ins once the
tourniquet is reapplied. Touching this needle to any surface before it pierces t
he skin will
cause contamination and possible intro- duction of bacteria into the vein. It is
important to
stabilize the vein, but if the thumb is placed too close to the draw site, it wi
ll be in the way
of the needle insertion and could cause interference with the angle used for the
process and
result in an unsuccessful blood draw. If the patient is not expecting the skin t
o be pierced, he
or she may be startled and move the arm or hand, causing an unsuccessful venipun
cture. If the
needle is not grasped appropriately, the bevel will point downward and could aff
ect the success
of the blood draw. 172 Section II Specimen Collection and Processing Procedure
8-3: Venipuncture
Using the Butterfly (Winged Infusion) Systemcontd 1899_Ch08_133-194 21/12/11 2:23
PM Page 172
24. Insert the needle at an angle of 5 to 10 degrees, with the bevel up. The act
ual insertion
site is approximately 1
/
4 to 1
/
2 inch below the identified draw site so that the needle is actually ins
erted into the vein
at the chosen site. 25. The needle needs to be inserted quickly, with one smooth
gentle motion.
As the insertion is accom- plished, follow the direction of the vein that was pr
eviously
identified; if the vein is running at an angle across the arm or hand, this is h
ow the needle
should be directed into the vein. Approximately a third of the needle is usually
below the
surface of the skin when the insertion is complete. 26. When the needle pierces
the vein, the
blood will immediately be present in the tubing. As soon as there is blood prese
nt, begin to pull
the plunger of the syringe back slowly, if using a syringe. If the evacuated tub

e holder is used,
push on the first tube to be drawn so that the vacuum pulls the blood through th
e tubing. 27. If
using the syringe system, continue to pull back slowly on the plunger and monito
r the volume of
blood entering the syringe. Change the evacuated tubes as needed if using these
directly to draw
the blood. Keep gentle pressure on the arm of the patient with the back of the f
ingers holding
the butterfly setup. 28. When the required amount of blood has almost been obtai
ned, release the
tourniquet and have the patient open the fist. If the angle is significantly les
s or more than 5
to 10 de- grees, it may slide just above the vein or puncture through both sides
of the vein
rather than just enter- ing the vein. The bevel facing upward allows the blood t
o enter the
needle with minimal trauma. Chapter 8 Collection and Processing of Blood Sample
s 173 Procedure
Rationale Smooth insertion minimizes the trauma to the patient. It is important
to follow the
direction of the vein as the needle is inserted; this allows a better opportu- n
ity for the blood
to enter the needle without obstruction. The needle needs to be inserted far eno
ugh to enter the
vein, but not so far that it punc- tures both sides of the vein. The blood will
not flow into the
tubing adequately without the vacuum of the plunger or the evacuated tube. Do no
t pull back
quickly, or it may cause hemolysis or collapse the vein. The medical assistant m
ust continue to
pull back on the plunger so that the blood will continue to enter the syringe. T
o keep the needle
from moving during the process, pressure should be applied with the back of the
fingers holding
the syringe. The tourniquet must not stay on longer than 1 minute. It is always
necessary to
release the tourniquet and have the patient open the fist before the needle is r
emoved from the
arm to avoid bleeding from the venipuncture site. Continued 1899_Ch08_133-194 21
/12/11 2:23 PM
Page 173 Procedure Rationale The gauze placed over the site will minimize bleedi
ng as the needle
is removed. The pressure should be adequate to stop any bleeding before the pati
ent leaves the
drawing area. Bending the arm increases the risk for bleeding and bruise formati
on. The safety
device may be a push-button device that is activated while the needle is still i
n the skin, or it
may be activated right after removal. It is imperative that the medical assistan
t keeps his or
her fingers be- hind the needle while activating the safety device. 174 Section
II Specimen
Collection and Processing 29. As the needle is removed from the skin, place gauz
e over the site,
without applying initial pres- sure. The needle is to be removed quickly, and at
the same angle
as the insertion. Do not apply pres- sure to the site with the gauze until the n
eedle has been
removed completely from the skin, as this will cause pain for the patient. 30. A

sk the patient to
apply pressure to the site for 3 to 5 minutes. Do not allow the patient to bend
his or her arm if
the draw was performed in the antecubital space. 31. Once the needle has been re
moved from the
arm, immediately activate the needle safety device. 32. If a syringe was used fo
r the procedure,
remove the tubing from the end of the syringe and discard the butterfly unit int
o a biohazardous
sharps container. If an evacuated tube system was used, discard the evacuated tu
be holder with
the butterfly setup. 33. Screw the transfer device onto the end of the syringe f
illed with blood.
34. While holding the syringe upright, insert each evacuated tube into the open
end of the
transfer device. Follow the recommended order of draw. 35. Dispose of the transf
er device and
syringe in a biohazardous sharps container. Procedure 8-3: Venipuncture Using th
e Butterfly
(Winged Infusion) Systemcontd The tubing must be removed so that the transfer devi
ce can be
applied to put the blood into the tubes. Make sure this is a secure seal so that
the blood will
flow adequately. Holding the syringe upright will minimize the oppor- tunity for
anticoagulant
crossover as the transfer device is used. There is a needle within the transfer
device, so this
must go into a sharps container. 1899_Ch08_133-194 21/12/11 2:23 PM Page 174 Ins
ufficient mixing
of the anticoagulant with the spec- imen will result in clotted blood and a samp
le that must be
discarded. All samples must be labeled using at least two unique identifiers. Th
e date and time
provides additional information that may be necessary for interpretation of the
results.
Identification of the phlebotomist may be helpful if there are questions about t
he pro- cedure or
the specimens collected. Verifying the details of the blood draw once more in th
e presence of the
patient allows for a redraw to be performed immediately if something is missing.
Some types of
specimens must remain at room temper- ature, whereas others may need to be put o
n ice immediately. This should be information that is ascer- tained before the procedure
starts. These
may include pallor, perspiration (especially on the upper lip or forehead), incr
eased anxiety, or
light-headedness. If the patient is exhibiting any of these symptoms, it is best
to have him or
her lie down if possible. This may be easily accomplished if the patient is in a
chair that can
recline. If not, a cold compress on the forehead and/or the back of the neck may
help. Continue
to converse with the patient and move the blood out of sight. Ask for assistance
if you feel that
your patient is feeling faint. If the patient loses consciousness, it may be nec
essary to lower
him or her to the floor from the phlebotomy chair. It is important to look under
the gauze for 2
or 3 seconds before applying the adhesive bandage to be certain that the site ha

s actually
stopped bleeding. Self-adhesive bandages (such as Coban) may be wrapped around t
he site rather
than applying an adhesive to the skin directly. Self-adhesive bandages may be es
pecially
effective for those patients who are on anti- coagulant therapy. Heavy lifting o
r exercise could
cause the site to resume bleeding. Chapter 8 Collection and Processing of Blood
Samples 175 36.
Gently invert the blood specimens containing anticoagulant 5 to 10 times. 37. La
bel the tubes,
including the full name of the patient, birth date (or other unique identifier a
ssigned by the
health-care provider), the date and time of collection, and the initials of the
collector. 38.
Use the requisition form or the labels to verify that all the necessary tubes we
re drawn for the
speci- mens ordered. 39. Observe any special handling instructions for the speci
mens. 40. Monitor
the patient for any signs of distress from the procedure. 41. Once the tubes hav
e been labeled,
check the draw site for bleeding. If it has not stopped bleeding, apply pressure
for another few
minutes, and if the bleeding is still present, contact a physician. 42. If the b
leeding has
subsided, apply an adhesive bandage, but leave the gauze in place to allow for a
dditional
pressure. 43. Advise the patient to avoid heavy lifting or exces- sive exercise
of the arm used
for venipuncture for at least 1 hour. Procedure Rationale Continued 1899_Ch08_13
3-194 21/12/11
2:23 PM Page 175 Procedure Rationale Patients may be a bit light-headed and assi
stance may be
needed when he or she first stands up. Touching the tubes of blood without weari
ng gloves offers potential opportunities for exposure to blood- borne pathogens. Hands must
always be
sanitized after removing gloves. All patient interactions must be carefully docu
mented. The site
used for vein access should always be writ- ten in the chart or on the requisiti
on form so that
if there are any negative outcomes associated with the procedure, the site has b
een noted. 176
Section II Specimen Collection and Processing 44. Assist the patient to stand (
if necessary) and
thank him or her for being cooperative. 45. Discard all trash, and place the tub
es in an appropriate vessel for processing. Never touch full tubes of blood without wearing gl
oves. 46. Remove
gloves and sanitize hands. 47. Document the procedure in the patients chart as we
ll as on the
requisition form. Include the date and time of collection, what was collected, a
nd if there were
any circumstances that were out of the ordinary. Also document where the vein wa
s accessed (such
as right arm, left hand, etc.). The documentation should include the type (color
) of tubes drawn,
as well as the identity of the person who collected the sample. Procedure 8-3: V
enipuncture Using
the Butterfly (Winged Infusion) Systemcontd Date 1/18/2020: Phlebotomy performed i

n rigft hand
for BMP and Hematocrit level. Lavender top tube drawn.
1100 a.m.
Connie Lieseke, CMA (AAMA) Procedure 8-4: Blood Collection From a Capill
ary Puncture
Capillary punctures are performed frequently to obtain blood for CLIA-waived tes
ts, as well as to
draw blood for testing on children and infants. Blood obtained by capillary punc
ture is the
preferred speci- men type in these situations. In some situations in which it ha
s been difficult
to perform a successful venipuncture for adults, a capillary puncture specimen m
ay also be
obtained for testing. TASK Successfully perform a capillary puncture and obtain
blood necessary
for the tests ordered. The process must be completed within 5 minutes. CONDITION
S Hand-washing
supplies and/or alcohol-based hand sanitizer Disposable gloves 70% isopropyl alc
ohol
Disposable safety equipped lancet Laboratory requisition form or labels with spe
cified test
Microcollection tubes 2 x 2 gauze pads Hand warmer (if necessary) Adhesive banda
ge or wrap
Biohazardous sharps container Biohazardous disposal bag 1899_Ch08_133-194 21/12/
11 2:23 PM
Page 176 ABHES Standards Medical Office Laboratory Procedures: Collect, label an
d process
specimens: Perform capillary puncture Medical Office Clinical Procedures: Apply
principles of
aseptic techniques and infection control Medical Office Clinical Procedures: Use
Standard
Precautions Chapter 8 Collection and Processing of Blood Samples 177 CAAHEP/ABH
ES STANDARDS
CAAHEP Standards I.P.I.3: Perform Capillary Puncture I.A.I.1: Apply critical th
inking skills in
performing patient assessment and care III.P.III.3: Select appropriate barrier/p
ersonal
protective equipment (PPE) for potentially infectious situations 1. Gather the r
equisition form
and/or labels for the blood draw, and greet the patient. Identify yourself appro
priately. 2. Wash
hands (if they are visibly soiled) or apply hand sanitizer. Allow hands to dry c
ompletely. 3.
Verify the identification of the patient by asking for his or her name and at le
ast one other
unique identifier (such as the patients birth date). Com- pare this information t
o the
requisition or labels. 4. Verify whether dietary restrictions were followed, and
time of last
medication dose, if needed. 5. Have the patient sit in the phlebotomy chair with
appropriate arm
support, and extend his or her arm so that the hand may be accessed easily. Mass
age the
fingertips if necessary for warmth, or apply a commercial warming device, hand w
armer, or warm
towel. 6. Assemble necessary equipment within reach. This includes the necessary
tubes for the
tests ordered, gauze, alcohol, and an adhesive bandage. 7. Apply gloves. Procedu

re Rationale The
requisition or labels are necessary to collect the correct type of specimen. It
is always correct
practice to identify yourself to the patient. Clean hands stop the spread of inf
ection. Hands
should be completely dry before attempting to apply gloves, or it will be diffic
ult to put the
gloves on the wet hands. Patient identification must always be verified using at
least two unique
factors. Many laboratory tests require fasting specimens or other dietary restri
ctions. Drug
dosage times are especially important for appropriate interpretation of the labo
ratory results.
The patient should be secure and comfortable for the capillary puncture process.
The fingers must
be warm for a successful capillary blood draw; warming the site and massaging wi
ll allow much
better blood flow. A commercial warming device works well, or immersing the fing
er or heel in
warm water will also help. The temperature of the warming device or water should
not exceed 42C
(108F). Three to five minutes is generally sufficient to warm the site. Once the
incision is
made, the process will go quickly, so it is important to have all supplies withi
n reach. Gloves
are required for procedures in which there is reasonable anticipation of exposur
e to blood or
other potentially infectious materials. Continued 1899_Ch08_133-194 21/12/11 2:2
3 PM Page 177 For
both adults and children, the ring finger or middle finger should be used. The i
ndex finger is
more sensitive and more callused, and the little finger does not have enough fle
sh to protect the
bone from puncture. The thumb should never be used as a capillary puncture site.
The alcohol may
contami- nate the specimen if not allowed to dry completely before performing th
e puncture.
Blowing or fanning the site may recontaminate the skin after cleansing. Lancets
come with
different depths and widths. There are recommendations for ages and uses provide
d by the
manufacturers. Lancet devices designed for home use that produce only a drop of
blood do not
provide enough blood to be used for microcollection tubes. This part of the devi
ce must remain
sterile until use. The lateral sides of the fingers need to be used to avoid pot
ential damage to
the bone. The incision needs to be perpendicular to the lines of the fingerprint
to keep the
blood from following the fingerprint and flowing away from the incision site. Th
e first drop of
blood is contaminated with tissue fluid, and must be discarded. The finger shoul
d be continuously
massaged from the proximal to the distal end of the fingertip. Do not squeeze ri
ght at the
collection site as this can contaminate the speci- men with tissue fluid and cau
se erroneous
results. The capillary order of draw must be followed to avoid cross-contaminati
on. The tubes
must be mixed well during the collection process to avoid clotting. The collecti

on device is to
be used only to collect blood that is free flowing; scraping or touching the inc
i- sion site can
cause infection and/or irritation. Capillary tubes that are held at a slant allo
w air to enter
the microhematocrit tube. The capillary tube will fill with capillary action if
held horizontal
to the incision site. Plug the end of the capillary tube when filled appropriate
ly. 178 Section
II Specimen Collection and Processing 8. Choose the appropriate finger for the
blood draw, and
disinfect the fingertip with an alcohol swab. Allow the alcohol to dry completel
y before
performing the skin puncture. Do not fan or blow on the site to dry the alcohol.
9. Choose the
correct lancet for the age of the patient and the site selected. The number of t
ubes to be drawn
must also be taken into consideration when choosing a device to use for the inci
sion. 10. Remove
the cap from the lancet device. Do not allow the surface to be placed against th
e patients skin
or to touch anything else before it is utilized. 11. Perform the dermal puncture
by holding the
lancet device firmly against the skin and activating the device. Use the lateral
side of the ring
or mid- dle fingertip, perpendicular (opposite) to the lines of the fingerprint.
Immediately
discard the lancet into a biohazardous sharps container. 12. Wipe away the first
drop of blood,
then gently massage the finger to achieve blood flow. 13. Fill the required tube
s in the correct
order of draw. If anticoagulant is used in the tubes, tap them against the count
ertop to mix the
specimen as the tube is filled. Do not touch the collection device against the i
ncision while
collecting the specimen. Instead, touch it to the drop of blood as it forms at t
he collection
site. 14. If a microhematocrit tube is to be filled, hold it horizontal to the s
ite to avoid
introduction of air bubbles to the specimen. Procedure Rationale Procedure 8-4:
Blood Collection
From a Capillary Puncturecontd 1899_Ch08_133-194 21/12/11 2:23 PM Page 178 15. Whe
n the desired
tubes have been collected, apply gauze to the puncture site and instruct the pat
ient to apply
direct pressure, if he or she is capable. 16. Tightly cap and invert any microco
llection tubes
containing anticoagulant 8 to 10 times. 17. Label the tubes with the patients nam
e, birth date
(or other unique identification number), your initials, the date and the time of
the blood draw.
18. Use the requisition form or the labels to verify that all the necessary tube
s were drawn for
the speci- mens ordered. 19. Observe any special handling instructions for the s
pecimens. 20.
Monitor the patient for any signs of distress from the procedure. 21. Once the t
ubes have been
labeled, check the draw site for bleeding. If it has not stopped bleeding, apply
pressure for
another few minutes, and if the bleeding is still present after 5 minutes, conta

ct a physician.
22. If the bleeding has subsided, apply an adhesive bandage, but leave the gauze
in place to
allow for additional pressure. Direct pressure helps the bleeding to stop. Tubes
must be
thoroughly mixed to avoid clotting. For microcollection tubes, it may be necessa
ry to write this
information on a label to be attached to the tube. The microcollection tubes may
also be placed
inside larger tubes that are labeled appropriately. Capillary tubes may also be
labeled in this
way, as it is very dif- ficult to label the actual collection container. Verifyi
ng the details of
the blood draw once more in the presence of the patient allows for a redraw to b
e performed
immediately if something is missing. Some types of specimens must remain at room
temper- ature,
whereas others may need to be put on ice immediately. This should be information
that is
ascertained before the procedure starts. These may include pallor, perspiration
(especially on
the upper lip or forehead), increased anxiety, or light- headedness. If the pati
ent is exhibiting
any of these symptoms, it is best to have him or her lie down if possible. This
may be easily
accomplished if the patient is in a chair that can recline. If not, a cold compr
ess on the
forehead and/or the back of the neck may help. Continue to converse with the pat
ient and move the
blood out of sight. Ask for assistance if you feel that your patient is feeling
faint. If the
patient loses consciousness, it may be necessary to lower him or her to the floo
r from the
phlebotomy chair. It is important to look under the gauze for 2 or 3 seconds bef
ore applying the
adhesive bandage to be certain that the site has actually stopped bleeding. Adhe
sive bandages
should not be applied for capillary punctures on small children as they may pose
a choking
hazard. Newborns may have adhesive bandages applied if they are not able to remo
ve them.
Self-adhesive bandages (such as Coban) may be wrapped around the site rather tha
n applying an
adhesive directly to the skin. Self-adhesive bandages may be especially effectiv
e for those
patients who are on anticoagulant therapy. Chapter 8 Collection and Processing
of Blood Samples
179 Procedure Rationale Continued 1899_Ch08_133-194 21/12/11 2:23 PM Page 179 23
. Assist the
patient to stand (if necessary) and thank them for their cooperation. 24. Discar
d all trash, and
place the tubes in an appro- priate vessel for processing. Never touch full tube
s of blood
without wearing gloves. 25. Remove gloves and sanitize hands. 26. Document the p
rocedure in the
patients chart as well as on the requisition form. Include the date and time of c
ollection, what
was collected, and if there were any circumstances that were out of the ordinary
. Also document
where the specimen was obtained (such as right middle finger, left hand, etc.).

The documentation
should include the type (color) of tubes drawn, as well as the identity of the p
erson who
collected the sample. Patients may be a bit light-headed, and assistance may be
needed when they
first stand up. Touching the tubes of blood without wearing gloves offers potent
ial opportunities
for exposure to bloodborne pathogens. Hands must always be sanitized after remov
ing gloves. All
patient interactions must be carefully documented. The site where the specimen w
as obtained
should always be written in the chart or on the requisition form so that if ther
e are any
negative outcomes asso- ciated with the procedure, the site has been noted. 180
Section II
Specimen Collection and Processing Procedure Rationale Procedure 8-4: Blood Coll
ection From a
Capillary Puncturecontd Date 1/18/2020: Capillary puncture performed in right ring
finger for
CBC. Lavender top microcollection tube drawn.
1100 a.m.
Connie Lieseke, CMA (AAMA) the analysis. It is the job of the medical as
sistant to process
the specimen properly so that it can be tested. Obtaining Serum for Testing When
blood is allowed
to clot and is then spun down in a centrifuge, the liquid portion is called seru
m. Serum is
plasma that no longer has the clotting factors included, as they have been used
up in the blood
clot that formed in the tube. Analytes such as glucose, lipids, cholesterol, ele
ctrolytes,
hormones, enzymes, and antibodies may be dissolved in serum. To isolate this liq
uid so that the
tests can be performed, it is necessary to separate it from the rest of the bloo
d specimen.
Whenever drawing blood for serum or plasma, it is necessary to collect approxima
tely 2.5 times as
much blood as the volume needed for the testing procedure. For instance, if ther
e is 1 mL of
serum required for an electrolyte test, the medical assistant draw- ing the bloo
d should obtain
at least 2.5 mL of blood. Tubes without anticoagulants are used to collect sampl
es for serum
testing. These include red top tubes, as well as those that contain thixotropic
gel and clot
activators. The blood must be allowed to stand for at least 30 to 45 minutes at
room temperature
to clot thoroughly before the specimen can be further processed. If the specimen
is spun in the
centrifuge be- fore there is a chance for a solid clot to form, the clot- ting f
actors will not
be mixed in with the cells at the bottom of the tube when centrifuged; instead,
they will form a
large fibrin clot in the serum layer. A fibrin clot is a soft, sticky mass that
makes it very
difficult to separate out serum for testing. Although the tube must be allowed t
o clot completely
before centrifuging, it should not be more than an hour after the blood draw is

performed before
the tube is spun, as prolonged con- tact with the cells in the tube may allow ch
emical changes to
take place in the serum, which will affect the test results. Potential changes m
ay include a
decreased serum glucose level, an increased serum iron level, and elevated serum
potassium
levels, among others. To fully separate the serum from the cells, the speci- men
should be
centrifuged for at least 10 minutes. The serum may then be removed from the spec
imen and placed
in a transfer tube. There are various methods that 1899_Ch08_133-194 21/12/11 2:
23 PM Page 180
Chapter 8 Collection and Processing of Blood Samples 181 may be used to remove
the liquid
portion of the blood; remember that regardless of the method used for separa- ti
on, adequate
personal protective equipment should be worn at all times, including a face shie
ld or plasticmounted barrier shield, gloves and a laboratory coat. (See Fig. 8-15.) The metho
ds that may be
used for sepa- ration include the following: SST or PST tubes: These tubes conta
in a
thixotropic gel that forms a barrier between the cells and the serum (or plasma
with PST tubes)
so that the liquid can remain in the tube, but be separated from the cells. If i
t is necessary to
remove the serum and put it in a transfer tube, it can be poured out because the
gel forms a
solid barrier to the cells in the bottom of the tube. Transfer pipette: A pipett
e may be used
to aspirate the liquid out of the tube and transfer it into another tube. Care m
ust be taken not
to aspirate out any of the cells that are present in the bottom of the tube; if
the serum appears
a hazy red color while aspiration is taking place, it should be spun again to re
move any cells
that may have been accidentally aspirated into the specimen. If the serum still
appears to be red
after recentrifugation, it is hemolyzed and the specimen will, in most circum- s
tances, have to
be redrawn. If the serum is no longer red, separate the serum again from the cel
ls that have
settled to the bottom of the tube. Plunger-type separators: These are devices th
at have a
filter on one end of a plastic tube, with an opening Test Your Knowledge 8-16 Ho
w are specimens
processed if serum is to be separated from the cells? (Outcome 8-17) Figure 8-15
. A and B. (A)
Serum tube after centrifugation and (B) various devices used for separation of s
erum. A B at the
other end. After the specimen has been cen- trifuged, the rubber stopper is remo
ved from the top
of the tube and the filter end of the separator is care- fully inserted into the
specimen tube
and pushed down through the serum or plasma. Proper protective equipment must be
used when
performing this proce- dure to keep from potentially splashing the liquid into t
he eyes or mucous
membranes. Also, once the separator has been place in the tube, it is important

to pull it back
up a bit to provide an air barrier between the serum and the cells. This keeps t
he blood cells in
the bottom of the tube from being in contact with the serum, causing chemical ch
anges as they
metabolize nutrients in the liquid. Specimen storage instructions for most chemi
stry tests will
advise that the serum and/or plasma be refrig- erated within a few hours after p
rocessing to
protect the various analytes from changing in concentration. Follow the directio
ns provided in
the laboratory directory for handling the serum specimen after it has been separ
ated. Also, if a
transfer tube is used, the labeling on the tube is critical. Not only does the p
atient
information need to be included, but there also has to be a notation of the 1899
_Ch08_133-194
21/12/11 2:23 PM Page 181 182 Section II Specimen Collection and Processing typ
e of specimen
(serum or plasma) and the type of anticoagulant present in the tube, because man
y body fluids are
similar in appearance. Transfer tubes are avail- able that are color coded to ma
tch the color
tube origi- nally used for the specimen collection, which may help eliminate con
fusion. Obtaining
Plasma for Testing The liquid portion of the blood in our bodies is plasma. Plas
ma is made up of
approximately 90% water, with dissolved substances making up the remaining porti
on. Plasma may be
analyzed for levels of chemicals involved in the clotting process such as fibrin
ogen and
prothrom- bin. Other common tests performed on plasma speci- mens include levels
of electrolytes,
calcium, glucose, and creatinine. Because plasma is the liquid portion of the bl
ood that contains
factors that contribute to clotting, a specimen that is to be used for plasma te
sting must not be
allowed to clot. A tube that contains an anticoagulant (such as heparin) must be
used for the
collection. The medical as- sistant should consult the laboratory directory to s
ee what type of
anticoagulant is to be used for specimen collection before the venipuncture is p
erformed. It may
be possible to use a PST tube, which contains anticoag- ulant and a thixotropic
gel that will
separate the plasma from the blood cells in the specimen after centrifugation. A
s in the case of
serum, it is necessary to collect a blood specimen that is approximately 2.5 tim
es the required
volume for the test ordered. Appropriate labeling of the transfer tube is essent
ial; remember to
include a notation that the fluid is plasma in addition to the patients name and
other necessary
information. Unlike the process for obtaining a serum sample, plasma samples sho
uld be well
mixed, then centrifuged as soon as possible. There is no need to allow the speci
men to sit for an
extended period of time before centrifuging, as the blood is not going to clot i
n the tube. This
makes plasma samples the specimen of choice for most STAT chemistry tests, becau

se the samples
can be processed and the test performed quickly after collection. After centrifu
gation, a sample
that has had anticoag- ulant added will separate into three layers. This will in
clude a layer
containing the red blood cells, topped by a very small layer that contains the w
hite cells and
platelets (sometimes called the buffy coat), with the liquid plasma present as t
he top layer in
the tube. The tube in Figure 8-16 is an example of the appear- ance of a tube to
be used for
plasma separation after centrifugation. The actual separation methods for plasma
are the same as
those used for serum, including the use of a PST tube, the transfer pipette, or
the plunger-type
separators. Remem- ber, whenever separating the liquid portion of the blood from
the cells, it is
imperative that the appropriate personal protective equipment is used to protect
the employee
from potential exposure. Removal of the rubberized stoppers may create an aeroso
l that could get
into the mouth or eyes, so face shields must be worn in addition to gloves and a
pro- tective
laboratory coat. Also, all supplies must be disposed of appropriately; the stopp
ers and any other
specimen con- tainers must be disposed of as biohazardous materials. Plasma Buff
y coat Cells
Serum Cells Gel Figure 8-16 The tube on the left shows plasma after centrifugati
on. Note the
cells, buffy coat, and plasma. The tube on the right shows serum separated from
the clotted cell
by gel. Reprinted with permission from Eagle S, Brassington C, Dailey C, and Gor
etti C: The
Professional Medical Assistant: An Integrative, Teamwork-Based Approach. Philade
lphia: FA Davis,
2009. Test Your Knowledge 8-17 Describe one way that serum and plasma are differ
ent. (Outcome
8-18) Whole Blood Specimens Tests that count or examine the cells present in the
blood require a
whole blood specimen. These tests are often performed in the hematology departme
nt, and include
1899_Ch08_133-194 21/12/11 2:24 PM Page 182 Chapter 8 Collection and Processing
of Blood Samples
183 complete blood counts, platelet counts, and hemoglobin and hematocrit tests.
For tests
requiring whole blood specimens, the blood is drawn into tubes that contain anti
coagulants so
that the cells are not involved in clot formation, which would make it very diff
icult to count
the cells or examine their appearance. Potassium EDTA is the anticoagulant that
is usually
preferred; this is pres- ent in the lavender top evacuated tubes. Whole blood sp
ecimens are to be
well mixed at the time of the initial blood draw, and again just prior to analys
is. The specimens
used for whole blood testing are not to be centrifuged, as the analysis is perfo
rmed on the
formed elements within the sample. In some small physician office laboratories,
the medical
assistant may place the whole blood specimens directly on a rocker that keeps the

specimen
mixed until the analysis can be performed. Remember that the mixing and inversio
n of these
samples must be a gentle motion to avoid damaging the cells. Eight inversions of
the tube
immediately after drawing the blood should provide appropriate mixing of the spe
cimen. Lipemic
specimens: Lipemia is the presence of excess lipids (fatty molecules) in the blo
od. Plasma or
serum in a lipemic specimen will appear cloudy or milk-like after centrifugation
. These lipid
molecules interfere with the testing methods for many analytes. Some lab- orator
ies are capable
of clearing the specimen with a special type of centrifuge, whereas others will
reject the
lipemic specimens (Fig. 8-17). Quantity not sufficient: When the medical assista
nt does not
draw enough blood to perform the tests or- dered, the specimen may be rejected a
s quality not
suf- ficient (QNS) because the amount drawn is not enough for the tests to be pe
rformed on it. In
almost all situa- tions, these samples will need to be redrawn so that there is
enough specimen
to complete the tests ordered. Clotted specimens: When a whole blood specimen is
necessary for
the test ordered, a clotted specimen is unacceptable. The clotting process draws
in the cells in
the specimen to be involved in the clot. This means that even if the clot is sma
ll, the cell
count in the tube will be inaccurate, because it is impossible to know how many
cells are
involved in the clot and how many are floating freely in the specimen. To avoid
clotted
specimens, be sure to invert the specimens thoroughly during the collection proc
ess. Incorrect
anticoagulant use: Each anticoagulant uses a different principle to keep the blo
od from clotting.
Some bind up the calcium in the specimen, as it is necessary for the clotting pr
ocess to proceed.
Others make the platelets in the specimen nonadhesive so that they cannot cling
to one another.
Tests are designed to be performed using a specific anticoagulant, and if the in
correct one is
used, it may alter the test results. For instance, potassium EDTA may cause fals
e elevation of
the potassium levels if a lavender top tube was used Test Your Knowledge 8-18 Tr
ue or False:
Tests that utilize whole blood specimens require that the specimen be centrifuge
d before testing.
(Outcome 8-17) Unacceptable Specimen Types In certain situations, the specimen c
ollected and
processed will be rejected for the test ordered. There are numerous reasons for
specimen
rejection, including the following: Hemolyzed specimens: Hemolysis means that t
he red blood
cells in the specimen have been damaged and broken. It may be a result of a trau
matic
venipuncture in which the cells were damaged as they entered the needle, or hemo
lysis may be the
result of mishandling the tube after the blood draw. Hemolysis is evident in the

speci- men after

centrifuging by the presence of a pink to red tint in the plasma or serum. (Fig.
8-17 is an
example of a hemolyzed specimen.) Potassium, magnesium, and iron levels are exam
ples of tests for
which a hemolyzed speci- men is unacceptable. To avoid hemolysis, be sure that t
he tubes used for
the blood draw are kept at room tempera- ture, and be sure to use the appropriat
e sized needle
for the draw. Also, if using a syringe, do not pull back on the plunger with a g
reat deal of
force, as this may damage the cells. Use good technique when performing venipunc
- tures, and
gently invert all tubes when mixing. Figure 8-17 Hemolysis and lipemia present i
n plasma tubes on
left and right. 1899_Ch08_133-194 21/12/11 2:24 PM Page 183 184 Section II Spec
imen Collection
and Processing for the plasma sample. Sodium citrate is an anticoag- ulant that
binds up the
calcium in the specimen so that it cannot participate in the clotting process. T
his means that
calcium levels performed on plasma from these light blue top tubes would be very
low, as the calcium is not in solution in a way that it can be tested. Fibrin clots: Tubes with
out added
anticoagulant must be allowed to clot properly before centrifugation, or it may
be impossible to
obtain enough serum from the specimen to perform the tests ordered. This may res
ult in a request
for a specimen to be recollected. It may be possible to physically remove the fi
brin clot and
recen- trifuge the specimen, but this may lead to damaged red cells and hemolysi
s. never be moved
from side to side after insertion into the arm, as this will cause damage to the
tissues and pain
for the patient. If the slight movements (small increments in or out) are not en
ough to allow
blood to enter the needle, discontinue the draw, and try again. Be sure to check
for alternative
sites before using the same area for a second attempt. If the person drawing the
blood is still
unsuc- cessful after two attempts, he or she should seek assistance from another
qualified
employee. Fainting Patients Some patients experience light-headedness, dizziness
, or fainting
during or immediately after a blood draw. This may be due to vasovagal syncope,
which is the
bodys exaggerated reaction to the sight of blood. Some of these patients may have
had negative
experiences in the past, whereas others cannot identify a specific reason for th
eir reaction.
Each person who experiences vasovagal syncope has his or her own triggers, which
may include
emotional distress, the sight of blood, and/or pain. The trigger causes a respon
se in the body
that includes a drop in blood pressure and a decreased heart rate. Young patient
s, thin patients,
nervous individuals, and those who are very quiet (or sometimes very talkative)
are more prone to
fainting. Also, hunger, fatigue, and environmental factors such as excessive hea

t or strong
smells may make the sit- uation worse. There are usually some symptoms that occu
r prior to the
actual fainting episode such as nausea, yawning, dizziness, weakness, perspiring
, pallor, and a
flushed feeling of warmth. If the patient communicates any of these symptoms, th
e blood draw
should be discon- tinued. The medical assistant should help the patient to put t
he head down
between the legs if he or she is still conscious. This may help to keep the pati
ent from fainting. If the patient shares a history of fainting, he or she should be drawn in t
he supine
position, and the medical assistant should make additional efforts to talk to th
e patient during
the procedure to monitor the level of con- sciousness. If a patient does faint w
hen sitting up in
a phlebotomy chair, the primary focus should be safety for the patient and the m
edical assistant.
Discontinue the draw, remove the tourniquet and the needle, activate the safety
device on the
needle, and bandage the draw site. Call for assistance from a coworker. If the p
atient is still
unconscious, it may be necessary to lower him or her to the floor from the chair
, with special
care taken to protect the head from hitting anything during the process. The pat
ients legs
should be elevated to help the blood flow return to the heart and brain, and a h
ealth-care
provider should be notified of the situation. Test Your Knowledge 8-19 Examples
of inappropriate
specimens may include: a. Hemolyzed and lipemic specimens b. Partially filled sp
ecimen tubes for
multiple tests c. Blood collected in tubes with the wrong anticoagulant d. All o
f the above
(Outcome 8-19) POTENTIAL NEGATIVE OUTCOMES OF VENIPUNCTURE AND CAPILLARY PUNCTUR
E Regardless of
the skill level exhibited by the medical as- sistant, sometimes the person who i
s attempting a
venipuncture may be unsuccessful. In addition, even when the person drawing the
blood is
successful, there may be physical patient complications resulting from the blood
draw. It is
important to realize that these neg- ative outcomes are sometimes unavoidable, a
nd to know what
action should be taken if they occur. Inability to Draw Blood Veins are not soli
d objects that
are incapable of move- ment. Sometimes even when the vein is anchored tightly, i
t will move just
a bit as the needle is inserted. Or, the health-care worker who is drawing the b
lood may not insert the needle far enough or go in just a bit too far so that the blood does no
t enter the
needle. It is never acceptable to probe when drawing blood. However, recommenda- t
ions from the
Clinical and Laboratory Standards Insti- tute do allow the phlebotomist to move
the needle a bit
further into the vein or a bit further out of the vein to see if the blood will
start to flow.
Sometimes a slight change in the location or angle of the needle is all that is

neces- sary for

the blood to enter the needle. The needle should 1899_Ch08_133-194 21/12/11 2:24
PM Page 184
Chapter 8 Collection and Processing of Blood Samples 185 Rolling Veins The medi
an cubital vein
is usually quite stable, which makes it an excellent choice for venipuncture. If
this vein cannot
be used for phlebotomy procedures, the other veins in the antecubital area may b
e considered.
However, these are not as well anchored, and have a tendency to roll or move away
when the
venipuncture is attempted. Special care must be taken to anchor these veins very
well to avoid
this problem. Hematoma Formation A hematoma is the result of blood leaking into
the tis- sues
from a vein. It can occur in routine venipunc- tures, but is more common when th
e process did not
go smoothly. If the initial insertion of the needle is too deep, the needle may
puncture and go
through the vein, which allows excessive blood to leak from the punctures in the
vein.
Conversely, if the needle does not go far enough into the vein, the bevel may no
t be totally
within the vessel, and blood may leak out around the slant at the end of the nee
dle. (See Fig.
8-18 for examples.) Hematomas can also be the result of too little pressure appl
ied after the
venipunc- ture procedure, with subsequent bleeding around the puncture site. Whe
n a hematoma
forms, there is a sud- den swelling (and sometimes a discoloration) around the s
ite where the
needle is inserted. If this occurs, the tourniquet and then the needle need to b
e removed and
pressure should be applied immediately. The med- ical assistant should be sure t
o keep pressure
on the site for at least 5 minutes, and also should be sure to document the situ
ation. The
patient may experience pain and more swelling in the area. The health- care prov
ider may suggest
ice application and anti- inflammatories to help with the discomfort. Skin Vein
Bevel on upper
wall of vein (does not allow blood to flow) Needle inserted too far Skin Vein Sk
in Vein Hematoma
Needle partially inserted (causes blood to leak into tissue) Figure 8-18 Problem
s with the way in
which the needle is entering the vessel. (A) The first drawing shows what occurs
if the angle of
insertion is too shallow and the needle goes above the vein. (B) The second draw
ing shows what
occurs if the angle of insertion is too high, and the needle goes through the ve
in. (C) The third
shows what can happen if the needle is not inserted far enough into the vein. Re
printed with
permission from Strasinger S, and Di Lorenzo M: Phlebotomy Textbook, ed. 3. Phil
adelphia: FA
Davis, 2011. A B C 1899_Ch08_133-194 21/12/11 2:24 PM Page 185 186 Section II S
pecimen
Collection and Processing Collapsing Veins Fragile veins may collapse with the a
mount of pressure
used to withdraw blood during a venipuncture proce- dure. Small veins or veins t

hat have been

damaged with IV therapy or medication treatment are more prone to collapse. If t
he medical
assistant recognizes that the vein is small or appears fragile, the evacuated tu
be system should
not be used for the venipuncture, as this will in- crease the likelihood of veno
us collapse. A
syringe and needle or a butterfly system should be used instead. Nerve Damage Ve
nipuncture
procedures performed in the median cubital vein rarely cause irritation to the n
erves in the arm,
as this vein is not usually in close proximity to the medial nerve. When drawing
from the
antecubital area, blood draws performed from the basilic vein are the most likel
y to cause nerve
irritation or damage due to the close proximity to the nerve. If a patient compl
ains of excessive
pain during a blood draw (especially if he or she describes it as shooting pain
that goes up or
down the arm), the procedure should be discontinued immedi- ately. Never attempt
a venipuncture
from the underside of the wrist, as there are numerous opportunities to cause ne
rve irritation or
damage in this area. Infection Infection or excessive irritation at the site of
a venipunc- ture
is not common, but can occur. To minimize the risk, the medical assistant should
always clean the
site thor- oughly before the procedure, and also allow the alcohol used to disin
fect the site to
dry completely before the nee- dle is inserted. If the alcohol has not been allo
wed to dry, it
can cause irritation to the skin in the area, which makes the site more prone to
infection. Using
good judgment when choosing a site for venipuncture will also help to minimize t
he chances of
inflammation and infection. Test Your Knowledge 8-20 True or False: The angle at
which the needle
is inserted for venipuncture has no impact on whether the procedure has a negati
ve outcome.
(Outcome 8-20) Procedure 8-5: Creation of Peripheral Blood Smear A peripheral bl
ood smear may be
requested at the time of the initial blood draw, or it can be created using bloo
d from a lavender
top tube containing EDTA anticoagulant. This procedure will explain how to creat
e a smear using
the lavender top tube. If creating a smear at the time of the blood draw, the pr
ocedure only
differs with the initial application of the sample to the slide. TASK Successful
ly create a
peripheral blood smear to be stained and used for a manual differential count or
pathologist
examination. The process must be com- pleted within 5 minutes. CONDITIONS Hand-w
ashing supplies
and/or alcohol-based hand sanitizer Disposable gloves Clean glass slides DIFF-SA
FE device
Lavender top (EDTA) tube filled with blood Biohazardous sharps container Biohaza
rdous
disposal bag OTHER PROCESSING PROCEDURES Processing a blood specimen may include
centrifugation,
separation of plasma or serum from the cells, and appropri- ate storage of the s

pecimen until
testing occurs. In addi- tion, the medical assistant may be asked to create and
stain a smear
from a whole blood specimen so that the health- care provider or other qualified
professional may
view it. PREPARATION OF A PERIPHERAL BLOOD SMEAR FOR STAINING When it is necessa
ry to view the
red blood cell morphol- ogy (appearance and size), identify the types and percen
t- ages of
various types of white blood cells, and quantitate the number of platelets prese
nt in the
circulation, a peripheral blood smear may be utilized. Automation has replaced t
he need to
perform a manual examination of the slide for most hematology testing procedures
, but there is
still a need to examine the slide manually in many 1899_Ch08_133-194 21/12/11 2:
24 PM Page 186
CAAHEP/ABHES STANDARDS CAAHEP Standards III.P.2: Practice Standard Precautions A
BHES Standards
None Chapter 8 Collection and Processing of Blood Samples 187 Procedure Rationa
le 1. Sanitize
hands (allow them to dry) and apply gloves. 2. Invert the blood tube 8 to 10 tim
es to mix the
sample. 3. Insert DIFF-SAFE device into the top of the lavender top tube. 4. Tur
n the tube upside
down and push the DIFF- SAFE device to the slide until a drop of blood is releas
ed. Gloves must
be worn for any procedures in which exposure to blood or other potentially infec
tious materials
is anticipated. The specimen must be well mixed or it will provide erroneous res
ults when the
blood smear is examined. The device has a blunt metal cannula that is inserted t
hrough the rubber
stopper on top of the tube. This is performed while the tube is in an upright po
sition. Pushing
down on the tube with the DIFF-SAFE device against the slide will release a drop
of blood onto
the slide. Continued 1899_Ch08_133-194 21/12/11 2:24 PM Page 187 5. Pull the sec
ond slide back
into the drop of blood at an approximate 30-degree angle, allowing the blood to
flow along the
edge of the slide. 6. Once the blood has flowed to cover approximately three-qua
rters of the
width of the slide, push the second slide forward to spread the blood across the
original slide.
This process must occur quickly. The angle allows for correct application of the
blood across the
slide. 188 Section II Specimen Collection and Processing Push the spreader slid
e forward
smoothly with a rapid motion. Do not apply weight or additional pressure during
this step, or the
slide will not move smoothly across the surface. The entire process must occur i
n less than 15
seconds or the drop of blood will begin to dry and the distribution of the cells
will be uneven
across the slide. Smears should have a feath- ered edge, with visible edges on the
heaviest
part of the smear. Ideally there will be no holes or ridges in the blood pattern
. If the cell
distribution is too thick, it will be difficult to see the morphology of the red

blood cells
clearly, and it may be difficult to visualize the white blood cells as well. The
completed smear
should have an appearance that is similar to a thumbprint, with a heavy distribu
tion at the
beginning of the smear and a gradual decrease in the thickness across the slide.
Procedure
Rationale Procedure 8-5: Creation of Peripheral Blood Smearcontd 1899_Ch08_133-194
21/12/11
2:24 PM Page 188 7. Allow the slide to air-dry. 8. Remove the DIFF-SAFE device f
rom the top of
the tube and discard the device in a biohazardous sharps container. Also discard
the second slide
used for spreading in the biohazardous sharps con- tainer. Store the tube as dir
ected by the
laboratory. 9. Label the slide with a pencil or a grease pen with the name of th
e patient and
other identification as required by the laboratory. 10. Transfer the slide to th
e appropriate
area of the laboratory for drying and staining. 11. Remove gloves and sanitize t
he hands. 12.
Document the procedure in the patients chart if it is available. The slide must b
e completely
dry before it is stained or the appearance of the cells will be altered during t
he staining
process. The device and the slide are contaminated with blood and are considered
to be a sharp.
All slides need to be properly labeled before staining. The medical assistant sh
ould not touch
the slide with- out gloves on, so the transport should occur before the gloves a
re removed. Hands
must always be sanitized after removing gloves. In a physician office laboratory
, this procedure
should be documented in the patients chart. If the medical assistant is working i
n a laboratory
setting where the chart is not available, this step is not necessary. Chapter 8
Collection and
Processing of Blood Samples 189 Date 1/18/2020: Blood smear prepared from lavend
er top tube.
1100 a.m.
Connie Lieseke, CMA (AAMA) Procedure Rationale instances. A lavender top
EDTA tube may be
used or, in some cases, a drop of blood may be taken directly from a capillary p
uncture and
applied to the slide. The safest method of applying the drop of blood to the sli
de from the tube
is to use a DIFF-SAFE device (Alpha Scientific Corporation, Malvern, Pennsylvani
a), which
eliminates the need to open the tube to gain access to the blood. WRIGHTS STAIN P
ROCEDURE Once
the peripheral blood smear has been prepared, it must be stained so that it can
be examined.
There are various products available for this staining process, including Diff-Q
uik stain by Dade
Behring. Wrights stain is another common stain often used in the physi- cian offi
ce laboratory
as well as in larger laboratories. It is a hematology stain that is used for sta
ining smears made

from blood and bone marrow samples. Wrights stain allows for visualization of the
red blood
cells and platelets in the sample, as well as differentiation of the various typ
es of white cells
that are present. The stain contains methanol, which acts as a fixative for the
cells, as well as
an acidic red dye and a blue dye that is alkaline in pH. These stains are absorb
ed differently by
the formed elements in the blood to allow for them to be ex- amined and counted.
1899_Ch08_133-194 21/12/11 2:24 PM Page 189 190 Section II Specimen Collection
and Processing
Procedure 8-6: Quick Stain of Peripheral Smear Using Camco Quik Stain II The Cam
co Quik Stain
procedure allows for the cells to be stained appropriately so that they can be i
dentified by an
individual who is qualified to perform this micro- scopic evaluation. This may b
e performed for a
differ- ential examination, in which a technician or technolo- gist will count t
he various types
of white cells present and report a percentage of each type. The stain solution
may be poured
into small vessels for dipping the slides, or it may be applied with a pipette t
o a slide on a
rack that is suspended over a sink or other receptacle. TASK Stain a peripheral
blood smear using
Camco Quik Stain II. CONDITIONS Air-dried blood smear Camco Quik Stain II soluti
on
Distilled water with a pH of 6 or 7 Laboratory wipes Sink or other receptacle fo
r excess
stain CAAHEP/ABHES STANDARDS None Procedure Rationale 1. Sanitize hands, and all
ow them to dry
completely. Apply gloves. 2. Dip the blood smear in the stain solution for 10 se
conds.
Alternatively, the smear may be placed on a rack and stain may be added until th
e slide is
covered with the stain for 10 seconds. 3. Allow excess stain to drain from the s
lide. Apply or
dip in distilled water for 20 seconds. 4. Wipe away any excess stain that may be
present on the
back of the slide with a laboratory wipe. 5. Allow the slide to air-dry. Make su
re that there is
no excess water standing on the slide. 6. Dispose of the laboratory wipe in the
trash and put
away supplies. 7. Remove gloves and sanitize hands. Gloves must be worn for any
procedures in
which exposure to blood or other potentially infectious materials is anticipated
. In addition,
the stain will discolor the fingers if gloves are not utilized. The 10 seconds i
s a minimum
staining time. If the smear is thick, additional staining time may be necessary.
It is necessary
to allow at least 20 seconds for the process to be complete. Excess stain on the
back of the
slide will obscure the view when examining the smear under the microscope. This
type of smear
does not need to be heat fixed. Excess water may change the staining characteris
tics or increase
the time necessary for the slide to dry. All work areas should remain clean and
organized. Gloves
should be removed before proceeding to the next task. Hands must always be sanit

ized after
removing gloves. 1899_Ch08_133-194 21/12/11 2:24 PM Page 190 Chapter 8 Collecti
on and Processing
of Blood Samples 191 SUMMARY Blood collection is the most common and most im- po
rtant part of the
preanalytical process for labora- tory testing. To perform quality venipuncture
and capillary
puncture, it is imperative that the medical assistant or phlebotomist understand
s the basics of
the anatomy and physiology of the cardiovascular system as well as areas and sit
uations to avoid
when collecting blood. Following recommended proce- dures during the collection
process is
critical, which includes knowledge of how to safely use the various collection d
evices. Patient
identification and appropriate preparation are of utmost importance. Knowledge o
f the various
tube types to be used is very important in collecting the sample correctly. Orde
r of draw is
critical to avoid crossover contamination. Finally, processing the sam- ples app
ropriately is the
final preparatory step before testing the sample. This may include centrifugatio
n and separation
of the plasma or serum, or it may include preparation and staining of slides. TI
ME TO REVIEW 1.
The bevel of a needle is: Outcome 8-1 a. The interior hollow space of the needle
b. The slanted
tip at the end of the needle c. The diameter of the needle d. None of the above
2. The flanges of
an evacuated tube holder: Outcome 8-1 a. Allow for the needle to be screwed on t
he holder b.
Provide a space for the tube to be inserted c. May be used to provide leverage w
hen inserting
and/or removing tubes d. Are decorative only 3. True or False: Interstitial flui
d Outcome 8-1 is
the fluid located between the cells of the tissues. 4. True or False: Venules ar
e larger Outcome
8-1 in diameter than are veins. 5. Identify all the ways that veins Outcome 8-3
and arteries are
the same: a. Transport blood b. Connect to capillaries c. May be punctured to wi
thdraw blood for
testing d. Have multiple layers of cells in the walls of the vessels e. Have a d
istinct pulse
that can be felt with palpation f. Have valves that prevent backflow g. Are vari
ed in size
throughout the body 6. Mark the veins below in Outcome 8-5 order of preference f
or venipuncture
procedures by numbering them 1, 2, and 3: ______ Cephalic vein ______ Basilic ve
in ______ Median
cubital vein 7. True or False: Capillary punctures Outcome 8-6 on infants may be
performed on the
great toe. 8. An example of an area to avoid Outcome 8-7 when choosing a site fo
r venipuncture
is: a. Scarred skin b. Varicose veins c. Veins on the back of the hand d. None o
f the above e. a
and b 9. How is a butterfly (or winged Outcome 8-8 infusion set) different from
the needle used
for evac- uated tube draws or syringe draws? 10. Using the following order of Ou
tcome 8-9 draw,
create a mnemonic that will help you to remember the order the tubes are to be d

rawn with an
evacuated tube system or a syringe draw. Yellow, light blue, red, green, lavende
r, gray 11.
Describe one way that a medical Outcome 8-12 assistant might put a child at ease
before a blood
col- lection is to be performed. 12. Why is it important to verify Outcome 8-14
whether a patient
has properly prepared for a test before the medical assistant performs the blood
draw? 13. Why
would a peripheral smear be used? Outcome 8-16 a. To test for certain hormones b
. To scan for
bacteria c. To identify various types of white blood cells d. To perform ABO blo
od typing
1899_Ch08_133-194 21/12/11 2:24 PM Page 191 192 Section II Specimen Collection
and Processing
Case Study 8-1: How long was this sitting here? A blood specimen for a glucose l
evel and
electrolyte analysis was drawn on Mr. Dee at 9:30 a.m. Shortly after the blood d
raw, Shannon, the
medical assistant who was covering the laboratory area of the office, was asked
to fill in for
another employee who became ill at work. At 2 p.m., after lunch, Shannon went ba
ck into the
laboratory and processed the specimens that she had drawn that morning so that t
hey were ready to
be picked up by the laboratory courier at 2:30. Just before closing, Shannon rec
eived a call from
the laboratory alerting the health-care provider that the potassium was elevated
above the
reference range for Mr. Dee, and the glucose levels were well below the referenc
e range. The
laboratory suggested that the specimen needed to be redrawn before the health-ca
re provider acted
on these results. 1. What event of the day may have affected these blood levels?
2. Do you agree
that the specimen should be redrawn before the physician acts on the results obt
ained from the
original specimen? Case Study 8-2: Clumps John George is performing a blood draw
for a CBC,
differential, and platelet count on Mrs. Charrone. As he completes the blood dra
w, he notices
that she is look- ing really pale and is no longer conversing with him. He remov
es the tourniquet
and the needle with the evacuated tube holder and lavender top tube from her arm
just as she
loses consciousness. He gently lowers her to the floor as she slides out of the
phlebotomy chair,
and elevates her feet as he calls for help. Within a few minutes she regains con
sciousness and
after mon- itoring her for a few minutes, the health-care provider states that s
he is ready to
leave the office. John helps her out to the waiting room to meet her husband, af
ter which he
returns to the blood draw area to process the specimen. He labels the specimen a
ppropriately and
places it on the blood rocker for the laboratory techni- cian working in the tes
ting area to
access it for the CBC, differential, and platelet count. In about an hour, the l
aboratory
technician comes to find John and asks him if he remembers anything unusual abou

t this blood
draw. The laboratory techni- cian said that the platelet count is extremely low
with the initial
analysis and that the hematology instrument flagged the sample with an error. Th
e laboratory
tech- nician is going to recheck the specimen and create a blood smear to look a
t the sample more
thoroughly. 1. How do you think the events of this blood draw may have affected
the platelet
count? 2. What do you think the technician may find when she looks at the blood
smear? 14. What
is one practice that can Outcome 8-15 help to protect patients and employees dur
ing inva- sive
procedures? 15. Capillary specimens may be preferred: Outcome 8-13 a. When perfo
rming CLIA-waived
tests that use whole blood b. When the patients medical condition warrants it c.
For infants d.
All of the above 16. Which part of the hand is used Outcome 8-15 to hold the eva
cuated tube
holder when the medical assistant performs a venipuncture? 17. Do all capillary
puncture devices
Outcome 8-15 provide incisions that are the same depth? RESOURCES AND SUGGESTED
READINGS
DIFF-SAFE Blood Dispenser: Directions for Use Provides step-by-step instructions o
n how to use
a DIFF- SAFE Blood Dispenser http://www.alpha-scientific.com/ Diff-safe2.html 18
99_Ch08_133-194
21/12/11 2:24 PM Page 192 Chapter 8 Collection and Processing of Blood Samples
193 NCCLS
simplifies the order of draw. by Ernst D, Calam R. Medical Laboratory Observer, M
ay 2004
National Committee for Clinical Laboratory Standards. Procedures for the Collect
ion of Diagnostic
Blood Specimens by Venipuncture. Approved Standard, H3-A5, Wayne, PA; 2003. Prean
alytical Errors
in the Emergency Department. from BD Company, LabNotes. 17, no. 1, 2007 http://
www.bd.com/vacutainer/labnotes/Volume17Number1/ Preparation of Peripheral Blood S
mear Staining
With Wrights Stain Directions on how to stain a peripheral blood smear using Wrig
hts Stain
http://www.scribd.com/doc/8801750/ Preparation-of-Peripheral-Blood-Smear-Stainin
gWith-Wrights-Stain Staining the Cells. How to stain a blood smear; instructions on
how to stain
a peripheral blood smear http://www.tpub.com/content/ medical/14295/css/14295_28
6.htm
Venipuncture Technique Using the Multisample Vacutainer System Description of the
use of the
Vacutainer system with details http://www.phlebotomycert.com/multi_vtainer_systm.
htm Newborn
Screening Washington State Department of Health. In-depth infor- mation about the
various
disorders that may be detected by newborn screening. Includes links to more deta
iled information
about the collection process and specimen handling. http://www.doh.wa.gov/ehsphl
/phl/newborn/
disorders.htm#msud 1899_Ch08_133-194 21/12/11 2:24 PM Page 193 1899_Ch08_133-194
21/12/11 2:24 PM
Page 194 195 Chapter 9 Collection and Processing of Urine Samples Constance L. L
ieseke, CMA

(AAMA), MLT, PBT(ASCP) CHAPTER OUTLINE Types of Urine Specimens Clean-Catch Mids
tream Urine
Specimen Collection Catheterized Specimens Suprapubic Aspiration Prostatitis Spe
cimen Collection
Timed Urine Specimen Collections Glucose Testing Specimens Urine Collection Proc
edures for
Infants and Pediatric Patients Urine Specimen Processing Refrigeration and Prese
rvation Proper
Disposal of Urine and Supplies Summary Time to Review Resources and Suggested Re
adings 9-1 Define
the key terms. 9-2 Explain the necessity of obtaining different types of urine s
amples for
laboratory testing. 9-3 Compare and contrast various urine specimen types. 9-4 D
escribe how urine
specimens are to be processed after collection. 9-5 Describe changes that may oc
cur in urine
speci- mens if they are left at room temperature after collection. 9-6 Analyze t
he details for
proper labeling of the various types of urine specimens presented in the text. 9
-7 Examine the
necessary patient education for col- lection of samples to be used for specializ
ed urine testing
procedures. 9-8 Instruct a patient on the proper collection proce- dure for a cl
ean-catch
midstream urine specimen. 9-9 Instruct a patient on the proper collection procedure for a
24-hour urine specimen. Learning Outcomes After reading this chapter, the succes
sful student will
be able to: CAAHEP/ABHES STANDARDS CAAHEP Standards I.P.I.6: Anatomy and Physiol
ogy: Perform
patient screen- ing using established protocols I.A.I.2: Anatomy and Physiology:
Use
language/verbal skills that enable patients understanding ABHES Standards Medical
Laboratory
Procedures: e. Patient Instruc- tions (collection of urine and feces); Instruct
patients in the
collection of a clean-catch mid-stream urine specimen. 1899_Ch09_195-214 26/12/1
1 2:08 PM Page
195 196 Section II Specimen Collection and Processing KEY TERMS Aliquot Distal
urethra Diurnal
variation Fasting urine specimen First morning void Formed elements Glucose tole
rance urine
specimen Indwelling catheter Intermittent (straight) catheter Prostatitis Prosta
titis specimen
collection process Random Suprapubic aspiration 24-hour urine collection 2-hour
postprandial
specimen Urinalysis Urinary meatus Urine culture TYPES OF URINE SPECIMENS Urine
analysis is one
of the most common tests per- formed in the clinical laboratory. The collection
process for urine
specimens is noninvasive, and is relatively easy to accomplish because the produ
ction of urine by
the body is an ongoing process. It is important to remember, however, that prope
r collection and
processing proce- dures are essential for the urine laboratory results to be acc
urate and
meaningful. (Table 9-1 summarizes the various types of urine specimens.) Specime
n collection
procedures may vary based on the length of time for the collection, dietary limi
tations, specimen

volume requirements, and the method of col- lection. Many urine specimens are co
llected to
diagnose potential urinary tract infections, in which case they are usually rand
om collections;
they could be collected at any time of the day, as long as the collection proced
ures TABLE 9-1
Types of Urine Specimens Specimen Type Time of Collection Uses Clean-catch midst
ream Random
Urinalysis, culture, random chemistry urine specimen testing, urine pregnancy te
sting
Intermittent (straight) catheter Random Urinalysis, culture, random chemistry sp
ecimen testing,
urine pregnancy testing Indwelling catheter specimen Not appropriate for urinaly
sis, Not
appropriate for urinalysis, culture, or chemistry testing culture, or chemistry
testing
Suprapubic aspiration specimen Random Urinalysis, culture, random chemistry test
ing, urine
pregnancy testing, urine cytology Prostatitis specimen Random as part of procedu
re To check for
bacterial prostatitis First morning void specimen Upon rising Urine pregnancy te
sting, specific
chemistry tests; urinalysis, culture 24-hour urine specimen 24 hours of collecti
on Chemistry
testing 2-hour postprandial specimen 2 hours after a 100-g Glucose and ketones c
arbohydrate meal
Glucose tolerance testing As part of a glucose tolerance Glucose and ketones tes
ting procedure
Infant urine specimens Random Urinalysis 1899_Ch09_195-214 26/12/11 2:08 PM Page
196 Chapter 9
Collection and Processing of Urine Samples 197 are followed appropriately. Other
urine specimens
are collected for chemical analysis to aid in the diagnosis of specific problems
with the kidneys
or other organ sys- tems. These chemicals often change in concentration througho
ut the day, which
is known as diurnal varia- tion. To provide accurate results, specimen collectio
n in these
circumstances is carried out over a specific period of time at a certain time of
the day.
Procedures for col- lection may also include dietary restrictions for some tests
to limit
potential erroneous results because of a diet rich in a particular substance. Th
e guidelines that
should be followed whenever a urine specimen is to be collected include the foll
owing: All
specimen containers must be correctly labeled. In the case of urine collection,
this should occur
immedi- ately after the patient returns the specimen container to the laboratory
or health-care
facility. All labels should include the patients name, birth date or other unique
identifier,
and the date and time of the collec- tion. Labels must be placed on the containe
r itself, not
just on the lid. It is also a good idea to document the type of specimen (e.g.,
urine) in the
container; many body fluids have a similar appearance when received in the labor
atory. The
required specimen volume must be verified before instructing the patient on coll
ection

requirements. Any medication the patient is taking that may poten- tially interf
ere with the
test results needs to be docu- mented on the requisition form. For timed specime
ns, the start
and finish time (and dates if appropriate) must be documented on the con- tainer
. Dietary
restrictions must be communicated to the patient before collection, both verball
y and in writing.
Collection of urine for analysis during the menstrual cycle should be avoided if
possible; the
presence of red blood cells may interfere with the testing procedures for some a
nalytes. If it is
not possible to delay the col- lection, care must be taken to instruct the patie
nt on proper
cleaning techniques to avoid gross contamina- tion, and a notation should be pla
ced on the
labora- tory requisition form (and/or in the patient chart if available) that th
e patient is
menstruating. Specimen containers that have preservatives added need to be clear
ly marked, and
in these situations, there should be an additional container provided for the pa
- tient to use
during collection to avoid urinating directly into the specimen container with t
he preservative.
Patients should always be provided with a specimen container, so that they are n
ot using a jar
or other con- tainer from home. Although these may appear clean, Test Your Knowled
ge 9-1 Please
provide two reasons that a urine specimen may be ordered for testing. (Outcome 9
-2) they may
contain chemicals or other substances that can affect the urine test results. An
y instructions
for collection must be given to the patient verbally and in writing. These inclu
de storage
instructions for the specimen until it is returned for analysis. Test Your Knowl
edge 9-2 List one
item that is the same for all urine collection procedures. (Outcome 9-2) POINT O
F INTEREST 9-1
Urine drug screens Many health-care providers and laboratories are now involved
in preemployment
physicals. These may include urine drug screens for drugs of abuse. This type of
urine collection
has very specific procedural parameters designed to prove that the specimen collected was not
tampered with prior to the completion of testing. There are guidelines that dict
ate the steps
involved in the collection procedures, as well as guidelines that outline the se
curity of the
specimen during transportation and processing. A series of doc- umentation on a
standardized form
is necessary; this process establishes the chain of custody for the speci- men.
Federal
regulations require preemployment, postaccident, and random drug screening for s
ome jobs, whereas
other large nonfederal employers choose to ensure a drug-free environment by req
uir- ing their
employees to undergo testing. The following is a summary of the steps involved i
n a urine drug
specimen collection procedure: 1. Collectors must be appropriately trained for t
he process. 2.

The collector verifies that there is a bluing agent (some sort of dye) added to
the toilet before
the donor process begins. 3. The donor is greeted and must provide photo identif
ication. In some
situations, alternative forms of identification are acceptable from an employer
representative.
Continued 1899_Ch09_195-214 26/12/11 2:08 PM Page 197 situations, it is imperati
ve that the
specimen received for testing is representative of the urine in the urinary blad
- der and
urethra, rather than contaminants that might be present on the outside of the bo
dy. A clean-catch
mid- stream urine specimen collection technique is the best noninvasive method t
o obtain a urine
specimen for these tests. This procedure involves cleaning the exter- nal openin
g of the urinary
tract and obtaining a mid- stream urine specimen. The clean-catch midstream urin
e collection
technique offers an opportunity to obtain a specimen that has less contamination
with epithelial
cells and bacteria from the distal urethra and urinary meatus than a specimen ob
tained without
proper cleansing and technique. The distal urethra is the area of the urethra th
at is closest to
the outside of the body. The urinary meatus is the exte- rior opening of the uri
nary tract.
Because these are both near the outside of the body, they are naturally potentia
l sources of
exterior contamination. Even though all urine specimens must pass through this a
rea of the
urinary tract as they exit the body, the goal is to obtain a specimen that conta
ins the bacteria
and other microscopic structures that are clinically significant, (those that ar
e present in the
bladder) and minimize those that are essentially contam- inants. This is critica
l for patients to
be properly diag- nosed and treated for urinary tract infections. 198 Section II
Specimen
Collection and Processing Test Your Knowledge 9-3 Why is the cleansing process f
or a clean-catch
mid- stream urine specimen so important? (Outcome 9-2) Test Your Knowledge 9-4 S
hould a urine
collection container be labeled before or after it is given to the patient for c
ollection?
(Outcome 9-6) 4. The collector fills out the first step of the chain of custody
form, and the
donor signs to verify the accuracy of this information. 5. The donor leaves all
purses, coats,
and so on out- side of the restroom to eliminate the possibility of smuggling in
concealed
substances to contam- inate the urine. 6. The donor washes and dries his or her
hands. 7. The
collector must tape the toilet lid and the faucet handles with tamper-proof tape
so that there is
no access to other water sources. 8. The collector remains in the restroom (if t
here is a private
stall) or outside the restroom door if there is no private stall during the coll
ection process.
Sometimes a witnessed collection is re- quested, in which case the donor must be
watched by the

collector during the collection. 9. The donor is not allowed to wash his or her
hands until the
specimen is handed to the collec- tor and the follow-up quality control measures
and
documentation have been completed. The urine specimen must remain within the sit
e of the donor
and the collector during this process. 10. The collector verifies the volume rec
eived, the
appearance of the urine, and records the temper- ature of the specimen. If there
is a problem
with the temperature or the appearance of the urine specimen, the collection pro
cess is void. 11.
As the donor observes, tamper-proof collection labels are placed over the top of
the collection
container and the donor initials these labels. The date and time are also added
to these labels.
12. These steps are documented on the chain of cus- tody form. 13. From this poi
nt forward, every
individual in- volved in transportation, processing, or testing of the specimen
must document
their actions and the purpose of their actions on the chain of cus- tody form. C
lean-Catch
Midstream Urine Specimen Collection When a urinalysis or urine culture is ordere
d for a patient,
it is important the specimen be as contaminant free as possible. A urinalysis in
cludes physical
observa- tions and chemical analysis of the urine specimen, and may also include
a microscopic
examination of the urine sediment. A urine culture is designed to test for bacte
rial growth in
the urine specimen. In both these Catheterized Specimens Another way to avoid po
tential specimen
contamination is to use a catheter to obtain the specimen. Only a licensed healt
h-care
professional may insert a catheter. This process may also be used when the patie
nt is not capable
of following the directions or performing the procedures necessary for a clean-c
atch urine
collection procedure, such as those who are very young or those who may have phy
sical
limitations. Catheters may be (Text continues on page 203) 1899_Ch09_195-214 26/
12/11 2:08 PM
Page 198 Chapter 9 Collection and Processing of Urine Samples 199 Procedure 9-1
: Instructing a
Patient for Collection of a Clean-Catch Midstream Urine Specimen for Urinalysis
and/or Culture
Clean-catch midstream urine specimens are required by most laboratories for perf
ormance of
urinalysis and cultures. By cleansing appropriately and providing a midstream sp
ecimen that comes
from the bladder and upper urethra, most extraneous microorganisms will be elimi
nated from the
specimen. TASK The student will demonstrate the ability to properly in- struct a
male or female
patient how to collect a clean- catch midstream urine specimen. CONDITIONS Appro
priately
labeled sterile urine collection container Three moist antiseptic towelettes Han
d-washing
facilities Paper towels CAAHEP/ABHES STANDARDS CAAHEP Standards I.P.I.6: Anatomy
and

Physiology: Perform patient screening using established protocols I.A.I.2: Anato

my and
Physiology: Use language/verbal skills that enable patients understanding ABHES S
tandards
Medical Laboratory Procedures: e. Patient Instructions (collection of urine and
feces); Instruct
patients in the collection of a clean-catch mid-stream urine specimen. Procedure
Rationale 1.
Wash hands and gather necessary supplies for the patient. 2. Greet and identify
the patient.
Verify the test orders and the labeling on the container. 3. Provide the patient
with a sterile
container and three antiseptic towelettes. Hand washing breaks the chain of infe
ction. The
patient identity should always be verified for every procedure. Verification of
test orders and
labeling reduces the potential for error. The patient will need to refer to thes
e items as the
procedure is explained. The towelettes will be used for cleansing around the uri
nary opening
area. Strong antiseptics should not be used because of the potential irritation
to the external
urinary structures. Continued 1899_Ch09_195-214 26/12/11 2:08 PM Page 199 200 Se
ction II
Specimen Collection and Processing Procedure 9-1: Instructing a Patient for Coll
ection of a
Clean-Catch Midstream Urine Specimen for Urinalysis and/or Culturecontd Procedure
Rationale
Instructions for Male Patients a. Instruct the patient to wash and dry his hands
, and once in the
restroom, remove his underwear. b. The patient should carefully remove the lid o
f the specimen
container and place it with the inside up on the counter near the toilet where t
he container can
easily be accessed for the collection process. Emphasize the importance of keepi
ng the interior
of the container sterile. c. Male patients who are uncircumcised must pull back
the foreskin, and
keep it withdrawn during the cleaning and collection process. d. The tip of the
penis must be
cleansed three times: Wipe with the first wipe from front to back on one side of
the tip of the
penis. Wipe with the second wipe from front to back on the other side of the tip
of the penis.
Use the third wipe over the urinary opening (the meatus) from front to back. Not
e: A new
antiseptic towelette must be used to clean each side of the penis and an additio
nal towelette
used to clean the tip of the penis. (A total of three towelettes are to be used
for the cleansing process.) Some laboratories may provide a fourth towelette to clean the outs
ide of the
container after the collection. Hand washing breaks the cycle of infection, and
removing the
undergarments allows for better access during the cleaning process. Placing the
lid with the
inside up prevents contamina- tion from microorganisms that may be present on th
e countertop.
Pathogenic microorganisms may be present under the foreskin. Thorough cleansing
eliminates

potential contaminat- ing substances. Once the cleaning process has started, the
patient should
keep holding the penis until the specimen has been obtained to eliminate the pos
sibility of
recontamination. 1899_Ch09_195-214 26/12/11 2:08 PM Page 200 Chapter 9 Collecti
on and Processing
of Urine Samples 201 Procedure Rationale e. Instruct the patient to pick up the
specimen container so that he is ready when for the collection. Begin to urinate into the to
ilet. Stop the
urine stream, move the specimen container into a posi- tion where it will inters
ect the urine
stream, and urinate into the container until it is at least half full. Stop the
urine stream
again and move the container out of the way. Remind the patient not to touch the
inside of the
container. f. Instruct the patient to finish urinating into the toilet. g. The p
atient must
carefully replace the lid on the container without contaminating the interior of
the cup or lid.
If urine is present on the outside of the cup, dry it off with toilet tissue or
a paper towel,
and discard the waste. h. Instruct the patient to wash and dry his hands. i. Ins
truct the patient
to place the urine in the des- ignated area of the laboratory if the specimen is
collected in the
office. If it is a home collection, instruct the patient to refrigerate the spec
imen until it can
be transported to the testing location. Instructions for Female Patients a. Inst
ruct the patient
to wash and dry her hands, and once in the restroom, remove her underwear. b. Th
e patient should
carefully remove the lid of the specimen container and place it with the in- sid
e up on the
counter near the toilet where the container can easily be accessed for the colle
ction process.
Emphasize the importance of keeping the interior of the container sterile. c. In
struct the
patient to move her knees apart until she can easily reach her labia. (These are
the struc- tures
that cover the urinary opening in females.) This process flushes out microorgani
sms that may be
present near the opening of the urethra and allows collection of a specimen that
represents the
urine that was present in the bladder and upper urethra. The specimen must be mi
dstream; the
first and last part of the urine void should not be included in the spec- imen s
ubmitted to the
laboratory. Contamination must be avoided on the inside of the container so that
the specimen
represents the urine as it is inside the body. Clean hands prevent the spread of
microorganisms.
The specimen will need to be refrigerated or tested in a timely manner to preser
ve the integrity
of the test results. Hand washing breaks the cycle of infection, and removing th
e undergarments
allows for better access during the cleaning process. Placing the lid facing up
prevents
contamination with microorganisms that may be present on the countertop. It is i
mportant that the

patient has full access to the labia to clean the area properly. Continued 1899_
Ch09_195-214
26/12/11 2:08 PM Page 201 202 Section II Specimen Collection and Processing Pro
cedure 9-1:
Instructing a Patient for Collection of a Clean-Catch Midstream Urine Specimen f
or Urinalysis
and/or Culturecontd Procedure Rationale d. Instruct the patient to spread apart th
e labia with
one hand to expose the urinary opening (the uri- nary meatus). The labia will ne
ed to remain
spread apart until the cleaning and collection process is complete. e. The patie
nt needs to clean
the area three times, using a clean antiseptic towelette each time. The first to
welette should
be used to clean from front to back on one side of the urinary opening. Use the
second
towelette to wipe front to back on the other side of the urinary opening. The th
ird towelette
is to be used to wipe front to back across the urinary opening for the final cle
ansing step.
Some laboratories may provide a fourth tow- elette to clean the outside of the c
ontainer after
the collection. f. Instruct the patient to pick up the urine speci- men containe
r in the hand
that is not holding the labia apart. g. The patient should begin to urinate into
the toi- let.
After a small amount has entered the toilet, stop the urinary stream and place t
he specimen
container under the urinary opening. The labia must remain apart after the area
is cleaned to
eliminate the potential for recontamination of the site. Cleansing in this manne
r avoids
potential contamina- tion from the anal area (front to back) and provides an opp
ortunity to
thoroughly clean away potential pathogenic microorganisms that could enter the s
pecimen while
urinating. The specimen container must be in hand before the patient starts to u
rinate. This
initial urine stream flushes out potential contami- nants that may have been aro
und the urinary
meatus. 2 1 3 1899_Ch09_195-214 26/12/11 2:09 PM Page 202 Procedure Rationale Ch
apter 9
Collection and Processing of Urine Samples 203 h. Instruct the patient to urinat
e directly into
the specimen container, filling it at least half full. Tell the patient to stop
urinating and
move the spec- imen container out of the way. Remind the pa- tient to avoid cont
amination of the
interior of the specimen container. i. Instruct the patient to finish urinating
into the toilet.
j. The patient must carefully replace the lid on the container without contamina
ting the interior
of the cup or lid. If urine is present on the outside of the cup, dry it off wit
h toilet tissue
or a paper towel. k. Instruct the patient to wash and dry her hands. l. Instruct
the patient to
place the urine in the des- ignated area of the laboratory if the specimen is co
llected in the
office. If it is a home collection, instruct the patient to refrigerate the spec
imen until it can

be transported to the testing location. 4. Verify whether the patient understood

the instructions as given, and check if he or she has any addi- tional questions. Supply co
ntact information
for fu- ture questions. 5. Provide the patient with a written copy of the instru
ctions. This is a
midstream specimen that includes urine from the bladder and the upper part of th
e urethra. The
first and last part of the urine specimen should not be submitted to the laborat
ory.
Contamination must be avoided on the inside of the container so that the urine i
s representative
of the conditions on the inside of the body. Hand washing stops the spread of mi
croorganisms. The
specimen will need to be refrigerated or tested in a timely manner to preserve t
he integrity of
the test results. This is a critical step for the appropriate collection of the
specimen. A
written copy will allow patients to refresh their memory when the collection is
performed. used
in various ways (listed below), and it is imperative that the requisition form a
nd the patient
chart include documentation of the type of collection performed. Intermittent (s
traight)
catheter: There may be times that it is necessary to empty the bladder for a pat
ient who is
unable to do so. If this is a tempo- rary situation, an intermittent (straight)
catheter may be
used for the process. This catheterization procedure involves a small, stiff, pl
astic tube that
is placed through the urethra into the bladder to allow the bladder to be draine
d. This procedure
may also be used to obtain a specimen for urinalysis and culture, as the potenti
al for
contamination is greatly reduced. Catheterization, however, does include risks o
f bacterial
infection because the lining of the urethra may be damaged as the catheter is in
serted or
removed. Indwelling catheter: Indwelling catheters are de- signed for long-term
use. They may
be inserted in sur- gery patients for a few days after surgery, or they may be i
nserted in
patients who have permanently lost the ability to control urination. These cathe
ters are larger
in diameter than the straight catheters, and have a small balloon that is pumped u
p to keep
them in place within the bladder once they have been inserted. Indwelling cathet
ers continuously
drain the urine from the bladder into a collection bag. This bag is emptied peri
odically.
Indwelling catheters are not recommended Date 10/24/2016: Patient provided suppl
ies and written
and verbal instructions for a clean-catch midstream urine collection procedure.
11:58 a.m.
Connie Lieseke, CMA (AAMA) 1899_Ch09_195-214 26/12/11 2:09 PM Page 203 2
04 Section II
Specimen Collection and Processing as a source of urine for urinalysis or urine
cultures, as the

catheters are kept in place for extended periods of time and become contaminated
with bacteria.
If a patient with an indwelling catheter needs to have a urinalysis, it is best
for the catheter
to be removed and for the health-care professional to use a straight catheter to
obtain the
specimen for analysis. Suprapubic Aspiration There are times, especially with yo
ung children,
when it is imperative that a urine specimen be collected quickly, without contam
ination. Skilled
health-care professionals (such as physicians or nurse practitioners) may choose
to perform a
suprapubic aspiration to obtain a specimen for urinalysis and culture. A needle
is placed
externally through the abdomen directly into the bladder, and a urine specimen i
s withdrawn. This
procedure may also be used to collect urine for cytology examination, a procedur
e in which the
cells present in the specimen are examined by a pathologist or cytologist for ab
normalities in
their appearance. Prostatitis Specimen Collection Prostatitis (inflammation of t
he prostate) may
be caused by various factors. Prostate enlargement and/or use of urinary cathete
rs are often
linked to this condition. The tissue of the prostate may be inflamed, or there m
ay be an
infection with pathogenic microorganisms. In order to plan the correct course of
action, it may
be necessary to collect a urine specimen utilizing a special procedure. In a pro
statitis specimen
collection process, there are three specimens collected in close progression. Th
e pa- tient is
provided with three antiseptic towelettes and three sterile specimen collection
containers,
numbered sequentially 1, 2, and 3. The patient cleansing process is the same as
that required for
the clean-catch midstream collection procedure. However, rather than urinating i
nto the toilet at
the beginning of the process, the first small amount of urine passed goes into c
ollection cup 1.
Next, the midstream specimen goes collected in cup 2. After this collection is c
ompleted into cup
2, the health-care provider will massage the patients prostate to allow prostatic
secretions to
enter the urethra for collec- tion. After the prostate has been massaged, the pa
tient will
immediately urinate into the third cup. Cultures are performed on all three spec
imens. If the
second speci- men has a high concentration of bacteria present, the third specim
en is considered
to be invalid, because of contamination by the bacteria already present in the u
re- thra.
Generally, if there is an infection of the prostate, the bacterial count of the
third specimen
will be much higher than that of the first two specimens. Timed Urine Specimen C
ollections Most
urine specimens collected in the office setting are ran- dom collections, becaus
e the time of day
is not significant for the desired results. The clean-catch midstream urine collections used

for urinalysis and culture are usually random specimens. Remember, however, that
the time of
collection still must be recorded accurately. A random collection is not always
desirable for all
urine specimens. There are situations in which the time of collection is critica
l: First
morning void specimen: A specimen that is collected when the patient first rises
from sleep is
known as a first morning void specimen. This specimen is concentrated (ideally i
t should be
approximately 8 hours since the patient last voided) Test Your Knowledge 9-5 Whi
ch type of
catheterization procedure is used to obtain a urine specimen for a routine cultu
re? (Outcome 6-3)
POINT OF INTEREST 9-2 Proper documentation for urine collection procedure educat
ion This chapter
includes a lot of information about dif- ferent types of urine collection proced
ures. The key
component in all these processes is patient education. The patient should be pro
vided with the
appropriate collection supplies in all situations, as well as verbal and written
instructions for
the collection process. Every laboratory should develop its own literature to di
stribute to
patients so that there is standardization of information provided for collection
and storage of
the specimens. Government regulations require that the instructions for patients
are to be
provided in their native language whenever possible. In addition, it is very imp
ortant to
remember that whenever in- structions are provided for the patient, doing so mus
t be documented
properly in the patient chart. 1899_Ch09_195-214 26/12/11 2:09 PM Page 204 becau
se it has been in
the bladder during the night while the patient slept. The first morning void spe
c- imen is
recommended for urine pregnancy tests (especially if it is very early in the pot
ential pregnancy) and for detection of the presence of protein or albumin in the urine. It
may also be used
for rou- tine urinalysis and culture, but the clean-catch mid- stream collection
procedure should
still be followed. There will be more dissolved substances present in this speci
men than in those
found later in the day, and it may also contain more microscopic structures. 24hour urine
collection: Routine urinalysis testing reports the presence or absence of numero
us chemi- cals in
the urine specimen and provides a rough quantitative estimate of the amount pres
ent for that
chemical. For some chemical components, however, it is necessary to have an exac
t measurement of
the amount of that chemical present in the urine. These analytes are not present
in the same
concentration at all times; they may vary with the time of the day (diurnal vari
ation), or their
concentration may be changed with exertion or the hydration status of the indivi
dual. To account
for these variables, it is often desirable to collect all the urine produced by
a patient over

the period of an entire day. This is called a 24-hour urine collection. This col
lection process
is used to test for various substances; among the most common are the following:
Urea nitrogen:
Urea nitrogen is a by-product of protein metabolism, and is used as an indicator
of kidney
function. Urine electrolytes: Urine electrolyte tests include those that check f
or the level of
calcium, chloride, potassium, and sodium in the urine. These tests may be ordere
d together or
individually. They are often part of a clinical workup for suspected en- docrine
disorders or
hormonal imbalances or kidney dysfunction. Urine calcium levels are sometimes or
- dered for
patients with recurring kidney stone for- mation. Situations that cause electrol
yte imbalances in
the bloodstream may also result in abnormal urine electrolyte levels. Catecholam
ines:
Catecholamines are substances that are created by nerve tissue and by the adrena
l glands of the
body. They include norepinephrine, dopamine, and epinephrine. Urine specimens do
not contain the
intact catecholamine molecules; instead, we test for the breakdown products of t
hese compounds.
The breakdown products include homovanillic acid (HVA), vanillymandelic acid (VM
A),
normetanephrine, and metanephrine. Urine catecholamines may be ordered as a grou
p or
individually. This test may be used when an adrenal gland tumor is suspected (ph
eochromocytoma),
and it may also be ordered for patients with symp- tomatic hypertension. 17-Hydr
oxysteroids:
This test is often performed when there is suspicion of Addisons disease, which i
s a type of
adrenal insufficiency. Urine total protein: The level of total protein in the ur
ine may be an
indicator of kidney damage. 5-Hydroxyindoleacetic acid: More commonly known as 5
-HIAA, this
test may be performed to detect a specific type of tumor, the carcinoid tumor, o
f the digestive
tract. 5-HIAA is a metabolite of serotonin in the urine, and these intestinal tu
mors secrete
unusually high amounts of serotonin. Urine creatinine: Creatinine is a breakdown
product of
creatine, present in muscle tissue throughout the body. Creatinine is cleared fr
om the body
exclu- sively by the kidneys, and the test is ordered to screen for possible kid
ney dysfunction.
In some situations, blood is also drawn and tested for the same analyte as the u
rine specimen at
the end of the 24-hour interval. For example, when urine creatinine is ordered,
there is often a
blood draw performed for crea- tinine as well, so that both results can be used
to reach a
diagnosis. Urine specimens collected over a 24-hour period may have dietary or f
luid
restrictions; this is to limit potential erroneous results because of a diet ric
h in a particular
substance. Patient education concerning these restric- tions is critical for a m
eaningful urine

test result. The patient must be given the instructions verbally and in writing,
and
documentation of the education should be added to the patients chart. It may also
be necessary
to deliver (or even ship) these urine specimens directly to a laboratory for pro
- cessing, rather
than returning them to the health-care providers office. These instructions shoul
d be explained clearly before the collection process is started. The patient should be
provided with all
shipping materials and written instructions so that the specimen is delivered su
ccessfully. When
refrigeration is not possible (especially when the specimen must be transported
over long
distances) chemical preservatives may be utilized to keep the 24-hour urine spec
imen from
undergoing changes upon standing. Chemical preservatives (such as boric acid or
Chapter 9
Collection and Processing of Urine Samples 205 1899_Ch09_195-214 26/12/11 2:09 P
M Page 205 dilute
hydrochloric acid) are often added to 24-hour urine specimen containers to keep
chemical changes
from occurring before the specimen is tested. These ad- ditives for 24-hour urin
e specimen
collection are listed in Table 9-2. There are additional handling procedures tha
t are required by
24-hour urine specimens once they arrive at the laboratory. These procedures inc
lude proper
documentation of the total specimen volume upon ar- rival at the laboratory, and
verification of
the times in- cluded in the collection. The specimen must also be well mixed and
an aliquot,
which is a small sample, must be poured off for further chemical testing. Figure
9-1 shows a
24-hour urine collection container. Procedure 9-2 details the instructions for c
ollection of a
24-hour urine specimen. Glucose Testing Specimens Glucose is not usually present
in the urine at
levels high enough to be measured. However, in patients with dia- betes mellitus
, blood glucose
concentrations may reach levels that are high enough to cause glucose to spill int
o the urine.
There are several urine collection proce- dures that may assist with the diagnos
is or monitoring
of those with diabetes mellitus or gestational diabetes. These include the follo
wing: 2-hour
postprandial specimen: For a 2-hour post- prandial specimen, the patient is inst
ructed to empty
the bladder before a meal that contains approximately 100 g of carbohydrates. Tw
o hours after
meal comple- tion, the patient is to collect a urine specimen. Ideally, the pati
ent will also
have a blood sample drawn 2 hours after eating so that both results can be used
to evaluate the
patients condition. Because there will not be a culture or complete urinalysis pe
rformed on the
specimen, 2-hour postprandial urine specimens do not need to be collected using
the clean-catch
midstream urine collection procedures, The specimen is tested only for the prese
nce of glucose.

(Additional 206 Section II Specimen Collection and Processing TABLE 9-2 Additiv
es used for
24-hour urine specimens Test Ordered Preservative Added Aldosterone 1 g boric ac
id per 100 mL
urine Amylase Add NaOH; adjust pH to 6 or above Urine calcium Add HCl to adjust
pH 1.52.0
Catecholamines Add HCl to adjust pH to 23 or add 25 mL 6N HCl Cyclic AMP 10 mL 6M
HCl (adenosine
monophosphate) 17-Hydroxy- Boric acid to adjust pH 57 corticosteroids Urine phosp
horus HCl to
adjust pH to 1.52 Testosterone 1 g Boric acid per 100 mL Uric acid NaOH to adjust
pH to 8 or
above Dopamine Glass container with 25 mL HCl Homovanillic Glass container with
25 mL HCl acid
(HVA) Iodine Glass container with 25 mL acetic acid Vanillymandelic Glass contai
ner with 25 mL
acid (VMA) 6N HCl Urea nitrogen 25 mL 6N HCl 5-Hydroxy- 25 mL 6N HCl indoleaceti
c acid (5-HIAA)
Test Your Knowledge 9-6 When providing instructions to a patient for a 24-hour s
pecimen
collection, what should the patient be told about urinating directly into the co
ntainer that
contains hydrochloric acid as a preservative? (Outcome 9-7) Figure 9-1 A 24-hour
urine collection
container. Notice the large-volume capacity, the measurements along the side of
the container,
and the amber color, which blocks light exposure, as some chemical concentration
s are decreased
with exposure to light. This 24-hour urine collection con- tainer includes a spe
cial closure
adaptation to make it easy to pour the specimen when it arrives at the laborator
y.
1899_Ch09_195-214 26/12/11 2:09 PM Page 206 Chapter 9 Collection and Processing
of Urine Samples
207 Procedure 9-2: Instructing a Patient for Collection of a 24-Hour Urine Speci
men This process
collects all urine that is produced by the body over a 24-hour period. It is non
invasive, and
pro- vides a great deal of information about the patients re- nal function. Remem
ber, urine
contains many chemi- cal substances such as sodium, potassium, and creatinine th
at are dissolved
in water. Because the con- centration of these chemicals may vary throughout the
day, it is
important to collect all the urine produced over a 24-hour period for an accurat
e assessment.
TASK Provide the necessary supplies and education for a patient to successfully
complete a
24-hour urine specimen collection. CONDITIONS An appropriately labeled 24-hour u
rine collection
container (or more than one container if a high volume of urine is anticipated)
Warning sticker
if preservative is added to the speci- men container An additional smaller conta
iner (such as a
urinal de- vice) for urine collection Written patient instructions, including an
y dietary
restrictions for the collection period CAAHEP/ABHES STANDARDS CAAHEP Standards I
.P.I.6: Anatomy
and Physiology: Perform patient screening using established protocols I.A.I.2: A
natomy and

Physiology: Use language/verbal skills that enable patients understanding ABHES S

tandards None
Procedure Rationale 1. Wash hands and gather necessary supplies for the patient.
Verify any
dietary restrictions and/or pre- servative requirements for the test ordered by
check- ing the
laboratory reference guide. Check to see if the instructions for the analyte ord
ered include a
blood draw. Hand washing breaks the chain of infection. It is im- perative that
the medical
assistant verify all restric- tions and special instructions before meeting with
the patient.
There should be a written copy of all in- structions (including dietary restrict
ions) available
so that they can be provided to the patient. information about this procedure is
included in
Chapter 17.) Glucose tolerance urine specimen: Glucose toler- ance urine specime
n tests are
used for diagnosis of gestational diabetes or diabetes mellitus. Urine and blood
specimens are
collected at specific intervals af- ter a fasting patient is given a high glucos
e substance to
drink. The first urine specimen collected should ideally be a fasting specimen, me
aning that it
is the second morning void, not the first. The first morning void contains the b
reakdown products
from the food ingested the night before the test; the second morn- ing void shou
ld be
representative of the body in a state of fasting. After the patient has been giv
en the high
glucose substance to drink, a blood and urine collection is performed at least t
hree more times
at hourly intervals for 3 more hours. Additional samples may be collected depend
ing on the policy
for that particular laboratory. It is not necessary to use the clean-catch midst
ream collection
procedures for this test, as the specimens collected are not used for cul- tures
or complete
urinalysis procedures. Continued 1899_Ch09_195-214 26/12/11 2:09 PM Page 207 208
Section II
Specimen Collection and Processing Procedure 9-2: Instructing a Patient for Coll
ection of a
24-Hour Urine Specimencontd Procedure Rationale 2. Add preservative to the collect
ion container
if necessary, using appropriate safety precautions. Apply warning label if acid
was added to the
container. 3. Greet and identify the patient. Verify the test order once more. 4
. Provide the
patient with the 24-hour urine collec- tion container and an additional smaller,
wide- mouth
container for urine collection. 5. Instruct the patient that the 24-hour specime
n must remain
refrigerated during the collection process. Also emphasize that all urine collec
ted during the
24-hour period must be collected in the container provided. 6. Instruct the pati
ent that upon
arising on the first day of the 24-hour period he or she is to empty the blad- d
er by urinating
into the toilet. This is the start time of the collection period, so the patient
is to note this

time on the collection container and on any paper- work that may have been provi
ded for the
process. Warning labels must be added to the container if there has been preserv
ative added
(e.g., hydrochloric acid) that could harm the patient. If there is a harmful pre
- servative added
to the container, the patient must be told that he or she cannot urinate directl
y into the
container or splash the specimen on bare skin. The patient identity must always
be verified for
every procedure. Verification of test orders and labeling reduces the potential
for error. Some
laboratories have labels that include the dietary restrictions that are also att
ached to the
container. The 24-hour urine collection container will be amber or dark in color
. It will hold
approximately 3 liters of urine. The dark color protects some of the urine chemi
cals from
decomposing with exposure to light. The smaller container is used to collect the
speci- men
during urination, after which it will be added to the large container. For accur
ate results the
patient must understand that all the urine in the 24-hour period must be collect
ed and preserved
appropriately. For convenience, the patient may want to choose a day for collect
ion when he or
she will be home most of the time. For accurate results, this part of the proces
s should be
emphasized; it is a bit difficult to understand with- out a thorough explanation
. Danger Acid
1899_Ch09_195-214 26/12/11 2:09 PM Page 208 Chapter 9 Collection and Processing
of Urine Samples
209 Procedure Rationale 7. Explain to the patient that all the urine for the nex
t 24 hours (after
that initial void) must be saved in the large container. Instruct the patient th
at he or she may
use the smaller collection container during the urination process, but this urin
e must all be
added immediately to the larger container. 8. Explain to the patient that if for
any reason all
the urine is not put in the container, the collection process must be started ov
er. 9. Explain to
the patient that the 24-hour collection period ends the following day at the sam
e time that the
process was started. This urine (from the following morning at the same time) is
to be added to
the collection container to complete the process. Document this time on the coll
ection container
and on any additional paperwork as required. 10. Tell the patient to transport t
he filled
container to the laboratory as directed. It may be necessary to collect blood wh
en the specimen
is returned to the laboratory. 11. Verify whether the patient understood the ins
truc- tions as
given, and check if there are any additional questions. Supply contact informati
on for future
questions. 12. Provide the patient with a written copy of the instructions. It m
ust be stressed
that all the urine must be collected during the 24-hour period for the test resu
lts to be valid.

The reference ranges for the tests are dependent on 24-hour specimens; any urine
not added to the
spec- imen container may potentially affect the results. Emphasize that the 24-h
our period starts
and ends with an empty bladder. The patient should be notified before the collec
tion process
begins if there is a blood draw necessary so that he or she is anticipating this
. This is a
critical step for the appropriate collection of the specimen. A written copy wil
l allow the
patient to refresh his or her memory when the collection is performed. type of c
ollection bag
designed to be attached to the skin surrounding the urinary opening of a young c
hild or infant.
The area around the urinary meatus must be carefully cleaned to reduce contamina
tion, and care
must be used to attach the device securely so that the urine does not leak out a
round the
adhesive. It is also important to inform the parents of the patient (if the coll
ection is to be
completed at home) to check for the presence of urine in the bag often so that i
t can be transferred to an appropriate sterile collection cup and refrig- erated. Figure 9-2 s
hows a pediatric
urine collection Urine Collection Procedures for Infants and Pediatric Patients
It can be very
difficult to collect a urine specimen from an infant or young child using noninv
asive procedures.
A routine specimen may be obtained by using a special Test Your Knowledge 9-7 Ho
w is a first
morning void specimen different from a 24-hour urine specimen? (Outcome 9-3) Dat
e 10/24/2013:
Patient provided supplies and written and verbal instructions for a 24-hour urin
e collection
procedure.
11:58 a.m.
Connie Lieseke, CMA (AAMA) 1899_Ch09_195-214 26/12/11 2:09 PM Page 209 T
est Your Knowledge
9-9 Why are gloves worn when handling urine specimens in the laboratory? (Outcom
e 9-4) bag. A
suprapubic aspiration or straight catheterization procedure may be performed by
the physician (or
other qualified health-care professional) for young children and infants if a st
erile specimen is
necessary for proper diagnosis. URINE SPECIMEN PROCESSING Because urine can be c
ollected
relatively easily without invasive procedures, it is often taken for granted. A
urine specimen
may have drastic changes occur while standing at room temperature, so care must
be taken to
handle the specimen correctly after collection until the testing process is comp
lete. Urine that
is not processed correctly can lead to misdiagnosis and incorrect treatment for
the patient.
Although urine is not considered to be capable of transmitting HIV, hepatitis B,
or hepatitis C,
it is im- portant that the processor uses gloves and a protective laboratory coa
t when handling

urine samples. Other pathogenic microorganisms may be present in the urine speci
men, and
employees need to be certain to protect themselves appropriately. Protective eye
wear may also be
considered if there is a potential for splashing the specimen. This may be parti
cularly critical when handling specimens that have acid added as preservative, or those that
may have a lot of
blood present in the urine. Refrigeration and Preservation Urine specimens shoul
d be refrigerated
(at 2 to 8Celsius) immediately after collection if they cannot be analyzed within
1 hour of
collection. If the specimen is collected in a patients home, instructions about r
efrigeration
are espe- cially critical. The sample should stay cool until delivered 210 Secti
on II Specimen
Collection and Processing Figure 9-2 Pediatric urine collection device. Note the
adhesive
surrounding the opening of the bag. The adhesive surface will be applied to the
childs cleansed
skin sur- rounding the urinary opening. Courtesy of Zask, Inc. Test Your Knowled
ge 9-8 Why is a
special collection device necessary to collect a urine specimen from an infant?
(Outcome 9-3)
POINT OF INTEREST 9-3 What now? Once the specimen has been collected and returne
d to the
laboratory or physicians office, it is up to the medical assistant to process and
store it
correctly. Here are a few basic guidelines: While still in the presence of the p
atient, verify
that the specimen is correctly labeled with name, birth date, and other identify
ing information.
Verify and, if necessary, document the date and time of collection on the approp
riate
paperwork. Review the collection process with the patient; ask specifically whet
her there were
any problems with the specimen collection or storage. If the collection or stora
ge of the
specimen was incorrect, the spec- imen should be discarded at this time, and the
patient should
be provided with materials to perform a recollection. Some facilities will have
the medical
assistant immediately document the color, appearance, and specific gravity of th
e specimen before
it is refriger- ated, as these can change once the specimen temperature decrease
s. Specimens
for urinalysis, culture, and most other procedures are to be tested or refrigera
ted as soon as
possible, and always within 1 hour of arrival at the laboratory. Twenty-four-hou
r urine
collections may need to be mixed well and an aliquot may need to be poured off.
This aliquot
would then be forwarded to the main laboratory for analysis. (This step will be
dependent on the
policy of the laboratory perform- ing the 24-hour urine collection container.) 1
899_Ch09_195-214
26/12/11 2:09 PM Page 210 to the laboratory; if a patient has numerous errands t
o run, or if the
patient is going to work, it is important that the patient use a cooler to keep
the urine

refrigerated until it is delivered to the laboratory. There are numerous changes

that may occur
as the urine is left standing at room temperature, but the most dramatic is the
change in the
bacterial count. The bacteria present in urine specimens are capable of multiply
ing very rapidly;
the bacterial count of the specimen may double within 2 hours at room temperatur
e. This means
that the patient may initially be treated for a urinary tract infection based on
a high bacterial
count reported as part of the uri- nalysis, when there were actually very few ba
cteria present in
the specimen at the time of collection. Refrigeration halts most of the changes
that may occur in
the urine spec- imen, and reduced temperatures are especially effective at limit
ing the
replication process of bacteria. The potential changes to a urine specimen with
extended room
temper- ature storage are listed in Table 9-3. Although it is necessary to prese
rve urine
specimens at reduced temperatures to stabilize some of the analytes, it is impor
tant to remember
that these reduced tempera- tures may also affect the specimen. Refrigeration ma
y increase the
specific gravity of the specimen, and cause some diffuse microscopic crystalliza
tion within the
urine specimen as well. The specific gravity is a measurement of the amount of d
issolved
substances in the urine speci- men. (More information about specific gravity is
covered in
Chapter 20.) Urine that has been refrigerated may also change in color and appea
rance, and these
parameters are recorded as part of a routine urinalysis in many situa- tions. In
order to
counteract the effects of refrigeration on these testing parameters, the urine s
pecimens should
be allowed to return to room temperature before routine uri- nalysis testing is
performed. This
reverses most of the changes. Also remember the urine specimens must be well mix
ed with gentle
inversion or swirling of the speci- men container before testing. Additives (pre
servatives) may
also be used for speci- mens that are to be tested for common urinalysis tests a
nd/or set up for
urine cultures. Many manufacturers produce tubes with additives for this purpose
. An exam- ple is
BD Vacutainer Plus Plastic Conical urinalysis pre- servative tubes, which contai
n chlorhexidine,
ethyl paraben, and sodium propionate for preservation of urine specimens for uri
nalysis. Some of
these additive tubes cannot be used for certain types of test procedures; it is
imperative that
the medical assistant check the pack- age insert to verify whether a specific ty
pe of collection
container with an additive may be used for the proce- dure ordered. These specia
l additive tubes
are not usually given to the patient for transfer at home; the urine spec- imen
is added to the
tube once it arrives at the laboratory or physician office. Because microscopic
examinations of

the specimens are performed, it is also important that the formed elements (subs
tances in the
urine specimen such as cells and microorganisms) are preserved so that they can
be documented as
part of the examination. Ad- ditives may assist with the preservation of these s
ub- stances as
well as the chemical components present in the specimen. Proper Disposal of Urin
e and Supplies
After testing, laboratories may immediately discard urine samples, or keep them
refrigerated for
a few days for potential follow-up testing and troubleshooting of test results.
When the urine is
no longer needed, it may be flushed down the sink, and the specimen containers m
ay be disposed of
as regular (nonbiohazardous) trash. Chapter 9 Collection and Processing of Urin
e Samples 211
Test Your Knowledge! 9-10 What change in the urine specimen is most dramatic if
the specimen is
left out at room temperature for more than an hour? (Outcome 9-5) TABLE 9-3 Chan
ges in urine
specimen when left at room temperature for more than 1 hour Changes in Details a
nd/or Urine
Specimen Clinical Significance Decreased clarity Crystallization of solutes; and
slight color may
also cause color inter- change pretation to change as these form pH increases Ba
cteria in
specimen convert urea to ammonia and CO 2 is lost Ketones decrease Ketones decre
ase with time at
room temperature Bilirubin and Exposure to light causes urobilinogen these chemi
cals to degrade
decrease in the specimen Cells and casts Microscopic examination is dissolve inc
onclusive as
identification of microscopic features is inaccurate Bacterial count Bacteria co
ntinue to
multiply increases exponentially Glucose decreases Glucose is used by bacteria a
nd other cellular
components as an energy source 1899_Ch09_195-214 26/12/11 2:09 PM Page 211 Urine
is not
considered a biohazard in the same way that blood and other body fluids are. Sin
ks used for disposal of urine should be disinfected daily with a concen- tration of 10% bleach
or another
approved laboratory disinfectant. SUMMARY Urine testing is a common method of sc
reening for
disorders of metabolism, pregnancy, and potential infection within the body. Pro
per patient
preparation and education are essential to ensure a quality speci- men that will
yield meaningful
results. Collection methods, required volume, and the need for preser - vatives
will vary,
depending on the test ordered. Also, once the urine specimen arrives at the labo
ratory, it is
imperative that the specimen is appropriately processed and preserved in a timel
y manner to prevent overgrowth of microorganisms and potential erroneous results. TIME TO REVIE
W 1. How is a
suprapubic aspiration Outcome 9-3 different from a catheterization? a. The urine
is collected
from a different part of the urinary system b. The collection device used is dif
ferent for each

procedure c. The amount of urine collected is not the same for the two types of
procedures d. All
of the above 2. True or False: The urine collected Outcome 9-3 using the clean-c
atch midstream
collection procedure may be collected at any time of the day. 3. Which of these
statements is not
Outcome 9-4 true of indwelling catheters? a. Indwelling catheters are inserted a
nd used continuously for an extended period of time b. Indwelling catheters are often colonize
d with bacteria
c. Indwelling catheters may be used to collect a urine specimen after they have
been in place for
a few days d. Indwelling catheters may be used for patients who have problems wi
th incontinence
4. Which of these measurements Outcome 9-5 may change when urine is left at room
temperature for
longer than 1 hour? (Circle all that apply.) a. Color b. Glucose concentration c
. Bacterial count
d. Appearance of microscopic elements e. pH f. Specific gravity 5. True or False
: It is not
necessary to Outcome 9-6 provide two unique identifiers (such as patient name an
d birth date) on
a urine specimen container. 6. True or False: Labels for urine Outcome 9-6 speci
men containers
may be placed on the lid only; it is not necessary to label the container. 7. Wh
ich of these
urine specimen types Outcome 9-3 may be collected at random times? (Circle all t
hat apply.) a.
Clean-catch midstream urine specimens b. Specimens to check for prostatitis c. S
pecimens used to
check for the presence of glucose as part of a glucose tolerance test d. Suprapu
bic aspiration
specimens e. Urine pregnancy test specimens f. Culture specimens 8. The urinary
meatus is:
Outcome 9-1 a. Part of the bladder b. The excess skin removed during the process
of circumcision
c. The external opening of the urethra d. Part of the prostate gland 9. True or
False: Different
collection Outcome 9-2 techniques for urine specimens are necessary be- cause ch
emicals are not
present in urine in the same concentration at the same time each day. 10. Diurna
l variation
means: Outcome 9-1 a. Fluctuations in the value of an analyte that occur during
each day. b.
Concentration of urine in the morning void specimen. c. Changes in urinary pH wh
en urine is left
at room temperature d. None of the above 11. True or False: An aliquot of a urin
e Outcome 9-1
specimen refers to a small portion (or fraction) of the whole. 212 Section II S
pecimen
Collection and Processing 1899_Ch09_195-214 26/12/11 2:09 PM Page 212 RESOURCES
AND SUGGESTED
READINGS Prostatitis Neal Chamberlain, computerized teaching materials for the Inf
ectious
Disease Course at Kirksville College of Osteo- pathic Medicine
http://www.atsu.edu/faculty/chamberlain/ Website/lectures/lecture/prostate.htm Ac
ute Bacterial
Prostatitis Overview of prostatitis, with specific information about di- agnosis
and treatment
http://www.drrajmd.com/conditions/ prostate/prostatitis/acute_bacterial_prostati

tis.htm Chapter 9
Collection and Processing of Urine Samples 213 Case Study 9-1: Postoperative pa
in Mr. Johnson
has had pain in his perineal area for more than a week, and he has noticed that
he is urinating
quite frequently. Mr. Johnson decides that he should call the physician for an a
ppointment,
because he now has a fever and doesnt feel as if he can go to work. He re- cently
had abdominal
surgery, and was catheterized with an indwelling catheter for several days befor
e he was mobile.
1. What are two possible explanations for his discom- fort and frequent urinatio
n? 2. How could
the physician decide on the correct diag- nosis? What procedures might be utiliz
ed? Case Study
9-2: Specimen dropoff Mrs. Brown brings her 24-hour urine specimen con- tainer t
o the office. The
medical assistant who is work- ing at the front desk receives the specimen from
Mrs. Brown. 1.
What does the medical assistant need to do before Mrs. Brown leaves the office? C
are Gram
24-Hour Urine and Food Drug Restrictions Information about dietary and medication
restrictions
for 24-hour urine collections from Licking Memorial Health Systems
http://www.lmhealth.org/pdf/CareGrams/Lab%20 Tests/24%20Hour%20Urine%20&%20Food%
20Drug%2
0Restrictions%201616-0550.pdf CAP Today: Cloudy or Clear? Best Forecasts for Urin
e Cul- tures,
CAP today online newsletter, November 2006 Details for a study about preanalytic
al errors with
urine specimen collection for cultures http://www.cap.org/apps/
portlets/contentViewer/show.do?printFriendly=true&
contentReference=cap_today%2Ffeature_stories%2F1106U rine.html 24-Hour Urine Coll
ection
Southwestern University Health Library selection about 24-hour urine collection;
includes
clinical significance and details about the collection process http://www.
utsouthwestern.edu/patientcare/healthlibrary/ healthtopics/0,,P08955,00.html Best
Practice: Tips
for Urinalysis Becton, Dickinson online newsletter, LabNotes, 13, no. 2, 2003 Det
ails about
urine processing for urinalysis and urine cul- tures, including information abou
t preservative
tubes that are available http://www.bd.com/vacutainer/labnotes/2003 spring/best_
practice.asp
Sample Meal for a 2-Hour Postprandial Glucose Test Patient instructions for 2-hour
postprandial
glucose testing procedure from the Delaware Valley Institute of Fertility and Ge
netics
http://www.startfertility.com/patient_fld/ form_pdfs/Sample_Meal-2-hr_PP_glucose
_test.pdf Laws,
Regulations, Standards and Guidelines A publication of the New Jersey Hospital As
sociation with
a summary of laws, regulations, standards, and guidelines that pertain to langua
ge assistance for
diverse populations in the health-care setting that may not have English as thei
r native language
http://www.njha.com/publications/pdf/ Laws_Regulations_Standards_and_Guidelines.
pdf
1899_Ch09_195-214 26/12/11 2:09 PM Page 213 1899_Ch09_195-214 26/12/11 2:09 PM P

age 214 215

Chapter 10 Collection and Processing of Samples for Microbial Studies Constance
L. Lieseke, CMA
(AAMA), MLT, PBT(ASCP) CHAPTER OUTLINE Microbiology Sample Collection Guidelines
Types of Media
Microbiology Terms Detailed Microbiology Sample Collection Procedures Throat Swa
b Collections for
Culture or Strep Screens Sputum Samples Urine Samples for Culture Blood Culture
Collection
Cerebrospinal Fluid Samples Genital Samples Wound Cultures Stool Specimens Nasop
haryngeal
Specimens Eye Cultures Ear Cultures Special Sample Collection and Processing Pro
cedures Fungal
Sample and Culture Collection Procedures Potassium Hydroxide Preparation Wet Mou
nt Procedure
Sample Collection Procedures for Detection of Parasites Ova and Parasite Examina
tion Pinworm
Collection Procedures Processing Microbiology Samples Slide Preparation and Gram
-Staining
Procedure Plating and Inoculation of Media Antibiotic Sensitivity Testing Microb
iology Test
Results Summary Time to Review Case Studies Resources and Suggested Readings 101 Define the key
terms. 10-2 Demonstrate understanding of the general guidelines to be followed w
hen collecting
for microbiology testing. 10-3 List various types of media used for bacterial an
d viral specimen
setup. 10-4 Describe how the collection processes and sup- plies for bacterial,
viral, and fungal
specimens may differ. 10-5 Compare and contrast sample collection of throat swab
s for
streptococcal screens and cultures. 10-6 Explain the collection procedure for sp
utum samples.
10-7 Differentiate the types of urine specimens that may be used for cultures. 1
0-8 Describe the
procedure for collecting a specimen for a blood culture. Learning Outcomes After
reading this
chapter, the successful student will be able to: 1899_Ch10_215-255 21/12/11 2:26
PM Page 215 216
Section II Specimen Collection and Processing 10-9 Describe how a cerebrospinal
fluid (CSF) sample is collected, and explain how the sample should be processed after collectio
n. 10-10 Explain
how genital screening samples are processed. 10-11 Demonstrate an understanding
of the various
types of wound cultures and how their process- ing differs. 10-12 Compare and co
ntrast collection
and process- ing of stool samples as compared to other com- mon microbiology spe
cimen types.
10-13 State when a nasopharyngeal specimen may be necessary, and describe the co
llection
technique used. 10-14 Describe the technique used for eye and ear cul- ture samp
le collection
procedures. 10-15 Classify the various types of fungal infections, and describe
the techniques
used to collect fun- gal culture samples. 10-16 Differentiate the requirements a
nd use of a KOH
prep and a wet mount specimen preparation. 10-17 Explain how a stool sample is c
ollected and preserved for an examination for the presence of ova and parasites. 10-18 Summarize

the sample
collection process used for detecting a pinworm infection. 10-19 Explain the ste
ps involved in
performance of a Gram stain, as well as the differential appear- ance of the sta
ined organisms.
10-20 Explain how a microbiological sample is plated for growth. 10-21 Describe
how sensitivity
testing is performed and explain the clinical significance of the process. 10-22
Translate a
microbiology laboratory report, and explain the clinical significance of the val
ues. CAAHEP/ABHES
STANDARDS CAAHEP Standards I.A.I.2. Use language/verbal skills that enable patie
nts
understanding III.C.III.3. Discuss infection control procedures III.C.III.5 List
major types of
infectious agents III.C.III.7. Match types and uses of personal protective equip
ment (PPE)
III.C.III.9. Discuss quality control issues related to han- dling microbiologica
l specimens
III.P.III.2. Practice Standard Precautions III.P.III.3. Select appropriate barri
er/personal
protective equipment (PPE) for potentially infectious situations III.P.III.7. Ob
tain specimens
for microbiological testing III.A.III.1. Display sensitivity to patient rights a
nd feelings in
collecting specimens III.A.III.2. Explain the rationale for performance of a pro
- cedure to a
patient III.A.III.3. Show awareness of patients concerns regard- ing their percep
tions related
to the procedure being performed ABHES Standards Apply principles of aseptic tec
hniques and
infection control Use standard precautions Practice quality control Perform sele
cted
CLIA-waived tests that assist with diagnosis and treatment, #5: Microbiology tes
ting Dispose of
biohazardous materials Collect, label and process specimens, #3: Perform wound c
ollection
procedures, #4: Obtain throat spec- imen for microbiology testing Instruct patie
nts in the
collection of a fecal specimen 1899_Ch10_215-255 21/12/11 2:26 PM Page 216 Chapt
er 10 Collection
and Processing of Samples for Microbial Studies 217 KEY TERMS Aerobes Agar Anaer
obes Antibiotic
sensitivity testing Broth Candle jar Cerebrospinal fluid (CSF) samples Colonies
Cover slip
Culture Culture and sensitivity (C&S) report Disk-diffusion method Ectoparasites
Endoparasites
Eustachian tube Exudate Gram stain Hanging drop slide Hemolytic uremic syndrome
Inoculation
Kirby-Bauer method KOH (potassium hydroxide) Lumbar puncture Medium (pl., media)
Methicillin-resistant Staphylococ- cus aureus (MRSA) Minimum inhibitory concentr
a- tion (MIC)
method Motility Mycoses Nasopharyngeal collection technique Nasopharynx Normal f
lora Otitis
Otitis externa Otitis media Ova and parasite examination (O&P) Parasites Pathoge
n Petri dish
Pinworm Resistant Scabies Sensitive Septicemia Sequela Slant Sputum Strep screen
s Trichomoniasis
Wet mount Woods lamp Zone of inhibition M icrobiology is the study of organisms t
hat require

magnification to be seen by the human eye. As introduced in Chapter 3, microorga

nisms are everywhere! These tiny creatures have been the objects of study since the early 1700s
, when Antony
Leeuwen- hoek first recorded observations of bacteria he watched with his homema
de microscopes.
These animalcules (as Leeuwenhoek called them) were described in great detail, and
Leeuwenhoek
hired an illustrator to provide pictures of the living creatures that he observe
d. How- ever, the
idea that microorganisms were capable of spreading disease was understood much l
ater. In 1847,
Ignaz Semmelweis was working in a maternity hospital in Siena, Italy, when he re
alized that some
sort of invisible agent seemed to spread from the mothers who died of puerperal fe
ver after
childbirth to the other mothers in the ward. He insisted that the physicians wor
king in the ward
begin to wash their hands between patients, and also had the practitioners chang
e their
laboratory coats after performing autopsies before they worked with expectant mo
thers. These
small changes resulted in a dramatic drop in the mortality rates in the maternit
y ward of the
hospital. Unfortunately, Semmelweis was ridiculed for his strict enforcement of
the rules, and
was subsequently fired. It would still be almost 100 years before observa- tions
such as the ones
made by Semmelweis began to change the way that the world viewed microorganisms
and their
relationship to disease. Louis Pasteur and Robert Koch were responsible for many
of the theories
that we use in microbiology today. In the late 1800s, they conducted a series of
experiments to
suggest that bacteria cause disease, and these scientists went even further to p
rove that
bacteria did not spontaneously generate, but instead replicated at a very fast p
ace when
introduced to an environment that supported their 1899_Ch10_215-255 21/12/11 2:2
6 PM Page 217 218
Section II Specimen Collection and Processing growth. It was also proved during
this time that
bacteria could be kept from contaminating a certain area if the appropriate prec
autions were
taken. These were revolu- tionary ideas that continue to shape the way we view m
icroorganisms
today. When working with microbiological samples, it is im- portant to keep thes
e core concepts
in mind, as our goal is to avoid extraneous contamination of the specimens, to p
rovide
appropriate samples for testing to allow for proper patient diagnosis and treatm
ent, and to
nurture the growth of microscopic organisms so that they can be identified. We n
ow know that the
microscopic animal- cules that can cause harm do not include only bacteria. Microb
iology
testing may also focus on viruses, fungi, and parasites. Because of this variety
, collection
methods and testing procedures vary, depending on the type of specimen collected
and the organism

that is thought to be present. The laboratory may process these samples in the g
eneral
microbiology department, or there may be subdi- visions for bacteriology, virolo
gy, mycology,
and/or para- sitology. This chapter presents collection and handling procedures
for the most
common types of microbiologi- cal tests ordered. MICROBIOLOGY SAMPLE COLLECTION
GUIDELINES In
order to provide appropriate treatment, health-care providers need to know which
type of pathogen
is causing the symptoms exhibited by the patient. A pathogen is a microorganism
that is capable
of causing disease in the body. Most infectious diseases are caused by viruses o
r bacteria.
Treatment choices vary dramati- cally based on the causative organism present in
the specimen
collected for testing. Variables for treatment may be based on the type of patho
gen present (such
as viruses, bacteria, fungi, or parasites), the amount of the microscopic organi
sm isolated, as
well as sensitivity testing for antimicrobials suitable for treatment. The micro
organism that
causes a disease is a pathogen, so health-care providers must always remember w
hich organisms
may be present as part of the normal flora (resident bacteria present in certain
areas of the
body) as these may contaminate the specimen, and their presence may be misleadin
g. To assure
quality processes and valid results, specific guidelines should be followed when
ever collecting
or processing samples for microbiology testing. These include the following: Spe
cimen collection
Collect the sample from the area of infection, and avoid contamination from surr
ounding areas
if at all possible. This is especially critical when collecting samples for woun
d cultures.
Ideally, bacterial culture specimens should be collected before antibiotics are
introduced. If
the antibiotics have already been administered, the causative organ- ism may not
be present in
high enough numbers to identify it appropriately. Use the correct collection and
transportation
methods. Research what type of swab or container is to be used, and how the samp
le is to be
handled after collection until it reaches the laboratory. Package inserts should
be consulted for
specific collection techniques. Some samples are to be refrigerated immediately,
whereas others
are to remain at room temperature until they are transported to the laboratory f
or processing.
Always collect a sufficient quantity of sample for testing. Be certain that the
sample is
appropriately labeled, including the source (be as specific as possible), the pa
tients name, the
identification of the individual performing the specimen collection, and the dat
e and time of the
collection. Document this information on the requisition form appropriately as w
ell. Verify and
adhere to any sample restrictions for trans- port time. Also verify whether the
sample needs to

be protected from light after collection. Use sterile supplies, and be careful t
o maintain
steril- ity while performing sample collection procedures. Store all laboratory
specimens in a
refrigerator or other container dedicated for that use. Personnel All personnel
participating
in the collection, process- ing, or testing of microbiological specimens must be
appropriately
trained in all procedures. Personnel should participate regularly in competency
testing to
assure quality of collection, processing and testing of specimens. Wear appropri
ate personal
protective equipment (PPE) when performing specimen collection or speci- men pro
cessing. This may
include items such as gloves, a laboratory coat, face shield, or special respira
- tory equipment
such as that needed for processing samples that may contain tuberculosis. Test Y
our Knowledge
10-1 What is the term used to describe a microorganism that causes disease?. (Ou
tcome 10-1)
1899_Ch10_215-255 21/12/11 2:26 PM Page 218 Chapter 10 Collection and Processin
g of Samples for
Microbial Studies 219 Media A medium provides nutrition for microorganisms when
grown in the
laboratory environment. There is an expira- tion date associated with all media
to ensure
appropriate performance. Media should be discarded when outdated. For a medium t
o function as
designed, it cannot be allowed to dry out or become contaminated. In ad- dition,
there are
specific storage requirements for each type of medium, and these must be followe
d carefully.
Verify that the correct medium is used for each type of specimen collection, as
this can have a
profound effect on the results. Medium performance should be verified on a regul
ar basis by
inoculating the medium with a known microorganism to observe growth. Stains All
products used
for staining microorganisms have expiration dates provided by the manufacturer,
after which the
stains must be discarded. Stain performance should be verified on a regular basi
s by staining
microorganisms with predictable staining characteris- tics to observe staining p
atterns. Test
Your Knowledge 10-2 What must be documented on the sample after the col- lection
of a
microbiology specimen? (Outcome 10-2) Test Your Knowledge 10-3 Should bacterial
culture specimens
be collected before or after antibiotic therapy has been started? (Outcome 10-2)
Types of Media
The growth of any microorganism in the laboratory is dependent on the presence o
f an appropriate
nutrition source and other chemicals necessary for survival. These are provided
in a culture
medium (plural, media). The medium may be in the form of a liquid nutrient broth
, a semi-solid
gel, or a solid gel. Agar is a thickening agent added to the medium that allows
the gel to solidify so that the microorganisms will grow on the surface. A medium may be provide
d in tubes, or it

may be provided in a small shallow container, known as a Petri dish. Figure 10-1
shows various
types of media used in a microbiology setting. Some laboratories create their ow
n media, but most
purchase commercially prepared media, which provide a longer shelf life, fewer i
mpurities, and
more consistent appearance and performance. All types of media contain nutrients
and additives
that support the growth of microorganisms. Ingredients may include blood, vitam
ins, dyes, sugar
mixtures, and organic sources of nutrition such as vegetable extracts. Figure 10
-1 Types of
media. Note the presence of the agar plate, the slant, and the broth. 1899_Ch10_
215-255 21/12/11
2:26 PM Page 219 Culture media is classified into categories based on whether th
e medium enriches
the growth of all bacteria or selectively inhibits growth of certain bacteria. S
elective media
have additives that prevent the growth of certain types of bacteria while promot
ing the growth of
other select species. One example is Thayer Martin agar, used for specimens when
a gonorrhea infection is suspected. It has lysed red blood cells, which provide an easy source
of hemoglobin to
promote the growth of the Neisseria gonorrhoeae organism, but the medium also co
ntains
vancomycin, colistin, and nys- tatin. These are antibiotics that prohibit the gr
owth of other
common nonpathogenic microorganisms often found concurrently with gonorrhea. Dif
ferential media
allow for different types of bacteria to be identified based on an indicator. A
common differential medium used in the laboratory is MacConkey agar, which has a special dye
additive. If the
organisms growing on the agar ferment lactose (the indicator), their growth will
appear pink on
the medium plate. This colored growth allows the microbiologists to make a preli
minary
identification of the pathogenic microor- ganisms based on their ability to ferm
ent lactose.
Enriched media include nutrients that allow for a wide variety of organisms to g
row. Blood agar
is an example of an enriched medium that is designed to support growth of microo
rganisms that
flourish in the human body, including both pathogens and nonpathogens. Solid gel
is provided in a
tube (called a slant) or in a Petri dish. Liquid medium (usually called nutrient
broth) comes in
a tightly sealed tube. It is important to keep all forms of media from drying ou
t or becoming
contaminated after receipt at the laboratory or physician office. The media shou
ld be
refrigerated for storage, but must be brought to room temperature before use. Al
l forms of media
have a limited shelf life, so it is impor- tant to be aware of their expiration
date. 220 Section
II Specimen Collection and Processing common test performed in the microbiology
laboratory. The
process of adding the specimen to a medium source is known as inoculation. Inocu
lation may occur

in the physician office immediately after specimen collection, or it may be perf

ormed once the
specimen arrives at the laboratory. The visible growth that occurs once the spec
i- men has been
added to the medium may be seen as colonies (or clumps) of growth, especially wi
th bacterial
cultures. The unique appearance of the colonies present on the culture may allow
for preliminary
identification of the microorganism. To accelerate bacterial growth, the specimen is usually
placed in an incubator that is kept near body temperature (37Celsius) for 24 to 4
8 hours. Some
organ- isms must be placed in an environment with little to no oxygen present fo
r growth
(anaerobes), whereas others like an oxygen-rich environment (aerobes). There are
incuba- tors or
other devices that are specifically designed to pro- vide these parameters for c
ulture growth.
Preliminary laboratory results for bacterial cultures are often available within
24 to 48 hours
after the speci- men has been submitted to the laboratory. Each labora- tory est
ablishes a
definitive time frame before which they will not report a negative result for a
bacterial
culture. This means that the laboratory gives the sample a chance to grow for at
least a few days
before posting a negative result. Most pathogenic bacteria are relatively easy t
o grow in the
laboratory, and identification techniques have been established for most of thes
e microorganisms.
Viral cultures require a longer time for growth and identification, and require
use of different
types of me- dia than those required for bacterial cultures. Because viruses are
parasitic
intracellular organisms, viral cultures require living tissue and cells to suppo
rt growth and
replication. It is imperative that the person collecting a viral specimen for cu
lture pay
scrupulous attention to specimen collection protocol, the technique of collec- t
ion, and
transportation requirements. Viral culture specimens should be collected, in gen
eral, within 72
hours of symptom onset. Collection swabs made of calcium alginate should not be
used for
collection of viral culture specimens, and cotton-tipped swabs with wooden shaft
s must also be
avoided. Generally, viral specimens are refrigerated to preserve their integrity
if there will be
a delay in transportation. Because it is a complicated process, viral culture pr
ocessing is
usually performed only in large reference laboratories. It may be 7 to 10 days b
efore a viral
culture result is confirmed. For this reason, if a viral infection is suspected
and the patients
symptoms warrant it, the health-care provider may administer antiviral medicatio
n to the patient
with- out a culture result or identification of the organism. Test Your Knowledg
e 10-4 What are
two ways that culture media may differ? (Outcome 10-3) Microbiology Terms A cult
ure is a group of

microorganisms grown in a labora- tory environment using prepared media. The wor
d culture is used
whether the sample is bacterial, viral, or fungal. A culture is created when a m
edium source has
a specimen added for potential growth. The culture is the most 1899_Ch10_215-255
21/12/11 2:26 PM
Page 220 Chapter 10 Collection and Processing of Samples for Microbial Studies
221 Fungal
cultures are even slower to grow than viral cul- tures. The fungal elements in a
specimen may be
difficult to isolate because of the faster-growing organisms present in or on th
e specimen, such
as bacteria. A selective media is used, including nutrition sources such as brai
n and/or heart
extract, blood, dextrose, and natural nutrition sources such as potatoes. Antibi
otics may be
added to re- tard the growth of the bacteria in the specimen so that the fungal
elements can be
identified. The exact type of media used will be dictated by the specific source
of the specimen
within the body, as, for example, the types of fungus growing on the skin may be
very different
from those growing in the lungs. A fungal culture may take up to 4 weeks to repo
rt results; it is
generally a minimum of 21 days before a negative result can be released. Test Yo
ur Knowledge 10-5
Which type of culture (viral, bacterial, or fungal) is quickest to grow? (Outcom
e 10-4) POINT OF
INTEREST 10-1 Bioterrorism Prior to September 11, 2001, the threat of widespread
bioterrorism was
a rare topic in most casual conversa- tions. However, the climate changed with t
he events of that
day and the weeks that followed. The Centers for Disease Control and Prevention
(CDC) strongly
recommends that all laboratories (even those in physi- cian offices) continue to
monitor their
procedures and remain aware of those that could create aerosols. An aerosol is a
suspension of
fine particles (such as bacte- ria or viruses) in the air. For those facilities
in which the risk
of aerosol formation is heightened because of the types of procedures performed
and the patient
population served, a biosafety hood is recommended. The procedures would be perf
ormed within the
hood workspace, and any microorganisms released into the air would be vented out
of the room.
Health-care facilities also must remain educated about what to do in case of an
exposure within
their facility; fast, appropriate action can save lives. The agents may be bacte
rial or viral in
nature. Most, but not all, agents that could be used for bioterrorism would be s
pread through the
aerosol form. It is difficult to predict which agents may be used for a biologic
al attack, but
the following are some that are considered to be most probable: Anthrax: In the
1800s, Louis
Pasteur documented work that he performed with this bacterium, and there are rep
orts of soldiers
using anthrax in World War I to deliberately infect animals that were to be eate
n by the enemy.

In October and November 2001, there were 22 cases of deliberate infection with t
he anthrax
bacterium in the United States. Anthrax is caused by Bacillus anthracis and is a
gram-positive,
spore-forming bacillus. In nature, the spores may be present in the soil, and th
ey are either
ingested or picked up on the skin and hair of animals when they are feeding. Hum
ans usually
become infected only when they come in contact with animals or products that are
contaminated,
and infection is rare. There are three routes of infection for anthrax: Cutaneou
s: The most
common natural route is cutaneous, or via the skin; humans may be infected when
handling
contaminated wool, or occasionally from the spores in the soil. The cutaneous in
fection causes a
papule that pro- gresses with time into a necrotic ulcer. If the ulcer penetrate
s deep enough
into the skin, the patients bloodstream may become infected, which can lead to mo
re serious
consequences. Inhalation: The route that is used most often for deliberate infec
tion is via
inhalation. The ex- posed patient has flu-like symptoms. Within days, the patien
t suffers from
hypoxia and has difficulty breathing, as pulmonary edema and further damages wit
hin the lungs
progress. Ap- proximately 50% of those who are infected via the inhalation devel
op meningitis,
and the mor- bidity rate is quite high. Prior to 2001, there had been only 20 ca
ses of anthrax
infection via inhalation reported in the United States. Gastrointestinal: The in
gestion of
poorly cooked, contaminated meat allows anthrax entrance via the gastrointestina
l route. The
patient may have abdominal discomfort, bloody diarrhea, and vomiting, and may ha
ve visible
ulcerations in the oropharynx when examined. Essentially, the necrotic lesions t
hat are visible
with cutaneous exposure form within the GI tract and impair the patients ability
to digest food
properly. All forms of anthrax exposure can be treated with antibiotics if caugh
t early. Once the
more serious symptoms have developed, it may be difficult treat successfully. Ci
profloxacin or
doxycycline is often used successfully for early treatment. Anthrax is not passe
d from person to
person. Brucellosis: Brucellosis is a disease that is common in cattle, sheep, g
oats, and pigs
in many areas of the 1899_Ch10_215-255 21/12/11 2:26 PM Page 221 222 Section II
Specimen
Collection and Processing world. It may also affect domestic animals such as dog
s. Humans may be
infected by direct exposure to an animal host. There are very few human infectio
ns in the United
States because of a rigid vaccination program, but the disease is much more freq
uent in other
areas of the world. Infection causes flu-like symptoms in most humans, but can l
ead to much more
serious CNS problems, as well as heart damage. Brucellosis forms an aerosol very
easily, so to

avoid potential inhalation in the workplace, it is important to remember not to s

niff cultures
in the microbiol- ogy area. This practice may be very dangerous. Botulism: The s
ymptoms
associated with botulism are related to the toxin produced by the spore- forming
bacterium
Clostridium botulinum. This toxin is one of the most lethal natural substances k
nown to humans.
The toxin paralyzes the muscles of those infected, which eventually leads to par
aly- sis of the
lungs, and death. The toxin is not used as an aerosol as much as some of the oth
er microorganisms considered as threats for bioterrorism use, but the bacteria could be ve
ry lethal if
added to a common food source or used in a contained area. C. botulinum may also
be introduced
into the body through a wound; there is evidence that armies in the past added i
t to their swords
to enhance the damage done during hand-to-hand combat. For those infected, the m
ost important
consideration is the treatment of symptoms, as the damage caused by the toxin sp
reads quickly
throughout the body. Plague: Everyone who has studied world history has heard of
the plague in
medieval Europe. The plague is caused by the bacteria Yersinia pestis and may in
fect humans
through two different routes. One is the bubonic plague, which is usually caused
by the bite of a
flea or tick carried on a host rodent. The other is through inhalation. This is
the method that
causes concern for potential use of this bacterium as a bioterrorist weapon. The
pneu- monic
plague may be spread from person to person via droplets in the air after the ini
tial infection,
and is relatively easy to isolate and grow in large amounts. Thus, initial infec
tion could lead
to wider and wider mortality. Infection may easily cause respiratory failure and
death. The
bacterium is treatable with tetracycline and/or fluoro- quinolone for at least 7
days if given
orally, or IV streptomycin or gentamycin, but the infection must be caught early
. Smallpox:
Smallpox is different from the other microorganisms that are considered bioterro
rist threats
because it is a virus instead of a type of bacterium. The last natural case of s
mallpox in the
United States occurred in 1949, and the causative agent (the variola virus) is c
onsidered to have
been eradicated by a long-term, aggressive, and world- wide vaccination campaign
that has been
carried out since 1980. There is no specific treatment for the smallpox virus in
fection except
for supportive care of the symptoms. The variola virus appears to infect only hu
mans, and it may
be passed from person to person through infected body fluids and contaminated be
dding. It is very
rarely passed through the aerosol route, and is not naturally pres- ent in natur
e, so use of the
virus as a bioterrorist tool would require more effort than some of the other ag
ents discussed

here. Hemorrhagic fever viruses: These viruses are car- ried by a host or vector
, usually a
rodent (such as a rat or mouse) or a tick, flea, or mosquito. For some of the vi
ruses (Ebola and
Marburg, for instance) the host is still unknown. Once a human has been infected
, it is possible
to spread the virus from person to person through contaminated body fluids. Outb
reaks are
sporadic around the world, and usually remain limited to the area where the vect
or or host is
located, but this has the potential to change. Because of the ease of travel tod
ay, cou- pled
with the fact that rats and mice can stow away on ships and planes, it is possible
for these
diseases to become widespread within a relatively short period of time. Those wh
o are infected
have flu-like symptoms early in the disease process. Then as the disease progres
ses, there may be
evidence of hemorrhaging under the skin, and bleeding from all orifices of the b
ody. Multiple
organs are affected by the virus, and it usually is the organ failure that cause
s fatalities, not
the loss of blood. There are no vaccines or cures for these infections at this t
ime; infected
individuals are quarantined and treated symptomatically. Tularemia: Tularemia is
caused by the
bacterium Francisella tularensis and is carried often by rodents, rabbits, or wi
ld hares. It is
very infectious; only a small number of the bacteria entering the body will caus
e disease. It is
easy to spread this bacterium as an airborne weapon, so it would be a likely cho
ice for
bioterrorist activities. It causes a severe respiratory illness and life-threate
ning pneumonia,
and is not difficult to find in nature. It is treatable with early intervention
and aggres- sive
antibiotic treatment. 1899_Ch10_215-255 21/12/11 2:26 PM Page 222 Chapter 10 Co
llection and
Processing of Samples for Microbial Studies 223 DETAILED MICROBIOLOGY SAMPLE COL
LECTION
PROCEDURES Procedures and supplies may vary for the different mi- crobiology col
lection
processes, but there are common techniques shared by all the systems. Specimens
may be collected
in a sterile cup or tube or, more commonly, on a swab to be transported to the l
aboratory. These
collection swabs are commercially prepared and sup- plied in a sterile pull-apar
t package. The
package in- cludes a sterile swab (often made of Dacron) and a transport medium
designed to keep
the swab from drying out before it reaches the laboratory. Culturette (manufactu
red by Becton,
Dickinson) is an example of a system used for transport. Figure 10-2 includes so
me of the common
sample collection devices available. The following are some techniques to be use
d for all culture
collections: Be certain that a laboratory request form has been completed for th
e patient. The
specific source of the specimen must be documented. Verify the collection techni
que necessary

for the test ordered, as well as how the specimen is to be handled after collect
ion:
refrigeration, room temperature stor- age, frozen. Most bacterial culture specim
ens are to be
kept at room temperature until transported. Always sanitize your hands, and wear
appropriate
personal protective equipment (PPE). In some situa- tions, this may be a face sh
ield or a
disposable gown that covers your scrubs. In patients who have a wound that is po
sitive for
methicillin-resistant Staphylococcus aureus (MRSA), for example, it is often nec
essary to take
extra precautions and to dis- pose of all the PPE used in collection before leav
ing the presence
of the patient. If using a swab, check the package for signs of poten- tial cont
amination
(e.g., water stains, torn outer pack- aging) and verify that the expiration date
has not passed.
If using a different type of collection container, ensure that the package is st
erile by
examining the outer wrapper or safety seal. For swab packages, carefully peel ap
art the plastic
outer envelope, using aseptic technique. Put this down on a flat surface. Pick u
p the swab by the
lid that is attached to the end of the stick end of the swab. (The lid is permanen
tly attached
to the swab in most cases.) It is very important that the swab does not touch an
y other surfaces
before the specimen is collected, or extraneous organisms may be added to the cu
lture specimen.
Collect the specimen appropriately, avoiding any other areas of the body except
those needed for
the collection. Without setting down the inoculated swab, remove the cap from th
e collection
tube (still sitting inside the sterile plastic package) and insert the inoculate
d swab fully into
the collection tube until the lid clicks closed. It may be necessary to activate
the transport
medium present in the tube by breaking an ampule at the bottom of the tube; this
will depend on
the type of collection device used. Remove gloves and other PPE that was used in
the collection
process, and sanitize the hands. Label the specimen carefully, documenting the s
peci- men
source, patients name, the date, the time, the source (be specific), and your ini
tials or
identification. Chart the procedure in the patients chart if it is avail- able to
you. If the
specimen is to be transported via courier to a laboratory for workup, place it i
n a biohazardous
specimen bag. The requisition form goes into the outer pocket of the bag. If the
bag has an area
for documentation for handling and storing the speci- men, mark this appropriate
ly (e.g., room
tempera- ture, refrigerated). Place the specimen in the pickup area for the cour
ier to
transport to the laboratory. Test Your Knowledge 10-6 When using a swab to colle
ct a culture
specimen, is it acceptable to set it down on a countertop while getting the pati
ent situated for

the collection procedure? (Outcome 10-2) Figure 10-2 Swab collection devices. Co
urtesy of BD,
Inc. Throat Sample Collections for Culture or Strep Screens Samples may be taken
from the throat
of patients for group A strep screens for general cultures, or sometimes both ty
pes of specimens
at the same time. For both a strep screen sample and a culture sample the collec
tion procedure is
identical, but the materials used for the col- lection may differ. Before beginn
ing the
collection, it is 1899_Ch10_215-255 21/12/11 2:26 PM Page 223 important to verif
y whether the
physician wants a cul- ture to be performed, a strep screen, or both. Once the s
trep screen is
performed, it is not possible to use the sample for the culture setup. If both a
culture and a
strep screen are ordered, the culture plate may be inoculated before the strep s
creen is
performed, but not afterward. It is also possible to use two swabs (these are pa
ckaged as a
double swab) at the same time to collect the sample so that one can be used for
each procedure.
Be careful about the type of collection swab used; strep screens rec- ommend the
use of rayon
collection swabs. Cotton swabs or wooden tipped swabs are not to be used for str
ep screens. Some
of the CLIA-waived procedures dont recommend the use of liquid or gel transport m
edia after
collection. Throat samples are used most commonly to test for streptococcal infe
ctions with a
group A strep screen rapid test completed in the physician office. Group A strep
tococcus (a
subtype of Streptococcus pyogenes) is the most common cause of streptococcal thr
oat infection.
Those who are positive for streptococcal infection of the throat should be treat
ed immediately to
avoid sequela that can develop as a result of the initial strep infection. A seq
uela is a serious
secondary complication or infec- tion that follows as a result of the primary ba
cterial
infection. For a group A streptococcal infection, these complications may includ
e heart damage
and kidney damage from glomerulonephritis. Throat specimen col- lections are per
formed using a
sterile swab, often made of Dacron, rayon, or a cotton mixture. For a throat cul
ture, the sterile
swab is part of a packaged culture collection kit, with transport media usually
present in the
transport tube. The throat culture specimen is trans- ported to the laboratory f
or processing,
whereas a strep screen sample is usually processed immediately after collection
by performing a
CLIA-waived strep screen test. A sterile swab provided with the strep screen kit
is used for the
collection, and there is no transport medium present. Remember to verify whether
the physi- cian
wants both a strep screen and a culture to be performed, as the medical assistan
t needs to know
this information before performing the strep screen. taken from the back of the
throat, a tongue

depressor, personal protective equipment, and the supplies in the kit. The entir
e process takes
approximately 10 minutes from the time the order is received to the time the res
ult may be
reported. This fast turnaround time and the ease with which the test can be perf
ormed allow the
patient to be treated immediately if the screen is positive for the streptococcu
s A antigen. The
CLIA-waived group A strep screen procedure is presented in Chapter 24. 224 Secti
on II Specimen
Collection and Processing Test Your Knowledge 10-7 What is one way that a collec
tion for a throat
culture and a rapid strep screen are similar? (Outcome 10-5) Strep screens are o
ne of the most
common CLIA- waived tests performed in all types of laboratories. The test is si
mple to perform,
and requires only a sample Test Your Knowledge 10-8 Is it acceptable to collect
only one swab if
a strep screen and a throat culture are ordered? (Outcome 10-5) Test Your Knowle
dge 10-9 Are the
samples for a strep screen and for a throat cul- ture collected from different a
reas of the
throat? (Outcome 10-5) Sputum Samples When patients are diagnosed with a lower r
espiratory
infection, such as pneumonia, it is important to identify the causative organism
if possible.
This allows the health-care provider to plan the best course of action for treat
ment. Sputum
samples are necessary for culture and organism identification in these situation
s. Sputum is the
substance produced from a deep cough or from aspi- ration caused by inserting a
tube down the
patients throat. Aspiration of sputum is primarily performed on patients who are
intubated in an
inpatient setting, but sputum cultures may be collected by patients at home with
out aspiration.
The medical assistant is not usually involved with the actual collection process
for a sputum
sample if employed in a physician office, but it is important that the procedure
is explained
thoroughly to the patient so that he or she may produce a quality sample. Sputum
samples are
collected into a sterile container (such as a urine cup or a centrifuge tube) an
d transported
imme- diately to the laboratory for processing. Ideally, a spu- tum collection s
ystem will
protect the sample from UV light. The system should also prevent the health-care
employees
processing the specimen from being exposed to the sputum. Becton, Dickinson offe
rs a sputum collection system that does both, composed of a large cen- trifuge tube enclosed in
an amber
funnel tube with a lid on the top (Fig. 10-3). The amber outer container is import
ant, as
Mycobacterium tuberculosis, the causative 1899_Ch10_215-255 21/12/11 2:26 PM Pag
e 224 Chapter 10
Collection and Processing of Samples for Microbial Studies 225 Procedure 10-1: C
ollection of a
Throat Specimen for Culture or Strep Screen Throat culture collections are very
common procedures

in physician offices. It is important to perform the col- lection process correc

tly to ensure
meaningful results. Remember to communicate appropriately with the patient to as
sist with the
collection process. TASK Collect an appropriate specimen from the throat for a c
ulture or strep
screen. Complete the procedure within 5 minutes. CONDITIONS Hand sanitization eq
uipment
Gloves Tongue depressor Safety shield Sterile culture swab or swab provided with
strep
screen kit Label Laboratory requisition form Biohazardous waste container Biohaz
ardous
transport bag CAAHEP/ABHES STANDARDS CAAHEP Standards I.A.I.2. Use language/verb
al skills that
enable patients understanding, III.C.III.3: Discuss infection control procedures,
III.C.III.9:
Discuss quality control issues related to handling microbiological specimens. II
I.P.III.2:
Practice Standard Precautions, III.P.III.3: Select ap propriate barrier/persona
l protective
equipment (PPE) for potentially infectious situations, III.P.III.7: Obtain spec
imens for
microbiological testing, III.A.III.1: Dis- play sensitivity to patient rights a
nd feelings in
collecting specimens, III.A.III.2: Explain the rationale for per- formance of a
procedure to the
patient. ABHES Standards Apply principles of aseptic techniques and infection co
ntrol Use
standard precautions Practice quality control Perform selected CLIA-waived tests
that assist
with diagnosis and treatment, #5: Microbiology testing Dispose of biohazardous m
aterials
Collect, label and process specimens, #3: Perform wound collection procedures, #
4: Obtain throat
specimen for microbiology testing Procedure Rationale 1. Greet and properly iden
tify the patient,
using at least two unique identifiers. Introduce yourself. 2. Explain the proced
ure to the
patient. Answer any questions that the patient may have about the collection pro
cess. 3. Sanitize
hands (allow them to dry) and apply gloves. It is imperative that the identity o
f the patient is
veri- fied before the specimen is collected. The medical assistant should always
identify him- or
herself with any patient interaction. Explaining the procedure will help the pat
ient know what to
expect and will facilitate cooperation. Answering questions allows the medical a
ssistant to
display sensitivity to patient rights and feelings in collecting specimens. Glov
es must be worn
for any procedures in which exposure to blood or other potentially infectious ma
terials is
anticipated. Continued 1899_Ch10_215-255 21/12/11 2:26 PM Page 225 Procedure Rat
ionale
Organization of supplies is important so that the collec- tion procedure may con
tinue without
interruption. The back of the throat must be well lit and accessible for the col
lection to be
successful. Because this procedure may initiate coughing or gag- ging in some in
dividuals, it is

important that the medical assistant protect against potential exposure. The mou
th must be opened
wide to gain full access to the collection area. Introduction of extraneous micr
oorganisms may
result in inaccurate culture results. Adequate sample must be obtained for the a
ccuracy of the
culture results. White areas may represent clus- ters of bacteria, so it is impo
rtant that these
are included in the sample. It is important that the swab be processed appropriately so that
the results are representative of the bacteria present in the throat. CLIA-waive
d strep screen
package inserts will specify whether liquid preservatives (such as Amies or Stua
rt media) can be
used. Rayon swabs with dry transport are recommended for strep screen specimen c
ollection and
transport. Proper disposal is necessary for quality control purposes. The specim
en should always
be labeled in the presence of the patient. Gloves should be removed when no long
er necessary. 226
Section II Specimen Collection and Processing 4. Gather necessary supplies with
in reach. If a
strep screen is ordered, be certain to use the swab supplied with the kit. If a
throat culture is
requested, use a sterile swab packaged with the transport media. 5. Position the
patient in an
upright position. If nec- essary, adjust available lighting so that the back of
the throat is
well lit. 6. Put on face safety shield. 7. While holding the tongue depressor in
one hand and the
collection swab in the other, instruct the patient to open his or her mouth wide
. 8. Push down on
the tongue lightly with the tongue depressor, and insert the swab into mouth. Be
cer- tain to
avoid touching the tongue, cheeks, gums, or teeth with the collection swab. 9. G
ently brush the
swab against the tonsillar area and the back of the throat. A gentle rotating mo
tion works best.
Be sure to touch any white or inflamed patches present with the collection swab.
10. After
removing the swab from the mouth, place it in the sterile container. If only a t
hroat culture is
requested, slide the swab into the container and activate the preservative or co
at the swab. If a
strep screen was ordered, only rayon swabs may be used for the collection, and l
iquid
preservative is not recommended in the swab container. 11. Dispose of the tongue
depressor in the
biohazard garbage. 12. Label the specimen appropriately and place the labeled sp
ecimen in a
biohazardous transport bag to go the laboratory. 13. Remove gloves and safety sh
ield. Procedure
10-1: Collection of a Throat Specimen for Culture or Strep Screencontd 1899_Ch10_2
15-255
21/12/11 2:26 PM Page 226 Date 1/18/2014 Throat culture specimen collected.
Connie Lieseke, CMA (AAMA) 11:10 a.m.
Procedure Rationale Chapter 10 Collection and Processing of Samples for
Microbial Studies

227 agent of tuberculosis infection, does not live long when exposed to light. T
he specimen must
remain protected from light until it is processed in the laboratory, or this pat
hogenic
microorganism may not be isolated from the culture even though it is present. On
ce the specimen
arrives at the laboratory, the technician will remove the inner tube that contains
the sputum
and process the specimen according to protocol to set up the culture. Patients c
ollecting sputum
samples must be instructed that a deep cough is absolutely necessary to produce
an acceptable
specimen. If saliva rather than sputum is sub- mitted for testing, the specimen
will most likely
contain only normal flora for upper respiratory system, and the culture results
will be
inconclusive. It is recommended that the sample be obtained first thing in the m
orning, after the
patient brushes his or her teeth and rinses the mouth, but before ingesting food
or drink.
Because the pathogenic microorganisms responsible for many lower respiratory inf
ections are
spread by droplets in the air, it is necessary that the patient perform collecti
on in a private
area, preferably at home. Do not allow a patient to attempt to produce a sputum
culture specimen
in the waiting room of the physician office, as this will potentially expose the
other patients
to the pathogenic microorganisms distributed as aerosol when the patient coughs.
The sample must
be delivered to the laboratory as soon as possible after collection, preferably
within 2 hours.
The specimen should not be refrigerated, nor exposed to extreme heat. 14. Wash h
ands, and thank
the patient for being coop- erative. Add documentation to the laboratory req- ui
sition form if
needed. 15. Chart the procedure appropriately. Hands must be washed whenever glo
ves are removed.
The requisition form must be completed with the date and time of collection as w
ell as the source
of the culture. All patient interactions should be recorded on the chart. Figure
10-3 BD sputum
collection container. The inner tube may be removed from the bottom of the conta
iner with minimum
exposure potential for the employee. Courtesy of BD, Inc. Test Your Knowledge 10
-10 Why should a
sputum specimen not be collected in the waiting room of a physician office? (Out
come 10-6) Once
the specimen arrives at the laboratory, the technician (or sometimes, in an inpa
tient setting, a
res- piratory specialist) will decide whether the specimen is 1899_Ch10_215-255
21/12/11 2:26 PM
Page 227 228 Section II Specimen Collection and Processing acceptable for cultu
re. The
technician also documents the volume and appearance of the specimen. A sputum sa
mple that has too
many epithelial cells present and is too watery in appearance is often a saliva sa
mple; it was
not the result of a deep cough and is not suitable for culture setup. Sputum col
or and thickness

are not indicators of any specific illness, and this information should never be
interpreted in
this way. Urine Samples for Culture Urine specimens used for culture must be col
lected in a
manner that reduces potential contamination by non- pathogenic microorganisms. T
his may be
accomplished by utilizing the clean-catch midstream collection method (see Chapt
er 9), or
alternatively, urine may be collected for culture with a straight catheter or su
prapu- bic
aspirate taken directly from the bladder. Urine samples for culture should never
be taken from an
indwelling catheter, as the potential for extraneous con- tamination is very hig
h. The medical
assistant must be sure to document on the requisition form whether the specimen
was obtained from
a catheter or via the clean- catch midstream urine method, as the amount of urin
e applied to the
agar plate and the interpretation of the re- sults are different for each type o
f specimen.
Figure 10-4 shows an example of the different sizes of inoculation loops used fo
r urine
specimens. Patients must be provided with a sterile cup for the urine collection
, and given
instructions in how to perform the collection to provide a satisfactory culture
sample. It is
also imperative that within 1 hour of collection the specimen is set up for cult
ure,
refrigerated, or preserved in some way to keep the bacterial count stable. Urine
tubes with
preservative are available for this purpose. The bacteria present in the culture
specimen will
multi- ply at a very high rate if the urine is left at room temper- ature for mo
re than an hour,
so the culture results may appear to be erroneously abnormal. Figure 10-4 Urine
loops for
culture. The larger loop is used to apply urine collected via catheterization an
d the smaller
loop is used for inoculation of urine collected via the clean-catch method. Cour
tesy of Fisher
HealthCare, Inc. Test Your Knowledge 10-11 Which of these urine specimen types m
ay not be used
for cultures? a. Specimens taken from indwelling catheters b. Specimens obtained
using a straight
catheter c. Specimens collected via the clean-catch midstream collection techniq
ue d. None of the
above (Outcome 10-7) Blood Culture Collection Health-care providers order blood
culture
collections when they suspect that the patient may have pathogenic bacteria in t
he bloodstream, a
condition known as sep- ticemia. The National Center for Injury Prevention and C
ontrol is part of
the Centers for Disease Control and Prevention (CDC) and is responsible for comp
iling statistics about injuries and reducing their consequences. According to its statist
ics, septicemia
was the 10th lead- ing cause of death in the United States in 2006, respon- sibl
e for more than
30,000 deaths. Septicemia is often a complication of urinary tract infections, p
neumonia, and

infected wounds. Blood cultures assist the health- care provider by providing in
formation about
the causative agent of the infection, as well as determining which antibiotics w
ill be best to
use for treatment. It is common for blood cultures to be ordered just before or
just after a
fever has spiked, and they are often ordered as STAT blood draws. Ideally, blood
cultures will be
drawn before antibiotics have been administered. Special bottles that contain nu
trients capable
of sup- porting all bacterial growth are used for blood cultures, one that inclu
des special
nutrition and a unique atmos- phere to encourage growth of microorganisms that n
eed oxygen to
grow (aerobes) and one that is specially designed to support growth of microorga
nisms that do not
do well in the presence of oxygen (anaerobes). There may be special instructions
with the order
for the timing of the blood draws; some practitioners ask that they are drawn 30
minutes apart,
whereas others will 1899_Ch10_215-255 21/12/11 2:26 PM Page 228 have them done s
erially, which
means that they are drawn at regular intervals over a set period of time. The or
der may also be
to draw two blood cultures, which means that they are to be drawn one after the
other in two
different sites. A syringe with a safety needle may be used to obtain the specim
en for the blood
cultures (at least a 20-mL syringe for adults; at least a 10-mL syringe for chil
dren) or a
butterfly setup may be used. The firm bioMrieux has created BacT/ALERT, a blood c
ulture system
that includes a butterfly adapter that can be used to fill the blood culture bot
tles directly
during the venipuncture, eliminating the need to transfer the blood from the syr
inge to the
bottles. The BacT/ALERT setup also includes an adapter that allows blood to be d
rawn directly
into other blood tubes if there are additional samples ordered at the same time
as the blood
culture specimens. This helps to minimize the invasive proce- dures performed fo
r that patient.
Adult specimens should have approximately 10 mL of blood added to each bottle. T
he vacuum will
automati- cally pull the blood into the bottle from the syringe or from the vein
if a butterfly
setup and adapter are used. Monitor the flow carefully, as the vacuum does not a
lways stop when
the correct amount of blood has been added, and it is possible to overfill the b
lood culture bottles. Depending on the manufacturers recommenda- tions, pediatric draws will most
likely call
for 2 to 5 mL of blood per bottle. There are special blood culture bottles avail
able for patients
who have already started on antibiotic therapy. These include substances that ne
utralize or
remove the antibiotics from the blood so that they cannot interfere with the gro
wth of the
microorganisms. Examples are the Antimicrobial Removal Device (ARD), produced by
Becton,

Dickinson, or a Fastidious Antimicrobial Neu- tralization bottle, made by bioMrie

ux. Chapter 10
Collection and Processing of Samples for Microbial Studies 229 Test Your Knowled
ge 10-12 Why are
multiple bottles inoculated when collecting blood cultures? (Outcome 10-8) Becau
se bacteria are
not usually present in the blood- stream, the presence of any growth in the bloo
d culture is
considered to be abnormal. It is imperative that a detailed, controlled aseptic
process is
followed to clean and disinfect the skin as thoroughly as possible before the sp
ecimens are drawn
to avoid contamination with normal skin flora. Contamination of the specimen may
lead to
thousands of dollars worth of treatment that otherwise would have been unnecessa
ry and additional
hospitalization days. Each laboratory will have established protocol for the blo
od cultures drawn
and processed within its facility. The majority of methods will include the use
of a combination
of 1% to 2% tincture of iodine provided in applicator sticks or cleaning pads, o
r 10% povidone
pro- vided in cleaning packets. Alcohol pads may also be used for a two-step cle
aning process.
The blood culture collec- tion supplies may be purchased as a kit; Figure 10-5 s
hows an example.
Surgical asepsis must be followed carefully to keep from contaminating the sampl
e, so the site
must not be repalpated after cleaning unless sterile gloves have been applied. F
igure 10-5 Blood
culture collection kit containing two bottles, an iodine-based scrub and brush,
and alcohol pads.
Courtesy of BD, Inc. Test Your Knowledge 10-13 How many times is the draw site
cleaned/disinfected prior to blood culture collections? a. One time b. Two times
c. Three times
d. Four times (Outcome 10-8) Cerebrospinal Fluid Samples Cerebrospinal fluid (CS
F) samples are
used to help diagnose various diseases of the central nervous system. These dise
ases include
meningitis and encephalitis caused by bacterial, viral, fungal, or parasitic inf
ections. CSF
samples are collected only by a qualified health-care provider by means of a lum
bar puncture, in
which a needle is placed between the lower lumbar vertebrae into (Text continues
on page 234)
1899_Ch10_215-255 21/12/11 2:26 PM Page 229 Procedure Rationale Procedure 10-2:
Blood Culture
Collection Procedure Blood cultures are ordered when the health-care provider su
spects an
infection of the bloodstream with a pathogenic microorganism. The collection pro
cess is similar
to that of a typical blood draw, but there are specific procedures for disinfect
ion of the
puncture site and inoculation of the blood culture media that must be followed c
arefully. Blood
cultures that are contami- nated with normal skin flora may result in improper t
reatment and
prolonged hospital stays. TASK Perform a venous blood culture collection. CONDIT
IONS Laboratory
requisition form Hand sanitization equipment Gloves Blood culture bottles 10% Po

vidone
iodine swab stick or other antiseptic scrub kit Alcohol prep pads 22- or 23-gaug
e, 1-in.
needle and 20-mL syringe or 22- or 23-gauge butterfly setup with luer adapter an
d special bottle
cap for inoculation of blood culture bottles Biohazardous sharps container Bioha
zardous waste
container CAAHEP/ABHES STANDARDS CAAHEP Standards I.A.I.2: Use language/verbal s
kills that enable
patients un- derstanding, III.C.III.3: Discuss infection control proce- dures, II
I.C.III.5: List
major types of infectious agents, III.C.III.8: Differentiate between medical and
surgical asepsis used in ambulatory care settings, identifying when each is appropriate, III.
C.III.9: Discuss
quality control issues related to handling microbiological specimens. III.P.III.
2: Practice
Standard Precautions, III.P.III.3: Select appropriate barrier/personal protectiv
e equipment (PPE)
for potentially infectious situations, III.P.III.7: Obtain spec- imens for micro
biological
testing, III.A.III.1: Display sensi- tivity to patient rights and feelings in co
llecting specimens, III.A.III.2: Explain the rationale for performance of a procedure to the p
atient. ABHES
Standards Apply principles of aseptic techniques and infection control Use stand
ard
precautions Practice quality control Dispose of biohazardous materials Collect,
label and
process specimens 230 Section II Specimen Collection and Processing 1. Verify t
he test ordered
on the requisition form. Pay special attention to the time and/or frequency of t
he blood culture
specimen collection. Note the age of the patient. 2. Gather necessary supplies.
Verify the
expiration date on the blood culture bottles and antiseptic solution. 3. Wash ha
nds (if they are
visibly soiled) or apply hand sanitizer. Allow hands to dry completely. The test
and
identification on the specimen label should be verified every time to avoid erro
neous re- sults.
Blood cultures may be ordered as STAT draws, which must be performed immediately
, or they may be
ordered at specific frequencies, such as 1 hour apart. The patients age may be si
gnificant, as
there are often special blood culture bottles or differences in the required blo
od volume for
pediatric patients. Expired bottles and antiseptics may not be used. Clean hands
stop the spread
of infection. Hands should be completely dry before attempting to apply gloves,
or it will be
difficult to put the gloves on the wet hands. 1899_Ch10_215-255 21/12/11 2:26 PM
Page 230
Procedure Rationale Chapter 10 Collection and Processing of Samples for Microbi
al Studies 231 4.
Apply tourniquet to the desired site and select an appropriate venipuncture site
. Release
tourniquet. 5. Cleanse the venipuncture site. 6. Prepare the setup for the blood
draw. This may
be a needle and syringe (at least 20 mL) or a butterfly setup with a luer adapte

r attached to a
special cap that goes over the blood culture bottles and allows the blood to be
introduced
directly into the bottles. 7. Mark the blood culture bottles on the side with th
e minimum and
maximum volumes. 8. Prepare the blood culture bottles. Flip off the re- movable
bottle cap and
clean the rubber stopper with an alcohol prep pad. Discard this pad and cover th
e rubber stopper
with a clean alcohol prep pad. Leave this pad in place until the blood is added
to the bottle. It
is important to establish a visual landmark for the venipuncture site chosen, as
it will not be
possible to repalpate the site before insertion of the needle. The tourniquet mu
st be removed
because appropriate skin cleansing techniques for blood culture collec- tion tak
e more than 1
minute. The cleansing process will vary with laboratory poli- cies. Some sites p
refer a two-step
process, in which the site is vigorously cleansed with alcohol for 30 seconds, f
ollowed by use of
a povidone or iodine swab stick. If a povidone/iodine swab stick or clean- ing p
ad is used, the
solution must be applied using a concentric circle motion, beginning at the chos
en venipuncture
site and moving outward without going over any area more than once. If an alcoho
l/chlorhexidine
cleansing kit is used, the site must be scrubbed vigorously for at least 30 to 6
0 seconds. This
is the recommended method for cleaning the site for infants older than 2 months
of age or for
those with iodine sensitivity. Regardless of the cleansing method, the site must
be allowed to
dry completely before insertion of the needle into the skin. The choice of needl
e setup is based
on the size and condition of the veins. The ideal ratio of blood to the medium i
n the bottles is
1:10. This means that each bottle should have 10 mL of blood added for optimal r
esults. Blood
culture bottles do have a vacuum that functions to pull in the blood specimen fr
om a syringe or
butterfly. However, the vacuum in these bottles is not controlled as carefully a
s that in the
evacuated tubes, so care must be used to monitor the amount of blood added to th
e bottle. It is
possible to overfill the blood culture bottles. It is important to make a mark o
n the bottle so
that the phlebotomist can estimate when the appropriate amount of blood has been
added. Asepsis
is critical for blood culture collections. Every precaution must be followed to
eliminate an
oppor- tunity for bacterial contamination of the specimen. Continued 1899_Ch10_2
15-255 21/12/11
2:26 PM Page 231 Procedure Rationale 232 Section II Specimen Collection and Pro
cessing 9.
Reapply the tourniquet and withdraw the necessary volume of blood; 20 mL is the
desirable volume
for most blood culture procedures. Draw the blood using a butterfly setup or a s
yringe with a
needle attached. Option 1: Blood Collection Using a Butterfly Setup a. Assemble

the butterfly
setup with a luer adapter attached to the end of the tubing. Screw the other end
of the luer
adapter into the special adapter cap designed for the blood cul- ture bottles to
be used, or an
evacuated tube holder if this works for the bottles. b. Using appropriate venipu
ncture technique,
in- sert the butterfly needle into the vein. Continue to hold the butterfly devi
ce or tape in
place. c. Remove the alcohol pad from the top of the bottle and push down the ad
apter to pierce
the septum of the blood culture bottle. Blood should be added to the aerobic bot
tle first. d.
Monitor the bottle volume and pull up the adapter to remove the needle from the
stopper when the
desired amount of blood has been added to the bottle. e. Follow the same procedu
re to add blood
to the anaerobic bottle. Monitor the volume as neces- sary and pull up the adapt
er when the
desired volume has been reached. 20 mL of blood will provide 10 mL per bottle, w
hich is the
desired volume for best detection and identi- fication of infective microorganis
ms. By using the
luer adapter and the special cap, the blood can be added directly into the blood
culture bottles
without need of additional transfer procedures. It is important to secure the ne
edle to avoid
damage to the vein and to ensure a successful blood draw. The vacuum in the bloo
d culture bottle
will pull the blood from the vein. It is possible to overfill the bottles, so th
is is an important step to follow. Anaerobic bottles should be filled after the aerobic bottle
s. Procedure
10-2: Blood Culture Collection Procedurecontd 1899_Ch10_215-255 21/12/11 2:26 PM P
age 232
Procedure Rationale Chapter 10 Collection and Processing of Samples for Microbi
al Studies 233
Option 2: Blood Collection Using a Syringe and Needle a. Open the sterile packag
e holding the
syringe. b. Pull back and push forward the plunger of the syringe several times
to verify whether
it moves smoothly. c. Remove the needle from the sterile wrapper. Do not take of
f the cap
covering the end of the needle until just before insertion into the patients arm.
d. Attach the
needle to the syringe tip. e. Reapply the tourniquet, taking care not to touch t
he venipuncture
site. Using appropriate technique, withdraw 20 mL of blood into the syringe, and
have the patient
place pressure over the venipuncture site. f. If the bottle is designed to fit a
transfer device,
activate the safety device on the needle, remove it from the syringe, and discar
d it in a biohazardous sharps container. Attach the transfer de- vice to the syringe. Remove the
alcohol pad from
the top of the bottle and push down the transfer device to pierce the septum of
the blood culture
bottle. Blood should be added to the aerobic bottle first. g. If the bottle is n
ot designed for a
transfer device to fit over the top of the bottle, it will be nec- essary to add

the blood to the

bottle with the needle on the syringe. Verify that the blood cul- ture bottle is
on a stable,
flat surface. Remove the alcohol prep pad from the top of the bottle, and punctu
re the septum
with the needle on the syringe, puncturing the aerobic bottle first. h. Monitor
the volume in the
blood culture bot- tle as the blood is introduced and remove the needle when 10
mL have been
added. i. Repeat the process to add 10 mL to the anaer- obic bottle. Discard the
syringe/needle
setup in a biohazardous sharps container. Syringes should remain sterile until t
he time of use.
Exercising the plunger in this manner allows for smooth movement when pulling back
the plunger
to allow blood to enter the syringe. If the plunger does not move smoothly or is
too loose within
the syringe, it should be discarded. The needle must remain sterile until just p
rior to insertion. It cannot touch other surfaces before piercing the skin of the patient. Ve
rify that this is
a secure connection so that blood will not leak out around the needle during the
venipunc- ture
process. Special care must be utilized to keep the disinfected site without cont
amination; 20 mL
of blood is optimal for the blood culture procedures. The blood culture bottles
may come with a
very small neck that is designed for use with a standard trans- fer device such
as that in an
evacuated tube system. Do not hold the blood culture bottle with your hand while
puncturing the
septum, as this will increase the chance of an accidental needlestick. Place the
bottle on the
counter or tabletop. Do not overfill the blood culture bottle. Avoid contaminati
on of the septum
on the anaerobic bottle. Continued 1899_Ch10_215-255 21/12/11 2:26 PM Page 233 2
34 Section II
Specimen Collection and Processing Procedure Rationale Procedure 10-2: Blood Cul
ture Collection
Procedurecontd 10. Label both bottles and the requisition form with the date, time
and site of
the blood draw, as well as the birth date or other patient ID and the initials o
f the collector.
Transport to the laboratory as soon as possible for processing. 11. Clean the io
dine solution off
the patients arm us- ing an alcohol swab. Clean up the work area and chart the pr
ocedure.
Accurate labeling and documentation are always necessary. The iodine solution ma
y become
irritating to the skin if left on the patients arm after the procedure. the subar
achnoid space,
and a sample of cerebrospinal fluid is withdrawn for analysis. This procedure ma
y also be known
as a spinal tap. Generally, four tubes are used for the collection, with 1 to 8
mL of fluid
placed in each tube. The tubes are numbered in order of collection, which is a v
ery important
part of the procedure. In most situations, the first tube collected during the l
umbar puncture is
used for chemical analysis, including protein and glucose levels. The second tub

e is used for
culture and other microbiology testing, and the last tube col- lected is used to
perform a cell
count to look for presence of red and/or white blood cells. Medical assistants m
ay aid in the
collection procedure for CSF samples, and they may also process the samples to b
e delivered to
the laboratory. All CSF analysis must be conducted on a STAT basis, as the integ
rity of the cells
present in the specimen may deteriorate rapidly once the spinal fluid leaves the
body. Some tubes
used for CSF collection are already labeled with numerals that are raised on the
side of the
tube, but if not, the num- bering of the tubes as the fluid is added is critical
, as is the
assurance that sterile technique is maintained when handling the specimen. The t
ubes must be
closed securely after the fluid is added and labeled appropriately with all pati
ent demographic
information and the date and time of the collection. Ideally, if the medical ass
is- tant knows
that a lumbar puncture is to be performed in the office, he or she may contact t
he laboratory to
request a STAT courier pickup before the procedure is started, so that the couri
er will arrive
very shortly after the process has been completed. Do not refrigerate or freeze
CSF samples after
collection before the routine testing can be performed. Test Your Knowledge 10-1
4 What is the
additional information required on the CSF collection tubes that is not required
for other types
of microbiology samples? (Outcome 10-9) Genital Samples Genital cultures use sev
eral types of
media to identify microorganisms that cause common genital infections such as ce
rvicitis
(inflammation of the cervix), urethritis (inflammation of the urethra), or pelvi
c inflammatory
disease. Not all organisms that cause genital infections can be easily cultured,
but common
infective agents isolated and identified with culture procedures include yeast i
nfections caused
by Candida albicans, and bacterial infections (vaginosis) caused by Gardnerella
vaginalis,
Neisseria meningitides, or Haemophilus ducreyi. Another common infection of the
genitals is
trichomoniasis, which is a sexually transmitted disease caused by the parasite T
richomonas
vaginalis. This parasite is identified through microscopic examination of vagina
l smears and
other testing methods, but not cultures. Date 3/12/2014: Blood culture collectio
n X2 from right
and left arm.
Connie Lieseke, CMA (AAMA) 4:40 p.m.
1899_Ch10_215-255 21/12/11 2:26 PM Page 234 Many sexually transmitted di
seases, such as
chlamy- dia, herpes, human papillomavirus infection, and syphilis, are not typic
ally identified
through culture, because the causative microorganisms are difficult to grow in t

he laboratory.
More often, these diseases are identified through serological tests that check f
or the presence
of antigens or antibodies. If a culture order is received for these microorganis
ms, the order
should be verified before proceeding with collection. If the health- care provid
er really wants a
culture to be performed, the medical assistant should carefully investigate the
collec- tion and
processing procedures so that the culture is viable and the results are meaningf
ul. Cultures from
the genitals of patients are usually ordered if the patient complains of itching
, discharge, or
burning, or if the patient has visible lesions on or near the external genitalia
. Remember to use
standard precau- tions at all times when assisting with the collection or proces
sing of these
specimens. The specimens may be collected via aspiration (as in the case of absc
esses), or more
commonly swabs are used to obtain a specimen from open lesions or discharge. Whe
n collecting a
ure- thral swab from a male patient, a small swab on a wire may be inserted into
urethra to
obtain the culture speci- men. It may also be necessary to collect specimens fro
m the rectum if
the sexual history of the patient makes this a probable site for infection. Vagi
nal and rectal
culture specimens may also be col- lected from pregnant women to test for the pr
esence of group B
streptococci. This is an important procedure to avoid newborn infection with the
se bacteria,
which can cause pneumonia or sepsis. Women infected with group B streptococci ar
e usually
asymptomatic, so this screening process is necessary as part of a routine prenat
al checkup. A
swab is used for the collection, and the specimen is handled following general b
acterial culture
guidelines. If a cervical culture is requested (as in the case of sus- pected go
norrhea), the
specimen collection will require the use of a speculum to widen the vaginal open
ing and provide
access to the cervix. Excess mucus and drainage are to be wiped away from the op
ening of the
cervix, af- ter which a collection swab is inserted into the opening of the cerv
ix and rotated
several times to obtain the spec- imen. Cervical specimens are often collected a
t the same time
that a specimen is collected for a Pap procedure. Specimens collected for gonoco
cci cultures may
be trans- ported in a tube that contains charcoal mixed in the transport medium.
The charcoal is
designed to absorb any interfering substances in the specimen that might decreas
e the growth rate
of the gonococci bacteria. A medical assistant may be asked to inoculate the aga
r plates used to
support bacterial growth from genital culture specimens in the physician office
at the time of
collection. It may be necessary to inoculate more than one type of agar to isola
te the causative
organism. Chocolate agar, which contains lysed (broken) red blood cells, is comm

only inoc- ulated

with the specimen, as it supports the growth of most pathogenic bacteria that ma
y be present in
the genital area. Chocolate agar is shown in Figure 10-6. Pathogens com- monly p
resent in the
genital area need growth factors that are present inside the red cells, so the r
ed blood cells
are lysed when preparing the nutrient agar. However, if the health-care provider
wants to
determine whether the patient may be infected with Neisseria gonorrhoeae (the ca
usative agent of
gonorrhea), he or she will also want to inoculate a Petri dish that contains Tha
yer Martin agar.
Thayer Martin agar contains lysed red cells just as the chocolate agar. In addit
ion, Thayer
Martin agar contains Chapter 10 Collection and Processing of Samples for Microb
ial Studies 235
Test Your Knowledge 10-15 What type of collection device is used for most genita
l sample
collections? a. An aspirate using a needle and syringe b. Skin scrapings c. Swab
s d. Urine
samples (Outcome 10-10) Figure 10-6 Chocolate agar. Courtesy of Fisher HealthCar
e, Inc.
1899_Ch10_215-255 21/12/11 2:26 PM Page 235 antibiotics (vancomycin, colistin, a
nd nystatin),
which inhibit the growth of other bacteria on the agar plate. This allows for th
e gonococci to
grow without competing with other normal flora from the vaginal area. The gonoco
cci also like to
grow in an environment with a low oxygen con- centration. A special CO 2 tablet
may be added to
the bag that contains the agar plate after it has been inoculated to enhance the
growing
environment, or the inoculated agar plate may be placed in a candle jar, a speci
al enclosed container in which the medical assistant places the specimen. After the specimen is
added, the
medical assistant lights a candle and inserts it into the container until the fl
ame goes out.
This process removes oxygen from the environ- ment inside the container and enha
nces the growth
of N. gonorrhoeae if present. Wound Cultures A wound is any break in the skin. A
wound may be a
deep break, an abrasion on the surface of the skin, a sur- gical incision, or a
scratch. Even an
ingrown toenail with signs of infection may be processed as a wound. Wound cultu
res may be
ordered when a patient has redness, swelling, drainage, or heat in or around a w
ound. Cul- tures
collected from breaks in the skin are the most var- ied in collection techniques
, processing
procedures, and results. The most important aspects of wound culture collection
to remember are
the following: Only culture the wound; not the area around it. Con- tamination f
rom extraneous
bacteria will complicate the culture process, and may cause inaccurate results a
nd incorrect
treatment. It is best to collect a culture from a clean wound; the process washe
s away
transient bacteria present in the area that are not involved in the actual infec

tion. Deep
wounds and aspirates are usually collected and processed as anaerobic culture sp
ecimens, as the
bacteria growing in this environment do not prefer exposure to environmental oxy
gen because they
are growing well in the deep tissues of the body. Anaerobic culture specimens ar
e collected using
special culture kits that protect the specimen from oxygen exposure while provid
ing moisture to
keep the specimen viable. It is very important that the source is documented tho
roughly when
working with wound cultures. De- tails of the culture source will dictate how th
e culture is set
up and which types of pathogens the microbiol- ogist is expecting to identify fr
om the wound.
Nor- mal flora may be pathogenic if present as an over- growth (very high in num
bers) within a
certain area of the body, or if present in an area that is usually considered to
be sterile, such
as the eye. Documenta- tion of the patients name, the date and time of collection
, and the
source of the sample should be affixed to the collection container as well as ad
ded to the
requisition form and the patient chart. The source 236 Section II Specimen Coll
ection and
Processing Gardasil vaccinations are available for women. If neces- sary, these
vaccinations may
begin at 9 years of age, but the recommended age range is 11 to 26 years. Gardas
il protects
against the strains of HPV linked to cervical cancer, and also protects against
most genital
warts. Cervarix is specific for the HPV strains that cause cervical cancer. Male
s may also be
vaccinated with Gardasil for protection. These vaccinations are recom- mended fo
r boys and young
men ages 9 to 26 years. POINT OF INTEREST 10-2 Pap smears and human papillomavir
us A Pap smear,
or Pap test, is performed on a sample of cells collected from a womans cervix dur
ing a pelvic
examination. The Pap test does not detect the pres- ence of infection with sexua
lly transmitted
patho- genic microorganisms, but it does detect changes in the cells of the cerv
ix that may
develop into cancer. It also detects malignant cervical cells that may already b
e present. A
genital culture may be obtained at the same time that a Pap sample is collected,
and this may be
tested for the presence of the genital human papillomavirus (HPV), or other susp
ected infectious
agents. A special kit is used for collection of the sam- ple for the Pap smear,
which may include
a brush-like device, a swab, and/or a wooden spatula. Once the sample has been c
ollected by the
health-care provider, it is placed into a solution for preservation and trans- p
ort to the
laboratory. Medical assistants may be responsible for processing the sample appr
opriately after
collection. Once the specimen arrives at the laboratory, a cytotechnologist exam
ines the sample
under a microscope to look for evidence of abnormal cervical cells. Certain stra

ins of the
genital HPV may cause geni- tal warts in males and females. Other strains of HPV
may cause
changes in the cells of the cervix that lead to cervical cancer. The cellular ch
anges are
detected with the Pap smear, but the presence of HPV and verification of the typ
e of HPV
infection must be accomplished with a separate sample collection. Vaccines are a
vailable for
protection against many of the most common strains of HPV. Cervarix and 1899_Ch1
0_215-255
21/12/11 2:26 PM Page 236 information includes details about the side of the bod
y (for instance,
wound left hand thumb) for the wound. If exudate (fluid from the blood vessels i
n the area of
the infection) or pus is present, the health-care provider may culture this drai
nage. However, in
the case of abscesses, sometimes the culture is not per- formed, as the most imp
ortant aspect is
to clear the area of all the abscess material, not find out what caused the absc
ess. Results
obtained from someone with a chronic wound may be very different from those of a
patient with a
wound that has just become infected. Sometimes the quantitative results (number
of colonies or
bacteria present in the culture specimen) may indicate whether current treatment
is working for a
specific wound. A Gram stain is often performed from the original collection swa
b at the same
time the culture is set up. Gram stains provide information about the shape and
staining
characteristics of the pathogen. Observation of the slide after performing a Gra
m stain can
provide preliminary information to guide how the culture is to be started, based
on the types of
bacteria present. For instance, gram-positive cocci often grow better on cer- ta
in media than do
gram-negative rods. Swabs are usually used to collect wound culture speci- mens.
Be sure to
keep the swab sterile until the speci- men is collected. If an aspirate is taken
using a needle
and syringe, the needle must be removed from the sy- ringe before transporting t
he specimen. In
this situa- tion the aspirate is often transferred into a sterile tube for trans
port.
Identification of the transfer tube is es- sential; the laboratory will not know
what type of
fluid is submitted without the documentation, as many body fluids are very simil
ar in appearance.
Wound cul- ture specimens should be delivered to the laboratory as soon as possi
ble, and should
not be refrigerated or frozen before the culture medium is inoculated. designed
to encourage the
growth of known gastroin- testinal pathogens, while discouraging the growth of t
he normal flora
of the area. Only pathogenic microor- ganisms are processed further for identifi
cation and
treatment. Sometimes the physician may also ask for a specimen to be collected t
o check for the
presence of parasites in the gastrointestinal (GI) tract. This is known as an ov

a and parasite
examination (O&P), during which the microbiologist will be looking for the prese
nce of parasites
or their ova (eggs). Stool cul- tures may be ordered when a patient has diarrhea
that lasts more
than a few days, or when there is mucus or blood visible in the stool. A patient
may be exposed
to pathogenic bacteria from eating food or drinking wa- ter that has been contam
inated. Common
sources in- clude water from a contaminated well, lake, or stream, or undercooke
d eggs, poultry,
or beef. Unpasteurized milk is another potential source. When patients travel ou
tside the
country, there may be exposure to bacteria that have become part of the normal f
lora for the occupants of that area, but that will make visitors sick who are not habituated to
them. Stool
specimens for bacterial cultures are collected in a sterile cup. The stool speci
men must be fresh
for cul- ture setup. The specimen should be delivered to the lab- oratory within
2 hours of
collection, and the specimen must be protected from extremes in heat during tran
s- port. The
sample cannot be taken from the water in the toilet bowl, and the sample cannot
contain urine.
Toilet tissue also should not be mixed in with the sample. To successfully colle
ct a stool
culture specimen, it is recom- mended that the patient spread plastic wrap acros
s the back half
of the toilet seat so that the stool can be col- lected on this plastic wrap whe
n eliminated. It
is impor- tant that urine is not introduced to the plastic wrap. For patients wh
o are wearing
diapers, it may be necessary to line the diaper with plastic wrap for successful
collection.
Chapter 10 Collection and Processing of Samples for Microbial Studies 237 Test
Your Knowledge
10-16 True or False: It is not advisable to wash a wound be- fore collecting a c
ulture specimen.
(Outcome 10-11) Test Your Knowledge 10-17 Why is it important for the medium use
d for stool cultures to be so selective? (Outcome 10-12) Stool Specimens Cultures for stool spe
cimens differ
from many of the other cultures that we have discussed because of the copious am
ount of normal
flora that is present in the digestive tract. The culture medium used to process
stool samples is
very selective; it has been Common pathogens isolated from stool specimens inclu
de the following:
Clostridium difficile: Infection with this bacteria often follows use of broad-s
pectrum
antibiotics, which dis- rupt the balance of normal flora in the body and allow t
his opportunistic
bacteria to flourish. C. difficile is a spore-forming bacterium that may live on
surfaces
1899_Ch10_215-255 21/12/11 2:26 PM Page 237 (hospital beds, walls, etc.) for ext
ended periods of
time. The bacteria are shed in the stool of infected individ- uals, and the infe
ction may be life
threatening if not treated appropriately. Patients may form a pseudomembrane, or

artificial
lining in the intestinal tract that impairs absorption of nutrients from the foo
d they ingest. C.
difficile is difficult to grow as a cul- ture (hence the name difficile, difficul
t), but a
toxin is secreted by the bacteria that may be detected in the stool specimen or
in blood from an
infected individual. Salmonella: This name actually describes a group of bac- te
ria of the
Salmonella genus. Salmonella species live in the intestines of many animals, suc
h as baby
chickens, cattle, or pigs. They may also be present in the feces of turtles and
domestic animals.
Food that has been con- taminated with animal feces is the most common means of
transmission. The
bacteria are transmitted via the fecal-oral route, and usually cause abdominal c
ramping and
severe diarrhea within 1 to 2 days of infection. Most of the time the infection
is resolved
without antibiotic treatment within a week, but occasionally the Salmonella bact
eria may enter
the bloodstream and cause more seri- ous illness. To avoid infection with this o
rganism, patients should always wash and cook food thoroughly, keep eggs refrigerated, and
wash their hands
using soap and clean water after working with or petting animals. Shigella: This
name describes
a genus of bacteria that causes diarrhea, including Shigella sonnei and Shigella
flexneri. These
two types cause almost all cases of Shigella infection in the United States. Shi
gella dysenteriae type 1 can cause deadly epidemics, but is very rarely seen in the United
States. Shigella
is transmitted through fecal material from one person to another. Common methods
for transmission
include food han- dlers who do not wash their hands after using the rest- room,
and small
children who share wading pools. In- fected patients will continue to shed the b
acteria in their
stools, which often appear bloody, for several weeks after the symptoms have sub
sided.
Campylobacter: This spiral-shaped organism causes diar- rhea, abdominal cramps,
nausea, and fever
in infected patients. The most common species of the Campylobac- ter genus to ca
use disease is
Campylobacter jejuni. Most cases are spread by the feces of birds or the ingesti
on of birds, as
they are able to carry the bacteria without be- ing ill with it themselves. Infe
ction may occur
from ex- posure to raw or undercooked poultry, but occasionally a dog or cat may
be infected and
the owner may become infected from them. Campylobacter can cause disease with ve
ry little
exposure, so cross-contamination can occur between, for example, cutting boards
in a food
preparation area and a preparers unwashed hands, lead- ing to illness. Campylobac
ter infection
is the most com- mon bacterial infection causing diarrhea in the United States.
Usually it
resolves without antibiotic treatment, but there are many documented cases of in

fected patients
who developed the neurological disorder Guillain-Barr syndrome. The Campylobacter
infection acts
as a trigger to cause an autoimmune response in which the body attacks the nervous
system,
causing paralysis. Escherichia coli: This family of bacteria is present in our e
nvironment, and
is part of our normal flora. However, there are certain strains of E. coli that
can cause
illness, especially when they are introduced into areas of our body where E. col
i is not normally
found. Some of the E. coli families, also known as enterohemorrhagic or verocyto
toxic types of E.
coli, produce the Shiga toxin. The most common one to cause disease in the Unite
d States is E.
coli O157:H7. When a patient has become infected with this type of E. coli, the
toxins produced
by the bacteria cause the illness. Those who are infected usually start to feel
ill within a few
days of ingesting the bacteria. Symptoms include severe abdominal cramps, vomiti
ng, and diarrhea,
which may be bloody. In most patients the infection resolves within a week. Howe
ver,
approximately 5% to 10% of those who are infected with E. coli O157:H7 develop h
emolytic uremic
syn- drome, which can be life threatening. Hemolytic ure- mic syndrome occurs wh
en the toxins
produced by the bacteria begin to destroy the red blood cells and platelets of t
he infected
patient. The torn or broken red cells begin to block the small capillaries in th
e kidneys, which
can lead to total renal failure. Nasopharyngeal Specimens When an upper respirat
ory infection is
suspected, it may be necessary to collect a specimen using a nasopharyn- geal co
llection
technique, commonly used when col- lecting samples to test for presence of viral
microorganisms. The nasopharynx is the area of the pharynx (throat) that runs from the bac
k of the nasal
cavity down to the back of the throat that is visible through the mouth. Nasopha
ryngeal specimens
are usually collected by entering the pharynx through the nose, but they may als
o be collected by
going through the mouth and sweeping the area of the pharynx that is above the uvu
la. Some key
points are the following: Generally, nasopharyngeal swab specimens will be collected 3 to 7
days after the symptoms have started, and 238 Section II Specimen Collection an
d Processing
1899_Ch10_215-255 21/12/11 2:26 PM Page 238 before antibiotics or antiviral medi
cations have been
administered. Always verify the order before collecting the sample. Verify wheth
er a viral
culture or a bacterial culture is requested, and have the correct supplies on ha
nd to handle the
specimen appropriately after collection. Copan Diagnostics makes several types o
f flocked swabs
designed for maximum specimen collection po- tential. Nasopharyngeal swabs tradi
tionally have a
flexible shaft, which may be made of wire or flexible thin plastic. Only Dacron

or rayon swabs
should be used for viral samples. To collect the sample on the nasopharyngeal sw
ab, it is
necessary first to measure how far the swab needs to be inserted for the collect
ion. The depth of
insertion is approximately half the length from the earlobe to the base of the n
ose (nostril) of
the patient. This should be measured and marked on the nasopharyn- geal swab sha
ft so that it is
visible during the collec- tion. The swab is inserted into the nose parallel to
the roof of the
mouth. Continue to insert the swab until the depth of insertion has been reached
and slight
resistance is felt, indicating that the nasopharynx has been reached. The swab s
hould be rotated
several times, and left in place for a few seconds to absorb any mucus that is p
resent. Remove
the swab in the same way that it was inserted. It may be necessary to insert the
swab in the
other nostril and repeat the process. The swab is then placed immediately into t
he viral
transport media (or bacterial transport media if ordered) and processed accordin
g to the
directions provided by the testing laboratory. Eye Cultures Samples from the eye
may be taken
from the conjunctiva, the mucous membrane that covers the inner area of the eyel
id and extends to
cover the exposed surface of the eye. The conjunctiva can be accessed just under
the up- per and
lower eyelids. Eye cultures less commonly are obtained as corneal scrapings or a
n aspirate from
the eye- ball. In the outpatient setting, conjunctival samples will be the most
commonly
collected. When assisting with this procedure, it is important to remember that
the microbiology laboratory will prefer a sample from each eye, even if the infection
is suspected in
only one eye. This al- lows the laboratory to compare any normal flora that may
be present, and
assists with identification of poten- tial pathogens. Also, the collection swabs
should be
moistened with sterile saline or nutrient broth before use to minimize discomfor
t when the
collection swab is rubbed across the delicate surfaces of the eye. Common pathog
ens present in
the eye may be iso- lated by inoculation of the specimens on 5% sheeps blood agar
, chocolate
agar, and mannitol salt agar. The pathogens often include Streptococcus genus, a
s well as
Haemophilus genus, and occasionally Gonorrhoeae bacte- ria may be evident, espec
ially in a
newborn infant whose mother had minimal prenatal care. Chapter 10 Collection an
d Processing of
Samples for Microbial Studies 239 Test Your Knowledge 10-18 Why is the swab used
for eye culture
samples usually moistened prior to use? (Outcome 10-13) Ear Cultures The human e
ar is separated
into three sections: the outer ear, the middle ear (located right behind the tym
panic membrane),
and the inner ear. The middle ear is con- nected to the back of the throat by a

small structure
known as the eustachian tube. Inflammation (with or without infection) of the ea
r is called
otitis and is further specified by adding the location to the name. Otitis me- d
ia describes
inflammation or infection of the middle ear, and otitis externa describes inflam
mation and/or
infection of the outer ear canal. Otitis media is the most common type of ear in
fec- tion, and
usually develops as a result of blockage of the eustachian tube. When this tube
is blocked, fluid
builds up in the middle ear, and if there are bacteria or viruses present (such
as those causing
a sore throat or the com- mon cold), these may be introduced to the fluid within
the ear by the
eustachian tube. (The middle ear is usu- ally a sterile environment.) This is a
common disorder
in children, as their eustachian tubes are shorter and straighter than those of
adults. If the
pressure builds up too much within the middle ear, the tympanic mem- brane may r
upture, and the
health-care provider will take a culture specimen of the drainage with a sterile
swab. Sometimes
it may be necessary to take a culture specimen of the fluid behind the tympanic
membrane when it
has not ruptured. A procedure called tympa- nocentesis may be performed, in whic
h the health-care
provider inserts a needle through the tympanic mem- brane and aspirates a sample
of the fluid
that is built up in the middle ear. Another procedure that may allow ac- cess to
the fluid is a
myringotomy, in which a tiny incision is made into the eardrum to allow for drai
nage of the infected fluid. In this situation, a sterile syringe may be used to aspirate some
of the sample for
a culture, or a sterile swab can be used to obtain the sample as it drains out o
f the eardrum.
1899_Ch10_215-255 21/12/11 2:26 PM Page 239 Otitis externa is a condition that i
s often known as
swimmers ear. When moisture is introduced into the ex- ternal ear canal, it can c
reate a perfect
environment for bacterial or fungal growth to occur. Otitis externa may also be
caused by excess
moisture or a break in or irrita- tion to the skin of this area. The introductio
n of foreign
objects (such as cotton-tipped swabs) or chemicals (such as those present in hai
r-care products
or dyes) may con- tribute to the development of otitis externa. The outer ear us
ually itches, and
there is often discharge and pain in the area as well. If a culture is needed to
identify the
infective microorganism, a sterile swab is used to swipe the lesions and/or obta
in a sample of
the discharge. The outer ear canal does contain normal flora, such as Staphyloco
ccus epidermis,
Staphylococcus aureus, and Corynebacterium genus. causative organisms. Common cl
assifications of
fungal infections include the following: Superficial or cutaneous mycoses: These
infect the
outermost (dead) layers of the skin and hair, as well as the epidermis, hair fol

licles and deeper

layers of the visible skin. Tinea corporis (ringworm) is an example of this type
of infection.
Subcutaneous mycoses: These fungal infections oc- cur in the dermis and subcutan
eous layers of
the skin, and may affect the muscles and tissue layers beneath the skin. Often t
hese are chronic
infections that resulted from an initial wound when the fungus was introduced in
to the body.
Systemic mycoses: Systemic fungal infections may be present in multiple organs a
nd/or areas of
the body. They are often introduced to the body through the respiratory tract. S
ystemic fungal
infections may be caused by opportunistic fungal organisms in patients who have
suppressed or
inactive immune systems (such as HIV-positive patients), or they may be caused b
y a pathogen that
is introduced to the body. Sample collection procedures will differ according to
the site of
infection. It is important that the medical as- sistant and health-care provider
verify which
type of specimen is necessary for the infection before the collec- tion process
begins. Sometimes
the health-care provider will utilize a Woods lamp, which shines a fluorescent li
ght over the
infected area. Certain types of fungi will fluoresce when exposed to this light,
and the
physician may use this information without the need of an actual specimen collec
tion to prescribe
treatment. Table 10-1 summarizes the type of specimen needed and the collec- tio
n method used to
identify the fungal elements in var- ious areas of the body. Sample types includ
e scrapings of
skin lesions for superficial infections, nailbed samples, aspirates from abscess
es, or swabs used
to sample vaginal drainage. 240 Section II Specimen Collection and Processing T
est Your
Knowledge 10-19 Which type of otitis is often linked to excessive moisture in th
e ear? a. Otitis
externa b. Otitis media (Outcome 10-14) SPECIAL SAMPLE COLLECTION AND PROCESSING
PROCEDURES The
role of a medical assistant does not end with the col- lection and labeling of t
he specimens.
Sometimes there are special procedures that must be completed after the collecti
on so that
specimens can be examined, or unique collection requirements for certain specime
ns that require
prior setup. Fungal Sample and Culture Collection Procedures As was presented ea
rlier in this
chapter, specimen collec- tion procedures performed to detect the presence of fu
n- gal elements
may be different from those procedures used for bacterial or viral organisms. Su
ccessful
isolation and identification of fungal elements are dependent on very specific c
ollection
methods, rapid transport, and use of the correct growth medium once the sample a
rrives at the
laboratory. Fungi may be isolated from wounds, ab- scesses, hair follicles, or l
esions on the
skin. Tinea pedis (athletes foot) and Tinea unguium (a fungal infection of the na

ils) are
frequently seen in the physician office. Fungal infections are referred to as my
coses and are
fur- ther identified by the area of infection and/or the Test Your Knowledge 1020 Are all fungal
infections superficial? (Outcome 10-15) Potassium Hydroxide Preparation Many tim
es it is not
necessary to identify the specific type of fungus responsible for an infection;
the most
important information is whether a fungal element is the causative agent. Patien
t treatment is
based on the presence of the fungi without further identification. An examinatio
n of the sample
under the microscope with a drop or two of 10% to 20% potassium hydroxide (KOH)
solution is
1899_Ch10_215-255 21/12/11 2:26 PM Page 240 Chapter 10 Collection and Processin
g of Samples for
Microbial Studies 241 TABLE 10-1 Information needed for collection of samples fo
r fungal
cultures* Type of Infection Specimen Required Collection Method Skin lesions Fun
gal infection of
the hair Nail infection Abscesses and other subcutaneous infections Deep tissue
infections *For
all cultures, specimen ideally will be processed within 2 hours of collections.
Skin scrapings
Pieces of hair with roots attached Pieces of nail and debris from underneath the
nail Aspirate
taken with a needle and syringe, or a sterile swab moistened with saline brushed
over the surface
from deepest area of infection possible Samples of tissue Use the dull edge of a
scalpel or a
glass slide; scrape across the lesion. If there are not enough loose pieces crea
ted with this
action, adhesive tape may be used to pick up a sample. Transport dry in sterile
container. Pluck
out the hair (including root material) with sterile forceps. Transport dry in st
erile container.
Samples from discolored or misshapen parts of the nail preferable; may use micro
drill method to
provide samples from the more proximal parts of the nail for better capture of t
he fungi. Samples
scraped from underneath the nail may also provide fungal elements. Transport dry
in sterile
container. Sample only the actively infected areas for best results. Be certain
that the sample
amounts are adequate for culture. Tissue to be excised; will be minced, then cul
tured for fungal
elements. performed immediately after collection to search for the presence of f
ungi. The KOH
dissolves other organic ele- ments in the specimen such as hair, mucus, skin cel
ls, and bacteria,
but it does not dissolve the fungus that may be present. This allows the healthcare provider to
visualize the fungus and decide on a plan of treatment without waiting for a cul
ture result. Some
fungal species do not show up with the KOH treatment, so the health-care provide
r may order a
culture in addition to the micro- scopic examination if a fungal infection is su
spected upon
examination. It is important to remember that results from a fungal culture may

not be available
until weeks after the sample is submitted, so alternative methods of detection a
re very important
to avoid delay in treatment. Wet Mount Procedure A wet mount is a means by which
living organisms
may be observed under the microscope. Trichomonas vaginalis is a common sexually
transmitted
parasitic microorgan- ism that needs to be visualized as it is alive and active
via a wet mount
examination. A wet mount is prepared by adding a few drops of saline to a sample
(usually a swab
with secretions on it) then placing a drop of saline/ sample mixture onto a micr
oscopic slide. A
cover slip (a small piece of plastic or glass) is applied over the solu- tion on
the slide, and
the health-care provider examines the sample. Diagnosis is made by examining the
struc- tural
characteristics and movement of the microorganism. Wet mount examinations (as we
ll as KOH preps)
are performed in physician offices only by health-care providers or trained labo
ratory
professionals, but not by medical assistants. The medical assistant may set up t
he sample
appropriately and bring it into focus on the microscope for examination, but the
health-care
provider or other appropriately trained personnel will be responsible for perfor
mance of the
examination. A hanging drop slide is another way that a sample, especially those
exhibiting a lot
of movement, may be exa mined for live microorganisms. In this case, a special d
epression slide
is used. These slides have a scoop out of the center of the slide, which forms a d
epression. A
cover slip is also used and petroleum jelly is applied with an applicator to the
four corners of
the cover slip. A drop of the sample (often an inoculated swab that has been agitated in
saline) is placed on the center of the cover slip. 1899_Ch10_215-255 21/12/11 2:
26 PM Page 241
The depression slide is placed over the cover slip, where the petroleum jelly se
als the edges.
The setup is inverted so that the specimen drop is hanging from the cover slip ove
r the
depression. This allows an excellent opportunity to exam- ine the sample for ana
tomy and motility
(movement) of the microorganisms that are present. An example of a hanging drop
slide can be seen
in Figure 10-7. the microorganisms entered the skin will be evident. When a lice
infection is
suspected, the diagnosis is usu- ally made with careful examination of the hair
for the adult
lice or the nits that are present near the scalp. Most infections with ectoparas
ites do not cause
the host to be- come ill; however, secondary infections from the scratch- ing an
d breaks in the
skin may be problematic. The most common internal parasitic infection in the Uni
ted States is
caused by Giardia lamblia. This single- cell parasitic microorganism is passed i
n the feces of
animals. Untreated water in ponds and mountain streams are contaminated with fec

es from
indigenous an- imals in the area such as beaver, muskrat, elk, and deer. The hum
an host then
ingests the parasite by drinking this contaminated water. The presence of the Gi
ardia in the
water cannot be detected without the use of a micro- scope, as it does not chang
e the waters
color, smell, or taste. Infection by other internal parasites such as round- wor
ms, tapeworms,
and hookworms may also occur, but this is not as common in the United States as
it is in other
areas of the world. Endoparasites can damage their hosts by causing cellular des
truction, chewing
damage to the gastrointestinal tract, anemia, blood vessel damage, bloody diarrh
ea, and failure
to absorb nutrients. Ova and Parasite Examination For most endoparasites, the ov
a and parasite
examination (O&P) is used to make a visual identification of the pres- ence of a
dult parasites or
eggs in the stool. Most parasites have adult forms and produce ova (eggs) or cys
ts with sexual or
asexual reproduction. When the gastrointestinal tract is infected with parasites
, the adult
parasites or their eggs are shed into the stool of the infected host. The O&P te
st is performed
by placing thin smears of stool (fresh or preserved) onto slides and examining a
nd/or staining
them for examination. The sample may need to be spun in a centrifuge for concent
ration before the
slide is prepared to allow for easier detection of any parasites or ova present.
The
microbiologist will be able to detect the presence or absence of adult parasites
or the eggs
(ovum), and based on the anatomical structures observed, an identification of th
e species may
also be performed. When a patient is to be tested for the presence of ova and pa
rasites, he or
she is provided with a collection kit that includes a container for the stool sp
ecimen, as well
as one or two small bottles of preservative solution (Fig. 10-8). The bottles mu
st be
appropriately labeled to warn the patient that they contain strong chemicals tha
t could be
harmful if swallowed or allowed to remain on bare skin for extended periods of t
ime. The bottles
may have a scoop built into the cap for the patient to add 242 Section II Specime
n Collection
and Processing Topview Figure 10-7 A depression slide. Note how the "scoop" is t
aken from the
middle of the slide. This is covered with a cover slip. The sample is actually p
laced on the
cover slip with the depression set over this area and the slide flipped for view
ing under the
microscope. Test Your Knowledge 10-21 How are KOH preps and wet mounts similar?
How are they
different? (Outcome 10-16) Sample Collection Procedures for Detection of Parasit
es Organisms that
live on or in a host and use their host for nourishment are known as parasites.
Pathogenic microorganisms that use the human body for nourishment include ectoparasites, whic

h live on the
outside of the body, and endoparasites, which live within the human body. These
parasites feed
off the human host, at the expense of the health of the human that they occupy.
Common
ectoparasites that use humans as hosts include lice, mites, fleas, and ticks. Di
agnosis of these
infections usually occurs with the visual examination of the site. For instance,
the health-care
professional may take a scraping from the skin of the infected individual and ex
amine it under
the microscope to see if there are mites present. Scabies is a parasitic infecti
on with Sarcoptes
scabiei, and this may be diagnosed with a skin scraping. The Burrow ink test is
another method
some- times used for verification of scabies infections, per- formed by rubbing
the site with an
ink pen, then wiping away the ink with an alcohol pad. If there is a parasitic s
cabies infection
then the burrow holes left from where 1899_Ch10_215-255 21/12/11 2:26 PM Page 24
2 the stool
specimen to the preservative in the bottle. Common preservatives are 10% buffere
d formalin and
polyvinyl alcohol (PVA). The formalin allows for ex- tended preservation of the
parasites and
eggs, but the stool sample may be used only for wet mount observa- tion; it cann
ot be stained for
a more permanent record of the examination. PVA does preserve the sample for a r
easonable amount
of time, but it also allows for staining of the slide for further study. Some la
boratories will
pro- vide two bottles with different fixatives. The patient should be advised to
collect the
stool sample into the larger container (provided) or use some other method to co
llect the sample
without contamination of urine or water. Then, the patient should use the scoop
or a pro- vided
applicator to put a small part of the sample into the provided preservative bott
les and return it
to the lab- oratory or physician office. Sometimes a stool culture is ordered at
the same time as
the sample for the ova and parasite examination, so it is important that the med
ical assistant
give appropriate in- structions for the time intervals before the specimen ar- r
ives back at the
office. Some laboratories will also prefer a fresh stool sample, in which case i
t needs to be
delivered to the laboratory within 1 hour of collection to preserve the anatomic
al features of
the parasitic microorganisms for identification. It is also common for health-ca
re providers to
order multiple sample collections, as the par- asites and/or eggs may be shed at
random times in
the stool. Identification of the specimen collection date and time is very impor
tant. Pinworm
Collection Procedures Pinworm infections, caused by the parasite Enterobius verm
icularis, are the
most common type of worm infec- tions in the United States. The pinworm is a sma
ll white worm
that can infect the colon and rectum of humans. School-age children and those wh

o are
institutionalized are at highest risk for this type of infection, as well as tho
se who care for
this population. The adult pinworms are large enough that they can sometimes be
seen around the
rectum without magnification. The adult female pinworm leaves the rectum at nigh
t and lays her
eggs around the opening. Within a couple of hours these eggs are infectious, and
may be shed into
the underwear and bedclothes. This infection often causes intensive anal itching
. Testing for
pinworm infection must occur first thing in the morning, before the individual h
as had a bowel
movement or bathed, as these actions may remove the eggs from the rectal area. A
piece of clear
adhesive tape (sticky side down) may be pressed against the perianal area, and a
ny eggs in the
area will stick to the tape. This process may need to be repeated for several da
ys before eggs
are identified. The eggs can then be viewed under the microscope when placed on
a slide. A
pinworm paddle may also be used for the collection. Becton, Dickinson produces a t
ool called
the FALCON SWUBE Pinworm Paddle, which is a clear plastic paddle with one adhesi
ve side at the
wide end. This sticky side is placed against the perianal area, and then the pad
dle is placed
within a tube to keep it secure until it is examined. The actual paddle can be u
sed as a slide
under the microscope, as it is transparent. Figure 10-9 shows the FALCON SWUBE P
inworm Paddle.
Chapter 10 Collection and Processing of Samples for Microbial Studies 243 Test
Your Knowledge
10-22 How does a collection procedure for an ova and para- site examination diff
er from a stool
culture collection procedure? a. The O&P collection procedures include container
s with
preservative solution, but stool culture sample procedures do not b. Stool speci
mens for cultures
can be kept at room temperature for extended periods of time, whereas specimens
for O&P cannot be
stored at room temperature c. The procedures are exactly the same for both types
of collections
d. None of the above (Outcome 10-17) Figure 10-8 Ova and parasite collection kit
. There are two
different types of preservatives provided, and each bottle has a scoop in the li
d that is used to
add the stool specimen to the preservative. 1899_Ch10_215-255 21/12/11 2:26 PM P
age 243 When the
slide is viewed using the microscope, those bacteria that retain the crystal vio
let dye will
appear pur- ple and be identified as gram positive. Gram-negative or- ganisms wi
ll have retained
the safranin counterstain, and will appear pink when examined. Figure 10-10 show
s gram-positive
and gram-negative bacteria after staining. Gram-stained slides also allow the ap
pearance and
shape (e.g., cocci, bacilli) microorganisms to be viewed. Com- plete identificat
ion (such as
genus and species) cannot be ascertained with a Gram stain, but the microorganis

ms
characteristics that can be determined will assist the physician in making appro
priate initial
treatment deci- sions. If the Gram stain is performed at a laboratory out- side
of the physician
office, the preliminary results are often called in to the physician office. The
medical assistant must be very careful to document all information and report it to the physi
cian in a timely
manner. 244 Section II Specimen Collection and Processing Figure 10-9 The FALCO
N SWUBE Pinworm
Paddle for pinworm collection. The end of the collection device is pressed again
st the anus to
collect the sample. The sample is transported in the outer tube to the laborator
y where the
actual collection device may be placed on the microscope for examination. Courte
sy of BD, Inc.
PROCESSING MICROBIOLOGY SAMPLES This chapter has explained the collection proces
s and immediate
handling for many different types of microbi- ology samples. In a physician offi
ce, the medical
assistant is often responsible for one more step; the processing of the sample t
o prepare it for
growth of the culture. This may include inoculation of the growth medium, slide
preparation, and
Gram staining, or even initiating the process for antibiotic sensitivity testing
. Slide
Preparation and Gram-Staining Procedure Developed in 1884, the Gram stain is a t
echnique that
quickly and inexpensively provides information about the bacteria that are prese
nt in a sample.
Identification of the microorganisms is based on the fact that almost all bacter
ia will
preferentially absorb different colors of stains, based on characteristics of th
eir cell walls.
Test Your Knowledge 10-23 What role does adhesive tape play in the collection of
the samples for
pinworm detection? (Outcome 10-18) Test Your Knowledge 10-24 Why are two differe
nt types of
stains used for the Gram-staining procedure? (Outcome 10-19) Figure 10-10 Gram-n
egative and
gram-positive bacteria. The purple bacteria (top) are gram positive, and the pin
k bacteria
(bottom) are gram negative. 1899_Ch10_215-255 21/12/11 2:26 PM Page 244 Procedur
e Rationale
Chapter 10 Collection and Processing of Samples for Microbial Studies 245 Proce
dure 10-3:
Gram-Staining Procedure The Gram stain is one of the most common procedures perf
ormed in the
microbiology department. It is a dif- ferential stain that allows bacteria to be
classified into
one of two groups depending on the way that the cell wall reacts with the dyes u
sed in the
staining process. The cell walls of the gram-positive bacteria have a greater af
finity for the
crystal violet stain than the bac- teria classified as gram negative. When viewe
d under the
microscope, the gram-positive bacteria will appear purple in color as a result o
f the crystal
violet stain, and the gram-negative bacteria will appear pink in color as a resu

lt of the
safranin counterstain. TASK Perform a Gram stain on a bacterial smear. CONDITION
S Heat-fixed
glass slide with bacterial smear Gram stain supplies (crystal violet, Grams iodin
e, 95% ethyl
alcohol, and safranin) Gloves Forceps Water Laboratory wipes CAAHEP/ABHES STANDA
RDS
CAAHEP Standards III.C.III.9: Discuss quality control issues related to han- dli
ng
microbiological specimens. III.P.III.2: Practice Standard Precautions, III.P.I
II.3: Select
appropriate barrier/personal protective equipment (PPE) for poten- tially infect
ious situations,
III.A.III. Applied Microbiology/ Infection Control ABHES Standards Apply princip
les of aseptic
techniques and infection control Use standard precautions Practice quality contr
ol Perform
selected CLIA-waived tests that assist with diagnosis and treatment, #5: Microbi
ology testing 1.
Sanitize hands and apply gloves. 2. Grasp the slide in the forceps. Hold it over
the sink or
other waste container. Flood the slide with the crystal violet stain and allow i
t to be covered
for 1 minute. 3. Pour off stain from slide and flush gently with water. Blot aga
inst laboratory
wipes to remove excess water. 4. Apply Grams iodine to the slide for one minute.
The gloves will
protect the hands from becoming stained by the materials used in this procedure.
The slide should
be held over the sink to allow excess stain to drain. It is important to keep th
e stain in
contact with the slide for 1 full minute. The slide should be flushed until the
liquid stain is
removed from the slide. It may be necessary to rub the underside of the slide wi
th a laboratory
wipe to remove excess stain if it drips onto the back of the slide. The Grams iod
ine forms a
complex to keep the crystal violet attached to the gram-positive bacteria. Conti
nued
1899_Ch10_215-255 21/12/11 2:26 PM Page 245 246 Section II Specimen Collection
and Processing
Procedure 10-3: Gram-Staining Procedurecontd Procedure Rationale 5. Pour off the G
rams iodine
and flush the slide with alcohol. Allow the alcohol to run over the slide until
the alcohol runs
clear. This may take 20 to 30 seconds, and depends on the thickness of the smear
. 6. Rinse the
alcohol from the slide with gentle running water. Blot off any excess water by t
apping the slide
against a laboratory wipe. Clean the underside of the slide with a laboratory wi
pe if necessary
to remove excess stain. 7. Cover the slide with safranin stain. Allow the slide
to be covered for
20 seconds. 8. Rinse the slide once more with water. If necessary, use alcohol o
n the underside
of the slide to remove any residual stain. Blot the stained slide with a lab- or
atory wipe to
absorb excess water. 9. Put away supplies and clean the work area. The alcohol i
s a decolorizing
agent, and it is imperative that the slide is flushed with this until it runs cl

ear. Rinsing the

water stops the decolorization process. The safranin is the counterstain, which
gives color to
the gram-negative organisms that did not absorb the crys- tal violet stain. With
out it, they
would appear color- less on the slide when viewed under the microscope. This is
the final stage
of the process. It is important to make sure that the residual stain is removed
so that the light
will not be obscured when the slide is viewed under the microscope. The laborato
ry area must
remain clean and tidy. POINT OF INTEREST 10-3 Tuberculosis and other acid-fast b
acilli Certain
types of bacteria resist colorization during the Gram-staining procedure. These
bacteria have a
higher concentration of lipids in their cell walls, so they do not retain the cr
ystal violet or
the safranin stain. At the end of the Gram-staining procedure they remain essent
ially colorless.
In order to iden- tify these bacteria, the Ziehl Neelsen stain is often used to
identify these
bacteria, known as acid-fast bacilli. The most common group of bacteria that rea
cts in this way
is from the genus Mycobacterium. Many species are harmless to humans, but there
are a few notable
exceptions. Mycobacterium tuber- culosis is the causative agent of tuberculosis,
Mycobacterium
avium is a bacterium that is capable of causing lung disease, and Mycobacterium
leprae causes
leprosy. Tuberculosis (TB) is a disease that has been around for a very long tim
e. Active
infection is on the rise, and it is imperative that the health-care community re
main aware and
educated about how to identify and treat this infection. M. tuberculosis is most
often thought of
causing a lung infection, but the bacterium may infect any area of the body. Oth
er common
infection sites include the kidneys and the central nervous system. The bacteria
are spread
through the air when an infective individual coughs, speaks, sneezes, or sings.
There are two
types of tuberculosis infection: 1. Latent infection: A patient has latent tuber
culosis infection
when he or she has become infected with the bacteria, but does not become active
ly ill. In the
case of latent infection, the patients immune system has walled off or isolated th
e bacterium
to the extent that it does not cause immediate harm. The TB infection may spread
at a later date,
especially if the patient develops other conditions that lower natural immunity,
such as HIV
infec- tion. The patients with latent infection will show a positive reaction on
the tuberculosis
skin test, and they need to be treated to kill the bacteria in their bodies befo
re they cause
active infection. 1899_Ch10_215-255 21/12/11 2:26 PM Page 246 Chapter 10 Collec
tion and
Processing of Samples for Microbial Studies 247 2. Tuberculosis disease: A patie
nt with
tuberculo- sis disease has the M. tuberculosis bacteria in the body, but the imm

une system has

not rendered it inactive. The bacterium has caused active ill- ness. Symptoms ma
y include severe
coughing for an extended period of time, spitting or coughing up blood, fatigue,
anorexia,
chills, fever, and night sweats. Patients with tuberculo- sis disease are infect
ious, and may
infect those around them in their home or workplace. They may also infect the he
alth-care
professionals who care for them. To aid in controlling tuberculosis disease, cer
tain high-risk
groups should be tested for latent infec- tion, as well those who show symptoms
of the active
disease. These groups include those who have been exposed to a TB-positive perso
n, patients who
have a compromised immune system, those who have lived in or traveled to a count
ry where TB is
widespread in the population, those who are incar- cerated, and those who are he
alth-care
profession- als. The tuberculin skin test is the most common way to screen for l
atent infection,
and this test is offered at local health departments as well as many physician o
ffices. Those who
immigrated to the United States from another country may have re- ceived the bac
ille
Calmette-Guerin (BCG) vaccine against tuberculosis, which is given in countries
outside of the
United States. However, the BCG vaccine is not considered to offer lifetime immu
- nity.
Individuals who have received the BCG vac- cine should still receive the tubercu
losis skin test.
They may show a false-positive result; if that is the case, patients will requir
e follow-up chest
x-rays and a physical examination to determine TB status. There is also a blood
test now
available for tubercu- losis infection, called an interferon-gamma release assay
. It does not
check for the presence of the TB bacilli; rather, it tests for the bodys immune r
esponse to the
bacteria. It is relatively expensive to perform, and not yet in widespread use.
An exam- ple of
this test is the Quantiferon-GOLD test. Those who have had the BCG vaccine have
less of a chance
of a false positive with the blood test than they do the skin test. Fortunately,
tuberculosis
infection, whether the infection is latent or active, is treatable. Those who te
st positive with
the skin test or the blood test are treated with a regime that may last 6 to 12
months, and
includes several medications at once. M. tuberculosis has become problematic in
recent years,
with development of several antibiotic resistant strains. Treatment with more th
an one medication
at once seems to reduce the chance of developing resistance. Common medications
include
isoniazid, rifampin, ethambutol, and pyrazi- namide. Patients with active infect
ion are required
to take their medication; if there is a high risk of noncom- pliance, they may e
ven be placed in
a directly observed therapy program in which a local health nurse will monitor t

heir dosages
daily. Incarceration is also an option; if the local health authority feels that
a patient poses
a high risk to other individuals and if that patient is noncompliant, jail time
may be required.
Plating and Inoculation of Media In some situations, laboratories may request th
at the physician
office laboratory inoculate the media at the time of collection. A nutrient brot
h or slant may
sometimes be innoculated. These types of media encourage growth of microorganism
s but do not
allow for isolation of specific colonies for further growth and identification.
To accomplish
separation of the growth into definitive colonies, an agar plate is used with a
specific pattern
of inoculation to create isolated colonies of the organism to be further identif
ied and tested.
The pattern of inoculation may be different depending on the type of agar plate
or type of specimen. A common method used to add a sample to an agar plate is the quadrant metho
d, in which the
agar plate is divided into four parts, either mentally or with a grease pencil i
f necessary. The
sample is applied to one quadrant of the plate fairly heavily with a swab that i
s twirled for
full exposure. Successive quadrants are streaked with the sample by passing throug
h the
previous quadrant one time to pick up specimen, then continuing with numerous st
reaks that are
close together. The goal is to provide an opportunity for growth of isolated col
onies so that
these can be further tested for identification and possibly sensi- tivity tested
. Figure 10-11
illustrates the quadrant streaking method. Test Your Knowledge 10-25 Which of th
ese may be used
for inoculation? a. Agar plates b. Slants c. Liquid nutrient broth d. All of the
above (Outcome
10-20) 1899_Ch10_215-255 21/12/11 2:26 PM Page 247 The lid should be placed so t
hat it does not
become contaminated. Gloves protect the hands from the microorganisms in the cul
ture. The
quadrant method requires that the plate be di- vided into four sections. The fir
st quadrant must
have an adequate amount of specimen present for the rest of the procedure to pro
ceed correctly.
The sample becomes less concentrated as it is spread across the second quadrant.
Each quadrant
will be inoculated in the same way with a very small amount pulled from the prev
ious quad- rant
and spread out. Appropriate incubation will be necessary to allow for specimen g
rowth. The
laboratory area must remain clean and tidy. Pro cedure Rationale 248 Section II
Specimen
Collection and Processing Procedure 10-4: Quadrant Streaking Inoculation Procedu
re CAAHEP/ABHES
STANDARDS CAAHEP Standards III.C.III.3: Discuss infection control procedures, II
I.C.III.9:
Discuss quality control issues related to handling microbiological specimens. II
I.P.III.2: Practice Standard Precautions, III.P.III.3: Select appropri- ate barrier/personal pr

otective
equipment (PPE) for potentially infectious situations, ABHES Standards Apply pri
nciples of
aseptic techniques and infection control Use standard precautions Practice quali
ty control
Dispose of biohazardous materials Collect, label and process specimens To isolat
e
microorganisms from pure culture or to iso- late specific colonies from agar pla
tes that contain
mixed flora, it is necessary to set up a streak plate. The most common method us
ed for this
procedure is the quadrant streaking method. The plate is divided into four secti
ons, and the
sample is streaked across each area, with every quarter slightly overlapping the
previ- ous area.
TASK Prepare a streak plate using the quadrant streaking method. CONDITIONS Agar
plate
Inoculation loops or sterilization equipment Gloves Culture specimen on swab 1.
Remove the
lid of the agar plate and place face down on the countertop. 2. Sanitize hands a
nd apply gloves.
3. Mentally divide the agar plate into four quadrants. This may also be accompli
shed physically
by drawing a four-part diagram on the bottom of the agar plate. 4. Use the cultu
re swab to
inoculate the first quadrant on the agar plate. Gently roll the swab across this
area for
complete coverage. 5. Turn the agar plate so that the second quadrant is at the
top. Use the
inoculation loop to apply sample into the next quadrant by passing it into the o
rigi- nal
application two times, then spreading it across the second quadrant without ente
ring the first
quadrant again. 6. Using a new sterile inoculation loop (or sterilize and cool a
reusable loop)
repeat the procedure with the subsequent quadrants. 7. Label the plate and incub
ate as directed.
8. Put away supplies and clean the work area. 1899_Ch10_215-255 21/12/11 2:26 PM
Page 248
resistant. A resistant bacteria is not susceptible to the action of a particular
antibiotic, so a
patient should not be treated with this medication. The zone of inhibition is me
asured for each
type of bacteria, and reported in the laboratory report so that the health-care
provider will
have the knowledge needed to treat the patient appropri- ately using antibiotics
that will
inhibit the growth of the specific pathogen. The Clinical and Laboratory Standar
ds Institute
(CLSI) outlines the reporting methods for disk- diffusion antibiotic testing. Th
e technician
reading the results in the microbiology laboratory will measure each zone of inh
ibition for the
antibiotics used. He or she will then use the NCCLS to report the antibiotic sus
ceptibil- ity as
sensitive, moderately susceptible, or resistant. The minimum inhibitory concentr
ation testing
proce- dure is usually performed using an automated instrument. A plastic panel
with rows of
small wells that are filled with a specific concentration of antibiotic is used.

The microbiology technician will inoculate each well with a dilution of the culture speci
men. (This may
also be performed au- tomatically.) After incubating for approximately 24 hours,
the wells are
checked for evidence of bacterial growth, which presents as a cloudy appearance.
The well that
has the lowest concentration of a specific antibiotic that does not show evidenc
e of growth is
reported as the minimum inhibitory concentration of that specific antibiotic. Th
e laboratory
report will include the list of antibiotics tested and the MIC for each of them.
It will also
interpret these data further to state whether that bacteria is susceptible, mode
rately
susceptible, or resistant to the antibiotic. Chapter 10 Collection and Processi
ng of Samples for
Microbial Studies 249 1 2 3 4 Figure 10-11 The quadrant streaking method of inoc
ula- tion. The
culture swab or a loop of a liquid sample is placed across quadrant 1. A sterile
inoculating loop
is used for the second quadrant; the streaks overlap quadrant 1 three times, the
n the swipes
continue to fill the quadrant. Another sterile inoculating loop is used for the
third quad- rant,
and the same procedure is used. This process is repeated once more for the fourt
h quadrant.
Antibiotic Sensitivity Testing Antibiotic sensitivity testing is performed to de
termine how
effective antimicrobial therapy is against a certain type of bacteria. There are
numerous methods
available for this procedure; instruments such as the VITEK 2 (produced by the f
irm bioMrieux)
are capable of performing antibiotic sensitivities in a fully automated fashion.
These automated
methods use the minimum inhibitory concentration (MIC) method to determine which
antimicrobial
agent is best to use for a specific pathogenic bacteria. However, many laborator
ies use an older,
more laborious method of testing known as the disk-diffusion method (also known
as the
Kirby-Bauer method) for antibiotic sensitivity testing. To set up the disk-diffu
sion
(Kirby-Bauer) procedure, a solution of the diluted specimen is applied to cover
an entire Mueller
Hinton agar plate. Absorbent paper discs that have been impregnated with various
antibiotics are
applied directly to the specimen on the plate (Fig. 10-12). The antibiotics are
absorbed into the
specimen and the agar as the plate is incubated for a period of 18 to 24 hours.
If an organism is
sensitive to a specific antibi- otic, it will have a zone of inhibition around t
he disc for that
specific medication, meaning that the antibiotic is able to stop the growth of t
hat particular
microorganism so that no growth occurs near the disc on the agar plate. If bacte
rial growth is
present right up to the disc and there is no visible zone of inhibition, this ba
cteria is Figure
10-12 Antibiotic sensitivity plate showing the disk- diffusion method. Note the

zones of
inhibition around some of the antibiotic disks. From CDC/Gilda L. Jones. 1899_Ch
10_215-255
21/12/11 2:26 PM Page 249 250 Section II Specimen Collection and Processing Tes
t Your Knowledge
10-26 Why are antibiotic discs used when performing sensitivities? (Outcome 10-2
1) POINT OF
INTEREST 10-4 Antibiotic resistance The discovery and further development of ant
ibiotics has been
an incredible asset to public health. Millions of lives have been saved, and our
life expectancy
has in- creased as a result of the positive steps we have taken to battle infect
ious diseases.
Unfortunately, these steps are not without complications. As we develop more and
more complex
drugs, the microorganisms in our envi- ronment are beginning to develop resistan
ce to our antibiotics. This is especially evident in the drug classifica- tions that are con
sidered first
line of defense: the drugs that are cheapest and easiest to use. This resistance
is most
recognizable in the types of infections that are most prevalent: those that caus
e diarrhea,
sexually transmitted diseases, diseases of the upper and lower respiratory tract
, and especially
those that are nosoco- mial (acquired as a result of hospitalization). Some of t
he most serious
problems include the following: Vancomycin-resistant Enterococcus (VRE): Enterococcus is a
genus of bacteria that normally is found in the gastrointestinal system. However
, when the
bacteria are introduced into other areas of the body (the urinary tract, for ins
tance) they are
considered to be pathogenic, and cause serious infections. Many strains have dev
eloped a
resistance to van- comycin, which was commonly used to treat this type of infect
ion.
Methicillin-resistant Staphylococcus aureus (MRSA): Staph is a common bacterium
found as normal
flora in various areas of our bodies. How- ever, when introduced into a wound or
into the
bloodstream, it can be a virulent pathogen. Methi- cillin is a classification of
antibiotic that
has histor- ically worked well against staph infections, but the levels of resis
tance are rising
dramatically to this drug. MRSA is an aggressive pathogen, and may be difficult
to treat
effectively because of its virulence. It is estimated that up to 20% of our popu
lation may be
colonized with MRSA at this point. Multiresistant Mycobacterium tuberculosis: As
the number of
cases of TB rises around the world, more and more show resistance to one or more
of the drugs
used for treatment. The regime used for those who have active or latent TB infec
tion now includes
more than one drug, as this seems to slow the development of resistant strains,
and accelerate
the elimination of the pathogen. Scientists believe that there are multiple fact
ors that
contribute to antibiotic resistance: the widespread use of antibiotics in our fo

od sources,
historical prescrib- ing patterns of health-care providers worldwide, and patien
t compliance
issues. Whenever an antibiotic is prescribed as treatment for a bacterial infect
ion, the
microorganisms either will be eliminated from the pa- tient or they will not. Th
ose bacteria that
are not elim- inated have now been exposed to the antibiotic, and many have deve
loped a way to
resist the effects of that particular medication. As these bacteria multiply, thei
r offspring
will also have this natural resistance. Medical assistants can help with educati
ng patients about
the importance of this issue. Encourage patients to keep the following issues in
mind with
antibiotic use: Always take antibiotics as prescribed. This in- cludes the frequ
ency of the
prescription (e.g., take one pill two times per day) as well as the length of ti
me for the
dosage. Many patients are tempted to stop taking the medication as soon as they
feel better; this
allows the bacteria that are still present in their bodies to survive and develo
p resistance to
the antibi- otic that they were taking. Patients need to take the prescription a
s it was written.
Do not take prescriptions that belong to other peo- ple. These medications were
not prescribed
for the specific type of infection that the patient may be ex- hibiting. Even if
two people have
the same infection, the required dosage for a medication may be different for ea
ch.
Self-medicating in this way is a dangerous practice, and contributes to antimicr
obial resistance.
Do not insist on antibiotics when the health-care provider feels that the infect
ion is viral in
nature. An- tibiotics are not effective against viral infections, and taking the
m when they are
not necessary only exposes the body to these medications when they are not neede
d. Do not insist
on a higher grade antibiotic when the more common drug may be just as effective. M
any patients
feel that penicillin, tetracycline, and similar first-line drugs could not be th
e best thing for
them, as they are convinced that the newest drug de- veloped must be better. Fol
low the guidance
of your health-care provider and your pharmacist; they are more familiar with th
e specific dosage
recommenda- tions for these drugs. 1899_Ch10_215-255 21/12/11 2:26 PM Page 250 C
hapter 10
Collection and Processing of Samples for Microbial Studies 251 MICROBIOLOGY TEST
RESULTS It can
be difficult to interpret the results for microbiology testing by identifying th
e information
that is clinically sig- nificant. Both the culture report and the sensitivity re
sult may be
present on the same document. This may be or- dered or reported as a culture and
sensitivity
(C&S) report. Each laboratory has a unique system that it uses for reporting, bu
t there are a few
similarities common to all reports. The report will provide information about th

e microorganisms that are isolated from the culture, as well as relative amounts of
these different
microorganisms. When the report is final, there may also be antibiotic sensitivi
ty data provided
for bacterial cultures so that the health-care provider will be able to suggest
treatment with
the best medication available. This may be reported in several ways, so it is im
portant for the
medical assistant to gain an un- derstanding of the report format used by his or
her labora- tory
in order recognize abnormal values and bring them to the attention of the health
-care provider.
Figure 10-13 provides an example of a microbiology laboratory report. LZ labs La
boratory Services
P.O. Box 44444 Seattle, WA 98124-1944 Patient: Thompson, Casandra (MR#: 123456)
DOB: 01/25/1930,
(81Y) Sex: F PCP: Grant, D. Status: Collected: Resulted: Printed: LabID: FINAL
02/02/2012 15:20
02/06/2012 09:12 02/09/2012 10:33 18081424 Culture, Urine SPECIMEN DESCRIPTION S
PECIAL REQUESTS
RESULT REPORT STATUS Urine 81yo female with catheter related UTI. Report princip
al pathogen only.
Providencia rettgeri Final 02/08/2012 SUSCEPTIBILITY ORGANISM METHOD Ampicillin
Amoxicillin/Clavulanic Acid Providencia rettgeri MIC 16 Intermediate 32 Resistan
t Resistant < =8
Susceptible < =4 Susceptible
>
128 Resistant 4 Resistant
< =2 Susceptible See below: Enterobacter, Citrobacter and Serratia speci
es may develop
resistance during prolonged therapy with third- generation cephalosporons. Repea
t testing of
these organisms is recommended after 4 days of therapy. Cefazolin Ceftriaxone Ge
ntamicin
Nitrofurantoin Trimeth-sulfamethoxazole Aztreonam **SUSCEPTIBILITY COMMENT Cefep
ime Ciprofloxacin
Amikacin Imipenem Meropenem Pip/tazobactam Tobramycin < =2 Susceptible 1 Suscept
ible < =4
Susceptible < =1 Susceptible < =1 Susceptible < =8 Susceptible Resistant Perform
ing Laboratory LZ
Laboratory,
Lincoln George, M.D. 42600 1st Ave, Seattle, WA 98168 206-983-44
56 Figure 10-13
Microbiology la boratory report. Test Your Knowledge 10-27 What is a C&S report
used to document?
(Outcome 10-22) 1899_Ch10_215-255 21/12/11 2:26 PM Page 251 SUMMARY One of the m
ost diverse areas
of the laboratory is the microbiology department. Specimen require- ments, proce
ssing procedures,
and culture tech- niques are very specific and varied. Basic aseptic procedures
and labeling
techniques are common for all specimen types. As part of their role in quality m
icrobiology
testing, medical assistants need to remain knowledgeable about the type of test
ordered, the
specimen required for each kind of test, and the processing requirements. It is
also very
important that medical assistants know how to read the microbiology reports used
by the
laboratory so that clinically significant results are recognized and handled app
ropriately. TIME

TO REVIEW 1. Inoculation is the: Outcome 10-1 a. Addition of a specimen to a cul

ture medium for
growth b. Addition of antibiotics to a culture medium c. Separation of colonies
on a culture
plate d. Gram staining of a specimen 2. True or False: Mycoses are the Outcome 1
0-1 various types
of fungal infections that may be present on or in humans. 3. Hemolytic uremic sy
ndrome Outcome
10-1 is a severe consequence of which type of infection? a. Shigella b. Salmonel
la c. E. coli
O157:H7 d. Yersenia 4. A nasopharyngeal culture Outcome 10-13 specimen is obtain
ed by access
through the: a. Mouth b. Nose c. Eye d. Pharynx 5. Which of these is not a type
Outcome 10-3 of
culture media? a. Slant b. Broth c. Agar d. Aerobe 6. True or False: Sample coll
ection Outcome
10-4 supplies and transport media for bacterial, viral, and fungal cultures are
all different. 7.
Why should sputum samples Outcome 10-6 be protected from light? 8. Which of thes
e statements is
Outcome 10-8 false concerning the collection procedures for blood cultures? a. B
lood cultures are
rarely collected b. Aseptic technique is essential to avoid contami- nation of t
he specimen and
misdiagnosis of the patient c. Blood is usually added to more than one bottle af
ter collection d.
Physicians may order blood cultures to be drawn serially at set time intervals 9
. Genital samples
may be used Outcome 10-10 to detect infections with: a. Candida albicans b. Tric
homonas vaginalis
c. Neisseria meningitides d. All of the above 10. Preservatives are used for Out
come 10-17
transport of specimens to be examined for presence of ova and parasites because:
a. The
preservatives provide nutrition for the para- sites in the sample b. The appeara
nce of the
parasites and their eggs are kept near those of their natural state in the body
c. The
preservatives keep the parasites alive so that they can grow in the laboratory d
. All of the
above 11. What time of day should a Outcome 10-18 pinworm sample collection occu
r? a. Just before
bedtime b. Randomly; the time of day is not important c. First thing in the morn
ing d. Right
after bathing in the morning 12. Gram-positive microorganisms Outcome 10-19 will
appear
_______________ after the Gram- staining procedure is complete. a. pink b. purpl
e c. blue d.
black 252 Section II Specimen Collection and Processing 1899_Ch10_215-255 21/12
/11 2:26 PM Page
252 Chapter 10 Collection and Processing of Samples for Microbial Studies 253 1
3. The quadrant
method describes: Outcome 10-20 a. A technique used to inoculate an agar plate b
. A technique
used for Gram stains c. A technique used for collection of wound cul- ture speci
mens d. A
calculation used for antibiotic sensitivity reporting 14. When reading a microbi
ology Outcome
10-22 laboratory report, why is it important for the health- care provider to be
familiar with

the normal flora commonly present in the area of the body where the specimen was
collected? Case
Study 10-1: How long is too long? Marti is a certified medical assistant working
in a busy
internal medicine practice. There is a new receptionist who is working at the fr
ont counter this
week, and Marti has found that the receptionist is a bit over- whelmed by the vo
lume of patients
the practice is see- ing today. The morning appears to be uneventful, but at 2 p
.m., the new
receptionist brings a urine specimen back to Marti. The receptionist tells Marti
that it was
dropped off that morning before lunch, but that she for- got to do anything with
it until now.
Marti sees that the physician has ordered a culture on the urine specimen, and t
hat the urine is
in a specimen cup without preser- vative. 1. What should Marti do? Case Study 10
-2: A sticky
situation Mrs. Oliver brings in her 3-year-old who is complaining of intense ana
l itching.
Lanette, the medical assistant, is asked to collect a sample for examination of
potential pinworm
infection. This is a procedure she has not per- formed often, and Lanette is a b
it nervous. She
decides that the best approach is to speak very little to Mrs. Oliver and the ch
ild so that
process goes quickly. 1. For this procedure, is this the best approach? 2. If yo
u were Lanette,
how would you explain the process to Mrs. Oliver and her child? RESOURCES Antimic
robial
Resistance World Health Organization Excellent overview about the progressing iss
ues with
antibiotic resistance around the world http://www.who.int/ mediacentre/factsheet
s/fs194/en/
Antony van Leeuwenhoek (16321723) History of Leeuwenhoek and the early discoveries
of
bacteriology http://www.ucmp.berkeley.edu/history/ leeuwenhoek.html BacT/ALERT b
lood culture
collection procedure An overview of the supplies provided with the culture colle
ction kit and
their use. http://www.biomerieux- usa.com/upload/Worksafe-Blood-Culture-Collecti
onProcedure-1.pdf Lumbar Puncture and Spinal Fluid by John E. Greenlee, MD. Informat
ion about how
a spinal fluid specimen is obtained, and how it is processed umed.med.utah.edu/n
euronet/pda/
2002/HO%20LP%20Spinal%20Fluid%20Greenlee% 202002.doc Cerebrospinal Fluid Analysis
, in
Encyclopedia of Surgery: A Guide for Patients and Caregivers Great article on th
e clinical
indications of a need for CSF collection, the laboratory test results, and poten
tial poor
outcomes of the procedure. http://www.surgery - encyclopedia.com/Ce-Fi/Cerebrosp
inal-Fluid-CSFAnalysis.html Disease Listing: Campylobacter General Information CDC Division of F
oodborne,
Bacterial and Mycotic Dis- ease. http://www.cdc.gov/nczved/dfbmd/disease_listing
/
campylobacter_gi.html Disease Listing: Salmonella General Information CDC Division
of

Foodborne, Bacterial and Mycotic Dis- ease, http://www.cdc.gov/nczved/dfbmd/dise

ase_listing/
salmonellosis_gi.html Disease Listing: Shigella General Information CDC Division o
f Foodborne,
Bacterial and Mycotic Dis- ease, http://www.cdc.gov/nczved/dfbmd/disease_listing
/
shigellosis_gi.html Pinworm Fact Sheet CDC Division of Parasitic Diseases Great in
formation
about pinworm infestation http://www.cdc.gov/ncidod/dpd/parasites/pinworm/ facts
ht_pinworm.htm
1899_Ch10_215-255 21/12/11 2:26 PM Page 253 Educational Commentary on the Preserv
ation of Fecal
Speci- mens for Ova and Parasite Examination Excellent information about pros and
cons of
different preservatives used for O&P examinations; sponsored by the American Soc
iety of Clinical
Pathology http:// www.api-pt.com/pdfs/2002Amicro.pdf Training Material Facilitate
s Proper
Nasopharyngeal Swab Collection Training module for nasopharyngeal swab collection
http://
www.rapidmicrobiology.com/news/2023h4.php UV Light Cuts Spread of Tuberculosis, Sc
ience Daily,
March 19, 2009 Information about studies performed for new methods of controllin
g the spread of
tuberculosis within healthcare facilities http://www.sciencedaily.com/releases/2
009/03/
090316201505.htm 254 Section II Specimen Collection and Processing 1899_Ch10_21
5-255 21/12/11
2:26 PM Page 254 255 Section II Specimen Collection and Processing What Does it
All Mean? As this
section clearly points out, proper specimen collection and processing is paramou
nt to obtain accurate and reliable laboratory results. Our Case in Point for this section demon
strates the
importance of proper specimen collection and processing. Case in Point As you ma
y recall, Wilma
F. is a 70-year-old female who presented to the doctors office where you work com
plaining of
burning and painful urination. She felt hot to the touch as confirmed by her tem
perature that was
101.5F. The doctor asked you to collect blood and urine samples for laboratory te
sting. Based on
the patients symptoms and the fact that Wilma has a history of urinary tract infe
ctions (UTIs),
it is likely that she once again has an infection. If she only has a UTI, the ur
ine collected for
culture will reveal significant microorganism growth but the bloodstream will be
free of
microorganisms and the corresponding blood culture results will be reported as ne
gative. If
however, microorganisms establish residence in Wilmas bloodstream, her blood cult
ure results
will be considered positive. It is common for patients to start out with a UTI and
then
progress into a bloodstream infection. In these cases, the same microorganisms o
ften are found in
both the blood and urine culture specimens. In Wilmas case, she has symptoms of b
oth a blood and
urine infection. Wilmas high temperature sug- gests a possible blood infection wh
ereas her

problems with urination indicate a urine infection. The question now is: What mi
croorganisms are
causing these prob- lems for Wilma? With the appropriate collection and handling
of Wilmas urine
and blood samples, the chances of getting reliable and accurate laboratory resul
ts is excellent.
While the doctor is waiting for the results to come back, he will likely begin W
ilma on a
suitable treatment known to treat a variety of microor- ganisms, often referred
to a
broad-spectrum treatment. He will then adjust treatment if necessary after the m
icroorganisms
have been identified and the labora- tory results are obtained. 1899_Ch10_215-25
5 21/12/11 2:26
PM Page 255 256 On the Horizon The study of blood and blood-forming tissues is k
nown as
hematology. Coagulation refers to the clotting of blood. Because these two conce
pts interconnect, corresponding testing is often con- ducted in the same area of the c
linical
laboratory. The results generated by performing hematology and coagulation testi
ng are of
monumental impor- tance in the diagnosis and monitoring of a number of diseases
and conditions.
Relevance for the Medical Assistant Medical assistants may be called upon to col
lect sam- ples
and in some instances perform CLIA-waived tests that fall into the hematology an
d coagulation
category. An understanding of this area of laboratory testing is essential to re
cognize the
clinical significance of test re- sults and to anticipate the needs of the healt
h-care provider
when dealing with the patients. In addition, medical assistants need to have a f
ull understanding
of their role in the preanalytical process while preparing patients and specimen
s for testing
Continued on page 258. 1899_Ch11_256-268 21/12/11 2:28 PM Page 256 257 Section I
II Hematology and
Coagulation On the Horizon The fundamental concepts associated with hematology a
nd coagulation
are covered in six chapters that make up this section of the text, as outlined b
elow. Chapter 11:
Overview of Hematology introduces the reader to the formation, description, and
analysis of the
three key types of cells in the circulating blood: red blood cells (RBCs), white
blood cells
(WBCs), and platelets. Chapter 12: Complete Blood Count With Differential explor
es the key
components of the most commonly ordered battery of hematology tests, known as a
complete blood
count (CBC). Chapter 13: Hemoglobin and Hematocrit examines the description, the
ory, and testing (with emphasis on CLIA-waived procedures) of these two important hematology
tests: hemoglobin
(Hgb) and Hematocrit (Hct). An independent examination of each test as well as a
n investigation
of the relationship between them are made, because of their importance in the di
agnosis and
monitoring of hemoglobinopathies, ane- mia, and polycythemia. Chapter 14: Erythr
ocyte

Sedimentation Rate covers the description, theory, and test- ing (with emphasis
on CLIA-waived
tests) of the erythrocyte sedimentation rate (ESR) test. This test, often in com
bination with
other laboratory tests, is of importance in instances of inflammation changes an
d in monitoring
pregnancies. Chapter 15: Coagulation Studies introduces the reader to the purpos
e of coagulation studies, the mechanism of blood clotting, disorders associated with abnorma
l coagulation
test results, and commonly performed coagulation tests. Select coagu- lation lab
oratory tests
that are useful in the diagnosis of disorders and monitoring of anticoagulant th
erapy as well as
specimen requirements for testing are covered. 1899_Ch11_256-268 21/12/11 2:28 P
M Page 257 258
Complete Blood Count (CBC) Patient Reference Range Test Result for Adult Males W
BC count 10.0
4,00011,000/mm 3 RBC count 3.0 5.56.5
10 6
/
mm
Hgb 9.0 1418 g/dL Hct 30 42%54% RBC Indices >>>>>>>>> >>>>>>>>> MCV 86 8096
femoliters MCH
31 2733 picograms MCHC 35 3338 g/dL Platelet count 28 140400
10 3
/
mm
3 Differential >>>>>>>>> >>>>>>>>> Neutrophils 65 50%70% Bands 5 3%5% Lymp
hocytes 23
23%30% Monocytes 6 3%7% Eosinophils 1 1%3% Basophils 0 0%1% Cell Few morphology schi
stocytes
present Coagulation Studies Test Patient Result Reference Range Prothrombin 18 s
econds 1014
seconds time (PT) Activated partial 47 seconds 2035 seconds thromboplastin time (
APTT)
LABORATORY REPORT PATIENT: M.J. Questions for Consideration: What type and color
of
blood-drawing tube should be used for this patient so that the laboratory can pe
rform the
complete blood count (CBC) test? What type/color of blood-drawing tube should be
used for this
patient so that the laboratory can perform the coagulation studies? Examine the
patients
laboratory results. Which of these results is/are considered as abnormal (that is,
out of the
reference range)? What laboratory results obtained most likely account for the p
atients being
pale? What is the purpose of the coagulation studies tests (PT & APTT)? Case in
Point You are
the primary medical assistant working at Mid- town Medical. In the midst of a ve
ry busy Monday,
Margie, the receptionist, informs you that a new pa- tient, M.J., has been worke
d into the
schedule and is here now to be evaluated. After greeting M.J. and recording his
weight and
height, you take him into the examination room. While preparing to take his bloo
d pressure and
pulse, you ask M.J. what brings him in to see the doctor today. You find out tha
t up until a few
weeks ago, this 38-year-old male had been in the best of health. The symptoms he
has been
experiencing con- sist of an overall feeling of being tired and weak, and every
time he brushes

his teeth his gums bleed. After questioning M.J. further, you find out that he w
as re- cently
hospitalized after a tractor accident and had re- ceived a blood transfusion at
that time. You
notice while talking to him that he looks very pale. The doctor orders blood to
be drawn for a
complete blood count (CBC), and coagulation studies (PT and APTT). The following
results are
obtained: Continued from page 256. 1899_Ch11_256-268 21/12/11 2:28 PM Page 258 2
59 Chapter 11
Overview of Hematology Nikki A. Marhefka, EdM, MT(ASCP), CMA (AAMA) CHAPTER OUTL
INE
HematopoiesisBlood Cell Formation Types of Blood Cells in the Circulating Blood E
rythrocytesRed
Blood Cells LeukocytesWhite Blood Cells Granular White Blood Cells Agranular Whit
e Blood Cells
ThrombocytesPlatelets Analysis of the Formed Elements Summary Time to Review Case
Studies
Resources and Suggested Readings Learning Outcomes After reading this chapter, t
he successful
student will be able to: 11-1 Define the key terms. 11-2 Summarize the process o
f blood cell
formation. 11-3 State the three types of formed elements in the circulating bloo
d and the
function of each cellu- lar element. 11-4 Describe the appearance of a reticuloc
yte and provide
examples of situations in which there are increased numbers of reticulocytes in
the circu- lating
blood. 11-5 Differentiate the appearance and function of the five types of leuko
cytes normally
present in the circulating blood. 11-6 Describe the appearance of a band cell, a
nd ex- plain when
there may be an increased number of band cells in the circulating blood. 11-7 De
scribe the
appearance and function of platelets. 11-8 List three CLIAwaived hematology testi
ng proce- dures
that may be performed in a physician office. CAAHEP AND ABHES STANDARDS CAAHEP S
tandards met:
I.C.I.2. Identify Body Systems I.C.I.4. List major organs in each body system I.
C.I.5. Describe
the normal function of each body system I.C.I.6. I dentify normal pathology rela
ted to each body
system ABHES Standards met: None 1899_Ch11_256-268 21/12/11 2:28 PM Page 259 260
Section III
Hematology and Coagulation KEY TERMS Agranular Band cell Basophil Bilobed Blast
cells Complete
blood count (CBC) Diapedesis Eosinophil Erythrocyte Erythrocyte sedimentation ra
te (ESR)
Erythroid Erythropoietin Formed element Granular Granulocyte Granulocyte-macroph
age
colony-stimulating factor (GM-CSF) Hematocrit Hematology Hematopoiesis Hemoglobi
n Hemostasis
Heparin Histamine Interleukin Intrinsic factor Leukocyte Lobulated Lymphocyte Ly
mphoid
Megakaryocyte Monocyte Myeloid Neutrophil Phagocytosis (phagocytic, phagocytize)
Platelet
Pluripotent Polychromatic stain Polymorphonuclear Red blood cell (RBC) Reticuloc
yte Reticulum
Stem cells Thrombocyte Thrombopoietin Thrombus White blood cell (WBC) B lood is
a specialized

connective tissue that consists of formed elements suspended in liquid plasma. A

p- proximately
38% to 48% of the total blood volume is made up of these formed elements, includ
ing red blood
cells (RBCs; erythrocytes), white blood cells (WBCs; leukocytes), and platelets
(thrombocytes).
The cells function in important ways to keep the human body healthy and safe. Th
e primary
function of the erythrocytes is to carry oxygen to the tissues of the body, wher
eas the
leukocytes help to fight off infection within the body. The thrombocytes are pre
sent to assist
with blood clotting and repair of blood vessel damage. Each of the cell types ma
y be identified
by characteristics of its nucleus and cytoplasm. Hematology is defined as the st
udy of blood and
blood-forming tissues. However, more specifically, it is the word used to descri
be the study of
the formed ele- ments in the blood. This chapter explores the process in- volved
with the
formation of cellular elements in the bone marrow, and discusses identification
and functions of
erythrocytes, leukocytes, and thrombocytes. HEMATOPOIESISBLOOD CELL FORMATION Blo
od cell
formation, a process known as hematopoiesis (Fig. 11-1), occurs primarily in the
red bone marrow.
In children, most bones contain red marrow. In the adult (in- dividuals greater
than age 20), red
marrow is found in the flat bones (vertebrae, ribs, iliac crest, and sternum). S
tem cells are the
precursors of all blood cells and are present in the bone marrow. They are pluri
potent, which
means that they have the ability to differentiate into several types of speciali
zed cells. These
stem cells may divide into precursor stem cells classified as myeloid or lymphoi
d. Erythrocytes
and most of the white blood cells are capable of arising from myeloid precursor
cells. Specialty
white blood cells responsible for the majority of the bodys immune protection, kn
own as
lymphocytes, arise from the lymphoid precursor Test Your Knowledge 11-1 List the
three formed
elements present in the circulating blood. (Outcome 11-3) 1899_Ch11_256-268 21/1
2/11 2:28 PM Page
260 stem cells. It is important to note that lymphocytes are also produced and p
rocessed in the
thymus gland and second- ary lymph organs, in addition to their production in th
e bone marrow.
Descriptions of the formed elements in the blood are summarized in Table 11-1. M
yeloid and
lymphoid stem cells, once developed, differentiate to produce blast cells, which
are the first
identifiable immature cell stages of what eventually become erythrocytes (RBCs),
leukocytes
(WBCs), and thrombocytes. Blast cells mature and go through a num- ber of stages
before they are
transformed into mature cells. Numerous functions of the spleen are associated w
ith the
development, storage, breakdown, and removal of specific blood cells, as noted i
n Box 11-1. Under

normal circumstances, only the mature blood cells will enter the circulating blo
od. Immature
forms of the blood cells may be present in the circulating blood in disease stat
es. For example,
immature red blood cells may be evident in the circulating blood with anemia, an
d im- mature
white blood cells may be present with leukemia. The cellular components of the b
one marrow can be
studied by making slides of the marrow, staining it, and studying it under the m
icroscope. The
sample for evaluation is obtained from the marrow cavity of the flat bones. Chap
ter 11 Overview
of Hematology 261 Eosinophilic metamyelocyte Proerythroblast Promyelocyte Lympho
id stem cell
Neutrophilic myelocyte Monocyte/ granulocyte progenitor Neutrophilic metamyelocy
te Neutrophilic
band Neutrophil Monocyte Basophil Eosinophil Lymphocyte Basophilic myelocyte Eos
inophilic
myelocyte Basophilic erythroblast Polychromatophilic erythroblast Polychromatoph
ilic erythrocyte
Erythrocyte Normoblast Basophilic metamyelocyte Basophilic band Eosinophilic ban
d Megakaryocyte
Platelets Figure 11-1 Hematopoiesis. The production and maturation of the blood
cells and
fragments. 1899_Ch11_256-268 21/12/11 2:28 PM Page 261 POINT OF INTEREST 11-1 Bo
ne marrow
aspiration In some clinical situations, medical practitioners need to visualize
what is occurring
in the bone marrow to make an accurate diagnosis. A bone marrow biopsy is not a
procedure that is
performed casually because the process may be painful and is very invasive. A sa
mple of the red
marrow may be obtained to look for the cell distribution, iron stores, or cell m
aturity. The
information gained from the sample may pro- vide valuable clues needed for a dif
ferential
diagnosis, and therefore, may be very valuable. Red bone marrow is found in the
ribs, sternum,
ilium, vertebrae, and the epiphyses of the long bones of adults. In children, it
is found in the
shafts of the long bones as well. The red marrow is generally the same in each o
f these areas, so
a sample may be taken from any location. The site for the biopsy and aspiration
is usually the
posterior iliac crest. The sternum and the broad end of the tibia are other site
s that may be
utilized, although not as frequently as the iliac crest. A number of factors are
produced by the
body to stim- ulate the production of blood cells. Intrinsic factor helps with B
12 absorption in
the digestive tract, and B 12 is critical for red blood cell formation. Thrombop
oietin from the
liver stimulates production of platelets, and granulocyte- macrophage colony-sti
mulating factor
(GM-CSF) in- creases the formation of leukocytes. Interleukins influence the gro
wth and
activation of the lymphocytes. Erythro- poietin stimulates the bone marrow to pr
oduce more red
blood cells when needed in the body. When the oxygen level is low in the tissues
, the kidneys

produce more erythropoietin to stimulate the differentiation and growth of the e

rythroid
(pertaining to erythrocyte) cells in the 262 Section III Hematology and Coagula
tion TABLE 11-1
Formed Elements of the Circulating Blood Blood Cell Size Description Function Le
ukocytes
Neutrophil 915 microns Multilobed nucleus, grayish purple granules Phagocytic, in
creases in
bacterial infection Band cell 915 microns C-shaped nucleus, grayish purple granul
es An immature
neutrophil, increases in bacterial infection Eosinophil 1016 microns Bilobed nucl
eus, large
red-orange granules Phagocytic, detoxifying Basophil 1014 microns Bilobed nucleus
, large
blue-black granules Release histamine and heparin Lymphocyte 718 microns Large da
rk nucleus,
little light blue Produce antibodies, involved in cytoplasm (There are larger on
es cell-mediated
immunity with larger less dense nuclei and more cytoplasm.) Monocyte 1220 microns
Large foamy
convoluted nucleus, little or Travel to tissue to become no granules in cytoplas
m macrophage,
phagocytic Erythrocytes 68 microns No nucleus, biconcave discs Carry oxygen in bl
ood to the
tissues Thrombocytes 0.53 microns Small cytoplasmic fragments Blood clotting BOX
11-1 Functions
of the spleen associated with blood cells Site of red blood cell formation in th
e fetus Site
of worn out red blood cell and platelet removal Site of old red blood cell break
down Site of
hemoglobin (from the worn-out red cells) decom- position Stores some iron from h
emoglobin
decomposition Contains red blood cell and platelet pools for use when needed Are
as of
lymphocyte proliferation and immune surveil- lance and response bone marrow to i
ncrease the
number of circulating red blood cells. Blood loss, such as from a bleeding ulcer
, ane- mia, or
low oxygen levels in the lungs due to high altitude or lung disease cause an inc
rease in
erythropoietin. 1899_Ch11_256-268 21/12/11 2:28 PM Page 262 TYPES OF BLOOD CELLS
IN THE
CIRCULATING BLOOD As was introduced earlier in this chapter, there are three cat
egories of cells
circulating in blood: erythrocytes, leukocytes, and thrombocytes. A description
and function
Chapter 11 Overview of Hematology 263 A sample of the bone marrow can be obtain
ed using a
special hollow needle with a stylus insert. The aspiration is completed using st
erile technique
to prevent infection and/or inflammation of the bone, which is called osteomyeli
tis. The patient
is usually in a prone position so that the iliac crest is fully exposed and supp
orted. The skin,
subcutaneous tissues, and the periosteum are anesthetized with a local anestheti
c to reduce
discomfort to the patient. A special hollow aspirate, needle is used to penetrat
e through the
layers of tissue and into the bone. A twisting motion is nec- essary for the nee
dle to reach the

destination. Once the marrow cavity has been entered, the stylus part of the nee
dle device is
removed, and a syringe is attached to the end of the hollow needle that is expos
ed. Fluid is
aspirated, and some of the marrow material is obtained. The medical assistant or
laboratory
technologist that is assisting with the procedure must verify whether the sample
is valid by
observing its appearance. The aspirated sample is placed on a clean glass slide.
The liquid
sample from the marrow may be spread across the slide using a similar procedure
as that used when
preparing a blood smear. There will also be solid components of the bone marrow
obtained; these
are called spicules, and they are slowly rotated across a slide to make impressi
ons for examination. These solid components are then placed in preservative for further studi
es if necessary.
The slides are stained and the preparations are assessed under the microscope by
a pathologist or
hematologist. After the procedure has been completed, the med- ical assistant wi
ll prepare the
slides, clean up the sup- plies and assist with the application of a pressure ba
ndage to the
puncture site. of the primary members in each category are detailed in the follo
wing sections.
ErythrocytesRed Blood Cells Erythrocytes, also known as red blood cells (RBCs), a
re the most
numerous formed element in the blood. The number of red blood cells in the body
varies with the
gender and age of the patient, but there are approximately 4.2 to 6.5 million in
a milliliter of
blood. Normal red blood cells measure 6 to 8 microns in diameter. The red blood
cells are smaller
than the white blood cells in the body, but larger than the platelets. Red blood
cells perform
their duties within the blood vessels and do not enter the tissues normally. The
primary function
of red blood cells is to carry oxy- gen to all tissues of the body. Each red blo
od cell contains
an iron pigment responsible for oxygen transport known as hemoglobin. Oxygen ent
ers the
capillaries that surround the alveoli of the lungs and moves to each red blood c
ell, where it
attaches to the hemoglobin. Hemoglobin is a protein composed of an iron-containi
ng pigment and
globulin (a type of protein). Hemoglobin gives red blood cells their characteris
tic reddish
color. Blood is a brighter red color in the arteries as more oxygen is attached
and is darker red
in the venous blood because of less oxygenation. It is interesting to note that
some carbon
dioxide is carried through the blood via hemoglobin in the red blood cells to be
released in the
lungs. Circulating red blood cells have no nuclei and are biconcave (the center
is thinner than
the thicker edges) in shape. Their unique shape and the lack of a nucleus allow
red blood cells
to increase their surface area for gas diffu- sion (oxygen transport) and allow
the cells to

contain more hemoglobin than a cell with a nucleus. The bicon- cave shape of the
erythrocyte also
eases the cells passage through the capillaries to bring oxygen to the tissues. E
ach red blood
cell has a life span of approximately 120 days. Mature red blood cells have no o
rganelles and
therefore a limited metabolism. Erythrocytes are not capa- ble of producing prot
eins or enzymes.
Red cells undergo much stress as they traverse the blood vessels in the body and
they have no
repair mechanisms. The red cells are continuously monitored and the old, worn-ou
t ones are
recognized and engulfed by the macrophages or the reticu- loendothelial system o
f the liver,
spleen, and bone marrow. The functions of the spleen are presented in Box 11-1.
Immature red
blood cells, called reticulocytes, may also be found in the circulating blood. R
eticulocytes
exhibit a blue network when stained with a special stain because the cells have
not fully matured
and still have residual struc- tures present in the cell cytoplasm. The reticulo
cytes will also
appear as large bluish red blood cells when viewed with Test Your Knowledge 11-2
Define
hematopoiesis. (Outcome 11-2) Test Your Knowledge 11-3 Stem cells are described
as pluripotent.
What does this mean? (Outcome 11-2) 1899_Ch11_256-268 21/12/11 2:28 PM Page 263
the standard
stains used for peripheral blood smears. The blue network is remnant RNA (ribonu
cleic acid) left
in the cell when the nucleus is expelled near the end of the red blood cell matu
ration. With use
of special staining proce- dures, the remnant RNA is visualized as fine, threadlike strands
known as reticulum. These immature reticulocytes should remain in the bone marro
w until maturity.
How- ever, when the demands of the body are increased for red blood cells (as in
the event of
hemorrhage or massive blood cell destruction), reticulocytes enter the circulati
ng blood.
Normally, less than 5% of the circulating red blood cells are reticulocytes. Bot
h erythrocytes
and reticulocytes are pictured for comparison in Figure 11-2. LeukocytesWhite Blo
od Cells
Leukocytes are specialized cells that play an essential role in the immune respo
nse of the body.
White blood cells are the largest blood cells and vary in size from 7 to 20 micr
ons. The total
number of white blood cells is 4,300 to 10,800 per cubic millimeter in normal ci
rculating blood.
The white blood cells spend most of their life span in the tissues of the body,
but the vascular
circulation allows white blood cells a mode of transportation throughout the bod
y so that they
can respond where necessary. Some WBCs only live a few hours, whereas others liv
e for months or
years. Many of them die when they have completed destroying foreign invaders. Th
ere are five
mature types of white blood cells that are generally found in circulating blood:
neutrophils,

lymphocytes, monocytes, eosinophils, and basophils (Fig. 11-3). These cells may
be categorized in
various ways based on their appearance. One such method is to define them as gra
nular or
agranular. Granular White Blood Cells White blood cells that have names ending i
n phil
(neutrophil, eosinophil, and basophil) have distinct granules visible in their c
ytoplasm and are
known as granulocytes. These granules contain digestive enzymes that are designe
d to destroy or
damage foreign cells or microorganisms, or 264 Section III Hematology and Coagu
lation C D E A B
F Figure 11-2 Top: Erythrocytes in the circulating blood. Bottom: Reticulocytes
The endoplasmic
reticulum is visible with new methylene blue stain. From Harmening, DM: Clinical
Hematology and
Fundamentals of Hemostasis, ed 5. FA Davis, Philadelphia, 2009, with permission.
Test Your
Knowledge 11-4 Do mature erythrocytes contain a nucleus? (Outcome 11-3) Test You
r Knowledge 11-5
What type of immature red blood cell may increase if a patient has hemorrhaged d
ue to an injury?
(Outcome 11-4) Figure 11-3 Leukocytes and thrombocytes in the circulat- ing bloo
d. A. neutrophil.
B. lymphocyte. C. monocyte. D. eosinophil. E. basophil. F. platelet. 1899_Ch11_2
56-268 21/12/11
2:28 PM Page 264 chemicals that assist with the process of destroying invaders.
The nuclei of
granular cells are arranged in lobes or sections. This appearance of the nucleus
is described as
lobulated. White cells are distinguished by the staining of their nucleus and gr
anules when using
a polychromatic stain (a stain having many colors, such as Wrights stain). The gr
anular cells
live only a few days and dissolve as they age, or are destroyed when they have p
articipated in
bacterial destruction. Neutrophils make up the majority of circulating granular
cells, and
provide much of the bodys protection against infection. A typical neutrophil meas
ures 9 to 15
microns in diameter, has a nucleus with 3 to 5 lobes, and has gray/pale purple g
ranules in its
cytoplasm. A neutrophil may also be called a polymorphonuclear (PMN) leukocyte,
or poly,
because of the multiple lobes of its nucleus. Some laboratories may also describ
e a neutrophil as
a seg, referring to the segmented appearance of the nucleus in these cells. The pr
imary
function of neutrophils is phagocytosis, which is the act of engulfing and destr
oying foreign
invaders. The majority of the circulating white blood cells of adults are usuall
y neutrophils.
The number of neutrophils often increases when a bacterial infection is present
in the body. A
mature neutrophil lives for 10 to 24 hours in the circu- lating blood. Typically
, it takes about
30 minutes for the neutrophil to engulf bacteria. This process destroys the cell
, and we often
see these dead white cells accumulated as pus. A band cell, as seen in Figure 11
-4, is an

immature form of the neutrophil that may appear in the circulating blood when th
ere is a high
demand for neutrophils by the body. Neutrophils are the first to respond to infe
ction or injury,
so the need is increased for an acute infection. The nucleus of a band cell is C
shaped as the
nucleus has not had a chance to mature into lobes or sections. The cyto- plasm o
f a band cell is
the same as that of a mature cell. Normal circulating blood may have some band c
ells, but they
usually make up less than 10% of the total. Band cells may also appear in the ci
rculating blood
of patients suffering from disease states that result in overproduction of neutr
ophils in the
bone marrow. Eosinophils are 10 to 16 microns in diameter, have bilobed nuclei (
that is, each
nucleus has two lobes or sections), and have large orange/red granules in the cy
toplasm. These
cells phagocytize invaders attached to antibodies (antigen-antibody complexes) a
nd detoxify
foreign substances. (Additional information on these concepts is located in Chap
ter 24.) An
increase in the number of eosinophils is often seen in allergic reactions, myoca
rdial disease, or
with parasitic infection. Eosinophils enter the tissues from the blood capillari
es and live there
for about 6 days. Chapter 11 Overview of Hematology 265 Test Your Knowledge 116 What is the
type of white blood cell that will increase in production when a patient has a b
acterial
infection? (Outcome 11-5) Figure 11-4 A band cell has a C-shaped nucleus and the
same granules as
the neutrophil. Test Your Knowledge 11-7 What is the name of the white blood cel
l that may be
increased in number in an allergic reaction? How can this cell be differentiated
from the other
types of white blood cells? (Outcome 11-5) Basophils are 10 to 14 micron in diam
eter, have
bilobed nuclei, and large dark blue granules in the cytoplasm. The nucleus is of
ten hard to see,
as the granules are so large and dark that they obscure it from view. The granul
es found in the
cytoplasm of basophils contain heparin and histamine. Heparin helps to prevent b
lood from
clotting, whereas histamine makes blood vessel walls more perme- able so that wh
ite cells can get
into tissues to phagocytize foreign cells and invaders. An increase in basophils
is often seen in
the presence of chronic infection, when there is healing of infection, in allerg
ic asthma, or in
contact allergies. Basophils have a life span of about 6 days. Agranular White B
lood Cells
Lymphocytes and monocytes are considered agranular, as they have few visible cyt
oplasmic
granules. Monocytes are the largest of the white blood cells with a diameter of
12 to 20 microns
and have a large, convoluted, less densely 1899_Ch11_256-268 21/12/11 2:28 PM Pa
ge 265 stained
nucleus. The cytoplasm often has a ground-glass appearance and a pale blue or ligh
t gray color.

In addition, the cytoplasm of monocytes often contains vacuoles (holes) when vie
wed under the
microscope. Monocytes travel through the vessel walls and out of the circulatory
system into the
tissues as needed in a process called diapedesis. Monocytes are phagocytic in fu
nction as they
destroy and remove dead cells from tissue. They defend the body against microorg
anisms and
malignant cells. Monocytes live in the circulating blood for 8 to 24 hours and t
hen as
macrophages in the tissue for several months. The macrophages assist with remova
l of all types of
old, dam- aged, or nonfunctional blood cells. Lymphocytes are the smallest of th
e white blood
cells, with dark, dense nuclei that often take up most of the cell. Lymphocytes
traditionally
have a small amount of light blue cytoplasm. Lymphocytes may vary in size from 7
to 19 microns in
diameter. Lymphocytes appear slightly larger than red blood cells when viewed on
a stained slide.
Lymphocytes mature into B cells, T cells, and nat- ural killer cells. B lymphocy
tes become plasma
cells and form antibodies. T cells and natural killer cells are active in cell-m
ediated immunity.
(More information about the bodys defense system may be found in Chapter 24.) Lym
phocytes are
usually the most predominant white blood cell in the circulating blood of childr
en until about
age 10 years, but they are the second most preva- lent type of white blood cell
in adults. An
increase in number may be seen in viral infections at all ages. The life span of
the T cells is
months to years and the B cells live only a few days. ThrombocytesPlatelets Throm
bocytes, or
platelets, are spherical or ovoid cell fragments which are 0.5 to 3 microns in d
iameter (Fig.
11-3). There are normally 150,000 to 450,000 platelets per millimeter of blood.
Platelets are
cytoplasmic fragments of large bone marrow cells called megakary- ocytes. Two-th
irds of the
platelets are in the circulat- ing blood at any given time, whereas the other th
ird is stored in
a pool in the spleen. The typical platelet life span is 8 to 10 days. Platelets
actively
participate in hemostasis (the stoppage of bleeding or of circulation). Platelet
s pre- vent blood
loss and have three functions that begin the 266 Section III Hematology and Coa
gulation Test
Your Knowledge 11-8 What type of white blood cell has forms that make antibodies
and are active
in cell-mediated immunity? (Outcome 11-5) clotting process (for more information
on hemostasis
see Chapter 15). When a capillary is damaged, platelets stick together and adher
e to the sides of
the cut to form a plug that fills the opening. While form- ing the plug, platele
ts secrete a
chemical known as serotonin designed to help constrict the blood vessels. Platel
ets also activate
the complex chemical process of coagulation to enhance the platelet plug. Younge
r platelets are

larger and more metabolically active and are more effective in hemostasis. Plate
lets sometimes
clot within the blood vessels when there is no vessel wall damage. This may resu
lt in a thrombus
(blood clot), which adheres to the wall of a vessel or organ. These clots can oc
clude (block) the
ves- sels and potentially stop the flow of blood. When the bodys tissue does not
receive oxygen
from the blood, body cells will die. A thrombus may be the cause of a heart atta
ck or a stroke.
Test Your Knowledge 11-9 What are the three hemostatic functions of platelets th
at prevent blood
loss? (Outcome 11-7) ANALYSIS OF THE FORMED ELEMENTS In reference and hospital l
aboratories
erythrocytes, leuko- cytes, and platelets may be identified and counted by au- t
omated analyzers
capable of processing large volumes of specimens. The cells that make up the for
med elements in
the blood are typically identified by size, appearance, and other specific chara
cteristics. A
complete blood count (CBC) is the most commonly ordered hematology test. As the
test name
implies, this comprehensive test provides practitioners with important informati
on about all
three formed elements in the circulating blood. The process of cell formation (h
ematopoiesis) may
be studied by collecting and microscopically examining bone marrow samples in la
rge laboratories.
Types of hemoglobin can be identified by the technique of hemoglobin electrophor
esis. (More
information about these tests is presented in Chapters 12 and 13.) In the physic
ian office and at
the bedside in hospitals, CLIA-waived hematology testing is often performed. The
hemoglobin
concentration of the blood cells is often measured using a CLIA-waived procedure
. The erythrocyte sedimentation rate and the hematocrit value are other common CLIA-waived te
sts performed in
physi- cian office laboratories. The hematocrit is the percent- age of red blood
cells in a given
volume of blood, and the erythrocyte sedimentation rate is a screening test 1899
_Ch11_256-268
21/12/11 2:28 PM Page 266 for inflammation that measures the speed at which eryt
hrocytes settle
out of anticoagulated blood. Medical assistants or phlebotomists often perform t
hese tests in the
physician office laboratory. TIME TO REVIEW 1. What is the difference between Ou
tcome 11-1
erythropoietin and thrombopoietin? a. Erythropoietin stimulates red blood cell f
orma- tion and
thrombopoietin stimulates white blood cell formation b. Erythropoietin stimulate
s platelet
production and thrombopoietin stimulates white blood cell pro- duction c. Erythr
opoietin
stimulates red blood cell forma- tion and thrombopoietin stimulates platelet pro
duction d.
Erythropoietin stimulates platelet production and thrombopoietin stimulates red
blood cell
production 2. True or False: During hematopoiesis Outcome 11-2 all blood cells a
re derived from

stem cells. 3. Which of these statements does not Outcome 11-3 describe the appe
arance or
function of erythrocytes? a. Erythrocytes are biconcave in shape b. Erythrocytes
assist in blood
clot formation c. Erythrocytes carry oxygen throughout the body d. Erythrocytes
are the most
numerous found ele- ments in the bloodstream 4. What is the substance in the Out
come 11-1 red
blood cells to which oxygen attaches? a. Nuclei b. Vacuoles c. Reticulum d. Hemo
globin 5.
Immature red blood cells that still Outcome 11-5 contain some endoplasmic reticu
lum which may be
visualized in the circulating blood in periods of high demand are called: a. Gra
nulocytes b.
Reticulocytes c. Band cells d. Lymphocytes 6. The number of white blood cells in
Outcome 11-3 the
circulating blood is 4,300 to 10,800 per milliliter and their main function is i
n: a.
Participation in the immune response of the body b. Carrying oxygen to the cells
of the body c.
Blood clotting d. Liver function Chapter 11 Overview of Hematology 267 Test You
r Knowledge 11-10
Name three CLIA-waived hematology tests. (Outcome 11-8) SUMMARY Hematology is th
e study of the
cellular (or formed) elements in the blood. The cells of the circulating blood a
re predominantly
formed in the bone marrow by the process of hematopoiesis. Each type of cell matures from the
same pluripotent stem cell. The stem cell differentiates into blast cells for ea
ch kind of blood
cell and then continues to mature into the functioning cells that are released i
nto the
circulating blood. These functioning cells include erythrocytes, leukocytes, and
thrombocytes.
Erythrocytes carry oxygen, leukocytes are part of the immune system, and platele
ts participate in
blood clotting. Erythrocytes contain hemoglobin, which enables them to transport
oxygen
throughout the body. An increase of a more immature form of the erythrocyte, the
reticulocyte, in
the circulating blood can show that the bone marrow is trying to provide suffici
ent red blood
cells at times of crisis. This may mean that the body has increased its demands
for oxygen, or
that there is a need to replace lost blood cells. There are five types of leukoc
ytes normally
seen in the circulating blood. These white blood cells are neu- trophils, eosino
phils, basophils,
lymphocytes, and monocytes. Each cell is identified by the properties of its nuc
leus and
cytoplasm and has a specific function in the immune process. Thrombocytes are sm
all round cell
fragments that are involved in the clotting process. Blood cells and platelets c
an be counted and
tested for their ability to function. Large analyzers in the ref- erence and hos
pital
laboratories can perform many tests on a large number of specimens or highly spe
- cialized
testing. The medical assistant can perform the CLIAwaived testing of hemoglobin,
hematocrit, and

the erythrocyte sedimentation rate. An abnormal number of the formed elements or

an abnormal test
result can be indicative of a disease process. Testing procedures and clinical s
ignificance of
the formed elements in the blood are discussed in the following chapters. 1899_C
h11_256-268
21/12/11 2:28 PM Page 267 7. The cytoplasm of these cells Outcome 11-6 have larg
e dark granules
that contain heparin and histamine: a. Neutrophils b. Eosinophils c. Basophils d
. Monocytes 8.
The type of white blood cells that Outcome 11-6 are most prevalent in adults and
that phagocytize
foreign invaders are called: a. Neutrophils b. Eosinophils c. Basophils d. Monoc
ytes 9. The
function of these cells is Outcome 11-6 to remove dead cells from tissue. They a
re called
macrophages when they have traveled into the tissues: a. Neutrophils b. Eosinoph
ils c. Basophils
d. Monocytes 10. An immature neutrophil that may be Outcome 11-7 visualized in t
he circulating
blood in a severe infec- tion is called a: a. Granulocyte b. Reticulocyte c. Ban
d cell d.
Lymphocyte 11. Which of the formed Outcome 11-3, Outcome 11-8 elements are invol
ved in hemostasis
and prevent blood loss? a. Reticulocytes b. Thrombocytes c. Erythrocytes d. Leuk
ocytes 268
Section III Hematology and Coagulation Case Study 11-1: Meaning of abnormal res
ults Dr. Stewart
has ordered a CBC to be collected on Mr. Marcus. Lily, the medical assistant, dr
aws the blood
sample and sends it to the local reference laboratory with the courier that afte
rnoon. The next
day, the results are available and Lily reviews them before placing them on the
chart for Dr.
Stewart to read. The leukocyte count and the neutrophil count are both flagged a
s elevated above
the normal range. 1. What do you think these two elevated results may mean? RESO
URCES AND
SUGGESTED READINGS Fun Science Gallery: Lets Observe the Blood Cells Contains pictu
res and
descriptions of the various blood cells. http:// www.funsci.com/fun3_en/blood/bl
ood.htm
1899_Ch11_256-268 21/12/11 2:28 PM Page 268 269 Chapter 12 Complete Blood Count
With Differential
Nikki A. Marhefka, EdM, MT(ASCP), CMA (AAMA) CHAPTER OUTLINE Complete Blood Coun
t Complete Blood
Count Specimen Requirements White Blood Cell Count Red Blood Cell Count Hemoglob
in and Hematocrit
Red Blood Cell (Erythrocyte) Indices Platelet Count Leukocyte Differential Count
Peripheral Blood
Smear Manual Leukocyte Differential Red Blood Cell Morphology Platelet Morpholog
y and Estimated
Count Manual Blood Cell Counts Automated Analyzers for Complete Blood Count Test
ing Summary Time
to Review Case Study Resources and Suggested Readings 12-1 Define the key terms.
12-2 Identify
the component tests of a complete blood count (CBC). 12-3 Recognize the normal r
eference ranges
for each CBC component. 12-4 Identify examples of disorders that are characterized by an

increased red blood cell, white blood cell, or platelet count. 12-5 Identify sit
uations where the
white blood cell count may be decreased. 12-6 State the clinical significance of
the erythrocyte
indices included in a CBC. 12-7 For the five types of normal white blood cells i
dentified on a
differential, state the normal reference range in the form of percentages. 12-8
Identify examples
of diseases characterized by an abnormal white blood cell differential. 12-9 Dif
ferentiate terms
used to describe normal and abnormal red blood cell morphology using appropriate
medical
terminology. 12-10 Describe the appearance of platelets when viewed under the mi
croscope. 12-11
Summarize the general principle of electrical impedance as it relates to automat
ed CBC testing.
Learning Outcomes After reading this chapter, the successful student will be abl
e to:
1899_Ch12_269-284 21/12/11 4:25 PM Page 269 270 Section III Hematology and Coag
ulation KEY TERMS
Anemia Anisocytosis Blast Complete blood count (CBC) Differential Electrical imp
edance Hematocrit
(Hct) Hemoglobin (Hgb) Hemocytometer Histogram Hyperchromic Hypochromic Leukemia
Leukocytosis
Leukopenia Lysed Macrocyte Mean corpuscular hemoglobin (MCH) Mean corpuscular he
moglobin
concentration (MCHC) Mean corpuscular volume (MCV) Microcyte Morphology Normochr
omic Normocytic
Ovalocyte Poikilocytosis Polychromatic stain Polycythemia Red blood cell index S
ickle cell
Spectrophotometrically Spherocyte Target cell Thrombocythemia Thrombocytopenia T
hrombocytosis A
complete blood count (CBC) provides physicians and other health-care professiona
ls with an
overview of cells and cell fragments in the circulating blood. The amounts of di
fferent types of
cells in the specimen as well as physical characteristics of these cells are inc
luded in the CBC
results. Used alone or along with other diagnostic and laboratory tests, the CBC
helps the
physician diag- nose disorders, follow the course of treatment, and deter- mine
prognoses. This
chapter introduces the reader to each of the major CBC components as well as pre
sents an overview
of automated analyzers used in CBC testing. COMPLETE BLOOD COUNT The complete bl
ood count (CBC)
comprises a series of tests, each with its own reference range, as listed in Tab
le 12-1. The
tests are usually performed using an automated hematology analyzer, but some of
them may CAAHEP
AND ABHES STANDARDS CAAHEP 2008 Standards I.C.1.6. Identify common pathology rel
ated to each body
system I.A.I.1. Apply critical thinking skills in performing patient assessment
and care ABHES
2010 Standards None also be performed using manual methods. Components of a CBC
include the
following: A white blood cell (WBC) count, providing the number of white blood c
ells present in
the sample. A red blood cell (RBC) count, which provides the total number of red
blood cells

present in the specimen. Hemoglobin concentration, which is the concentra- tion

of the
iron-containing pigment in red blood cells which binds to oxygen. Hematocrit, wh
ich is the
percentage of red blood cells in a given volume of blood. Three red blood cell i
ndices, defined
as numerical descriptions of the RBCs present. A platelet count, which provides
a quantitative
measure- ment of the platelets present in the specimen The white blood cell diff
erential, which
provides quan- titative information about the types of white blood cells present
in the specimen.
1899_Ch12_269-284 21/12/11 4:25 PM Page 270 Chapter 12 Complete Blood Count Wit
h Differential
271 Test Your Knowledge 12-1 What tests are components of the CBC? (Outcome 12-2
) The hemoglobin
and hematocrit tests included in the CBC are CLIA-waived test procedures. Howeve
r, the other
tests included in the complete blood count are categorized as moderately or high
ly complex by
CLIA. Medical assistants may perform moderately complex automated hematology tes
ting with
appropriate docu- mented training and supervision. Medical assistants can also p
erform a normal
manual differential from a stained blood smear if they are specially trained and
appropri- ately
supervised for this moderately complex procedure. For the CLIA moderately comple
x tests, the
following additional steps must be taken for appropriate documen- tation, traini
ng, and quality
control: 1. All laboratories that perform tests of moderate com- plexity must be
registered with
the Centers for Medicare & Medicaid Services (CMS) as a moder- ately complex lab
oratory. The
Certificate of Waiver that is used for CLIA-waived testing procedures will not b
e valid if the
tests of higher complexity are also performed in the laboratory. 2. The requirem
ents for quality
control increase with the higher level of test complexity. This includes the doc
umentation of
daily calibration and maintenance, TABLE 12-1 Suggested Reference Ranges for Com
ponent Tests of
the Complete Blood Count White blood cell count 4,300 to 10,800/mm 3 Red blood c
ell count Adult
10 6
female: 4.25.9
/
mm
3 Adult male: 4.6 6.2 10 6
/
mm
Hemoglobin concentration Adult female: 12 to 16 g/dL Adult male: 13 to 1
8 g/dL Hematocrit
Adult female: 37%48% Adult male: 45%52% Red blood cell indices MCV 80100 femtoliter
s MCH 2731
picograms/cell MCHC 3236 g/dL Platelet count 150 to 450
10 3
/
mm
3 Differential Neutrophils 54%65% Lymphocyte 25%40% Monocyte 2%8% Eosinophi
l 1%4%
Basophil 0%1% the testing of two levels of quality control performed routinely, a
nd
participation in a proficiency testing program. 3. Those employees who perform t
hese tests must

also have documentation of all training, and regular doc- umented updates when t
he process
changes. Complete Blood Count Specimen Requirements Blood samples for the comple
te blood count
can be col- lected by venipuncture or capillary collection. The CBC requires a w
ell-mixed
lavender top tube containing EDTA as an anticoagulant. There is an emphasis on t
he mixing of the
sample for CBC analysis because the whole blood tested must represent the circul
ating blood in
the body. If the sample is not inverted five to ten times immediately after coll
ection, small
clots may form, lead- ing to inaccurate results. 1899_Ch12_269-284 21/12/11 4:25
PM Page 271
TABLE 12-2 Types of leukemias Type Abbreviation Description Chronic myelogenous
CML A large
number of all types of white blood cells and platelets; (granulocytic) leukemia
subtyped
according to the type of predominant cell Acute myelogenous AML The bone marrow
produces a large
number of granulocytic blast (granulocytic) leukemia cells; predominantly an adu
lt leukemia
Chronic lymphocytic leukemia CLL Accumulation of lymphocytes that live a long ti
me; predominately
identified in older adults Acute lymphocytic ALL Abnormal growth and development
of lymphocytes;
diagnosed (lymphoblastic) leukemia most frequently in children Hairy cell leukem
ia HC or HCL
Excess B lymphocytes are produced; these lymph have projections that make them l
ook hairy;
generally affects middle-aged and older adults Test Your Knowledge 12-2 What is
the reference
(normal) range of the red blood cell count for an adult? (Outcome 12-3) 272 Sect
ion III
Hematology and Coagulation A lavender Microtainer tube will be used in the capillary collection
process for a CBC. As in the case of the tube used for venipuncture, the specime
n in the Microtainer tube must be mixed during and immediately following the collection proces
s. A steady,
consistent blood flow is necessary so that small clots do not form during the bl
ood collection.
CLIA-waived analyzers have special collection chambers that can be filled direct
ly with blood
from a capillary puncture, eliminat- ing the need for a Microtainer tube. These
collection
chambers are placed in the instrument for testing. White Blood Cell Count The to
tal number of
WBCs in the circulating blood (known as a white blood cell count) is another com
ponent of a CBC.
There is no distinction between types of white blood cells in this total white b
lood cell count.
Since there are so many blood cells, a method known as scientific notation is us
ed to express the
values for the white blood cell count and the red blood cell count. Scientific n
otation is used
when numbers are too large to be written in the common decimal format, in which
the numbers are
re- ported as a number 10 6 . The normal reference range for the WBC count is app
roximately 4.3

to 10.8
/
mm

10 3

3 (4,300 to 10,800 cells per cubic mm). Leukocytosis is the term used wh
en the white blood
cell count exceeds the normal range. The most frequent cause for an elevation of
leukocytes is
infection. Increased WBC counts may also be associated with stress, intense exer
cise, trauma,
inflammation, and pain. Smoking may also cause slight leukocytosis. In addition,
white blood cell
counts are usually elevated well above the normal range in the presence of leuke
mia. In cases of
leukemia, white blood cell counts may range from 30,000 to 200,000 per cubic mil
limeter of blood.
Leukemia is a cancer of the bone marrow in which a large number of immature whit
e blood cells are
being produced or disease states in which mature forms live an exceptionally lon
g time. These
white blood cell clones are not capable of performing their roles as part of the
immune system.
Leukemias are classified according to the predominant cell type present, and whe
ther the disease
is acute or chronic in nature. Table 12-2 provides more information about the va
rious types of
leukemia. Leukopenia refers to a WBC count that is below the normal range (value
s below 4,000 per
cubic millimeter). The number of white blood cells may be decreased in a chronic
viral infection.
Exposure to lead, mercury, some chemotherapy agents, and radiation may also caus
e the white blood
cell count to be diminished. Red Blood Cell Count Red blood cells are the most p
revalent formed
element in circulating blood. Because there are so many red blood cells, scienti
fic notation is
used as it is for the white blood cell count to express these values. There are
millions of red
blood cells present in each specimen, so these are reported as 10 6 . The refere
nce (normal)
ranges for red blood cell measurements will vary based on the age and gender of
the patient. For
instance, adult males normally 1899_Ch12_269-284 21/12/11 4:25 PM Page 272 Chapt
er 12 Complete
Blood Count With Differential 273 have more red blood cells present in their bod
ies than do adult
females. Red blood cell counts are performed using an automated hematology analy
zer. The
reference ranges will vary from 4.2 to 6.2 10 6 cells per microliter. Red blood
cell counts
that exceed the normal range may be present in various diseases, including polycythemia (a
condition that results in an excess of RBCs). Those results below the normal ran
ge suggest a
reduction in the oxygen-carrying capacity of the blood known as anemia. The vari
ous types of
anemia are further described in Chapter 13. be measured directly utilizing hemat
ocrit tubes after
centrifugation, or the hematocrit result may be calcu- lated using the hemoglobi
n and one of the
red blood cell indices, called the mean corpuscular volume (MCV). This red blood
cell index

represents the average volume of the individual red blood cells in a sample. The
hematocrit is
always reported as a percentage, and the reference ranges vary with gender and a
ge of the
patient. Adult normal ranges include values from 38% to 52%. More details of hem
oglobin and
hematocrit testing and further evaluation of their clinical signifi- cance are p
rovided in
Chapter 13. Red Blood Cell (Erythrocyte) Indices A typical CBC includes three ca
lculated values
that help classify RBCs in terms of size and hemoglobin concen- tration. The cal
culations use the
word corpuscular in referring to the red blood cells. These calculations are kno
wn as red blood
cell indices: 1. Mean corpuscular volume (MCV), defined as the average volume o
f a red blood
cell in a sample 2. The average weight of hemoglobin in the red blood cells in a
sample, known as
mean corpuscular hemoglobin (MCH) 3. Mean corpuscular hemoglobin concentration
(MCHC), the
average weight of hemoglobin in a given volume of packed blood cells These value
s are calculated
from the hemoglobin con- centration, the hematocrit value, and the red blood cel
l count. The
indices are most often used to classify various types of anemias. Table 12-3 inc
ludes more
information about each of the indices, including a brief description, the Test Y
our Knowledge
12-3 List two disorders that are characterized by an increased white blood cell
count. (Outcome
12-4) Hemoglobin and Hematocrit Hemoglobin (Hgb) is an iron-containing pigment p
res- ent in all
red blood cells and is responsible for oxygen transport. The Hgb concentration i
s typically
measured in grams per deciliter (g/dL). For this test, RBCs are lysed (broken op
en) and the free
hemoglobin enclosed in the cell is then measured spectrophotometrically. Spectro
photometric
measurements measure color changes produced by the hemoglobin present in a sample using a
specific wavelength of light. The reference ranges for hemoglobin also vary by g
ender and age.
The hemoglobin normal range for adults is 12 to 18 g/dL. The hematocrit (Hct) is
the amount of
space occu- pied by the red blood cells in a whole blood sample as compared to t
he total sample
volume. A hematocrit can TABLE 12-3 Red Blood Cell (Erythrocyte) Indices Red Blo
od Cell Index
Suggested Reference Units Description Formula (normal range) MCV: Mean corpuscul
ar volume The
average volume 80100 fL Femtoliters of red blood cells in the specimen MCH: Mean
corpuscular
Content or weight of 2731 pg/cell hemoglobin hemoglobin in the Picograms per cell
average red
blood cell MCHC: Mean corpuscular The average concentration 3226 g/dL hemoglobin
concentration
of hemoglobin in a volume g/dL of packed cells fL is the abbreviation for femtol
iters, and pg is
10 RBC count (millions) Hemoglobi
the abbreviation for picograms. Hematocrit (%)
n (g/dL) 100

hematocrit (%) Hemoglobin (g/dL)

100 red blood cell count (million) 1899_Ch12_26
9-284 21/12/11
4:25 PM Page 273 274 Section III Hematology and Coagulation formula used for ca
lculation, and a
suggested reference range. These indices provide clinicians with valuable information about the
size and condition of the red blood cells in the sample as well as more details
about the amount
of hemoglobin present. The calculated indices may be com- pared with the appeara
nce of the
corresponding red blood cells as noted on a stained blood smear to verify their
clinical
significance and the accuracy of the values. 2. Eosinophils: Assist with allerg
ic reactions,
parasitic infections, and chronic inflammation 3. Basophils: Play a key role in
the inflammatory
process 4. Lymphocytes: Ingest and kill microorganisms and play a key role in t
he immune
response with antibody formation 5. Monocytes: Attack and eliminate foreign sub
stances;
monocytes function as macrophages in the tissues of the body As introduced in Ch
apter 11,
immature neutrophils, known as band cells, are also identified and reported sepa
rately when a
leukocyte differential is performed. The band cells may be increased in number d
uring a bacterial
infection because the bone marrow is attempt- ing to produce an increased amount
of white blood
cells (especially neutrophils) to meet the bodys need. Immature cells that are ea
rlier in the
developmental stage than band cells are not normally present in the bloodstream,
and their
presence indicates a serious infection or other blood disorder. The immature for
ms of other white
blood cell types may occasionally be present and must be identified, as their pr
esence may assist
with a diagnosis or prognoses. When reporting the leukocyte differential, each t
ype of white
blood cell is reported as a percentage (%). This procedure is completed utilizin
g automated
methods or performed manually with visualization of a stained blood smear by a p
roperly trained
clinical laboratory professional. In blood samples for most adults, neu- trophil
s are typically
seen in the greatest numbers (between 54% and 65%). Lymphocytes are next in freq
uency; 24% to 40%
would be the normal range. Monocytes make up approximately 2% to 8% of the white
blood cell
count. The rest of the white blood cells are made up of eosinophils, which total
1% to 4%, and
the basophils, which make up 1% or less of the circulat- ing white blood cells.
The immature
neutrophils (band cells) may total up to 5% of the normal differential as well.
The cells are
identified on a stained slide by their size, shape, color, and the structures wi
thin the cell.
Automated instruments may also report these parame- ters. Table 12-4 provides a
summary of
information about the various types of white blood cells. The results of the dif
ferential can be

used for initial diagnosis or to monitor treatment. An increase in neu- trophils

often indicates
a bacterial infection. With acute infections, there usually will be an increase
in the number of
the immature band cells as well as an overall increase in neutrophils. Eosinophi
ls may increase
in number with allergies and parasitic infections. Lymphocytes often Test Your K
nowledge 12-4
What information is provided by the red blood cell indices? (Outcome 12-6) Plate
let Count As was
introduced in Chapter 11, platelets are small cell fragments that interact with
chemicals in the
blood- stream to assist in the clotting process. The reference ranges for platel
et counts may
vary with the blood sam- ple collection technique employed. Capillary collection
values are lower
than those in venous blood because some of the platelets in the area are immedia
tely involved
with the formation of the plug for the injury of the skin puncture. The venous r
eference range
for the platelet count is 150
10 3 to 450
10 3
/
mm
3 (150,000 to 450,000 per cubic millimeter). Thrombocytopenia means a de
creased platelet
count. Platelets may be decreased with some types of infection and in situations
where the
individual has been exposed to certain medications or toxic substances. Thromboc
ytosis refers to
an increased platelet count in the circulation, and may be associated with a var
iety of diseases.
If the platelet count is increased in response to a specific trigger, it is known
as reactive
thrombocytosis. When the elevated platelet count becomes pronounced over an exte
nded period of
time and the bone marrow begins to produce excessive amounts of abnormally funct
ioning platelets,
the condition is known as throm- bocythemia. Thrombocythemia is considered to be
a serious
condition, as these excess platelets can cause small clots to form intravascular
ly, or the
platelets may not function properly to stop bleeding when needed. Leukocyte Diff
erential Count A
differential is a process by which the percentage of the five normal types of wh
ite blood cells
in the circulating blood is calculated. These cell types include the following:
1. Neutrophils:
First responders to foreign invasion of the body 1899_Ch12_269-284 21/12/11 4:25
PM Page 274
Chapter 12 Complete Blood Count With Differential 275 POINT OF INTEREST 12-1 Ba
nanas in the
blood? The order of frequency for the presence of the five types of white blood
cells may be
remembered by using this simple sentence: Never Let Monkeys Eat Bananas! Startin
g with the most
prevalent to the least, the five types of white blood cells identified in the ci
rculating blood
are Neutrophils, Lymphocytes, Monocytes, Eosinophils, and Basophils. exceed the
normal range in
viral infections. In immediate hypersensitivity reactions (such as asthma) basop
hils are often

increased. An increase of monocytes may suggest a chronic infection (tuberculosi

s is an example)
or the pres- ence of a malignancy. Lymphocytes may be elevated with infectious m
ononucleosis. In
addition to the increase in the per- centage of lymphocytes, many of the lymphoc
ytes may be
larger than normal. Reactive lymphocytes are also identified with mononucleosis; t
hese are
larger than the typical lymphocyte, and when visualized under the microscope, th
ey have a nucleus
that is less dense than a typical lymphocyte. An increase of regular, larger, an
d reactive
lymphocytes accompanied by other physical signs and symptoms and a positive mono
screening test
will be used to diagnose infectious mononucleosis. The white blood cell differen
tial is
significant for patients with leukemia because the various types of leukemia are
categorized by
the type of predominant white blood cell present in the bone marrow and bloodstr
eam. Leukemia
classification is also based on whether the disease process is acute or chronic
in nature. The
acute leukemias primarily present with immature white blood cells in the form of
blasts (the
earliest form of the white blood cell that is iden- tifiable), while the chronic
types of
leukemia are characterized by dramatically increased numbers of dysfunctional ma
ture cells. In
acute lymphoblastic leukemia, the differential would have many immature lymphocy
tes, referred to
as lymphoblasts. The blood smear of a patient with chronic myelogenous leukemia
typically has an
increased number of the granulocytic white blood cells, (neutrophils, eosinophil
s and basophils).
The granulocytic white blood cells have granules present in their cytoplasm. POI
NT OF INTEREST
12-2 Infectious mononucleosis Clinical Facts Viral infection caused by the Epste
in-Barr virus
Virus enters through the oropharynx, transmitted in saliva; called the kissing di
sease Most
prevalent in adolescents and young adults Virus infects the B-cell lymphocytes C
linical
Symptoms Fatigue Fever Sore throat Swollen lymph glands Hematological Features S
light
elevation in the white blood cell count (12,000 to 25,000) Increased percentage
of lymphocytes
(60% to 90%) Presence of reactive (atypical) lymphocytes Larger T cells than nor
mally
visualized Larger; nuclei with more open chromatin and deep indentations Cytopla
sm with
basophilia, azurophilic granules, and vacuoles Immunology Features Positive rapi
d-screen mono
test Increased heterophile antibody titer Treatment Rest NSAIDs, such as ibuprof
en No
lifting or contact sports if the spleen is enlarged Test Your Knowledge 12-5 Des
cribe the
appearance of a normal red blood cell on a stained blood smear. (Outcome 12-9) P
eripheral Blood
Smear A peripheral blood smear may be used for a manual white blood cell differe
ntial as well as

visualization of other formed elements in the blood. A blood smear con- sists of
a slide with a
drop of blood spread across it. The blood sample may be created directly from a
capillary
puncture or from an EDTA-anticoagulated venous blood sample that is less than 2
hours old. The
smear is then dried, stained, and viewed under the microscope. White blood cells
, red blood
cells, and platelets are observed. Examination of cell morphology (appearance 18
99_Ch12_269-284
21/12/11 4:25 PM Page 275 TABLE 12-4 White Blood Cell Types in the Circulating B
lood and
Reference Ranges for the Leukocyte Differential Percentage Normally Present Whit
e Blood Cell
Image of Cell Description of Morphology (suggested reference range) Neutrophil M
ultilobed
nucleus; 54%65% lavender gray granules in cytoplasm (From Harmening, DM: Clinical
Hematology and
Fundamentals of Hemostasis, ed. 5. FA Davis, Philadelphia, 2009, with permission
.) Lymphocyte
Large, dense, 25%40% dark blue nucleus; small amount of pale blue cytoplasm (From
Harmening, DM:
Clinical Hematology and Fundamentals of Hemostasis, ed. 5. FA Davis, Philadelphi
a, 2009, with
permission.) Monocyte Foamy, convoluted nucleus; 2%8% ground glasslooking cytoplas
m (From
Harmening, DM: Clinical Hematology and Fundamentals of Hemostasis, ed. 5. FA Dav
is, Philadelphia,
2009, with permission.) Eosinophil Bilobed nucleus; 1%4% large orange-red granule
s in cytoplasm
(From Harmening, DM: Clinical Hematology and Fundamentals of Hemostasis, ed. 5.
FA Davis,
Philadelphia, 2009, with permission.) 276 Section III Hematology and Coagulatio
n
1899_Ch12_269-284 21/12/11 4:25 PM Page 276 TABLE 12-4contd White Blood Cell Types
in the
Circulating Blood and Reference Ranges for the Leukocyte Differential Percentage
Normally Present
White Blood Cell Image of Cell Description of Morphology (suggested reference ra
nge) Basophil
Bilobed nucleus 0%1% (difficult to see clearly); large dark blue granules in cyto
plasm (From
Harmening, DM: Clinical Hematology and Fundamentals of Hemostasis, ed. 5. FA Dav
is, Philadelphia,
2009, with permission.) Band cell C-shaped nucleus; 0%5% (immature neutrophil) la
vender-gray
granules in cytoplasm (From Harmening, DM: Clinical Hematology and Fundamentals
of Hemostasis,
ed. 5. FA Davis, Philadelphia, 2009, with permission.) Chapter 12 Complete Bloo
d Count With
Differential 277 of the red blood cells including their size, color, and shape)
and determination
of size are used to identify each type of blood cell. The leukocyte differential
, the red blood
cell morphology, and a platelet estimate are re- ported as part of the results.
Examination of
the blood smear is necessary when the automated results indicate that there is a
need to
double-check the differential count or cell morphology of the specimen, or when
the method used

for the CBC does not allow for an auto- mated white blood cell differential. use
d for blood
smears. Different structures will absorb more of one color or the other, as they
will naturally
be attracted to the alkaline or acidic components of the stain. The resulting co
lors and cell
structural appearance are used to differentiate the cells. Nuclei are stained bl
ue by the
basophilic (alkaline) part of the stain; other struc- tures are stained red oran
ge by the
eosinophilic (acid) stain component. Some structures pick up both stain componen
ts. Manual
Leukocyte Differential For performance of a manual differential, the stained blo
od smear is
placed on the stage of microscope and the immersion oil objective (100X) is used
to magnify the
blood smear. An area where cells appear in a single layer and are not overlapped
is located while
looking at the slide. The viewing field is moved from side to side across the wi
dth of the smear.
Typically 100 consecutive white blood cells are observed and accounted for by ty
pe. The size of
the cell and the structures of the nucleus and the cytoplasm are used to Blood s
mears are stained
with a polychromatic stain, which consists of a combination of an alkaline and a
cidic component
that allows for cells to appear in a variety of colors. Wrights stain is a popula
r polychromatic
stain Test Your Knowledge 12-6 What characteristics of the white blood cells are
used to
differentiate the different types? (Outcome 12-7) 1899_Ch12_269-284 21/12/11 4:2
5 PM Page 277
identify each white blood cell type. An electronic or a manual tabulator keeps c
ount. When 100
cells are counted, the percentage of each type is the total number observed. in
which there is a
variety of sizes of red blood cells pres- ent. Cells larger than normal size are
considered
macro- cytes and those smaller than normal are microcytes. 278 Section III Hema
tology and
Coagulation Test Your Knowledge 12-7 List the five white blood cell types in ord
er from those of
the greatest number to those of the least. (Outcome 12-7) Red blood cells that h
ave too little
hemoglobin will have larger, paler central areas than normal cells. These cells
are described as
hypochromic. Spherocytes are RBCs that assume a spherical shape and are said to
be hyperchromic,
because they have excess hemoglobin concentration and thus no central pallor. Po
lychromatic (a
multicolored appearance achieved using a mixture of varied colored stains) red b
lood cells appear
a little more bluish in hue as they contain RNA that attracts the alka- line com
ponent of the
stain. Anisocytosis is a condition Test Your Knowledge 12-8 What is the term use
d to describe a
red blood cell visual- ized on a stained smear that is paler or lighter in color
than a normal
erythrocyte? (Outcome 12-9) Test Your Knowledge 12-9 What is the term used when
the red blood

cells on a smear are varied in shape more than usual? (Outcome 12-9) Red Blood C
ell Morphology As
well as counting the different types of WBCs on a dif- ferential, it is importan
t to observe the
RBCs and pay careful attention to their size and shape. As introduced in Chapter
11, normal red
blood cells are circular bicon- cave disks with pale centers. They are 6 to 8 mi
crons in
diameter. They are a soft red color and have no nuclei. Red blood cells are smal
ler than white
blood cells and larger than platelets. The red blood cells on the stained slide
should all be
similar in size, with natural slight dif- ferences in the sizes and shapes. Thes
e normal red
blood cells are called normocytic and normochromic. The suffix cytic refers to th
e size and
shape of the red blood cells and the suffix chromic refers to the color of the ce
lls when viewed
under the microscope. Normocytic red blood cells are the normal size of 6 to 8 m
icrons.
Normochromic red blood cells have a center that is paler than the surrounding ce
ll, which means
that they contain a sufficient concentration of hemoglobin. In hematological dis
orders, the red
blood cells may vary in the amount of hemoglobin, the size and shape of the cell
s, the staining
characteristics (pale or dark red) and the structures present within the cells.
Poikilocytosis
describes red blood cells that are pres- ent on the slide in a variety of differ
ent shapes. Some
types of cells are named for their descriptive shape. Exam- ples of these includ
e teardrops,
helmet cells, sickle cells (arch-shaped cells that result from low oxygen tensio
n and that
contain an abnormal substance known as hemo- globin S, and elliptical-shaped cel
ls known as
ovalocytes. Cells that have a reduced hemoglobin concentration (known as target
cells) have so
little hemoglobin that there is only a slight ring of color at the edges. These
tar- get cells
have a spot of trapped hemoglobin in the center (the bulls eye of the target). Fi
gure 12-1
includes exam- ples of normal and abnormal red blood cell morphology. Immature n
ucleated red
blood cells may be present on the slide when there has been an event that puts a
n extreme demand
on the bone marrow for production of new blood cells. These nucleated red blood
cells (NRBCs)
will have a blue staining nucleus. NRBCs are not normally present in the circula
ting blood of an
adult but they may be seen in fetal blood or that of young infants. If NRBCs are
present, it is
important to report this as part of the CBC result, as their presence may be cli
nically
significant. Platelet Morphology and Estimated Count Platelets are small, oval-s
haped, and purple
cellular fragments when visualized on the stained blood smear. A platelet estima
te may be
calculated by counting the number of platelets on a stained blood smear in field
s viewed under

the microscope where cells are not over- lapped and red blood cell morphology is
easily visualized. Ten fields are counted, and the average number of platelets per field is m
ultiplied by
20,000 to achieve a platelet estimate. In a normal platelet count, there are 8 t
o 20 platelets on
an oil immersion field. Manual Blood Cell Counts Red blood cells, white blood ce
lls, and
platelets may be counted manually by a qualified laboratory professional. This i
s not a
CLIA-waived procedure, so in most circumstances it is not a procedure that will
be
1899_Ch12_269-284 21/12/11 4:25 PM Page 278 performed by a medical assistant. A
manual cell count
may be necessary when the automated system is non- functional or in situations i
n which the cell
counts are too low to be measured by the instrument commonly used. For a manual
count, blood
samples are mixed with a specified amount of diluent (Fig. 12-2A) and added to a
hemocytometer.
The hemocytometer is a chamber of specific dimension and depth that has a grid m
arked for
counting the cells under the microscope (Fig. 12-2B). The cells are counted usin
g the
magnification of the microscope. Because of the standardized dilution ratio and
dimensions of the
hemocytometer, a mathematical calculation is used to determine the number of cel
ls in a
milliliter of blood. AUTOMATED ANALYZERS FOR COMPLETE BLOOD COUNT TESTING Blood
cell analyzers
have come into use with advances in technology. In hospitals and reference labor
atories, these
analyzers allow for large volumes of tests to be performed in a short period of
time. Automated
instruments in the physician office laboratory have added greater accuracy and p
recision to the
results. Most of these test procedures use electrical impedance (a process for c
ounting blood
cells that depends on their resistance to the flow of an electrical current) and
light-scattering
principles to count and differentiate blood cells. Beckman-Coulter, Abbott, ABX,
and
Bayer-Technicon are companies that produce these automated analyzers for large-s
cale,
time-efficient hematology testing. In electrical impedance analyzers, the cells
pass through an
opening with an electrical current flowing through it. The changes of electrical
resistance due
to the formed elements in the sample are monitored and they are counted as volta
ge pulses. These
pulses are propor- tional in height to the volume of the cells, which allows the
m to be
identified as white blood cells, red blood cells, or platelets. Some instruments
may also use a
beam of light to measure the number and size of the cells in the sample, a proce
ss called light
scattering. A light-sensitive detector measures the light scattered as the sampl
e is introduced
into a chamber and the beam of light is interrupted. The size of the pulse detec
ted is propor-

tional to the size of the cellular element. Many of the analyzers use a combinat
ion of these two
techniques to count the formed elements in the blood sample. A Chapter 12 Compl
ete Blood Count
With Differential 279 RED BLOOD CELL MORPHOLOGY Size variation Normal Microcyte
Macrocyte Oval
macrocyte Hypochromic macrocyte Polychromasia (Reticulocyte) Hypochromia 1 + 2 +
3 + 4 + Sickle
cell Burr cell Stomatocyte Tear drop Howell-Jolly Schistocyte (fragmented cell)
Basophilic
stippling (coarse) Helmet cell (fragmented cell) Cabots ring Acanthocyte Pappenhe
imer bodies
(siderotic granules) Ovalocyte Spherocyte Target cell Crystal formation HbSC HbC
Hemoglobin
distribution Red cell distribution Agglutination Rouleaux Shape variation Inclus
ions Figure 12-1
Normal and abnormal red blood cell morphology. From Harmening, DM: Clinical Hema
tology and
Fundamentals of Hemostasis, ed. 5. FA Davis, Philadelphia, 2009, with permission
.
1899_Ch12_269-284 21/12/11 4:25 PM Page 279 280 Section III Hematology and Coag
ulation 1 2 3 4 1
mm 0.2 0.25 Figure 12-2 (A) Steps involved in using the Unopette system. From We
dding, ME, and
Toenjes, SA: Medical Laboratory Procedures. FA Davis, Philadelphia, 1998, with p
ermission. (B)
Hemocytometer counting chamber. From Ciesla, B: Hematology in Practice, ed. 2, F
A Davis,
Philadelphia, 2012, with permission. A B graph of the distribution of cell sizes
made during cell
counting on an automated analyzer, known as a histogram, may also be reported. A
n example of the
results of an automated CBC is shown in Figure 12-3. The automated white blood c
ell differential
is performed by a combination of techniques. The infor- mation gathered using th
ese techniques is
combined to classify the type of white blood cell. The cell volume can be determ
ined by
electrical impedance, electromagnetic procedures define nuclear characteristics
and granular
composition, and light-scattering techniques can analyze cell surface and morpho
logical and
granular qualities to determine the type of white blood cell. The automated anal
yzers work well
for the vast majority of specimens, but they do have their limitations. Certain
samples with
abnormal results must have a manual differential performed for accurate results.
The QBC STAR
Centrifugal Hematology System (QBC Diagnostics) is an example of an automated in
strument that
tests one sample at a time (Fig. 12-4). It may be used in the physician office l
aboratory where
automation is desired, but specimen-testing volumes are not high. The QBC STAR s
ystem is a CLIA
test of moderate complexity, so those performing the testing will participate in
proper training
of specified quality assur- ance procedures. The analysis tube used for testing
within the
instrument may be filled with EDTA-anticoagulated blood or directly from a capil
lary puncture.

The analysis tube contains a dye and a special float that is used for the testing
process. The
tube is filled with blood and placed directly into the analyzer. The testing pro
cess involves
centrifugation within the instrument and use of the float to measure different par
ameters of
the speci- men. This instrument is desirable for some office settings because th
ere are no liquid
reagents to work with, and the calibration of the instrument is done internally.
The analysis
tubes contain all the reagents necessary for the procedure. The QBC Star is capa
ble of measuring
most of the components of a typical CBC, with the exception of a red blood cell
count and some of
the indices. 1899_Ch12_269-284 21/12/11 4:25 PM Page 280 Chapter 12 Complete Bl
ood Count With
Differential 281 ID Number: 00014 Patient ID: Name: Address: Seq#: 4291 Type:
Mode: Date: Time:
Sex: Age: 3YR to 4YR BLOOD 02172012 04:15:00PM PARAMETERS RESULT NORMAL RANGE ALAR
MS
DIFFERENTIAL + H + WBC LYM# MID# GRA# LYM% MID% GRA% RBC HGB HCT MCV MCH MCHC RD
W + PLT MPV 15.1
6.0 1.0 8.1 39.7 6.6 53.7 4.47 11.7 36.7 82.0 26.2 31.9 13.1 381 7.9 K/uL K/uL K
/uL K/uL
%
%%
%%%
M/uL g/dL
%
fl pg g/dL
%
K/uL fl R1 140 6.0 5.0 1.5 0.1 1.5 25.0 2.0 50.0 3.50 10.0 30.0 75.0 24.
0 28.0 11.7 440 9.5
14.5 3.5 1.0 6.6 50.0 10.0 80.0 4.90 14.0 42.0 96.0 32.0 30.0 15.0 PLT Histogram
WBC Histogram
RBC Histogram Comments: Signature: Figure 12-3 CBC result from an automated hema
tology analyzer,
including histograms. 1899_Ch12_269-284 21/12/11 4:25 PM Page 281 SUMMARY The co
mplete blood
count (CBC) is a comprehensive hematology test consisting of a white and red blo
od cell count,
hemoglobin and hematocrit determinations, red blood cell indices, a platelet cou
nt, and a white
blood cell differential. These tests may be performed manually or by use of auto
mated
instrumentation. The three red blood cell indices (MCV, MCH, MCHC) are calculations that
numerically describe the size of the red blood cells and the amount of hemoglobi
n that they
contain. There may be times in which examination of a blood smear is necessary t
o clarify the
differential results or view morphology for other cellular elements in a sample.
A stained blood
smear is viewed with the microscope for a manual white blood cell differential,
red blood cell
morphology, and platelet estimation. The complete blood count can be used as a t
ool to diagnose
and monitor disease and to follow the course of treatments. TIME TO REVIEW 1. Ch
oose the correct
list of Outcome 12-2 components of a complete blood count. a. Hemoglobin, hemato

crit, red blood

cell count, white blood cell count, erythrocyte sedimentation rate, WBC differen
tial b.
Hemoglobin, hematocrit, red blood cell count, white blood cell count, red blood
cell indices,
platelet count, WBC differential c. Hemoglobin, hematocrit, red blood cell count
, platelet count,
erythrocyte sedimentation rate, WBC differential d. Hemoglobin, hematocrit, red
blood cell count,
white blood cell count, hemoglobin electrophore- sis, WBC differential, platelet
count 2. The
reference range for an adult Outcome 12-3 white blood cell count is: a. 4,300 to
10,800/mm 3 b.
140,000 to 400,000/mm 3 c. 5.0 to 6.5 million/mm 3 d. 12 to 14 g/dL 3. A white b
lood cell count
may be Outcome 12-5 decreased because of: a. A chronic viral infection b. Exposu
re to toxins c.
Chemotherapy use d. All of the above 4. The reference or normal range for Outcom
e 12-3 the
platelet count is: a. 4,300 to 10,800/mm 3 b. 150,000 to 450,000/mm 3 c. 5.0 to
6.5 million/mm 3
d. 12 to 14 g/dL 5. This type of white blood cell is the Outcome 12-7 most numer
ous in a healthy
adult and makes up about 60% of the white blood cells: a. Eosinophil b. Monocyte
c. Neutrophil d.
Lymphocyte 6. This is the term used to describe Outcome 12-9 a variety of sizes
of red blood
cells on the stained smear: a. Anisocytosis b. Poikilocytosis c. Spherocytosis d
. Hemolysis 7.
This type of cell appears as small, Outcome 12-10 purple, circular, or ovoid fra
gments on the
stained blood smear. a. White blood cell b. Red blood cell c. Platelet d. Band c
ell 282 Section
III Hematology and Coagulation Figure 12-4 QBC STAR hematology analyzer. Courte
sy of QBC
Diagnostics. 1899_Ch12_269-284 21/12/11 4:25 PM Page 282 Chapter 12 Complete Bl
ood Count With
Differential 283 8. An increased white blood cell Outcome 12-4 count may be evid
ent with which
disease? a. Thrombocythemia b. Anemia c. Leukopenia d. Leukemia 9. Microcytosis
is a word used to
Outcome 12-9 describe: a. Large red blood cells b. Large white blood cells Case
Study 12-1:
Clinical significance Mr. Smith, a 67-year-old patient, presented to the office
with symptoms of
a cough, a little tightness in his chest, and complaints of a slight fever. The
medical assistant
took Mr. Smiths vital signs and wrote his results and chief complaint in his char
t. When the
physician examined the patient, he believed that Mr. Smith was suffering from a
respiratory
infection. His plan was to prescribe an antibiotic if the infection turned out t
o be caused by
bacteria, so he asked the medical assistant to draw blood for a CBC. The medical
assistant
performed a venipuncture on Mr. Smith and processed the sample for pickup by the
reference
laboratory for testing later that day. She explained to Mr. Smith that the resul
ts should be back
in the office in the mor - ning and if the CBC results indicate the presence of

a bacterial
infection, the physician will call in a prescription for an antibiotic to his ph
armacy. She told
the patient that she would call him in the morning. The next morning these resul
ts were faxed to
the office: ID Number: 09123 Patient ID: 98789 Name: Address: Seq#: 43210 Type:
Mode: Date:
Time: Sex: Age: Blood 10-14-2012 10:45 AM Male 67 James Smith 3456 Waterview Ter
race Seattle, WA
98103 CBC RESULTS TEST PATIENT RESULTS REFERENCE RANGE Hemoglobin 14.2 g/dL 13 1
2 Hematocrit 43%
45 37 Red blood cell count 5.7 x 10 6
/
mm
3 4.6 4.2 White blood cell count Neutrophils Lymphocytes Monocytes Eosin
ophils Basophils
Platelet count 12,000/mm 3 48% 48% 2% 1% 1% 320 x 10 3
/
mm
3 4,300 54 25 2 1 0 150 10,800 65 40 8 4 1 450 18 16 male female male fe
male 52 48 male
female 6.2 5.9 CB LABORATORY c. Small red blood cells d. Small platelets 10. A h
emocytometer is
used to: Outcome 12-1 a. Measure a hematocrit level b. Perform manual white bloo
d cell counts c.
Perform staining of peripheral blood smears d. Measure hemoglobin concentrations
Continued
1899_Ch12_269-284 21/12/11 4:25 PM Page 283 284 Section III Hematology and Coag
ulation RESOURCES
AND SUGGESTED READINGS QBS Star Provides an overview of the function of the QBC St
ar hematology analyzer http://www.qbcdiagnostics.com The medical assistant highlighted
the abnormal
results, retrieved James Smiths chart, and took the laboratory report and chart t
o the
physician. The doctor reviewed the results and asked the medical assistant to co
ntact Mr. Smith
to let him know that he would not be prescribing antibiotics at this time. The m
edical assistant
called Mr. Smith and explained that the results were not consistent with a bacte
rial infection.
She told Mr. Smith that no antibiotics would be prescribed at this time, but to
check back in a
week if the symptoms had not gotten better or if things appeared to be worse. 1.
What color tube
was used for the blood sample? 2. What out-of-range laboratory results should th
e medical
assistant have highlighted for the physician? 3. Are the abnormal laboratory res
ults consistent
with a bacterial infection? 1899_Ch12_269-284 21/12/11 4:25 PM Page 284 285 Chap
ter 13 Hemoglobin
and Hematocrit Nikki A. Marhefka, EdM, MT(ASCP), CMA (AAMA) CHAPTER OUTLINE Hemo
globin
Hemoglobinopathies Hemoglobin Testing CLIAWaived Hemoglobin Testing Potential Err
ors in
Hemoglobin Testing Hematocrit CLIAWaived Hematocrit Testing Potential Errors in H
ematocrit
Testing The Relationship of Hemoglobin and Hematocrit Values Anemia Summary Time
to Review Case
Study Resources and Suggested Readings Learning Outcomes After reading this chap
ter, the
successful student will be able to: 13-1 Define the key terms. 13-2 Describe the

structure and
function of a hemo- globin molecule. 13-3 State the type of normal adult hemoglo
bin and list
other types present with various hemoglo- binopathies. 13-4 Analyze the general
principle of and
sources of error associated with CLIA-waived testing of hemoglobin. 13-5 Evaluat
e the concept of
the hematocrit. 13-6 Identify the layers into which the blood sample has separat
ed in a spun
hematocrit specimen. 13-7 Examine the general principle of and sources of error
associated with
CLIA-waived hematocrit procedures. 13-8 Recognize the normal reference ranges fo
r hemoglobin and
hematocrit. 13-9 Define anemia and examine its clinical signifi- cance. 13-10 Li
st the various
types of anemia and explain how they are classified. CAAHEP AND ABHES STANDARDS
CAAHEP 2008
Standards I.C.I. Anatomy and Physiology #6: Identify common pathology as it rela
tes to the
interaction of body systems. I.C.I. Anatomy and Physiology #7: Analyze pathology
as it relates to
the interaction of body systems. I.P.I. Anatomy and Physiology #12: Perform hema
tology testing.
ABHES 2010 Standards 10. Medical Laboratory Procedures, b. CLIA-waived tests, Gr
aduates: 2.
Hematology Testing. 1899_Ch13_285-302 21/12/11 4:26 PM Page 285 T wo of the most
important
hematology test proce- dures are for hemoglobin (hgb), a protein respon- sible f
or oxygen
transport, and the percentage of the space occupied by red blood cells compared
to the en- tire
blood volume known as the hematocrit (hct). Measurement of the hemoglobin and he
matocrit
(abbreviated as H&H) is commonly performed in all laboratories and physician off
ices. The results
of these two tests may be used to help diagnose or monitor the progress of treat
ment for anemia,
a condition in which the oxygen-carrying capacity of the blood is reduced. This
chapter presents
additional information about the clinical significance of the hemoglobin and hem
atocrit
measurements, and provides details of testing methods for these parameters. HEMO
GLOBIN As was
established in previous chapters, mature red blood cells are filled with fluid a
s they are
released from the bone marrow. The intracellular fluid is primarily made up of h
emoglobin. Oxygen
attaches to this protein complex for subsequent transport to the tissues of the
body, where it is
needed for the production of energy. The primary function of hemoglobin (and thu
s, the red blood
cells) is to transport oxygen to the tissues of the body. Hemoglobin is composed
of four
molecules of heme within a globin protein chain. Each of these heme molecules ha
s one atom of
iron, and one molecule of oxygen can attach to each of these iron atoms. Thus, o
ne red blood cell
can transport four molecules of oxygen. Hemoglobin production begins in the eryt
hroid pre- cursor
cells of the bone marrow. The heme is synthesized by the mitochondria of the bon

e marrow cells,
and the globin chains are constructed by the ribosomes of the cells as they matu
re in the bone
marrow. Most of the he- moglobin is formed by the early precursor cells, which a
re nucleated, but
the production continues even after these cells have lost their nucleus until th
ey are released
into the general circulation (Fig. 13-1). 286 Section III Hematology and Coagul
ation KEY TERMS
Anemia Anisocytosis Aplastic anemia Bilirubin Cyanmethemoglobin Erythropoiesis H
ematocrit (hct)
Hb A Hemoglobin (hgb) Hemoglobin and hematocrit (H&H) Hemoglobin electrophoresis
Hemoglobinopathy
Hemolysis Heterozygous Homozygous Hypochromic Interstitial fluid Intrinsic facto
r Iron-deficiency
anemia Macrocytic Microcytic Packed cell volume Pernicious anemia Poikilocytosis
Protoporphyrin
Sickle cell anemia Sickle cell disease Sickle cell trait Splenomegaly Target cel
l Thalassemia
Urobilinogen Test Your Knowledge 13-1 Hemoglobin is made up of one molecule of _
_________ and
four molecules of _________. (Outcome 13-2) Test Your Knowledge 13-2 What is the
function of
hemoglobin? (Outcome 13-2) The hemoglobin molecule becomes oxygenated in the lun
gs where the
oxygen concentration is very high. As the red blood cells leave the pulmonary ci
rculation, the
affinity of tissues for the oxygen carried by the hemoglobin molecule will cause
the oxygen to
diffuse through the red blood cell membrane and across cap- illary walls to ente
r the tissues.
After the oxygen has left the red blood cells, the cells are capable of trans- p
orting carbon
dioxide back to the lungs to be expelled. With the delivery of oxygen and transp
ort of
1899_Ch13_285-302 21/12/11 4:26 PM Page 286 Chapter 13 Hemoglobin and Hematocri
t 287 2 chain
1 chain 2 ch in 1 ch in Heme group HEMOGLOBIN Figure 13-1 A hemoglobin molecule.
Note the
polypep- tide ch nges with the heme molecules in the center of the complex. c rb
on dioxide, the
hemoglobin molecules of the red blood cells help the body control the cid-b se
b l nce th t is
necess ry for surviv l. M ture red blood cells h ve
life sp n of pproxi- m te
ly 120 d ys.
During their lifetime, they must tr vel const ntly through the c rdiov scul r sy
stem, rem ining
flexible enough to p ss through c pill ry beds to perform their duties. Eventu l
ly, worn-out red
blood cells re re- moved by the tissue m croph ge system in the spleen nd the
hemoglobin is
degr ded into iron, protoporphyrin, nd globulin. Protoporphyrin is included in
the heme portion
of the hemoglobin molecule, nd is necess ry to m ke the iron function l nd v
il ble to tt ch
to the oxygen. The iron rele sed by the bre kdown of old red blood cells is remo
ved from the
heme, nd tr nsported to the bone m rrow to be used g in. The globulin is degr
ded into mino
cids to be used by the body for cre tion of protein. Protoporphyrin is converte

d into bilirubin,
which combines with lbumin for tr nsport to the liver. The liver cells further
process the
bilirubin nd it is excreted s bile, which enters the intestines where b cte- r
i convert it to
urobilinogen to be excreted in the feces. HEMOGLOBINOPATHIES The norm l dult he
moglobin is
denoted s Hb A. Hemoglobin in red blood cells of the fetus nd the newborn is H
b F. There re
genetic hemoglobin v ri nts present in the popul tion, in which the structure of
the globin p rt
of the molecule is ltered. The presence of n bnorm l hemoglobin is known s
hemoglobinop thy. The hemoglobinop thies re result of genetic ch nges th t m
y be inherited or
c used by mut tions. Both the homozygous form in which the p tient h s two ident
i- c l genes for
the s me ch r cteristic or the heterozygous form th t cont ins two genes for bn
orm l hemoglobin
v ri nts c n le d to
mild or severe nemi . If Hb A is present in the cells s
well s the
bnorm l hemoglobin, the bnorm lity m y be m sked nd no symptoms will be evide
nt. Sickle cell
dise se nd sickle cell tr it re
result of the presence of Hb S. Other hemogl
o- binop thies
m y be symptom tic, where s others c n le d to severe nemi . POINT OF INTEREST
13-1
Hemoglobinop thies The hemoglobin molecule must h ve
very specific structure i
n order to
function optim lly. Any ch nge in the structure of the globin ch ins in the hemo
glo- bin molecule
m y be cl ssified s hemoglobinop - thy. M ny of these bnorm lities rem in un
detected bec use
they re not clinic lly signific nt. Others, however, will h ve
signific nt ef
fect on the
bodys bility to tr nsport oxygen. Methemoglobinemi : For the hemoglobin mole- c
ule to
function ppropri tely, it is necess ry for the iron molecule to be ferrous. Thi
s me ns th t the
iron molecule is positively ch rged with two more protons th n electrons present
in the molecule. If the iron is present in st te other th n this, the hemoglobin molecule
h s poor
ffinity for oxygen. This results in st te of cy nosis for the body, bec use t
he red blood
cells c nnot deliver the oxygen ppropri tely if they do not pick it up s they
should in the
lung tissues. Hemoglobinop thies with decre sed oxygen ffinity: Cert in bnorm
lities of the
hemoglobin molecule m y cre te
situ tion in which there is
pronounced decre
se in the
ffinity for oxygen. This me ns th t the molecules do not pick up the oxygen s
they should in
the lungs. This type of hemoglobinop thy is ch r cterized by cy nosis. Hb Se ttl
e nd Hb
V ncouver re ex mples of this type of hemoglobinop thy. Incre sed oxygen ffin
ity:
Erythrocytosis is com- mon symptom of hemoglobinop thies with in- cre sed oxyg
en ffinity. In
this situ tion, the mole- cule holds on so tightly to the oxygen molecules th t
they c nnot be

deposited throughout the Continued 1899_Ch13_285-302 21/12/11 4:26 PM P ge 287 T

h l ssemi s re
group of inherited disorders in which bnorm l hemoglobin is present in the red
blood cells. In
th l ssemi , nemi results either from defec- tive production r te of the lp
h or bet globin
ch ins th t m ke up the globin portion of the norm l hemo- globin molecule. With
out these ch ins,
it is not possible for the red blood cell precursors to build Hb A, the nor- m l
hemoglobin
present in the dult red blood cell. Those who re homozygous for the defective
gene h ve severe
hypochromic, microcytic nemi , nd
v riety of other issues rel ted to the sev
ere nemi (T ble
13-1). This is sophistic ted test th t is performed in reference or hospit l l
bor tories.
HEMOGLOBIN TESTING Hemoglobin testing is one of the most frequently per- formed
l bor tory
procedures. The results c n be used to detect nemi nd provide inform tion to
deter- mine its
severity. Hemoglobin testing m y lso be used to monitor the tre tment for nemi
. Hemoglobin 288
Section III Hem tology nd Co gul tion body. The kidneys will incre se their se
cretion of
erythropoetin bec use of the reduced oxygen in the tissues of the body. Hb Ches
pe ke is n
ex mple of this type of hemoglobinop thy. Hemolytic hemoglobinop thies: Hb S n
d Hb C re
bnorm lities of the hemoglobin molecule structure th t ffect the integrity of
the red blood
cell molecule s well s the hemoglobin molecule. These bnorm lities occur bec
use of the w y
th t the globin ch ins re interconnected. The red blood cell membr nes h ve inc
re sed hemolysis
be- c use the hemoglobin molecule form tion is unst - ble. This h s
profound e
ffect on the life
sp n of the red blood cell. The high levels of hemolysis le d to
const nt st t
e of nemi ,
j undice, nd cholelithi sis. Hb S (sickle cell) lso m y c use the vessels of t
he body to become
occluded due to the distinct sh pe of the red blood cells. The bnorm l crescent
sh pe becomes
lodged in the sm ll c pill ries of the body, with multiorg n effects. Test Your
Knowledge 13-3
List two bnorm l types of hemoglobin. (Outcome 13-3) When
hemoglobinop thy is
suspected,
identific - tion of the hemoglobin v ri nt present in the red blood cells c n be
ccomplished
through hemoglobin elec- trophoresis. In this technique, blood for ex min tion i
s pl ced on
cellulose cet te gel support medium th t is c p ble of tr nsmitting n electric
l current. An
lk line electrolyte solution is dded, nd n electric l current is pplied to
the support
medium. E ch hemoglobin sub- type moves cross the support medium t different
r te nd cre tes
distinctive p ttern. The b nds of hemoglobin re detected by st ining nd iden
tified by their
pl cement on the medium s they h ve moved. TABLE 13-1 Th l ssemi s Alph Th l s
semi s Bet

Th l ssemi s Insufficient lph globin protein produced Clinic l defect: A gene

or genes rel ted
to the lph globin protein of hemoglobin is/ re missing or ch nged Frequency: F
ound in persons
of Southe st Asi n, Middle E stern, Chinese, nd Afric n descent Subtypes M jor
Hydrops
fet lisb bies die before or shortly fter birth Hemoglobin H dise se, moder te to
severe
nemi Minor: C lled lph th l ssemi tr it, mild nemi . Alph th l ssemi sil
ent c rrier
h s the bnorm l gene, but it is not evident bec use these genes re heterozygou
s. *Th l ssemi
is genetic defect in the protein portion of the hemoglo- bin molecule nd ffe
cts lph or bet
globin protein production. Both globin proteins re necess ry to cre te he lthy
hemoglobin.Th l ssemi c uses the body to m ke fewer he lthy red blood cells bec
use they re
hemoglobin deficient nd re not s well equipped to tr nsport oxygen s norm l
hemoglobin.
Insufficient bet globin protein Clinic l defect: Gene defects ffect the produc
tion of the bet
globin protein of hemoglobin Frequency: Found in persons of Mediterr ne n descen
t, nd to
lesser extent in Chinese, other Asi ns, nd Afric n Americ ns Subtypes M jor Coo
leys nemi
severe nemi Intermedi te, moder te nemi Minor: C lled bet th l ssemi tr it
1899_Ch13_285-302 21/12/11 4:26 PM P ge 288 reference r nges v ry by ge nd gen
der of the
p tient (T ble 13-2). The norm l reference r nges for the dult m le re 13 to 1
8 g/dL, nd the
reference r nges for the dult fem le re 12 to 16 g/dL. Women of child-be ring
ge h ve lower
norm l reference r nge th n do men due to the blood loss experienced s
result
of the monthly
menstru l cycle. Inf nt hemoglo- bin v lues re signific ntly lower th n those o
f dults, with n
ver ge of 11 to 14 g/dL. Childrens hemoglo- bin v lues gr du lly incre se from i
nf ncy levels
to dulthood. Hemoglobin is usu lly converted to nother com- pound, c lled cy n
methemoglobin,
for me surement. Cy nmethemoglobin is colored pigment, so the ch nge in color
once this
conversion h s been ccomplished c n be me sured s bsorb nce by spectrophoto
meter, us- ing
w velength of 540 nm. To rele se the hemoglobin from the cells to be converted
nd me sured, the
red blood cell membr nes must be broken or dissolved,
process c lled hemolysis
. The
cy nmethemoglobin re gents used for hemoglobin testing cont in surf c- t nt th
t promotes r pid
hemolysis nd form tion of the cy nmethemoglobin moledule. L rge complex n lyze
rs used in
reference nd hospit l l bor tories s well s CLIA-w ived point of c re testing
methods use this
b sic procedure. CLIAW ived Hemoglobin Testing The CLIA-w ived hemoglobin procedu
res re performed by h ndheld, point-of-c re instruments. These n lyzers h ve been pprove
d by the U.S.
Food nd Drug Administr tion (FDA) for perform nce of hemo- globin testing. E ch
instrument

determines the hemo- globin v lues with minim l steps involved in the testing pr
ocess. The
HemoCue Hb instrument (m nuf ctured by HemoCue Inc.), nd i-STAT (m nuf ctured b
y Abbott) re
ex mples of common CLIA-w ived hemo- globin n lyzers used in physici n offices
(Fig. 13-2).
There re simil rities in the testing methods for ll the CLIA-w ived hemoglobin
testing
procedures. These include the following: 1. For most of these instruments, blood
is collected by
c pill ry puncture nd pl ced on
re ction ch mber. The re ction ch mber includ
es the necess ry chemic ls to lyse the red blood cells nd llow the conversion of the hemog
lobin to cy nmethemoglobin. For m ny of these procedures, blood m y lso be t ken from
tube
cont ining
ntico gul nt. 2. The re ction ch mber is pl ced into the n lyzer, nd the colo
r intensity is
re d by spectrophotometer to determine hemoglobin content. 3. The h ndheld ins
truments require
very little m inte- n nce or c libr tion procedures to produce reli ble results.
However, it is
imper tive th t the oper tor follow ll m nuf cturer recommend tions for c libr
- tion nd
qu lity control procedures. These results must be logged ppropri tely, nd must
ll be within n
ccept ble r nge before p tient testing is per- formed on the instrument. 4. Tes
t results re
v il ble s digit l re dout on the in- strument. In ddition, some of the ins
truments m y be
connected to
computer for result stor ge nd printout. 5. 6. Potenti l Errors
in Hemoglobin
Testing Even though the hemoglobin testing procedure is str ightforw rd, it is s
till possible to
m ke errors th t m y h ve signific nt imp cts on the results. Potenti l Ch pter
13 Hemoglobin
nd Hem tocrit 289 TABLE 13-2 Hemoglobin Reference R nges (Norm l V lues) Age/Ge
nder Hgb (g/dL)
Adult m le 1418 Adult fem le 1216 Newborn 1723 Two-month-olds 914 Child, 114 ye rs 11
.314.4
Figure 13-2 A hemoglobinometer. 1899_Ch13_285-302 21/12/11 4:26 PM P ge 289 290
Section III
Hem tology nd Co gul tion Procedure 13-1: CLIA-W ived Hemoglobin Testing Using
the HemoCue
Hemoglobin An lyzer Hemoglobin n lysis is one of the most common CLIA-w ived te
sts performed in
physici n office l bor - tories nd l rger, more complex l bor tories. For the H
emoCue method,
c pill ry, venous, or rteri l blood m y be used. Hemoglobin results m y be used
to screen or
monitor the progress of the tre tment for nemi . TASK Accur tely perform hemogl
obin testing
using Hemo- Cue hemoglobin n lyzer. CONDITIONS H nd-w shing supplies nd/or
lcohol-b sed
h nd s nitizer Dispos ble gloves L ncet for c pill ry punctures Alcohol prep p d
G uze
p ds Bioh z rdous sh rps cont iner HemoCue hemoglobin n lyzer HemoCue microcuve
ttes
HemoCue c libr tion cuvette HemoCue control solution Disinfect nt wipes for cle
ning work

re CAAHEP/ABHES STANDARDS CAAHEP St nd rds I.P.I.12. Perform Hem tology Testin

g ABHES St nd rds
Perform selected CLIA-w ived tests th t ssist with di gnosis nd tre tment: 2.
Hem tology
testing Procedure R tion le Gloves must be worn for ny procedures in which expo
sure to blood or
other potenti lly infectious m teri ls is nticip ted. The HemoCue instrument wi
ll complete set
of inter- n l verific tion procedures. Once this h s been suc- cessfully complet
ed, the digit l
re dout on the screen will indic te th t the instrument is re dy. Expired suppli
es re never to
be used for control or p tient testing. The microcuvette cont iner must st y clo
sed securely.
These microcuvettes re very sensitive to moisture exposure. The qu lity control
m teri l comes
with set of ccept- ble result r nges. There re m teri ls v il ble to test
t low, medium,
nd high levels of hemoglobin concentr tion. Verify th t the re dout on the digi
t l displ y
indic tes result within the ccept ble r nge for th t level of control before
performing
p tient testing. Document the result for this qu lity control m teri l. 1. S nit
ize h nds, llow
them to dry completely, nd pply gloves. 2. Turn on the HemoCue instrument, nd
w it until the
digit l printout on the screen indic tes th t the instrument is re dy for testin
g. 3. Verify the
expir tion printed on the microcuvette cont iner. 4. Open the microcuvette bottl
e, nd remove
microcuvette. Close the bottle securely s soon s the desired microcuvette is r
emoved. 5. Using
the qu lity control m teri l th t is designed for this instrument, verify th t t
he instrument is
working correctly. Follow the m nuf cturers instructions for use nd frequency of
testing these
m teri ls. Fill the microcuvette with the control m teri l, then insert the cuve
tte into the
holder nd push into the instrument for n lysis. Note the digit l re dout when
re dy, nd
comp re the results to those design ted s ccept ble for this control m teri l.
1899_Ch13_285-302 21/12/11 4:26 PM P ge 290 Ch pter 13 Hemoglobin nd Hem tocri
t 291 Procedure
R tion le 6. Perform c pill ry puncture, using ppropri te technique. Wipe w
y the first drop
of blood. 7. Touch the open end of the HemoCue microcu- vette to the drop of blo
od. The
microcuvette will fill by c pill ry ction to the ppropri te level. 8. Wipe off
ny excess blood
from the bottom nd sides of the microcuvette with g uze p d, then pl ce the m
icrocuvette in
the cuvette holder nd push the holder into the instrument for n lysis. Appropr
i te c pill ry
puncture procedure includes disinfection of the dr w site, llowing the lcohol
to dry, using n
ppropri te site, performing the punc- ture perpendicul r to the fingerprints on
the finger, nd
wiping w y the first drop of blood th t forms. This drop of blood is cont min t
ed with
interstiti l fluid nd if used for the n lysis, c n produce erro- neous results

. Dont touch the

c pill ry puncture site with the microcuvette; it should be pl ced into the drop
of blood. The
microcuvette will not overfill. It is import nt to wipe w y excess blood. Howev
er, do not llow
the g uze to bsorb blood from the inte- rior of the cuvette. The interior of th
e microcuvette is
co ted with chem- ic l th t lyses the red blood cells, nd converts the hemogl
obin present to
cy nmethemoglobin to be me sured in the instrument. Continued 1899_Ch13_285-302
21/12/11 4:26 PM
P ge 291 292 Section III Hem tology nd Co gul tion Procedure 13-1: CLIA-W ived
Hemoglobin
Testing Using the HemoCue Hemoglobin An lyzercontd 9. The digit l displ y will pre
sent result
within 10 to 20 seconds. Document this hemoglobin result. 10. After recording th
e hemoglobin
result, pull out the cuvette holder nd remove the cuvette. The used cuvette mus
t be disc rded s
bioh z rdous m teri l. 11. Cle n nd disinfect the work re , then remove glov
es nd s nitize
your h nds. 12. Document the procedure in the p tients ch rt if it is v il ble.
Procedure
R tion le The result will continue to be displ yed until the cuvette holder is p
ulled out of the
instrument. The blood cont ined in the microcuvette is still consid- ered to be
infectious, so it
must be disposed of ppropri tely. The work re should lw ys be cle ned fter
use to prep re it
for the next user, nd h nds must lw ys be s nitized fte removing gloves. In
physici n office
l bor tory, this procedure should be documented in the p tients ch rt. If the med
ic l ssist nt
is working in l bor tory setting where the ch rt is not v il ble, this step i
s not necess ry.
D te 4/2/2012: Hemoglobin test performed. QC within r nge. Hgb 13.3 g/dL
09:30 .m.
Connie Lieseke, CMA (AAMA) sources of error to t ke into consider tion i
nclude the following:
Adequ te blood flow during the c pill ry collection is necess ry to get
homoge
neous (well
mixed) s mple without clots. To void diluting the blood s mple with interstiti
l fluid (the
fluid between cells), there should be no squeezing during c pill ry s mple colle
ction nd the
first drop or two of blood present fter the puncture must be wiped w y before
the blood is
pplied to the testing ch mber or device. If the s mple is diluted by interstiti
l fluid, the
hemoglobin v lue will be erroneously lowered. There should be no ir bubbles or
sp ces in the
collecting device. 1899_Ch13_285-302 21/12/11 4:26 PM P ge 292 As is the c se wi
th ll
utom ted instruments, the re gents nd supplies must not be expired when used,
nd stor ge
requirements for ll re gents nd s mples must be followed s directed. The test
should be
performed within the ppropri te time limits fter specimen collection s indic

ted on the
instructions for the n lyzer. All instructions for use of the n lyzer must be
fol- lowed
ex ctly s described. Intern l nd extern l qu lity control must be per- formed
t the
interv ls recommended by the m nuf c- turer, nd the results must be within the
desired r nges
before p tient results re reported. CLIA-w ived procedures for hem tocrit testi
ng re m nu l
methods requiring centrifug tion of the speci- men. Hem tocrit v lues m y lso b
e derived by
using moder tely or highly complex utom ted instruments. These n lyzers will u
se the hemoglobin
concentr tion nd the me n corpuscul r volume (MCV) to c lcul te hem tocrit re
sult. Ch pter 13
Hemoglobin nd Hem tocrit 293 Test Your Knowledge 13-4 Are hemoglobin tests perf
ormed on int ct
red blood cells? (Outcome 13-4) Test Your Knowledge 13-5 List two potenti l erro
rs in performing
hemoglobin testing. (Outcome 13-4) Test Your Knowledge 13-6 Define hem tocrit. (
Outcome 13-5)
HEMATOCRIT The hem tocrit is the percent ge of sp ce occupied by red blood cells
s comp red to
the entire blood volume in s mple of whole blood. It m y lso be c lled the p
cked cell volume.
The hem tocrit is n indirect test th t provides import nt inform tion bout the
concen- tr tion
of red blood cells in the circul ting blood. The sp ce occupied by the red blood
cells depends on
the size of the cells nd the tot l number of cells present. If there is n ppr
opri te mount of
red blood cells with nor- m l hemoglobin concentr tion in specimen, the hem
- tocrit will be
in the norm l reference r nge. If the red blood cells re sm ll with insufficien
t hemoglobin or
the number of red blood cells is decre sed, the hem tocrit v lue will be below t
he norm l
reference r nge. The norm l reference r nges for hem tocrit v ry with gender nd
ge of the
p tient (T ble 13-3). Newborns h ve
very high hem tocrit v lue, but it decre s
es quickly fter
birth. The reference r nge for child is less th n th t of n dult, but it con
tinues to
incre se s they ppro ch dulthood. Adult men h ve
norm l r nge of 45% to 52%
, nd dult women
h ve norm l r nge of 37% to 48%. Hem tocrit v lues re decre sed with the v ri
ous forms of
nemi , nd m y be elev ted in situ - tions with n overproduction of red blood
cells, such s in
polycythemi . TABLE 13-3 Hem tocrit reference r nges (norm l v lues) Age/Gender
hct V lue (%)
Adult m le 4552 Adult fem le 3748 Newborn 5062 Two-month-olds 3139 Child, 16 ye rs 304
0
CLIAW ived Hem tocrit Testing In typic l hem tocrit testing, the red blood cells
re forced to
the bottom of the tube by centrifug tion (Fig. 13-3). This tube m y be known s
c pill ry tube
or microhem tocrit tube bec use the tube is very sm ll nd designed to be spun
in sm ll
centrifuge. After cen- trifug tion, the tube is comp red to re ding device to

me sure the
hem tocrit v lue. The hem tocrit is lw ys reported s percent ge, indic ting
the volume of red
blood cells in the s mple s comp red to the tot l blood volume. There re some
v ri bles in the
testing process, but the following common components re present in ll the CLIA
-w ived m nu l
hem tocrit procedures: Two hem tocrit tubes re lw ys filled from e ch p tient.
Both tubes re
centrifuged nd results re me sured from both tubes. The fin l result reported
will be n
ver ge of the two tubes, s long s they re within 2% of e ch other. If the re
sults from the
two tubes re more th n 2% p rt, the s mple will need to be recollected nd res
pun. The
hem tocrit tubes must cont in ntico gul nt (the tube interior is co ted with he
p rin) if they
re to be used for c pill ry s mples dr wn directly from the 1899_Ch13_285-302 2
1/12/11 4:26 PM
P ge 293 p tient. If ntico gul nt is not used, the blood will clot in the hem t
ocrit tube nd
the results will be er- roneous. It is lso possible to use pl in tubes (without
ntico gul nt)
if the hem tocrit s mple is t ken from n EDTA l vender top tube. Gl ss tubes sh
ould not be
used for this process in consider tion of employee s fety. S fety co ted gl ss t
ubes re
v il ble, which h ve
gl ss interior nd re covered with Myl r co ting to k
eep them from
bre king. Pl stic tubes re lso v il ble. The s mple must be well mixed prior
to filling the
hem tocrit tube (if utilizing n EDTA ntico gul ted s mple). If c pill ry s m
ple is to be
used, the site must not be squeezed, s this will dd too much inter- stiti l fl
uid to the
s mple. The ddition l fluid m y result in f lsely decre sed hem tocrit result
. As the tube
is filled, ir bubbles should be voided. The ddition of bubbles in the specime
n c n c use the
tube to fill insufficiently, in which c se it m y not be possible to me sure the
results fter
centrifug tion. The end of the hem tocrit tube will be plugged with se ling cl y
to keep the
s mple from le ving the tube during the centrifug tion process. Follow the m nuf
cturers
recommend tions for the centrifug tion times necess ry, which m y v ry with e ch
type of
centrifuge. Re d the results immedi tely fter centrifug tion us- ing
built-in
re der, or
nother device designed for hem tocrit results. Following centrifug tion, the bl
ood in the tube
will h ve been divided into three l y- ers. The hem tocrit result is re d t the
top of the red
blood cell column, which is the bottom l yer in the tube. There is thin re c
lled buffy
co t (lighter in color nd m de of the white blood cells nd pl telets in the s
mple) th t is
visible t the top of the red blood cells, nd the pl sm m kes up the rest of t
he volume of the
s mple in the tube (see Fig. 13-3). The moder tely complex utom ted procedures

v il- ble for

hem tocrit testing re often used in the physi- ci n office l bor tory. An ex mp
le of common
instrument is the i-STAT n lyzer, m de by Abbott L bor tories. The process requ
ires only few
drops of blood. This instrument uses individu l c rtridges to which the blood s
mple is dded.
The hem tocrit level is determined by use of n electric l current. As is the c
se with ll
CLIA-w ived testing procedures, ll instructions nd qu lity control procedures
recom- mended by
the m nuf cturer must be followed. Potenti l Errors in Hem tocrit Testing The he
m tocrit testing
process m y be considered simplistic. However, it is possible to neg tively ffe
ct the results if
not p ying close ttention to det il. The follow- ing re some of the most commo
n errors
encountered when using the m nu l hem tocrit procedure: If c pill ry specimen
is used for the
procedure, the s mple must be collected from free-flowing blood from skin punc
ture. If the re
is squeezed, intersti- ti l fluid (tissue fluid) m y cont min te the s mple or t
he red blood
cells c n be broken open (hemolysis). The first drop of blood from the skin punc
ture must be
wiped w y, s this cont ins some interstiti l fluid s the l ncet cut through t
issue. If the
pl sm ppe rs pink or reddish, cells m y h ve been hemolyzed during collection.
Excessive
hemolysis c n decre se the v lue of the hem tocrit. Hemolysis m y occur during t
he collection
process or s result of intr v scul r hemolysis in severe dise se st tes. The
hem tocrit tube
must be filled ppropri tely. If too little blood is dded to the tube, it will
not be pos- sible
to re d the result using re ding device fter cen- trifug tion. Conversely, th
e result for
tube th t is overfilled c nnot be me sured using re ding device. 294 Section I
II Hem tology
nd Co gul tion Pl sm White blood cells nd pl telets, buffy co t Red blood cells
HEMATOCRIT =
% OF RBCs Figure 13-3 L yers of the hem tocrit tube. The bottom l yer is m de up
of red blood
cells covered with very thin l yer of buffy co t, which represents the white b
lood cells in the
specimen. The uppermost l yer is m de up of pl sm . There is ir t the very top
of the tube.
1899_Ch13_285-302 21/12/11 4:26 PM P ge 294 Procedure 13-2: CLIAW ived Hem tocrit
Testing Using
the St tSpin CritSpin Microhem tocrit Centrifuge nd Digit l Re der Ch pter 13
Hemoglobin nd
Hem tocrit 295 Hem tocrit testing is common CLIA-w ived test th t is performed
in physici n
office l bor tories nd l rger, more complex l bor tories. Spun hem tocrit n ly
sis is rel tively
inexpensive, requires sm ll mount of blood, nd t kes only few minutes. Alt
hough c pil- l ry
spun microhem tocrit testing is the most common method, venous blood m y lso be
used for
testing. Hem tocrit results m y be used to screen for or moni- tor the progress

of the tre tment

for nemi . TASK Accur tely perform microhem tocrit n lysis utilizing the St tS
pin CritSpin
microhem tocrit centrifuge nd digit l re der. The process must be completed wit
hin 15 minutes.
CONDITIONS H nd-w shing supplies nd/or lcohol-b sed h nd s nitizer Dispos ble
gloves
L ncet for c pill ry punctures Alcohol prep p d G uze p ds Bioh z rdous sh rps c
ont iner
St tSpin CritSpin microhem tocrit centrifuge nd digit l re der Pl stic hep rini
zed
microhem tocrit tubes Se ling cl y HemoCue control solution Disinfect nt wipes f
or cle ning
work re CAAHEP/ABHES STANDARDS CAAHEP St nd rds I.P.I.12. Perform Hem tology T
esting ABHES
St nd rds Perform selected CLIA-w ived tests th t ssist with di gnosis nd tre
tment: 2.
Hem tology testing Procedure R tion le Gloves must be worn for ny procedures in
which exposure
to blood or other potenti lly infectious m teri ls is nticip ted. The qu lity c
ontrol m teri l
comes with
set of ccept ble result r nges. There re m teri ls v il- ble to
test t low,
medium, nd high levels of hem - tocrit results. Verify th t the result is withi
n the ccept ble
r nge for th t level of control before performing p tient testing. Document the
result for this
qu lity control m teri l. The tubes need to be within e sy re ch for the next st
ep of the
process. Hep rinized tubes must be used for c pill ry s mples bec use the blood
must be
ntico gul ted to void clotting within the tube. 1. S nitize h nds, llow them
to dry
completely, nd pply gloves. 2. Use the qu lity control m teri l th t is design
ed for this
procedure nd this instrument, nd verify th t the instrument is working correct
ly. Follow the
m nuf cturers instructions for use nd fre- quency of testing these qu lity contr
ol m teri ls.
3. Remove two hep rinized microhem tocrit tubes from the cont iner, nd set them
on piece of
g uze in the work re . Continued 1899_Ch13_285-302 21/12/11 4:26 PM P ge 295 29
6 Section III
Hem tology nd Co gul tion Procedure 13-2: CLIAW ived Hem tocrit Testing Using th
e St tSpin
CritSpin Microhem tocrit Centrifuge nd Digit l Re dercontd 4. Perform c pill ry
puncture,
using ppropri te technique. Wipe w y the first drop of blood. 5. Hold the micr
ohem tocrit tube
by the end with the color-coded b nd. Touch the opposite end of the tube to the
drop of blood.
The blood will enter the tube vi c pill ry ction. Fill the tube until the bloo
d re ches the
colored b nd t the opposite end. 6. Remove the tube from the blood source, nd
tilt the tube
until the blood is h lfw y between the colored b nd nd the end of the tube. Pro
cedure R tion le
Appropri te c pill ry puncture procedure includes disinfection of the dr w site,
llowing the
lcohol to dry, using n ppropri te site, performing the punc- ture perpendicul

r to the
fingerprints on the finger, nd wiping w y the first drop of blood th t forms.
This drop of
blood is cont min ted with interstiti l fluid nd if used for the n lysis, c n
produce erroneous
results. For best results, do not llow ir bubbles to form in the tube. The tub
e should be
filled to the colored b nd to llow for ccur te re ding of the results. This st
ep is import nt
to llow for room for the se ling compound t the end of the tube. 1899_Ch13_285
-302 21/12/11
4:26 PM P ge 296 Ch pter 13 Hemoglobin nd Hem tocrit 297 Procedure R tion le 7
. Hold the
microhem tocrit tube horizont lly nd push the end of the tube with the color-co
ded b nd into the
se ling cl y. Twist the tube nd re- move from the se ling cl y. Wipe w y ny e
xcess blood th t
m y h ve le ked from the opposite end of the tube. 8. Pl ce the tube with the se
led end tow rd
the outer rim of the rotor. 9. Repe t steps 5 through 8 with nother microhe- m
tocrit tube.
After it is pl ced in the rotor, screw the rotor cover in pl ce securely. 10. Ho
lding the bl ck
knob in the center of the rotor, pl ce it in the rotor holder in the centrifuge.
11. Close the
cover on the centrifuge nd st rt the cen- trifuge. The St tSpin CritSpin centri
fuge requires 2
minutes to fully p ck the cells in the microhem - tocrit tubes. 12. When the rot
or stops
spinning, remove the rotor nd pl ce it in the digit l re der. 13. Line up the p
ointer on the
digit l re der with the bottom of the cells in the microhem tocrit tube nd pres
s the zero on
the re der. Then line up the pointer with the top of the pl sm column nd set t
he 100 st tus
on the re der. The fin l re ding is ccomplished t the top of the red blood cel
l column. The
result is displ yed on the digit l re der. If the microhem tocrit tubes re not
se led in this
w y, the blood will le k out of the tubes during the spin- ning process. If the
se led end of the
tube is not pl ced to the outer edge of the rotor, ll the blood will le k out o
f the tube when
it is spinning. There should lw ys be two tubes spun for e ch result to verify
the ccur cy of
the result. The rotor must be se ted securely in pl ce to void m lfunction of t
he centrifuge.
The time llowed for the centrifug tion will v ry by method used. The digit l re
der is n
option l device. A circul r or c rd re der m y lso be used to re d the results.
All three steps
must be followed to llow for ccur te re ding of the hem tocrit results. Note:
If digit l
re der is not v il ble, line up the tube with the bot- tom of the red blood cel
l column t the
zero line on hem tocrit re der c rd, fter which the top of the pl sm column is
to be
ligned t the 100 on the c rd. Re d the hem tocrit result t the top of the red b
lood cell
column. Continued 1899_Ch13_285-302 21/12/11 4:26 PM P ge 297 298 Section III H

em tology nd
Co gul tion Test Your Knowledge 13-7 Wh t is used to cre te the l yers in the bl
ood s mple in
m nu l CLIA-w ived hem tocrit procedures? (Outcome 13-6) Procedure 13-2: CLIAW iv
ed Hem tocrit
Testing Using the St tSpin CritSpin Microhem tocrit Centrifuge nd Digit l Re de
rcontd 14.
Record this result. 15. Following the s me procedure, re d the hem t- ocrit resu
lt on the second
tube. 16. Remove the microhem tocrit tubes from the rotor nd dispose of them s
bioh z rdous
sh rps. 17. Cle n nd disinfect the work re , then remove gloves nd s nitize y
our h nds. 18.
Document the procedure in the p tients ch rt if it is v il ble. Procedure R tion
le The result
must be recorded before removing the rotor from the system, or going on to re d
the second tube.
The results must be within 2% of e ch other for this to be v lid result. If th
ey re not, the
process must be repe ted. Report the me n ( ver ge) of the two tubes re d. Altho
ugh these re
pl stic tubes, they should still be disposed of in puncture-resist nt cont ine
r. The work re
should lw ys be cle ned fter use to prep re it for the next user, nd h nds mu
st lw ys be
s nitized fter removing gloves. In physici n office l bor tory, this procedur
e should be
documented in the p tients ch rt. If the medic l ssist nt is working in l bor
tory setting
where the ch rt is not v il ble, this step is not necess ry. D te 4/2/2012: Hem
tocrit test
performed. QC within r nge. Hct 41%
09:50 .m.
Connie Lieseke, CMA (AAMA) The required volume of blood for the hem tocr
it n lysis is
determined by following the procedure s written. The test m y be ffected if th
e timing or the
speed of the centrifuge is insufficient. The cells will not p ck t the bottom o
f the tube fully,
which m y c use the results to be f lsely elev ted. In ccur te lignment when re
ding the
result will c use errors. The employee must be c reful to re d only the red bloo
d cell column,
nd to h ve the tube pl ced ppropri tely g inst the re ding device for ccur t
e results. If
the se ling cl y h s not dequ tely filled the end of the tube, some of the bloo
d will le k out
during centrifug tion nd will ffect the result. The end of the tube th t is fi
lled with cl y is
pl ced to the outside of the centrifuge so th t the cl y keeps the blood in the
tube s the
specimen is spun. The hem tocrit v lue m y be in ccur te immedi tely fter exces
sive blood loss
or following tr nsfusion. Excess pl sm m y be tr pped between the red blood cel
ls in m crocytic,
hypochromic, or sickle cell ne- mi s. The cells will not p ck s well bec use o
f the re
occupied by the tr pped pl sm . 1899_Ch13_285-302 21/12/11 4:26 PM P ge 298 THE

RELATIONSHIP OF
HEMOGLOBIN AND HEMATOCRIT VALUES Hemoglobin nd hem tocrit testing is often orde
red together s
H&H. To verify the v lidity of the results, it is import nt to comp re the hem t
ocrit nd hemoglobin v lue of the p tients s mple. The hem tocrit v lue is pproxim tely three
times th t of
the hemo- globin v lue in
norm l specimen. The hemoglobin v lue multiplied tim
es three should
be within two of the hem tocrit results. In ddition, the hemoglobin v lue is b
out three times
th t of the red blood cell count. By checking these rel tionships e ch time thes
e tests re
performed, the medic l ssist nt c n verify th t the s mples re ll from the s
me p tient nd
th t the test procedures were performed correctly. Lipemi , hemolysis, nd other
clinic l
conditions c n m ke these comp risons in ccur te. If the s mple results dont f ll
within these
p r meters, the tests should be repe ted. ANEMIA Anemi is disorder ch r cteri
zed by the
decre sed oxygen-c rrying c p city of the blood. The following three clinic l sc
en rios m y be
evident with nemi : 1. A decre sed tot l red blood cell count 2. A decre se in
the hemoglobin
content of e ch cell 3. A dysfunction l bnorm l hemoglobin content th t is not
c p ble of
tr nsporting oxygen s it should To tre t nemi , pr ctitioners will ttempt to
identify the
c use. The problem m y be chronic in dequ te red blood cell production, red bloo
d cell
destruction or loss, or the in bility of the bone m rrow to re ct to blood loss
dequ tely.
P tients with nemi m y exhibit signs of f tigue, p llor (p le skin), t chyc rd
i (r pid
he rtbe ts), or dyspne (difficult bre thing). Difficulty with concen- tr tion
nd memory issues
m y lso be common symp- toms. These symptoms re ll rel ted to the decre sed o
xygen-c rrying
c p city of the blood, which st rves the cells of the body. Di gnosis nd cl ssi
fic tion of the
type of nemi m y be ccomplished with physic l ex min tion results, p tient hi
story, nd
l bor tory tests. P tients with ne- mi m y h ve decre sed red blood cell count
s, hemoglo- bin
concentr tions, or hem tocrit v lues. Some types of nemi exhibit low v lues in
more th n one of
these p r meters, where s others m y demonstr te only one bnorm l result. Anemi
is often
ch r cterized by red blood cell indices th t re outside of the norm l r nge s
well s specific
red blood cell morphology ch nges. Red blood cell morphology is observed on the
st ined blood
sme r utilized for the white blood cell differenti l by tr ined l bor tory tec
hnologist.
Anisocytosis (red blood cells which ppe r in v rious sizes) nd poikilocy- tosi
s (red blood
cells which ppe r in v rious sh pes) m y be present. The red blood cells of ne
mic p tients will
ppe r bnorm l, nd m y be microcytic, (sm ll) m crocytic (l rge), or hypochrom

ic (p le in
color). Imp ired red blood cell production m y be idiop thic (c use unknown) or
due to toxins or
infection. Anemi m y lso occur when there is defective synthesis of the heme o
f the hemoglobin
molecule. Acute or chronic hem- orrh ge m y c use nemi when the body is inc p
ble of m king
enough cells to m ke up for the loss. Hemolytic nemi occurs with excessive lys
is of the red
blood cells in- tr v scul rly. This c n be the result of red blood cell mem- br
ne disorders,
hemoglobin disorders, met bolic dise se, chemic l toxins, extensive burns, m l r
i , or utoimmune
destruction of the erythrocytes. A few specific types of nemi re presented be
low:
Iron-deficiency nemi occurs when there is insuffi- cient iron v il ble for d
equ te hemoglobin
form - tion. This is hypochromic, microcytic nemi , s e ch cell h s reduce
d mount of
hemoglobin. Iron deficiency m y be c used by m ny situ tions: the bodys supply of
iron m y be
low, the bsorption of the iron m y be imp ired, or the dem nd m y be high. As o
ur body bre ks
down old red blood cells, most of the v il ble iron present in the system is in
the tissue
m croph ge/reticuloendotheli l tissue of the spleen. Diet ry iron is bsorbed in
the sm ll
intestines. Clinic l fe tures of iron deficiency nemi m y in- clude sores on o
r burning
sens tion of the tongue, ulcers t the corner of the mouth, pic (cr ving for dirt
or ice), or
chronic g stritis. Milk nemi is often
c use in 6- to 24-month-old children, s
their diet
m y not cont in sufficient iron. Other c uses m y in- clude g strectomy (tot l o
r p rti l) or
prolonged tre t- ment of peptic ulcers or cid reflux. R pid growth Ch pter 13
Hemoglobin nd
Hem tocrit 299 Test Your Knowledge 13-8 N me the disorder where the oxygen-c rry
ing c p city of
the blood is reduced. (Outcome 13-9) 1899_Ch13_285-302 21/12/11 4:26 PM P ge 299
during childhood
nd incre sed red blood cell produc- tion during pregn ncy m y be c uses s well
. Apl stic
nemi s result from decre sed hem topoiesis in the bone m rrow th t le ds to dec
re sed red blood
cell production. Only the red blood cells c n be f- fected (erythropoiesis) or
ll blood cell
production c n be decre sed. R di tion, medic tions, chemic ls, or vir l infecti
ons m y be the
c use. Chemother py gents nd r di tion tre tment for c ncer re ex m- ples. In
most c ses, no
specific re son for the decre sed production of red blood cells is determined. T
he red blood cell
count will be low, nd the red blood cell morphology m y show nisocytosis nd p
oikilocyto- sis.
If pl telet form tion is decre sed in ddition to the low number of red blood ce
lls, bleeding
gums nd nosebleeds m y lso be pp rent. Pernicious nemi results from in deq
u te secretion
of intrinsic f ctor by the p riet l cells of the stom ch lining. Intrinsic f cto

r is necess ry
for bsorption of vit min B 12 , which is necess ry for red blood cell for- m ti
on in the bone
m rrow. The symptoms of perni- cious nemi m y include p llor, slight j undice
(p le yellow
skin), tongue sores, nd tingling feelings in the extremities. The red blood cel
ls of the
circul ting blood re often m crocytic. Auto ntibodies to intrin- sic f ctor m y
be present. The
defective bsorption of B 12 m y lso be ssoci ted with celi c dise se, m lnutrition, or
infl mm tory dise se of the sm ll intestines. P tients with pernicious nemi wh
o l ck the
intrinsic f ctor will need to receive B 12 injections regul rly to meet the bodys
needs.
Sickle cell nemi is c used by hemoglobinop thy. These p tients re homozygou
s for Hb S; the
m jority of their hemoglobin is the S v ri nt. The red blood cells of p tients w
ith sickle cell
nemi re missh pen; they ppe r crescent or sickle sh ped. The red blood cells
re destroyed
bec use of their bnorm l sh pe during ch nges in oxygen tension, The Hb S lso
c uses the cells
to be more rigid, which incre ses their r te of destruction s they try to squee
ze through
c pill ries. Sickle cell dise se c uses splenomeg ly ( n enl rged spleen), s bl
ood pools in the
spleen. P tients h nds nd feet re sometimes swollen, nd p tients h ve in- cre
sed ch nce of
infection nd exhibit joint p in. The bnorm lly sh ped red blood cells become s
tuck in the blood
vessels, c using p in nd poor delivery of oxygen to tissues. The red blood cell
morphology will
include sickle nd t rget cells if ex mined under the microscope. SUMMARY Hemogl
obin in the
erythrocytes is the molecule to which oxygen tt ches nd tr vels in the blood t
o every cell in
the body to be v il ble for energy pro- duction. The norm l hemoglobin of dult
s is desig- n ted
s Hb A. The hemoglobin concentr tion c n be me sured by n lyzers spectrophotom
etric lly, by
me suring color ch nge ccomplished s the hemo- globin in the red blood cells i
s ch nged to
cy nmethe- moglobin. The type of hemoglobin present in cells c n be identified b
y hemoglobin
electrophoresis per- formed in reference or hospit l l bor tories. The hem tocri
t is the mount
of sp ce occupied by red blood cells s comp red to the whole s mple, expressed
s percent ge.
Hem tocrit v lues c n be c lcul ted by utom ted n lyzers or directly re d from
hem tocrit
tube fter spinning in centrifuge. The hemoglobin nd hem tocrit tests re the
most frequently
ordered procedures used to monitor the oxygen-c rrying c p cities of the body. I
f these v lues
re below the norm l reference r nge, nemi is sus- pected, nd he lth-c re pro
fession ls will
use ddition inform tion to pl n course of tre tment. Anemi is di gnosed by t
he history nd
physic l ex min tion of the p tient, s well s l bor tory test results. The res

ults of
l bor tory tests th t describe the volume nd other ch r cteristics of erythrocy
tes re used to
cl ssify the type of nemi present nd est blish course of tre tment. TIME TO
REVIEW 1. A
degr d tion product of hemoglobin is: Outcome 13-1 . Anisocytosis b. Intrinsic
f ctor c.
Bilirubin d. Polycythemi 300 Section III Hem tology nd Co gul tion Test Your
Knowledge 13-9
Wh t l bor tory tests m y be ordered by
physici n to verify whether symptom
tic p tient m y
be nemic? (Outcome 13-8) Test Your Knowledge 13-10 List four ex mples of specif
ic nemi s.
(Outcome 13-10) 1899_Ch13_285-302 21/12/11 4:26 PM P ge 300 2. _________ from th
e tissues c n
Outcome 13-1 cont min te hemoglobin or hem tocrit specimens nd decre se the res
ult. . Anemi b.
Interstiti l fluid c. Intrinsic f ctor d. Erythropoiesis 3. Hemoglobin is m de o
f ch ins Outcome
13-2 of globin nd four molecules of: . Heme b. Sodium c. Cy nmethemoglobin d.
Urobilinogen 4.
_________ tt ches to the Outcome 13-2 hemoglobin nd tr vels from higher oxygen
concen- tr tion
levels in the lungs to the cells of the body with incre sed oxygen need. . Iron
b. Vit min B 12
c. Glucose d. Oxygen 5. The type of hemoglobin norm lly Outcome 13-3 seen in du
lts is
__________. . Hb A b. Hb C c. Hb F d. Hb S 6. Hemoglobin n lyzers determine Ou
tcome 13-4
hemoglobin concentr tion by using: . Electrophoresis b. Spectrophotometry c. Ce
ntrifug tion d.
Visu l ex min tion of the cells 7. Rest te the dult reference r nges Outcome 13
-8 for hemoglobin
nd hem tocrit testing. 8. P cked cell volume is Outcome 13-5 synonym for ____
_______. .
Hemoglobin b. Hem tocrit c. Sickle cell tr it d. Polycythemi 9. List the l yers
of the blood
s mple Outcome 13-6 of spun hem tocrit. 10. Anemi m y be the result of: Outco
me 13-9 .
Excessive blood loss b. In dequ te red blood cell production in the bone m rrow
c. Abnorm l
hemoglobin molecule structures d. All of the bove 11. N me the nemi c used by
Outcome 13-10 n
insufficient iron supply in the body. . Hemolytic nemi b. Iron-deficiency ne
mi c. Pernicious
nemi d. Sickle cell nemi 12. A subst nti l decre se in red blood Outcome 1310 cell
production m y le d to (n) __________ nemi . . Iron-deficiency b. Apl stic c.
Pernicious d.
Sickle cell Ch pter 13 Hemoglobin nd Hem tocrit 301 C se Study 13-1: Why m I
so tired? A
35-ye r-old m le p tient c me to the medic l office with compl ints of being we
k, leth rgic, nd
un ble to focus on t sks. The he lth-c re provider ssessed the symptoms nd ord
ered hemoglobin
nd hem tocrit test to be performed. The results were Hgb 12.3 g/dL nd Hct 38%.
B sed on the
result, the physici n ordered nother blood dr w for iron studies. 1. Wh t disor
der w s indic ted
by the results? 2. Why did the physici n order the iron studies? RESOURCES AND S

UGGESTED READINGS
Hemoglob l org niz tion; det ils bout th l ssemi http://
www.hemoglob l.org/wh tisth l ssemi .html M yo Clinic inform tion bout nemi h
ttp://www.
m yoclinic.com/he lth/ nemi /DS00321 Inform tion bout the v rious HemoCue testi
ng instruments
http://www.HemoCue.com 1899_Ch13_285-302 21/12/11 4:26 PM P ge 301 1899_Ch13_285
-302 21/12/11
4:26 PM P ge 302 303 Ch pter 14 Erythrocyte Sediment tion R te Nikki A. M rhefk
, EdM, MT(ASCP),
CMA (AAMA) CHAPTER OUTLINE Erythrocyte Sediment tion R te Pl sm Proteins Affect
ing the
Erythrocyte Sediment tion R te The Influence of Red Blood Cells on the Erythrocy
te Sediment tion
R te Reference R nges Clinic l Signific nce of Erythrocyte Sediment tion R te Te
sting Erythrocyte
Sediment tion R te Determin tion CLIAW ived Erythrocyte Sediment tion R te Method
s Autom ted
Erythrocyte Sediment tion R te Methods Potenti l Sources of Error for the Erythr
ocyte
Sediment tion R te Procedure Summ ry Time to Review C se Study Resources nd Sug
gested Re dings
14-1 Define the key terms. 14-2 An lyze the effect of pl sm proteins on erythro
- cyte
sediment tion r tes. 14-3 Describe the effects of bnorm lly sh ped red blood ce
lls in norm l nd
bnorm l erythrocyte sediment tion r tes. 14-4 Recognize norm l reference r nges
for erythrocyte sediment tion r tes for m les nd fem les. 14-5 List the p thologic l nd n
onp thologic l
st tes th t m y exhibit n incre sed sediment tion r te. 14-6 Describe the CLIAw ived testing
methods for the erythrocyte sediment tion r te. 14-7 Correctly perform n erythr
ocyte
sediment tion r te. 14-8 Highlight procedur l errors th t c n c use erroneous er
ythrocyte
sediment tion r te results. Le rning Outcomes After re ding this ch pter, the su
ccessful student
will be ble to: CAAHEP AND ABHES STANDARDS CAAHEP 2008 St nd rds I.P.I.12: An t
omy nd
Physiology: Perform Hem tology Testing I.C.I.6: Identify common p thology rel te
d to e ch body
system ABHES 2010 St nd rds Medic l L bor tory Procedures; Perform selected CLIA
- w ived tests
th t ssist with di gnosis nd tre tment;
#
2: Hem tology Testing
1899_Ch14_303-312 21/12/11 4:28 PM P ge 303 304 Section III Hem tology
nd Co gul tion T he
erythrocyte sediment tion r te is one of the oldest l bor tory tests still perfo
rmed tod y. The
test provides me surement indic ting how f r the red blood cells settle in s
pecimen over
given period of time. The proteins present in the pl sm nd the specific condit
ions of the red
blood cells in the specimen influence this r te. The erythrocyte sediment tion r
te test m y be
performed using utom ted methods in hospit l nd ref- erence l bor tories or us
ing CLIA-w ived
m nu l meth- ods, which m y be performed in ny l bor tory. The presence of infl
mm tion (the

protective re ction of the bodys tissues to injury or irrit tion), cute or chron
ic infection,
or neopl sms m y be ch r cterized by elev ted ESR results. However, norm l physi
ology m y lso
c use the erythrocyte sediment tion r te to be elev ted. ERYTHROCYTE SEDIMENTATI
ON RATE The
erythrocyte sediment tion r te ( lso known s the ESR or sed r te) is used (in
ddition to other
more spe- cific l bor tory tests nd p tient history) to screen for in- fl mm to
ry processes in
the body. The results of n ESR re nonspecific; n bnorm l result does not pro
vide inform tion bout the type or c use of the infl mm tion, but only th t it is prese
nt. In most
situ tions, n EDTA (l vender top) ntico gul ted venous blood s mple is used fo
r the test. (Some
test methods require different type of tube, specified l ter in the ch pter.)
A long, hol- low,
pl stic tube (pipette) is filled with blood ( n liquot) which h s been diluted
with citr te or
s line solution, nd the tube is pl ced upright on st ble, vibr tion-free, lev
el surf ce.
Gr vity c uses the red blood cells to settle out of solution nd f ll to the bot
tom of the
pipette. After 1 hour, the mount th t the red blood cells settled is me sured i
n millimeters.
The results of the ESR re reported in millimeters per hour (mm/hr). PLASMA PROT
EINS AFFECTING
THE ERYTHROCYTE SEDIMENTATION RATE Blood pl sm norm lly cont ins the proteins k
nown s lbumin,
globulin, nd fibrinogen. Infl mm tory processes or infection m y c use n incre
se in the levels
of globulin nd fibrinogen in the body. When these pro- tein levels re elev ted
, this will
incre se the v lue of the erythrocyte sediment tion r te. Elev ted mounts of gl
obulin nd
fibrinogen decre se the neg tive ch rge on the surf ce of the red blood cells, w
hich me ns th t
the cells re not s repelled from one nother s they would be norm lly. This c
uses the cells
to become somewh t sticky, llowing the red blood cells to st ck on top of one no
ther like
coins (Fig. 14-1). This configur tion is known s roule ux form tion. Roule ux
re not uncom- mon
occurrences, but the incre se in pl sm protein concentr tions will c use it to
become more pronounced. The incre sed roule ux will c use the ESR result to be elev ted bec use
these st cked
cell form - tions f ll f ster th n single cells. The pl sm proteins influence t
he settling most
when the p tients hem tocrit is between 30% nd 40%. KEY TERMS Albumin Aliquot Er
ythrocyte
sediment tion r te (ESR, sed r te) Fibrinogen Globulin Infl mm tion Pipette Roul
e ux Wintrobe
Westergren Test Your Knowledge 14-1 Wh t is me sured by the erythrocyte sediment
tion r te?
(Outcome 14-1) Figure 14-1 Roule ux form tion. Note how the red blood cells st c
k on top of
one nother, resembling st cks of coins. From the College of Americ n P thologis
ts, with

permission. 1899_Ch14_303-312 21/12/11 4:28 PM P ge 304 Ch pter 14 Erythrocyte

Sediment tion
R te 305 THE INFLUENCE OF THE RED BLOOD CELLS ON THE ERYTHROCYTE SEDIMENTATION R
ATE When the
r tio of red blood cells to pl sm is lower th n norm l, the potenti l for roule
ux form tion
incre ses nd will incre se the speed th t the red blood cells settle. For ex mp
le, someone with
nemi m y h ve n ele- v ted erythrocyte sediment tion r te, bec use his s mple
h s fewer red
blood cells s comp red to the tot l s mple volume th n would be present norm ll
y. The presence
of m crocytes (l rge cells) in the specimen will lso c use the ESR to be gre te
r th n norm l.
Erythrocyte sediment tion r tes below the norm l r nge m y be present when the s
mple h s lot
of microcytes (sm ll red blood cells) or spherocytes (sm ll, dense red blood cel
ls) present.
Sickle cells will lso c use decre se in the ESR, s the cells do not st ck to
gether s they
would norm lly, so they will not settle out s expected. P tients with polycythe
mi will
demonstr te
decre sed erythrocyte sediment tion r te bec use of the excess num
ber of red blood
cells. Excessive leukocytosis ( s in the c se of chronic myelogenous leukemi ) w
ill lso c use
decre sed ESR result. When the ESR v lues re out of the norm l r nge bec use of
the sizes or
sh pes of the red blood cells, the results m y not ch nge r pidly with tre tment
. Red blood cells
live for pproxim tely 120 d ys in the circu- l tion, nd the ESR result will no
t be
signific ntly ch nged until the red blood cells present in the body h ve been re
pl ced by he lthy
cells. It lso t kes time for the protein levels in the blood to ch nge signific
ntly with
tre tment. This me ns th t the erythrocyte sedi- ment tion r te is used more oft
en for initi l
screening for infl mm tion or infection th n it is to monitor the immedi te effe
cts of tre tment.
REFERENCE RANGES The norm l reference r nges for the ESR v ry by gender nd by
ge. This is
p rtly c used by the difference in the norm l number of circul ting red blood ce
lls for men nd
women. The reference r nges re lso elev ted in dults over the ge of 50. The
norm l reference
r nges re listed in T ble 14-1. CLINICAL SIGNIFICANCE OF ERYTHROCYTE SEDIMENTAT
ION RATE TESTING
Infl mm tory processes nd cute infection with tissue bre kdown incre se the m
ount of
fibrinogen nd globulins present in the bloodstre m. These proteins will inter c
t with the red
blood cells nd c use the erythro- cyte sediment tion r te to be elev ted. The E
SR c n be used to
di gnose dise se or condition, monitor n ongoing dise se process or tre tment
, or ssist with
dif- ferenti l di gnosis in cert in disorders. For inst nce, the ESR will be e
lev ted when
p tient h s recently experi- enced
myoc rdi l inf rction, but will not be elev
ted with ngin

pectoris. The ESR is not s sensitive to Test Your Knowledge 14-2 Wh t h ppens t
o the red blood
cells in the roule ux form tion? (Outcome 14-1) Test Your Knowledge 14-4 Why do
red blood cells
in roule ux form tion settle f ster th n single red blood cells? (Outcome 14-3)
Test Your
Knowledge 14-3 Wh t pl sm proteins contribute to the form tion of roule ux when
incre sed in
concentr tion? (Outcome 14-2) TABLE 14-1 Reference r nges for the Westergren ery
throcyte
sediment tion r te M le Fem le Younger th n 50 ye rs of ge Less th n 15 mm/hr L
ess th n 20 mm/hr
Older th n 50 ye rs of ge Less th n 20 mm/hr Less th n 30 mm/hr Older th n 85 y
e rs of ge Less
th n 30 mm/hr Less then 40 mm/hr Test Your Knowledge 14-5 List norm l ESR v lues
for men nd
women younger th n the ge of 50. (Outcome 14-4) 1899_Ch14_303-312 21/12/11 4:28
PM P ge 305
ch nges in tre tment s some other l bor tory tests m y be, but it still m y be
used to monitor
tre tment over n extended period of time. It is import nt to remember th t nonp
thologic l
issues m y lso c use the ESR to ppe r elev ted. Preg- n ncy is
norm l physio
logic l process
th t will exhibit n elev ted ESR. By the 12th week of pregn ncy, the ESR result
will h ve
incre sed bove the norm l r nge, nd will rem in so through the first month pos
tp rtum. Women
who re menstru ting m y lso h ve n elev ted erythrocyte sediment tion r te. T
he disorders of
polymy lgi rheum tic ( n infl m- m tory condition of the muscles) nd tempor l
rteritis
(infl mm tion nd d m ge to the blood vessels th t supply the he d) re the only
two dise se
conditions for which n elev ted ESR is the prim ry me ns of di g- nosis. The te
st m y lso be
used (in ddition to other clin- ic l inform tion nd l bor tory tests) to ev lu
te septic
rthritis, pelvic infl mm tory dise se, nd ppendicitis. Rheum toid rthritis,
chronic
infection, coll gen dise se (systemic lupus erythem tosus [SLE]), nd cert in ne
o- pl sms
(especi lly prost te or kidney c ncer) re ch r cter- ized by incre sed ESR resu
lts. Erythrocyte
sediment tion r tes m y be used to the monitor the effic cy of ther py in osteom
yelitis. The ESR
results m y be misle ding in p tients with osteo rthritis, s these p tients m y
h ve ESR results
within norm l r nge even with the presence of infl mm tion in the joints. The ES
R results m y
lso offer v lu ble inform tion to help determine the risk sso- ci ted with cor
on ry rtery
dise se. ERYTHROCYTE SEDIMENTATION RATE DETERMINATION There re two methods used
for performing
the ESR. The oldest method is the Wintrobe method. To perform the Wintrobe ESR,
well-mixed blood
from tube con- t ining EDTA ntico gul nt is tr nsferred directly to Wintrob
e tube using
pipette with
long, slim end. The Wintrobe tube is short, with gr du ted m rkin
gs up to 100 mm.

The ESR result is re d fter the s mple h s been llowed to sit undisturbed for
1 hour. It is
impor- t nt th t the ESR is not vibr ted or disturbed during the time th t the t
est is performed.
The Wintrobe method is not used s widely s is the Westergren method. The Weste
rgren method
involves the dilution of the EDTA- ntico gul ted blood with
sodium citr te sol
ution or s line
before the blood is dded to the pipette. The Westergren pipette is lso sm ller
in di meter nd
t ller th n the Wintrobe tube. Most offices use CLIA-w ived modified Westergre
n method th t
uses closed system, llowing the blood to be dded to the pipette with minim l
mount of
exposure to the specimen for the employee. The test is performed on n EDTA- nti
co gul ted venous
blood s mple. A specified mount of room-temper ture, well- mixed blood is dilut
ed with
preme sured citr te solu- tion nd introduced into hollow column. The column i
s m rked off into
millimeters for e se of re ding the results. The top of the s mple must be t th
e 0 m rk when
the timing is st rted s point of reference. The column is pl ced in
r ck so
th t it is
ex ctly level, nd timing begins immedi tely. The column must not be dis- turbed
during the
timing process, nd the specimens must be kept out of direct sunlight. At ex ctl
y 1 hour, the top
of the red blood cell column is noted. The ESR result is documented s the milli
meters per hour
th t the cells h ve settled. The result is comp red to the reference r nges for
the p tient,
b sed on gender nd ge. During the 60 minutes of the testing process, the settling of the red
blood cells occurs in three st ges. The first 306 Section III Hem tology nd Co
gul tion Test
Your Knowledge 14-6 If n ESR is elev ted, wh t process is occurring in the body
? (Outcome 14-5)
POINT OF INTEREST 14-1 Sedit iner procedure Becton, Dickinson h s cre ted the Se
dit iner system,
unique setup for the erythrocyte sediment tion pro- cedure. It is designed to
me sure the
erythrocyte sed- iment tion r te without tr nsferring the blood to sep r te tu
be. This
elimin tes the potenti l for expo- sure to blood products while tr nsferring the
speci- men, s
well s the possibility of dding bubbles to the specimen during the ESR setup.
In the Sedit iner
system, the ev cu ted tubes used for dr wing blood during the venipuncture h ve
bl ck top, nd
they cont in 1.25 mL of sodium citr te solution. The tube needs to be filled t
o the point t
which the v cuum is exh usted, nd the specimen needs to be well mixed. The tube
is pl ced in
speci l Sedit iner st nd, nd the knob on the st nd is used to djust the top of
the blood column
to the 0 level. E ch spot in the Sedit iner st nd is m rked with sc le used to r
e d the ESR
level t the end of 1 hour. The tubes re then disc rded without ever being open
ed.

1899_Ch14_303-312 21/12/11 4:28 PM P ge 306 st ge t kes pl ce within the first 1

0 minutes of the
testing period. Roule ux form tion (the st cking of red blood cells) is beginnin
g to occur so
there is little sediment - tion, even in bnorm l s mples. The second st ge occu
rs in the next 40
minutes, during which there is const nt r te of settling s the roule ux re s
et up (if
present). The st cks of cells f ll r pidly during this time bec use of the incre s
ed volume to
surf ce re . The fin l st ge occurs in the l st 10 minutes of the testing proce
ss. At this time
the settling is slowing s the cells re forming the p cked cell volume t the b
ottom of the
column. CLIA-W ived Erythrocyte Sediment tion R te Methods There re v rious mod
ified Westergren
ESR systems v il ble for use in the l bor tory. Sedipl st (m nuf c- tured by Po
lymedco) is one
of the most common kits. An EDTA- ntico gul ted venous blood s mple of 0.8 mL is
pipetted into
vi l cont ining 0.2 mL of 3.8% sodium citr te diluting solution. The vi l is the
n gently inverted
to mix nd pl ced into the ccomp nying r ck. A 100-mm m rked tube is gently pus
hed into the vi l
until it sits on the bottom of the sm ll vi l cont ining the blood. The tube is
designed for
utozeroing, s the blood mixture will re ch the 0 m rk nd ny extr will enter i
nto n
overflow re . The timing must begin immedi tely nd continue for ex ctly 60 min
utes. The
sediment tion r te in mm/hr is re d t the top of the red blood cell column. Thi
s closed system
minimizes poten- ti l exposure to the s mple while setting up the proce- dure n
d lso prevents
the potenti l for spl shing when disposing of the setup fter testing. This proc
ess is exp nded
nd det iled in Procedure 14-1. Autom ted Erythrocyte Sediment tion R te Methods
For l bor tories
th t perform high volumes of testing, there re utom ted ESR n lyzers v il bl
e. These instruments utom tic lly perform the dilutions (if neces- s ry), set up the ESR t
ubes, nd h ve
intern l re ders th t detect the color ch nge present t the top of the red bloo
d cell column
when the design ted time h s p ssed. Some determine the ESR in less th n the 60
minutes required
for the m nu l methods. Polymedco m kes the Sedim t nd the Sedten n lyzers. Th
e Ves-m tic, m nuf ctured by Diesse, uses the EDTA l vender top tube directly to perform the ESR
me surement.
M ny of these n lyzers re c p ble of processing multiple ESR tests t one time
. POTENTIAL
SOURCES OF ERROR FOR THE ERYTHROCYTE SEDIMENTATION RATE PROCEDURE The ESR test m
ust be performed
very c refully; proce- dur l errors will directly ffect the results. The first
consider tion is
the collection of the blood s mple to be used. If the blood is llowed to clot,
the ESR will be
f lsely decre sed bec use the fibrinogen in the s mple will be used forming the
blood clot.

S mples will ide lly be used for the ESR within few hours of the blood dr w. M
ost l bor tories
st te th t the s mple m y be used for the test if it is kept t room temper - tu
re (20 to 25C)
for up to 24 hours. Refriger tion m y c use irreversible ch nges in the w y the
cells inter ct in
the s mple, so the process must occur within 12 hours if the s mple is refriger
ted. The blood
must be t room temper ture t the time the test is performed. Ch pter 14 Eryth
rocyte
Sediment tion R te 307 Test Your Knowledge 14-7 List two CLIA-w ived ESR procedu
res. (Outcome
14-6) POINT OF INTEREST 14-2 The C-re ctive protein The erythrocyte sediment tio
n r te is
elev ted when infl mm tion occurs within the body. However, the ESR does not re
ct quickly when
infl mm tion first st rts, nd the result does not ch nge immedi tely when tre t
ment begins. The
C-re ctive protein (CRP) is lso elev ted with systemic infl mm tion processes i
n the body. The
CRP is lso known s n cute ph se protein. The level of the CRP is elev ted wi
th infection,
c rdiov scul r dise se, nd the form - tion of therosclerosis. Bec use the leve
l of CRP is
ffected immedi tely with tre tment th t reduces infl m tion, this test m y be
better choice
th n the ESR with which to monitor course of tre tment. Although the Wintrobe
method is not
used s often s is the modified Westergren method, the Wintrobe method is still
CLIA-w ived
procedure c rried out some l bor tories. The Wintrobe method requires
speci l
pipette to dd
the specimen to the tube used for the test, nd the method is not considered s
s fe for the
employee bec use it provides n opportunity for more potenti l exposure to blood
borne p thogens
s the blood is dded to the tube. 1899_Ch14_303-312 21/12/11 4:28 PM P ge 307 3
08 Section III
Hem tology nd Co gul tion Procedure 14-1: Perform CLIAW ived Sedipl st Westergre
n Erythrocyte
Sediment tion R te Erythrocyte sediment tion r tes re one of the oldest, e sies
t, nd le st
expensive testing procedures per- formed in l bor tories. The Westergren method
is the most
common CLIA-w ived m nu l system employed. TASK Perform n erythrocyte sediment
tion r te using
the Sedipl st system, nd re d nd record the results correctly. CONDITIONS H nd
-w shing
supplies nd/or lcohol-b sed h nd s nitizer Dispos ble gloves Sedipl st Modifie
d Westergren
ESR reservoir tube, pipette, nd r ck L vender top (EDTA) tube filled with blood
Bioh z rdous
dispos l b g F ce shield nd l bor tory co t Tr nsfer pipette Test tube r ck CAA
HEP/ABHES
STANDARDS CAAHEP 2008 St nd rds I.P.I.12 An tomy nd Physiology; Perform Hem tol
ogy Testing ABHES
2010 St nd rds Medic l L bor tory Procedures, b. Perform selected CLIAw ived test
s th t ssist
with di gnosis nd tre tment; #2: Perform Hem tology Testing Procedure R tion le
1. S nitize

h nds ( llow them to dry), then pply gloves, l bor tory co t, nd f ce shield.
2. G ther testing
supplies. Check the expir tion of the ESR kit components. Verify th t the necess
ry qu lity
control h s been performed prior to testing the p tient s mple. 3. Verify the te
st ordered nd
th t the s mple is ppropri tely identified. 4. Verify th t the EDTA tube is t
room temper ture.
5. Invert the EDTA tube 8 to 10 times to mix the s mple. 6. C refully remove the
rubber stopper
on the top of the EDTA blood tube. Avoid erosol form tion by removing the top s
lowly. Pl ce the
stopper top down on the t bletop, nd pl ce the blood tube in
test tube r ck.
Gloves must be
worn for ny procedures during which exposure to blood or other potenti lly infe
ctious m teri ls
is nticip ted. This procedure h s n incre sed risk for exposure to blood produ
cts, so
l bor tory co t nd f ce shield should lso be worn. Expired products must never
be used for
testing. If the required qu lity control h s not been performed, this needs to b
e ccomplished
( nd the results verified) before the p tient test results re reported. The tes
t nd p tient
identity should lw ys be verified before ny testing procedure is st rted. The
blood must lw ys
be t room temper ture for the ESR test result to be v lid. The specimen must be
well mixed or it
will provide erroneous test results. If the stopper is removed too quickly,
fi
ne mist of
blood m y be rele sed, incre sing the potenti l for exposure. 1899_Ch14_303-312
21/12/11 4:28 PM
P ge 308 Procedure R tion le Ch pter 14 Erythrocyte Sediment tion R te 309 7. R
emove the pink
c p from the prefilled reservoir vi l provided with the test kit. Be c reful not
to spill ny of
the solution. 8. Using the tr nsfer pipette, dd blood to the reser- voir vi l u
ntil it re ches
the fill line. Avoid bubbles or ir sp ces in the reservoir vi l. Rec p the EDTA
blood tube. 9.
Repl ce the pink c p on the reservoir vi l nd invert fully t le st 8 times. 10
. Pl ce the vi l
in the r ck on level surf ce. Insert the m rked ESR pipette through the pink c
p nd push down
until it comes to the bottom of the vi l. The blood will rise to the 0 m rk within
the ESR
pipette, nd ny excess blood will enter the overflow reservoir. 11. M ke cert i
n th t the r ck
is in pl ce where it will not be disturbed nd where it is not in direct sunli
ght. Set
timer
for 1 hour. The proper mount of diluent in the tube is vit l for the dilution f
ctor to be
correct nd the results to be v lid. It is import nt to dd the necess ry volume
of blood to the
diluent to llow for the correct dilution r tio nd to provide enough specimen f
or n ccur te
ESR re ding. The specimen must be mixed thoroughly with the dilu- ent for the re
sults to be
ccur te. The blood must re ch the 0 m rk or the test will not be v lid. This proc
ess should be

ccomplished f irly slowly to m ke cert in th t the blood re ches the top of the
ESR pipette.
Vibr tions, movement or direct sunlight m y ffect the ESR results. A timer is n
ecess ry for
ppropri te timing of the procedure. Courtesy of Fisher He lthC re, Inc. Continu
ed
1899_Ch14_303-312 21/12/11 4:28 PM P ge 309 Procedure R tion le 310 Section III
Hem tology nd
Co gul tion 12. After 1 hour, note the number t the top of the red blood cell c
olumn. This will
be in mm m rked on the side of the ESR tube. Note this number s the result in m
m/hr, nd
document the result on the log sheet or the p tients ch rt. The m rks should be r
el tively e sy
to re d, nd re re d from the top of the pipette down. Procedure 14-1: Perform
CLIAW ived
Sedipl st Westergren Erythrocyte Sediment tion R te Procedure 14-1: Perform CLIAW
ived Sedipl st
Westergren Erythrocyte Sediment tion R te Procedure 14-1: Perform CLIAW ived Sedi
pl st
Westergren Erythrocyte Sediment tion R tecontd Pl sm /s line solution Re d result
t this point
Blood cells Stopper nd bsorbent m teri l 100 0 13. Dispose of the ESR setup n
d the tr nsfer
pipette in the bioh z rdous g rb ge. Disinfect the work re . 14. Remove gloves
nd s nitize
h nds. Remove f ce shield. There is blood in the tr nsfer pipette nd the ESR se
tup, so both must
be disposed of in the bioh z- rdous g rb ge. H nds must lw ys be s nitized ft
er removing
gloves. The f ce shield is not necess ry for ll procedures, so should be remove
d until needed
g in. 1899_Ch14_303-312 21/12/11 4:28 PM P ge 310 Procedure R tion le The tube
of venous blood
must be well mixed so th t the liquot removed for the test is represent tive of
the s mple.
Before removing the blood for the test, the tube is gently inverted t le st eig
ht times. After
the blood is dded to the diluent, dequ te mixing is g in imper- tive. When r
e ding the
results, if there is not cle r definition t the top of the red blood cells in t
he pl sm , the
result is to be re d t the point when there is definitive border to the red b
lood cells in the
column. There c n be no bubbles in the column of blood or diluted blood. The tub
e (column) must
be ex ctly verti- c l during the testing process, so the holding r ck into which
it is pl ced
must be level s well. M ny of the r cks come with leveling devices t the corne
rs so th t this
c n be verified. Movement (such s vibr tions) c n lter the results, so it is i
mport nt th t
this test is not performed on counter next to
centrifuge or printer. The t
iming must be
ex ct for ccur te re dings, so
timer is usu lly employed r ther th n w tch
or clock. cells
in 60 minutes constitutes the test procedure. The CLIA-w ived procedures include
m nu l
Westergren nd Wintrobe methods. There re lso utom ted testing systems v il
ble for

l bor tories th t perform high volume of testing or desire the results in less
th n 1 hour. The
erythrocyte sediment tion r te is used s tool to id in di gnosis, monitor di
se se process,
follow tre tment, nd ssess prognosis of cert in disorders. TIME TO REVIEW 1. R
oule ux form tion
is: Outcome 14-1 . An bnorm l collection of proteins in the circul t- ing bloo
d b. The test for
infl mm tion c. A group of red blood cells st cking together like coins d. None
of the bove 2.
Ex mples of proteins th t Outcome 14-2 re incre sed in the pl sm when the sedi
ment tion r te is
elev ted include: . Albumin nd fibrinogen b. Fibrinogen nd globulins c. Globu
lins nd lbumin
d. Globulin nd tyrosine 3. A 30-ye r-old m le p tient Outcome 14-4 h s n ESR o
f 38 mm/hr. The
result of this test for this p tient is ______ ______. . Within the reference r
nge for the
p tients gender nd ge b. Elev ted for the p tients gender nd ge c. Within r ng
e for his
ge, but not his gender d. Below the reference r nge Ch pter 14 Erythrocyte Sed
iment tion R te
311 15. Document the ESR results in the p tients ch rt if not completed previousl
y. If
necess ry, lso log the lot number nd expir tion of the kit components on the l
og sheet. All
procedures must be ppropri tely documented in the p tients ch rt. Test Your Know
ledge 14-8 List
two testing procedure errors th t c n ffect the v lue of the ESR. (Outcome 14-7
) SUMMARY The
erythrocyte sediment tion r te is test th t screens for the presence of infl m
m tion. The ESR
results c n be ltered s result of infection, utoim- mune dise se, or growth
of neopl sms in
the body. With infl mm tion, there is ch nge in the levels of pl sm proteins
with n incre se
in fibrinogen nd some globulins. This protein ch nge c n c use the red blood ce
lls to form
excessive roule ux, which settle out of solution f ster th n do single red blood
cells. The
observ nce of this sediment tion of red blood D te 1/18/2020: ESR 22 mm/hr.
1100

.m.

Connie Lieseke, CMA (AAMA) 1899_Ch14_303-312 21/12/11 4:28 PM P ge 311 4

. An 87-ye r-old
wom n h s Outcome 14-4 sediment tion r te of 38 mm/hr. The result for this p t
ient is ______
bec use of this p tients gender nd ge. . Norm l b. Elev ted c. Elev ted d. Dec
re sed 5. An
elev ted ESR indic tes the Outcome 14-5 presence of: . Infl mm tion b. Erythrop
oiesis c. Albumin
d. Ren l dise se 6. A/ n ___________ ntico gul ted Outcome 14-6 venous blood s
mple is used for
the erythrocyte sediment tion r te. . Citr te b. Hep rin c. EDTA d. Fluoride 7.
True or F lse:
Westergren nd Outcome 14-6 Wintrobe re CLIA-w ived erythrocyte sediment tion p
rocedures. 8.
______ is me sured to determine the Outcome 14-7 ESR v lue. . The r tio of prot
eins in the blood

b. The roule x form tion of red blood cells c. The settling of the red blood cel
ls d. The
presence of red blood cells in the bone m rrow 9. Ex mples of potenti l errors w
hen Outcome 14-8
performing n ESR include: . Insufficient s mple dded to diluent b. Insufficie
nt mixing of
s mple nd diluents c. Re ding result t 50 minutes d. All of the bove RESOURCE
S AND SUGGESTED
READINGS Polymedco Products Inform tion bout the v rious clinic l di gnostic test
kits nd
educ tion l m teri ls provided by Polymedco. http:// www.polymedco.com/productsp ges-7.php
Diesse USA Product Line Products from Diesse USA including n ESR system.
http://www.diesse-us .com/products.html 312 Section III Hem tology nd Co gul t
ion C se Study
14-1: Cutting corners M rg ret Lindon is new employee, nd she w s nervous on
her first d y
lone in the l bor tory. One of the first orders she received w s to collect
s
pecimen nd
perform n ESR test. She h d been tr ined on this procedure the week before, nd
remembered th t
it w s not very difficult. The requisition indic ted th t l ven- der top tube
w s to be dr wn,
nd M rg ret knew where the ESR supplies were kept. As M rg ret w s col- lecting
the blood
s mple, the blood flow stopped, nd she could not get it to continue. She discon
tinued the blood
dr w with p rti l l vender top tube filled. After the p tient left, M rg ret b
eg n to set up
the ESR test. She dded the blood to the reservoir tube con- t ining the citr te
solution, but
re lized th t she did not h ve quite enough specimen to fill it to the required
line. She
inserted the ESR pipette, nd the blood-citr te solution c me lmost to the top
of the pipette,
but w s shy by few millimeters. After 1 hour, M rg ret re d the results of the
ESR, nd
reported out th t it w s 28 mm/hr. 1. W s the correct specimen dr wn for the ESR
order? 2. Wh t
were the potenti l sources of error for this scen rio? W s this result of 28 mm/
hr
v lid
result? 1899_Ch14_303-312 21/12/11 4:28 PM P ge 312 313 Ch pter 15 Co gul tion S
tudies Const nce
L. Lieseke, CMA (AAMA), MLT, PBT(ASCP) CHAPTER OUTLINE Purpose of Co gul tion St
udies Mech nisms
of Blood Clotting Disorders Di gnosed or Monitored With L bor tory Co gul tion T
ests Thrombosis
Atri l Fibrill tion Postsurgic l Prophyl xis Dissemin ted Intr v scul r Co gul t
ion
Thrombocytopeni Antiphospholipid Syndrome Hemophili L bor tory Tests Used to D
i gnose
Co gul tion Disorders or Monitor Antico gul nt Ther py Prothrombin nd Intern ti
on l Norm lized
R tio Activ ted P rti l Thrombopl stin Time/P rti l Thrombopl stin Time Pl telet
Count Fibrinogen
Fibrin Degr d tion Products D-dimer Bleeding Time Test Other Tests Used to Asses
s Pl telet
Function Specimen Requirements for Co gul tion Testing Summ ry Time to Review C
se Study
Resources nd Suggested Re dings 15-1 Define the key terms. 15-2 Expl in the pur

pose of
co gul tion studies. 15-3 Describe the process of co gul tion. 15-4 Comp re the
form tion of
thrombus to th t of n embolus. 15-5 Comp re nd contr st the disorders di gnose
d or monitored
with l bor tory co gul tion testing. 15-6 Ex mine how the prothrombin test nd I
NR c lcul tion
re used together to monitor co g- ul tion st tus for
p tient. 15-7 Successful
ly perform
CLIA-w ived PT/INR test. 15-8 Expl in ppropri te use of PTT test for monitori
ng co gul tion.
15-9 Ev lu te the use of pl telet counts in co gul - tion testing. 15-10 Expl in
why bleeding
time tests re not performed s frequently s PT nd PTT tests. 15-11 Describe o
ther tests of
pl telet function. 15-12 List other co gul tion tests th t m y be ordered. 15-13
List the
requirements for co gul tion specimen collection nd potenti l sources of error
for the v rious
tests. Le rning Outcomes After re ding this ch pter, the successful student will
be ble to:
1899_Ch15_313-331 21/12/11 4:29 PM P ge 313 314 Section III Hem tology nd Co g
ul tion W hen
most of us receive
p per cut or other minor injury, we t ke for gr nted th t t
his minor blood
vessel injury will stop bleeding nd he l within
short period of time. The pro
cess of blood
clotting, known s co gul tion, nd the bre kdown of these clots within the body
re monitored by
use of v rious co gul tion testing procedures. Pl telets, fibrinogen, thrombin,
nd 13 other
clotting f ctors re ll involved in the process of clot form tion, which is nec
ess ry for rep ir
of blood vessel d m ge. The blood vessels lso pl y
role. In ddition, chemic
ls re pro- duced
by the body to bre k down the clots when they re no longer needed. This process
is known s
fibri- nolysis. Co gul tion studies include qu ntit tive nd qu lit tive n lysi
s of the v rious
components, s well s their function. PURPOSE OF COAGULATION STUDIES Co gul tio
n studies re
performed in the l bor tory when the v rious elements in the clotting process p
- pe r to be
imb l nced or m lfunctioning. These defects c n c use excessive bleeding, bruisi
ng, or unw nted
blood vessel occlusion (blocking of the vessel) with for- m tion of blood clots
in the
bloodstre m. Antico gu- l nt medic tion use is lso closely monitored with l bor tory
co gul tion testing. L bor tory tests m y include qu ntit tive n lysis of cert
in pl sm
proteins involved in the clotting process, s well s n lysis of pl telet count
nd function.
Co gul tion studies re of- ten performed prior to surgic l procedures to verify
th t the b l nce
between bleeding nd clotting in the body is t desir ble level. Hemost sis is
the word KEY
TERMS Afibrogenemi Aggreg te Antiphospholipid syndrome Atri l fibrill tion Clot
ting c sc de
Clotting f ctor Co gul tion Coum din D-dimer Deep vein thrombosis (DVT) Dissemin

ted
intr v scul r co gul tion (DIC) Dysfibrinogenemi Embolus Endotheli l cell linin
g Extrinsic
p thw y Fibrin degr d tion products (FDPs) Fibrinogen Fibrinolysis Fibrinolytic
drugs Hemophili
Hemost sis Hep rin Hypofibrinogenemi Intern tion l norm lized r tio (INR) Intri
nsic p thw y
Occlude P rti l thrombopl stin time (PTT) P thologic l thrombosis Pl smin Pl tel
et count
Prophyl ctic Prothrombin time (PT) Stroke Thrombin Thrombocytes Thrombocytopeni
Thrombosis
Viscous W rf rin von Willebr nds f ctor CAAHEP/ABHES STANDARDS CAAHEP St nd rds N
one ABHES
St nd rds None 1899_Ch15_313-331 21/12/11 4:29 PM P ge 314 used to describe the
processes needed
to b l nce clot form tion nd fibrinolysis in the body. content of these gr nule
s into the
pl sm . This chem- ic l c uses the pl telet plug to become more st ble nd the c
onnections
between the pl telets to be very tight. 3. The pl telets rele se compound know
n s pro ccelerin, or l bile f ctor, th t works with vit min K to st rt the rest of the ch
nges necess ry
for perm nent fibrin clot to form. Ch pter 15 Co gul tion Studies 315 Test Y
our Knowledge
15-1 Wh t is one re son th t co gul tion studies m y be performed? (Outcome 15-2
) Test Your
Knowledge 15-3 Wh t is the bodys first response to vessel injury? (Outcome 15-3)
Test Your
Knowledge 15-4 Wh t does the term clotting c sc de refer to? (Outcome 15-3) Test
Your Knowledge
15-2 Are pl telets solely responsible for co gul tion when vessel is d m ged?
(Outcome 15-3)
MECHANISMS OF BLOOD CLOTTING The b l nce between blood clotting nd excessive bl
eed- ing involves
numerous f ctors. These include the blood vessels of the body (including the cel
ls th t line
those vessels); the pl telets (thrombocytes) circul ting in the bloodstre m; nd
numerous
co gul tion f ctors present in the circul tion s enzymes, substr tes, inhibitor
s, nd pl sm
proteins. The study of co gul tion nd hemost - sis focuses on two m jor systems
. The prim ry
co gul - tion system includes the ction of the pl telets nd the v scul r respo
nse to vessel
injury. The ctions of the pl sm proteins nd other chemic ls in the circul tio
n m ke up the
second ry co gul tion system, nd com- plete the co gul tion process. When d m g
e occurs to
blood vessel, the endothe- li l cell lining of th t rtery, vein, or c pill ry i
s dis- rupted.
The first response of the body is to constrict the d m ged blood vessel nd othe
r vessels in the
vicinity, lim- iting the blood flow to the re so th t pl telet ggreg tion c n
begin. In sm ll
rterioles, venules, nd c pill ries, this m y stop the bleeding without moving
to the next step.
In l rger vessels, however, this will not be enough. When int ct, the blood vess
el lining does
not ttr ct pl telets; in f ct, the two repel e ch other. However, when the endo

theli l cell
lining is d m ged, the exposed coll - gen l yer underne th the endotheli l cells
ttr cts the
pl telets to ggreg te nd begin the process of co gul - tion. Fibrinogen nd vo
n Willebr nds
f ctor ssist in the dhesion of the pl telets to one nother. The following re
some of the next
steps involved in prim ry co gul tion: 1. The pl telets in the re of the d m g
ed vessel ch nge
sh pe nd begin to dhere tightly to one nother. 2. Pl telets re filled with g
r nules in their
cytopl sm. As they ggreg te nd ch nge sh pe, they rele se the Second ry co gul
tion includes
series of events described s the clotting c sc de. This c sc de involves contin
uous feedb ck nd
inter ction in which e ch clotting f ctor ffects other clotting f ctors to chi
eve the form tion
of solid fibrin clot over the re of the d m ged vessel. All of the clotting
f ctors re
produced in the liver nd introduced into the bloodstre m. Some of the clotting
f ctors re lso
produced by endotheli l cells in the vessel lining nd meg k ryocytes in the bon
e m rrow. There
re t le st 10 clotting f ctors, nd they re design ted by Rom n numer ls. The
y work in two
different p thw ys, the intrinsic p thw y nd the extrinsic p thw y, to ccompli
sh the s me go l.
The intrinsic p thw y involves chemic ls th t re ll present in the bloodstre m
n tur lly,
where s the extrinsic p thw y is initi ted by rele se of chemic ls into the bloo
dstre m by the
subendotheli l cells exposed during the vessel injury. T ble 15-1 lists the clot
ting f ctors with
their Rom n numer l numbers, ltern tive n mes, nd the l bor tory tests used to
monitor their
ctivity in the body. It is import nt to keep in mind th t the b l nce of bleedi
ng nd clotting
in the body must be regul ted n t- ur lly by clotting processes, s well s by f
ibrinolysis (the
bre kdown of the formed clots when they re no longer needed) nd inhibitors th
t keep the system
from over- re cting to d m ges to the vessel w lls. Any n tur l or cquired inte
rference in this
b l nce will neg tively f- fect hemost sis. 1899_Ch15_313-331 21/12/11 4:29 PM
P ge 315
DISORDERS DIAGNOSED OR MONITORED WITH LABORATORY COAGULATION TESTS Co gul tion t
esting is used to
di gnose or monitor v riety of dise ses or disorders. Some of the results provide inform tion
th t will help the he lth-c re provider to nticip te problems (such s those pe
rformed prior to
surgic l procedures), where s other l bor tory v lues re used to chieve di g
nosis or monitor
the progress of dise se. Thrombosis Thrombosis is the clot form tion th t occu
rs n tur lly in
the body. However, there m y lso be times when p thologic l thrombosis occurs.
Clots m y form in
ny vessel of the body rel ted to different risk f ctors nd exhibiting differen
t symptoms
dependent on the loc - tion of clot form tion. Arteri l thrombosis c n be c used

by hypertension,
therosclerosis, blood th t is too vis- cous, or thick, nd by function l pl tel
et bnorm lities.
Clots in the rteries usu lly include sm ll mount of fibrin nd more white ce
lls th n
thromboses formed in the other vessels. P thologic l thrombosis in the venous sy
stem is usu- lly
m de up of red blood cells nd l rge mounts of fibrin. Deep vein thrombosis (DV
T) m y be c used
by imp ired (slow) blood flow, especi lly in those p tients who re recovering f
rom surgery nd
re therefore in ctive. Other f ctors th t m y contribute to form tion of venous
thrombi include
imp ired bre kdown of clots (fibrinolytic deficiency) nd in dequ te levels of c
lotting
inhibitors th t keep the body from excessive thrombosis form tion. A very seriou
s complic tion of
deep vein thrombosis occurs when pieces of the blood clot dislodge from the vess
el of form tion
nd enter the bloodstre m. This is c lled n embolus, nd if it becomes lodged i
n the pulmon ry
tissues, it m y be f t l. 316 Section III Hem tology nd Co gul tion TABLE 15-1
Clotting f ctors
with ltern tive n mes nd common tests used to monitor levels or detect deficie
ncies* Clotting
F ctor Altern tive N me L bor tory Test I Fibrinogen Fibrinogen level II Prothro
mbin Prothrombin
time (PT) III Thrombopl stin PTT IV Ionized c lcium Ionized c lcium levels V Pro
ccelerin or
l bile f ctor PT nd PTT VII Proconvertin or st ble f ctor PT VIII Antihemophili
c ( lso linked to
von Willebr nds f ctor) PTT IX Pl sm thrombopl stin component PTT X Stu rt-Prowe
r PT nd PTT XI
Pl sm thrombopl stin ntecedent PTT XII H gem n f ctor PTT XIII Fibrin st biliz
ing f ctor PT nd
PTT *There is no f ctor VI. Test Your Knowledge 15-5 How is n embolus different
from thrombus?
(Outcome 15-4) Atri l Fibrill tion Atri l fibrill tion is
condition in which t
here re err tic
electric l sign ls sent through the tri , which re the upper ch mbers of the h
e rt. Bec use of
these err tic sign ls, the he rt does not be t with the correct rhythm or t the
correct speed.
This c uses turbulence, or dis- rupted blood flow through the he rt, nd n in
cre sed risk of
blood clot (thrombus) form tion within the tri . This is especi lly common in t
he left tri . If
thrombus is present, the p tient is t very high risk of embolus for- m tion
s well, s the
blood tr vels through the he rt nd m y pick up pieces of the clot. The emboli o
ften tr vel to
the br in, where they occlude (block) the sm ll vessels 1899_Ch15_313-331 21/12/
11 4:29 PM P ge
316 nd c use stroke. A stroke ( lso known s cerebrov s- cul r ccident) is
the result of
block ge of blood flow to n re of the br in. P tients who h ve chronic tri l
fib- rill tion
re often prescribed w rf rin s lifelong tre t- ment option, s w rf rin is
drug th t
interferes with the extrinsic clotting f ctor system of the body, nd decre ses

the risk of blood

clots forming in the tri . Postsurgic l Prophyl xis Bec use the opportunity for
thrombosis
form tion is heightened when the blood flow to specific re of the body is sl
owed, those who
re immobile or recovering from surgery re t high risk of blood clot developme
nt in their legs,
especi lly. This is c lled
deep vein throm- bosis, or DVT. Incre sed p ssive e
xercise (when
possi- ble) helps to reduce this risk, nd is often st rted the s me d y or one
d y postsurgery
with the ssist nce of
member of the physic l ther py te m. However, this m y
not lw ys be
enough to keep clots from forming in the deep veins of the legs. M ny p tients w
ho nticip te
extended hospit liz tion fter surgery will be pl ced on hep rin during or immed
i tely fter the
procedure s prophyl ctic me sure, tre tment in nticip tion of potenti l pr
oblem, s opposed
to tre tment fter the blood clot h s occurred. Hep rin is f st cting, is given
vi IV or
injection, nd ffects the intrinsic clotting sys- tem of the body. Hep rin is
very good choice
for inp - tient tre tment, but s p tients ne r disch rge, they re usu lly st r
ted on or l
w rf rin tre tment, s this is e s- ier to m int in in the home environment. Dis
semin ted
Intr v scul r Co gul tion Dissemin ted intr v scul r co gul tion (DIC) occurs wh
en the blood
clotting system is ctiv ted throughout the body, r ther th n just t site wit
h injury to
blood vessel. Sm ll thrombi form everywhere, including within org ns nd c pill
ry beds. Th t
p tients co gul tion f ctors re used up fter
time, s well s the subst nces
th t bre k down
blood clots. This often results in uncon- trolled bleeding. DIC c n be process
th t is slow to
develop, nd in this situ tion the individu l usu lly h s systemic thrombi devel
op, but no
uncontrolled bleeding. In cute (or r pid- cting) DIC, the p tient develops the
multiple thrombi,
but they lso m y hemorrh ge be- c use of the r pid use of the co gul tion f cto
rs within their
body. There is lw ys n underlying c use for p tients who exhibit dissemin ted
intr v scul r
co gul tion. M ny times (especi lly in cute c ses) if the underlying situ - tio
n is ddressed
nd resolved, the DIC will lso resolve. Potenti l c uses of dissemin ted intr v
scul r co gul tion include the following: Systemic infection with b cteri or fungi Severe tr
um Solid
tumors or hem tologic l c ncers Obstetric l complic tions such s pl cent l bru
ption or
mniotic fluid emboli Aortic neurysms or other v scul r disorders Systemic infl
mm tory
responses, such s those th t occur with tr nsfusion re ctions The first course
of tre tment for
DIC is to resolve the underlying problem, if possible. However, in situ tions in
which the
initi l dise se process c nnot e sily be re- solved, or c nnot be resolved quick

ly enough, the
symp- toms of dissemin ted intr v scul r co gul tion m y be tre ted with tr nsfu
sions of
pl telets, co gul tion f ctors cont ined in fresh frozen pl sm , nd fibrinogen
s pro- vided in
cryofibrinogen precipit te. Ch pter 15 Co gul tion Studies 317 Test Your Knowl
edge 15-6 How re
DIC nd DVT simil r? (Outcome 15-5) Test Your Knowledge 15-7 How is thrombocytop
eni different
from the other disorders presented thus f r in this ch pter? (Outcome 15-5) Thro
mbocytopeni In
thrombocytopeni , the p tient does not h ve enough pl telets circul ting to co g
ul te effectively
when necess ry. Cert in medic tions or other underlying hem tology dise se st te
s m y c use this
condition. Be- c use of the low numbers of pl telets, the clots th t form in res
ponse to v scul r
d m ge will not be dequ te. In ddition to thrombocytopeni , p tients m y exhib
it disorders of
pl telet dhesion, where the pl telet count is norm l for the p tient, but their
pl telets l ck
the bility to stick to other pl telets nd form the ggreg te plug th t is nece
ss ry to stop the
bleeding with v scul r injuries. Antiphospholipid Syndrome Antiphospholipid synd
rome is
condition in which sm ll systemic blood clots form, presenting potenti l risk fo
r embolism or
org n f ilure. Bec use the blood clots c n form nywhere, the p tient is t hi
gh risk for
1899_Ch15_313-331 21/12/11 4:29 PM P ge 317 stroke, or tot l occlusion of blood
vessels providing
cir- cul tion to intern l org ns. Hemophili Hemophili is sex-linked inherite
d disorder th t
ffects pproxim tely 1 in 5,000 m les. There re two types of hemophili : type
A nd type B.
Those ffected with type A hemophili l ck the clotting f ctor VIII. Those with
type B l ck the
clotting f ctor IX. Both groups of p tients m y bleed excessively nd experience
v scul r d m ge,
in ddition to intern l bleeding in the elbows, knees, nd other joints. Not ll
p tients with
hemophili re ffected to the s me extent; the disorder m y express itself with
mild to moder te
symptoms. It is lso possible to develop hemophili in response to chemother py
tre tment or
other dise se st tes. In those situ tions, the p tients ctu lly develop ntibod
ies to the
clotting f c- tors, which render them useless when needed within the body. P tie
nts with ll
types of hemophili will need to be tre ted with the missing clotting f ctors to
void excessive bleeding. The clotting f ctors m y be derived from hum n don ted pl sm , or
they m y be
cre ted in l b- or tory without hum n elements. LABORATORY TESTS USED TO DIAGN
OSE COAGULATION
DISORDERS OR MONITOR ANTICOAGULANT THERAPY As we h ve le rned, cert in dise se s
t tes m y c use
p tient to be more prone to thrombosis form tion, where s other p thologies m y
c use excessive
bleeding. For those who h ve disorders c using excessive bleeding, the co gul ti

on tests
ssoci ted with di gnosis nd monitoring of the conditions re usu lly performed
t hospit l or
reference l bor tory. These tests m y include the prothrombin time (PT), the ct
iv ted p rti l
pro- thrombin time (PTT), fibrinogen levels, fibrin degr d - tion products (FDPs
), nd D-dimer.
He lth-c re providers m y lso request levels of specific clotting f c- tors. T
ble 15-2 cont ins
inform tion bout the tests covered in this ch pter, why they re commonly order
ed, nd the
specimen types required. Medic l ssist nts m y perform PT/INR tests, nd will b
e involved in the
spec- imen collection process for the tests performed outside the physici n offi
ce, so they will
benefit from the b sic knowledge bout the specimen requirements nd clinic l si
gnific nce of the
v rious test results. 318 Section III Hem tology nd Co gul tion TABLE 15-2 Com
mon co gul tion
tests, clinic l indic tion or signific nce, nd specimen requirements Test N me
Abbrevi tion Test
Use Specimen Type Activ ted p rti l prothrombin time Fibrin degr d tion products
D-dimers
Fibrinogen level Bleeding time Pl telet count Pl telet function ss y 100 PTT or
PTT FDP D-dimers
Fib BT Plt Ct PFA 100 Screening for co gul tion dys- function; intrinsic system
of blood
co gul tion. Also used to moni- tor hep rin ntico gul nt use. Monitoring of bre
kdown products
from blood clot dissolution Fibrin bre kdown products from blood clot dissolutio
n Me sures mount
of circul ting fibrinogen in bloodstre m Pl telet function Assessment of number
of pl telets
v il ble for blood co gul tion Assessment of pl telet function; clotting bilit
y of pl telets
Light blue top tube with citr te nti- co gul nt; must be filled completely. Spe
ci l FDP tube for
pl sm levels; m y lso use red top tubes for serum levels. Citr ted pl sm from
full light blue
top tube. Pl sm should be frozen if the test c nnot be performed immedi tely. P
l sm from full
light blue top citr te tube. Test performed on p tient L vender top tube with ED
TA nticogul nt. Test performed on whole blood. Full light blue top citr ted tube; whole
blood is used
for the ss y. 1899_Ch15_313-331 21/12/11 4:29 PM P ge 318 Prothrombin nd Inter
n tion l
Norm lized R tio The prothrombin time (PT) is test th t me sures the effic cy
of the extrinsic
co gul tion process. Prothrom- bin is clotting f ctor th t is m nuf ctured by
the liver, nd
the ch nge of prothrombin to thrombin is one of the l st steps to forming clot
when vessel is
d m ged. The ction of clotting f ctors I, II, V, VII, nd IX m y be monitored w
ith the
prothrombin time test result. The prothrombin time m y be elev ted in p tients w
ho h ve
insufficient mounts of these clotting f ctors, s well s those who re deficie
nt in vit min K.
P tients suffering from liver dise se m y lso h ve n incre sed prothrom- bin t

ime result
bec use of the in bility of the liver to cre- te the clotting f ctors s needed
. The PT is
reported in seconds, s it is me surement of the mount of time needed for
c
lot to form in
the specimen fter the ddition of thrombopl stin nd c l- cium to
s mple of p
l telet-poor
pl sm . PT tests re often performed s p rt of co gul tion screen before surg
ic l procedures
or when p tient shows signs of excessive bleeding or bruising. Prothrombin tim
es m y be used to
screen for initi l co gul tion disorders. The PT is lso used to help monitor or
l ntico gul nt
use, s the result is elev ted when p tient is being tre ted with these or l
ntico gul nts.
Ch pter 15 Co gul tion Studies 319 TABLE 15-2 Common co gul tion tests, clinic
l indic tion or
signific nce, nd specimen requirementscontd Test N me Abbrevi tion Test Use Speci
men Type
Prothrombin time Intern tion l norm lized r tio Prothrombin time or PT INR Scree
ning for
co gul tion dysfunc- tion; specific lly extrinsic blood clotting c sc de. Also u
sed for
monitoring or l ntico gul nt use. F ctor used for monitoring or l ntico gul nt
use;
st nd rdizes results using v rious re gents nd testing methods Full light blue
top citr te tube
or c pill ry s mple if performed with point-of-c re testing. Full light blue top
citr te tube or
c pill ry s mple if test is performed with point-of-c re testing instrument POIN
T OF INTEREST
15-1 History of w rf rin As the popul tion in the United St tes grew dr m t- ic
lly in the e rly
1900s, so did the dem nds for f rming. The Midwest w s f rmed extensively, growing crops to
feed the U.S. popul tion s well s the food to feed d iry nd beef c ttle. Once
the n tur l
feed products of the re were exh usted (such s whe t nd gr sses n tive to th
e region), it w s
neces- s ry to rese rch other crops th t might suffice to feed the nim ls. Swee
t clover w s
introduced, s the protein content nd digestibility w s simil r to th t of lf
lf . However,
sweet clover w s more prone to spoil ge th n the other food sources h d been bec
use of issues
rel ted to its high moisture content. Soon, there were reports of unexpl ined he
morrh ge nd
sickness in c ttle th t h d been fed from the sweet clover fter h rvest. Throug
h n lysis, it
w s found th t the spoil ge of the clover cre ted dicoum rol. Dicoum rol tt che
d itself to the
vit min K present in the intestines of the c ttle. Vit min K is essenti l for se
ver l blood
clotting mech nisms, so these c ttle would bleed excessively, s the necess ry v
it min w s no
longer us ble. In 1948, w rf rin w s cre ted s deriv tive of dicoum rol, nd
in 1952 it w s
introduced to the world s type of r t poison. A young n vy recruit decided th
t he w nted to
end his life, nd ingested l rge dose of this w rf rin r t poison. Rem rk bly,

he did not die,

lthough his blood clotting processes were definitely ffected. This situ tion p
rompted more
rese rch into how w rf rin could be used to tre t hum ns, nd in 1954, it w s fi
rst uthorized
for hum n use s n or l ntico gul nt. In 1955, President Eisenhower w s tre te
d with w rf rin
fter he rt tt ck. W rf rin (br nd n me Coum din) is the most common drug pre
scribed
worldwide. It is t ken by those who h ve
prior history of blood clots or he rt
disorders such
s tri l fibrill tion nd he rt v lve deformities, s well s given to surgic l
p tients. The
effic cy of w rf rin c n be ffected by ingestion of foods th t re high in vit
min K, such s
c bb ge, c uliflower, spin ch, soybe ns, nd broccoli. 1899_Ch15_313-331 21/12/1
1 4:29 PM P ge
319 Procedure 15-1: CLIAW ived Prothrombin Time/INR Testing Using the Co guChek S
Instrument A
CLIA-w ived PT test procedure is used to monitor the ntico gul nt effects of me
dic tions such s
w rf rin (Coum din) in the physici n office l bor tory. These drugs re used by
p tients who re
t high risk for blood clot form tion. Close monitoring of the effects of or l
n- tico gul nts
is necess ry, s p tients who h ve too much in their bloodstre m run the risk of
excessive
bleeding, where s those with too little could develop thrombosis. A c lcul tion
c lled the
intern tion l norm lized r tio (INR) is reported with the PT result. The INR is
f ctor th t
llows for st nd rdiz tion of prothrombin tests performed with different methodo
logies nd/or
re gents. Prothrombin tests performed with different lot numbers of re gents or
different
methodologies m y differ by 10% to 20% from one l bor tory to nother. This c n
be prob- lem tic
when djusting or l ntico gul nt dos ges b sed on PT test results. In 1983 the
World He lth
Org niz - tion proposed c lcul tion (the INR) to st nd rdize the v ri bles th
t re present
when performing prothrombin testing with v rious instruments nd lot numbers for
re gents. For n
individu l who is not on or l ntico gu- l nts, the INR would be pproxim tely 1
, nd for those
who re being tre ted with w rf rin or Coum din, the INR should be 2 to 3. Decis
ions to ch nge
medic tion levels re b sed on the INR result, not the PT result th t 320 Sectio
n III Hem tology
nd Co gul tion TASK Perform PT/INR testing utilizing the Co guChek S instrument
nd document the
results ppropri tely. Complete ll steps within 10 minutes. CONDITIONS H nd s n
itiz tion
supplies Gloves Completed p tient requisition form nd p tient ch rt Co guChek S
instrument
Test strips Qu lity control m teri l Test strip code chip Bulb nd c pill ry pro
vided
with instrument for pplic tion of s mple G uze or cotton b lls Alcohol p d for
s nitiz tion
L ncet device or venipuncture supplies Bioh z rdous dispos l cont iner Bioh z rd

ous sh rps
cont iner Note: This test m y be performed on c pill ry blood s mple or s mp
le obt ined
through venipuncture. Be cert in to h ve the necess ry supplies v il ble for th
e method used for
s mple collection, s well s bioh z- rdous sh rps dispos l cont iner nd glo
ves. CAAHEP/ABHES
STANDARDS CAAHEP 2008 St nd rds None ABHES 2010 St nd rds None Test Your Knowled
ge 15-8 True or
F lse: Is the INR used when screening for poten- ti l co gul tion defects? (Outc
ome 15-6) m y be
reported with the INR. Reference r nges for the prothrombin time m y v ry betwee
n l bor tories,
but they re pproxim tely 11 to 13 seconds. The Co guchek S, m nuf ctured by Ro
che Di gnostics, is
CLIA-w ived PT/INR testing method often used in the physici n office
l bor tory. This
type of n lyzer is point-of-c re test (POCT) th t llows for immedi te result
s. Perform nce of
this test in the office c n benefit the p tient by llowing the results to be v
il- ble to the
he lth-c re provider within minutes. This l- lows the p tient to receive ny ne
cess ry
instruction bout medic tion ch nges w rr nted by the results while still in the
office. The test
requires only 10 microliters of blood ( pproxim tely one drop), nd the s mple m
y be obt ined
through c pill ry puncture or
venipuncture. In situ tions in which the PT n
d INR re ordered
s p rt of co gul tion screen or when the testing is per- formed t referenc
e l bor tory,
full, well-mixed, light blue top sodium citr te tube is required for the test. 1
899_Ch15_313-331
21/12/11 4:29 PM P ge 320 Ch pter 15 Co gul tion Studies 321 Procedure R tion
le 1. Verify test
ordered on requisition form. Greet nd identify p tient. 2. S nitize h nds, llo
w them to dry,
nd pply gloves. 3. G ther necess ry supplies. Test strips must be t room temp
er ture for t
le st 5 minutes prior to use. Comp re the number on the code chip (loc ted in
sm ll comp rtment
t the top of the box of test strips) to the l st three numbers fter the lot sy
mbol on the test
strip pouch. If these numbers do not m tch, this code chip m y not be used with
these strips. 4.
Verify whether qu lity control (QC) testing needs to be performed on the instrum
ent. If so,
perform QC testing nd verify v lidity of results before proceeding with p tient
testing. 5.
Determine the method to be used for specimen collection. . If c pill ry s mpl
e is to be used,
prep re the l ncet. Roche m nuf ctures
c pill ry tube nd bulb to id with spe
cimen collection,
s well s l ncet specific lly designed to be used with the Co guChek system.
Assemble the
c pill ry tube nd bulb if desired. The blood m y lso be pplied directly to th
e test strip
without the id of the c pill ry tube. b. Blood obt ined through venipuncture is
ccept ble, s
long s it is collected into preserv tive-free pl stic syringe using
21- to

23-g uge needle.

The specimen would need to be pplied to the strip immedi tely fter the collect
ion h s been
completed. The requisition should lw ys be ex mined to be cer- t in which test
is ordered, nd
the p tient identity must lw ys be verified before proceeding. Gloves protect t
he h nds from
exposure to potenti l bloodborne p thogens. Gloves should lw ys be pplied in t
he presence of
the p tient. Supplies must be within re ch before st rting the process so th t t
he timing of the
testing is ccur te. The code chip must be the correct number for the re gent st
rip for the test
result to be ccur te. The frequency of the QC testing is b sed on the m nuf ctu
rers nd
individu l l bor tory recommend tions. The c pill ry s mple is the most common m
ethod of testing
used in the physici n office l bor tory. Preserv tives nd/or ntico gul nts re
not ccept ble
for this testing method. The blood c nnot be llowed to clot before pplic tion
on the test
strip, or the results will be in ccur te. Continued 1899_Ch15_313-331 21/12/11 4
:29 PM P ge 321
Procedure 15-1: CLIAW ived Prothrombin Time/INR Testing Using the Co guChek S Ins
trumentcontd
Procedure R tion le 322 Section III Hem tology nd Co gul tion 6. Insert the co
de chip into the
m chine, nd pl ce the instrument on fl t, vibr tion-free surf ce. Turn on the
power, nd m ke
cert in th t the code displ yed on the screen m tches the numbers printed on the
foil wr pper
enclosing the test strip. 7. The test strip icon will fl sh on the Co guChek S d
ispl y screen.
Open the foil pouch nd insert test strip into the instrument by sliding it (p
rinted side up)
into the tr y on the front of the instru- ment in the direction of the rrows. C
ontinue to push
the test strip into the instrument until it stops. Test strips must be used with
in 4 minutes of
remov l from the foil p ck ge. If the codes do not m tch, the instrument will no
t pro- vide
test result. For most of the testing process, the Co guChek S displ y screen wil
l guide your next
steps. Courtesy of Roche Di gnostics. 8. Prep re the ppropri te site for the c
pill ry puncture, or obt in the blood s mple vi venipuncture. 9. Monitor the displ y screen
; t this point,
test strip icon should be visible s well s fl shing clock icon. Do not pp
ly the s mple
until the icon for
blood drop ppe rs on the screen. Once the test strip is pl
ced into the
instrument, the time will be limited for the specimen to be collected nd pplie
d for the testing
process. If the s mple is pplied too soon, the instrument will not process the
s mple nd the
screen will displ y n error. 1899_Ch15_313-331 21/12/11 4:29 PM P ge 322 D te 0
4/18/2013: PT/INR
test performed from c pill ry puncture. PT result 23.2 seconds, INR 2.1

Connie Lieseke, CMA (AAMA) Procedure R tion le Ch pter 15 Co gul tion S

tudies 323 10. Once
the fl shing blood icon ppe rs on the screen, countdown for 180 seconds begin
s. The instrument
will beep every 30 seconds until n d- equ te s mple h s been pplied to the te
st strip. The
s mple must be pplied before the count- down re ches 0. 11. Utilizing ppropri
te c pill ry or
venipuncture procedure, obt in the blood s mple. Apply drop of blood to the te
st strip directly
over the fl shing yellow light. This fl shing light indic tes where the s mple i
s to be pplied.
12. After specimen pplic tion, the screen will displ y clock icon. Do not tou
ch the instrument
or the test strip during this time. The result will be v il- ble on the screen
( nd stored in
the memory of the instrument) within 1 minute. 13. Document the result on the in
strument log
sheet. 14. Disc rd the test strip by pulling it out of the instrument nd disc r
ding it into
bioh z rdous w ste cont iner. 15. S nitize the work re nd put w y supplies.
16. Remove gloves
nd s nitize h nds. 17. Document the test results in p tient ch rt. A countdown
of 180 seconds
should be dequ te time to obt in the c pill ry s mple, or to prep re to pply t
he venipuncture
specimen. For this procedure, the first drop of blood obt ined from c pill ry
s mple is to be
used; do not wipe w y the first drop of blood s you would custom- rily do for
other types of
collections. For s mples obt ined through venipuncture, the first four drops of
blood re to be
disc rded from the end of the needle, fter which the next drop is to be pplied
to the s mple
re . Do not llow bubbles to form when pplying the s mple. The clock icon is d
ispl yed during
the entire testing procedure. Once the test strip is removed from the m chine, t
he result is no
longer displ yed on the screen, so it is best to record it immedi tely. The test
strip is
cont min ted with blood nd must be disposed of ccordingly. Be sure to refriger
te the test
strips right fter use. H nds must lw ys be s nitized fter removing gloves. Al
l results must be
documented in the p tients ch rt. Activ ted P rti l Thrombopl stin Time/ P rti l
Thrombopl stin
Time Activ ted p rti l thrombopl stin time is bbrevi ted PTT. The PTT is me s
urement of the
effic cy of the intrinsic co gul tion p thw y. This p thw y includes the ctions
of clotting
f ctors VIII, IX, XI, nd XII. The PTT is me sured in seconds, just s the PT is
. Technic lly it
is the mount of time th t the blood s mple t kes to clot when phospholipid nd
c lcium re dded
to the speci- men. The PTT test m y be ordered (with the PT) s p rt of presur
gic l screen,
when p tient h s excessive bleed- ing or bruising, or to monitor the use of he
p rin ther py.
Hep rin is f st- cting ntico gul nt th t ffects the f ctors in the intrinsic
blood-clotting

p thw y. Hep rin is used to tre t p tients who re t high risk for thrombosis 1
899_Ch15_313-331
21/12/11 4:29 PM P ge 323 nd to tre t those who h ve lre dy developed blood cl
ots, especi lly
in postsurgic l settings. Hep rin is not
medic tion commonly used in the home
setting, bec use
it must be dministered IV or by subcut neous injection multiple times per d y.
Reference r nges
for the PTT re 25 to 31 seconds, nd the specimen must be full light blue top
sodium citr te
tube. genetic dise se th t c uses bnorm l fibrinogen ctivity; the fibrinogen c
re ted in the
liver is not ble to convert to fibrin correctly to complete blood clot form tio
n. Low levels of
fibrinogen m y contribute to excessive bleeding, nd conversely, levels th t re
bove the norm l
r nge m y contribute to form tion of sm ll in- tr v scul r blood clots. Fibrinog
en levels m y be
ele- v ted in ny condition th t c uses infl mm tion includ- ing pregn ncy, cut
e infection,
c ncer, coron ry he rt dise se, myoc rdi l inf rction (MI), nd stroke. These in
cre sed levels of
circul ting fibrinogen will m ke the p tient more prone to p thologic l blood cl
ot form - tion,
so the fibrinogen level test is often performed with the PT, PTT, nd pl telet c
ount ss ys to
screen for co gul tion dysfunction. Reference r nges for fibrino- gen re pprox
im tely 20 to 400
mg/dL, but m y v ry with the method used for testing by ny individu l l b- or t
ory. Fibrinogen
requires full light blue top sodium citr te tube. 324 Section III Hem tology
nd Co gul tion
Test Your Knowledge 15-10 If fibrinogen levels re decre sed, wh t might poten
- ti l outcome be
for the p tient? (Outcome 15-11) Test Your Knowledge 15-9 Which medic tion is mo
nitored by using
the PTT? . Coum din b. w rf rin c. hep rin d. spirin (Outcome 15-8) Pl telet C
ount One of the
first steps in the co gul tion process is the g- greg tion of pl telets t the
site of the
vessel injury. For this re son, it is imper tive th t pl telets re present in s
ufficient numbers
nd lso th t they function ppropri- tely in order for the body to rep ir vess
el d m ge s it
should. Pl telets re produced by the bone m rrow, nd when the blood vessels r
e injured, they
dhere to the site of the injury nd to other pl telets. This prim ry plug helps t
o protect the
body from excess blood loss, nd lso st rts the clotting c sc de, which ends wi
th more
perm nent fibrin mesh t the site to llow for the d m ge to he l. Insufficient
pl telet mounts
(thrombocytopeni ) will put the p tient t risk for excessive bleeding with vess
el injury. A
pl telet count is performed to monitor the number of pl telets present in the ge
ner l circul tion. Pl telet counts re routinely performed s p rt of complete blood count,
nd m y lso be
ordered s p rt of co gul tion screen. The specimen required is l vender top
EDTA tube, nd

the reference r nge is 150,000 to 450,000 mm 3 . Fibrinogen Fibrinogen is stick

y subst nce
m nuf ctured by the liver th t is n essenti l p rt of the blood-clotting proces
s. It is
n tur lly dissolved in pl sm , nd is the precursor to fibrin. Fibrin is necess
ry for effective
blood clot form tion. Fibrinogen is lso known s clot- ting f ctor I. The prese
nce of dequ te
levels of fibrino- gen is essenti l to pl telet ggreg tion. Levels of fibrinogen m y be
decre sed in the presence of genetic disorders, resulting in di gnosis of fib
rinogenemi or
hypofibrinogenemi . Dysfibrinogenemi is r re Fibrin Degr d tion Products Clot
cre tion nd
subsequent bre kdown must rem in in b l nce for the body to m int in he lthy c
o gul - tion
response. Once
d m ged vessel h s he led, pl s- min ( n enzyme designed to dis
solve blood
clots) nd other chemic ls in the pl sm immedi tely begin to dissolve the fibri
n mesh forming
the clot so th t it does not become too l rge. The by-products of fibrinolysis m
y be me sured in
the l bor tory with n ss y th t me sures fibrin degr d tion products (FDPs). F
DPs re
essenti lly fr gments th t re rele sed s blood clots re dissolved. These fr g
ments re
rele sed when fib- rinogen (the precursor of fibrin) or fibrin is broken down by
pl smin. The
mount of fibrin degr d tion products incre se in dissemin ted intr v scul r co
gu- l tion,
pulmon ry embolism, nd with some obstetric l complic tions. In most l bor torie
s, the FDP test
is performed on pl sm collected in light blue top tube with sodium citr te n
tico gul nt. If
the test is to be performed within 4 hours, the tube is to rem in t room temper
ture. If the
s mple must be tr nsported elsewhere for testing nd the processing t kes more t
h n 4 hours, the
tube should be spun down nd the pl sm must be frozen. Serum FDP ss ys m y ls
o be performed,
which m y require specific tubes th t 1899_Ch15_313-331 21/12/11 4:29 PM P ge 32
4 cont in
thrombin to clot the blood nd chemic ls to prevent fibrinolysis within the tube
. Norm l
reference r nges for FDP re b sed on the testing procedure, nd m y v ry. D-Dim
er The FDP test
me sures ll the bre kdown products cre- ted s blood clots dissolve. One of th
ese by-products
is very specific for cert in cross-linked components of the fibrin clot, nd th
t c n be me sured
by perform- ing D-dimer test. D-dimers re
specific type of bre kdown produc
t th t indic tes
the dissolution of fibrin, r ther th n just fibrinogen. The D-dimer test is curr
ently repl cing
the FDP n lysis in m ny l bor to- ries. D-dimers re lw ys present in sm ll m
ounts in the
blood, but elev ted levels m y be indic tive of dissemin ted intr v scul r co gu
l tion, pulmon ry
embolism, or deep vein thrombosis. The body incre ses the mount of D-dimers pro
duced s soon s

clot be- gins to form bec use the clot dissolution process st rts lmost simul
t neously to keep
the blood clot from growing l rger th n necess ry. Surgic l procedures m y elev
te D-dimer
levels, s well s pregn ncy, infl mm - tion, some types of c ncer, nd liver di
se se. Use of
fibrinolytic drugs ( lso c lled clot busters) will lso incre se the mount of F
DP nd D-dimers
in the bloodstre m, so these tests m y be used to monitor fib- rinolytic medic t
ion ther py s
well. The reference r nges for D-dimers re b sed on the testing method used for
the ss y. The
D-dimer n lysis requires pl telet-poor citr ted pl sm , dr wn in light blue t
op tube. The
specimen must be spun in
typic l benchtop centrifuge for t le st 10 minutes b
efore sep r tion
of the pl sm from the cells. In ddition, there re speci lized centrifuges th
t re speci lly
equipped to cre te pl telet-poor pl sm in less th n 10 minutes for tests th t r
equire this type
of specimen. Bleeding Time Test A bleeding time test is performed to ev lu te ho
w well pl telets
function to form plug in the c pill ry beds with induced d m ge. It is not t
est performed
from blood s mple, but is me surement performed di- rectly on the p tient. B
ec use there re
other tests used to monitor the different p rts of the co gul tion c s- c de, th
e bleeding time
is gener lly used to identify pl telet function bnorm lities, nd it m y lso d
etect
deficiencies of von Willebr nds f ctor, which is p rt of the f ctor VIII used for
blood
clotting. The pl telet count nd ll other clotting f ctors m y be within the no
rm l reference
r nges, but if the pl telets do not perform s they should, the p tient m y stil
l h ve issues
with prolonged bleeding. In the p st, the bleed- ing time test w s common pres
urgic l
l bor tory or- der, but the true bility of the bleeding time to detect potenti
l surgic l
hemorrh ge h s been c lled into question in recent ye rs. Bleeding times h ve be
en performed
using v rious methods since they were first developed pproxim tely 85 ye rs go
. M ny of these
procedures were not st n- d rdized, so it w s difficult to reproduce the results
or to est blish
reli ble norm l reference r nges. Histori- c lly, the procedures ll included s
t b into soft
tis- sues of the body (usu lly the e rlobe) nd monitoring the wound until bleed
ing h d stopped.
A l ncet or surgic l bl de w s used, but there w s l ck of unifor- mity concer
ning the depth or
length of the incisions cre ted. Ch pter 15 Co gul tion Studies 325 Test Your
Knowledge 15-11
List two re sons th t the bleeding time test is not consid- ered to be the test
of choice for
pl telet function n lysis s it once w s. (Outcome 15-10) Most modern f cilitie
s th t perform
bleeding times tod y use modified Ivy method. This method includes the use of
the Surgicutt,

spring-lo ded l ncet device m nuf ctured by the Intern tion l Technidyne Corpor
- tion. The bl de
in the l ncet device h s depth of 1 mm nd
width of 0.5 mm. The device is e
sy to use, nd
the bl de retr cts fter use so th t there is minim l opportunity for ccident l
employee
exposure to p tient fluid. The st nd rdized depth nd width of the incision h s
ssisted in the
determin tion of reli ble reference r nges nd s fety for the p tients. There r
e lso speci l
l ncet devices v il ble for use on inf nts. Bleeding times re used to determin
e how long it
will t ke for
p tient to stop bleeding fter
superfici l puncture or incisio
n is m de into
the skin. The bleeding time procedure requires n incision device (such s the S
urgicutt),
sphygmom nometer (blood pressure cuff ), n ntiseptic wipe, sterile filter p pe
r provided in
circles, nd n dhesive b nd ge. Figure 15-1 shows the sup- plies necess ry to
perform
bleeding time test. The per- form nce of bleeding time is unique procedure
nd includes the
following concepts: 1. It is essenti l to sk the p tient bout spirin use with
in the p st week.
Even one spirin, or other products th t include spirin, c n profoundly ffect
the results
obt ined with the bleeding time. 1899_Ch15_313-331 21/12/11 4:29 PM P ge 325 The
p tient should
be sked whether he or she is under ther py with hep rin or or l blood thinners
such s w rf rin.
If the p tient h s t ken ny of these medic tions, you must check with the physi
- ci n before
performing the test, s the v lidity of the results m y be ffected. Long-term u
se of other
NSAIDs (such s ibuprofen) m y lso incre se the bleeding time. 2. The bleeding
time is to be
performed 2 to 3 inches below the bend of the elbow on the skin of the fore- rm
. Visible veins,
moles, t ttoos, sc rs, bruises, shunts, or fistul s nd edem tous re s should b
e voided, s
well s re s with excessive h ir growth. Cle n the site thoroughly with n lco
hol ntiseptic
wipe nd llow the lcohol to dry completely before continuing with the procedur
e. 3. Apply
blood pressure cuff bove the elbow to the rm to be used, nd infl te the cuff
to 40 mm Hg. 4.
The bleeding time device ( Surgicutt l ncet) is to be pplied to the rm in h
orizont l m nner,
nd pres- sure must not be used when m king the incision. St rt the stopw tch s
soon s the
incision is m de. At 30-second interv ls, wick w y excess blood with filter p p
er, t king c re
not to disturb the ctu l inci- sion site. Rot te the filter p per s the blood
is blot- ted w y
e ch time so th t e ch wicking session is definitive. 5. When no more blood c n
be blotted w y,
stop tim- ing the process nd rele se the blood pressure cuff. The time th t h s
el psed since
the incision w s m de is the bleeding time. Norm l results re usu lly 1 to 9 mi
nutes. If the

results re less th n 1 minute or more th n 9 minutes, some l bor tories will re

quire th t the
test be repe ted, s there m y be procedur l errors th t contributed to the resu
lt. Bleeding
times re not used s frequently s they once were, nd m ny l bor tories no lon
ger offer this
test s n option. It h s been shown th t the correl - tion of n elev ted bleed
ing time to the
risk of exces- sive surgic l bleeding is not lw ys conclusive, nd the results
for bleeding
times re not reproducible. The procedure often c uses
sc r t the site of the
incision, which
c n be signific nt consequence to some p tients. In ddition, the use of NSAID
s (such s
ibuprofen or Advil) m y ffect the bleeding time, in ddition to spirin or spi
rin-cont ining
products. The effect of the drugs on the bleeding time result is not predict ble
; the bleeding
time m y be extended, but it is difficult to predict the mount th t it will be
ffected. Other
v ri- bles m y be the result of incorrect technique; if the incision is too dee
p or too sh llow,
the results will not be ccur te. Also, when blotting w y excess blood, if the
incision is
touched, the bleeding time m y be f lsely elev ted. It is import nt to re lize t
h t the PTT nd
PT tests re ordered much more commonly th n the bleeding time test. These tests
h ve fewer
v ri bles th t could c use erroneous results th n the bleeding time does, nd b
norm l results
re m pped more specific lly to the v rious co gul tion f ctors. The bleeding ti
me technique lso
requires specific tr ining, where s the PT nd PTT tests require more common c
pill ry or
venipuncture procedure. In ddition, the bleeding time requires 10 to 20 minutes
to complete,
which m y be too time intensive for busy pr ctice or l bor - tory settings. Othe
r Tests Used to
Assess Pl telet Function Pl telet function c nnot be me sured just by counting t
he number of
cells, nd screening for pl telet dysfunc- tion is not s precise or e sily perf
ormed s is
pl telet count. The bleeding time test m y help to identify gross pl telet funct
ion
bnorm lities, but it is not sensitive or specific enough to identify ll issues
. M ny reference
nd hospit l l bor tories re now using the Pl telet Function An lyzer 100 (PFA100),
m nuf ctured by Siemens Corpor tion. This m chine tries to simul te the bleeding
process th t
occurs in the body by using tube of blood obt ined through
venipuncture. The
testing process
involves the ddition of whole blood into tube th t is co ted with dditives t
h t promote 326
Section III Hem tology nd Co gul tion Figure 15-1 Bleeding time supplies incl
uding Surgicutt
l ncet nd filter p per. 1899_Ch15_313-331 21/12/11 4:29 PM P ge 326 pl telet d
herence nd
ggreg tion in order to mimic these ctions within the hum n body. The m chine m
e sures the

mount of time th t is necess ry for blood clot to form within this tre ted tu
be, nd this is
reported s closure time (CT). There re other types of utom ted pl telet fun
ction tests
v il ble, but they re not used s widely s is the PFA-100. Controversy still
exists bout
whether these new utom ted tests re s useful for predicting over ll pl telet
function
ssessment s the bleeding time once w s, even though the bleeding time test is
no longer
performed in m ny institutions. SPECIMEN REQUIREMENTS FOR COAGULATION TESTING Wi
th the exception
of CLIA-w ived point-of-c re PT testing, when collecting s mples for co gul tion
testing, light
blue top tube with sodium citr te is used for most co gul tion tests ordered. Th
is includes the
fibrinogen test, PTT, PT, nd sometimes the FDP test. Some l bo- r tories use
speci l FDP tube
th t only requires 2 mL of blood in 5-mL tube. Ev cu ted light blue top v cuum
tubes m y
include different concentr tions of citr te (with the s me volume of fluid ntic
o gul nt in the
tube), so it is import nt to cl rify which type should be dr wn for the testing
method used in
the l bor tory where the testing will occur. The light blue top tubes m y be v
il ble with 3.2%
citr te or 3.5% citr te. In ll sit- u tions,
r tio of one p rt ntico gul nt
to nine p rts
blood must be m int ined, or the result will be erro- neous bec use of specimen
dilution. The
citr te tube must be filled until the v cuum h s been exh usted; no short s mple
s c n be tested.
If the ev cu ted tube is not filled until the v cuum is exh usted, the clotting
time ( nd
subsequently the testing results) will be f lsely elev ted bec use of the diluti
on f ctor with
the ntico gul nt in the tube. Tubes re spun in the centrifuge before the test
is performed,
nd the pl sm is tested immedi tely or sep r ted from the cells. Ide lly, the s
mple will be
tested within 1 hour of collection, or within 4 hours if the specimen h s been r
efriger ted.
For p tients who h ve hem tocrit me suring bove 55%, it is necess ry to reduc
e the mount of
ntico g- ul nt used in the tube to void prolonged clotting times bec use of th
e ch nge in the
r tio of pl sm to ntico gul nt. L bor tories will h ve n est blished procedur
e for the
perform nce of this process. It is critic l th t s mples used for co gul tion te
sting rem in
free of IV fluid or other cont min ting sub- st nces. M ny times the s mples re
dr wn s p rt of
the di lysis process, so it is especi lly critic l to cle r the line of ll othe
r fluids before
the specimen is obt ined. Clotted or hemolyzed s mples will lso not be cceptble for
co gul tion testing, s the results will be in c- cur te. To void microclot for
m tion in the
tube, it is very import nt th t the tubes used for co gul tion studies re inver
ted t le st

eight times s soon s pos- sible fter collection. Ch pter 15 Co gul tion Stud
ies 327 Test
Your Knowledge 15-12 True or F lse: Light blue top tubes collected for co gul tion studies m y
be p rti lly filled with no neg tive effects. (Outcome 15-13) A l vender top tub
e with EDTA
ntico gul nt is used for pl telet counts. Pl telet counts m y be performed s p
rt of complete
blood count, or they m y be ordered sep r tely when needed. As in the c se with
the light blue
top citr te tube, it is very import nt th t the l ven- der top tube be mixed tho
roughly right
fter the blood dr w to void microclot form tion. Pl telet counts re performed
on whole blood,
so the specimen is not cen- trifuged fter collection. SUMMARY Co gul tion nd c
lot dissolution
re vit l processes to m int in homeost sis in the hum n body. The rep ir of d m
ged blood
vessels within the body is
com- plex process th t includes pl telets nd
v r
iety of chemic l
re ctions to work efficiently. Co gul tion studies determine whether there re e
nough pl telets
nd other chemic ls present for the process to be successful, s well s ev lu t
ing the
efficiency of the clotting process to predict excessive bleeding or unnecess ry
blood clot
form tion. Other dise se processes m y be complic ted by form tion of sm ll bloo
d clots, so
p tients m y be medic ted with nti- co gul nt drugs to void potenti l problems
. This medic tion
use must be monitored closely with the use of co gul tion tests on regul r b s
is. The nticogul nt medic tions t rget the v rious spects of the clotting c sc de nd requi
re different
testing mech - nisms to monitor their levels. Common tests used to monitor co gu
l tion processes
in the body nd med- ic tions th t ffect the clotting mech nisms include the PT
/INR test,
pl telet counts nd pl telet function 1899_Ch15_313-331 21/12/11 4:29 PM P ge 32
7 tests, nd the
ctiv ted p rti l thrombopl stin time. Other tests m y be performed to ev lu te
the mount of
clot dissolution or fibrinolysis occurring in the body. Co gul tion testing m y
be performed in
the physici n office l bor tory s well s in hospit l nd reference l bor torie
s. TIME TO REVIEW
1. Aggreg te is word used to describe: Outcome 15-1 . Pl telet dhesion nd c
lumping b.
Consolid tion of clotting f ctors c. Deep vein emboli d. Fibrinolysis 2. Which o
f these terms
might be used Outcome 15-1 to define FDP? . The f ctors necess ry to form clo
t b. Products
produced s clot dissolves c. Pl telet count d. Clotting time 3. A subst nce t
h t is viscous
m y lso Outcome 15-1 be described s: . Runny b. Thin c. Syrupy d. Dry 4. Fibr
inolysis is n
import nt p rt of Outcome 15-3 hemost sis bec use: . Fibrinolysis helps to cont
rol the number of
unw nted blood clots in the body b. Fibrinolysis is the first step in co gul tio
n c. Fibrinolysis

helps to keep the blood viscous d. None of the bove 5. True or F lse: A di gnos
is of tri l
Outcome 15-5 fibrill tion incre ses the risk of unw nted blood clot form tion. 6
. True or F lse:
Postsurgic l prophyl ctic Outcome 15-5 tre tment is provided only to p tients wi
th hemophili . 7.
Pl telet counts m y be ordered s p rt Outcome 15-8 of
co gul tion workup bec
use: . Adequ te
numbers of pl telets re necess ry for hemost sis b. Pl telets pl y very impor
t nt role in the
rep ir process for d m ged vessels c. Extremely high numbers of pl telets c n co
n- tribute to
excessive clot form tion d. All of the bove 8. Wh t re two potenti l sources o
f Outcome 15-7
error for the CLIA-w ived PT/INR test procedure? 9. How re D-dimers nd fibrin
Outcome 15-12
degr d tion products simil r? 328 Section III Hem tology nd Co gul tion C se S
tudy 15-1:
Presurgic l puzzle Mr. H mmond will be h ving
tot l hip repl cement next week.
His physici n
orders
co gul tion screen, including PT, PTT, pl telet count, fibrinogen lev
el, nd
bleeding time. All results re within the norm l r nge except for the bleeding t
ime, which t 12
minutes is elev ted slightly. 1. Wh t m y be n expl n tion for this situ tion?
C se Study 15-2:
Rel tive v lues? Cindy Lou is new medic l ssist nt who h s just st rted to wo
rk in the
l bor tory. She h s experience high volume of p tients this morning, nd she f
eels bit
overwhelmed. L ter in the d y, the physici n office re- ceives c ll from the l
bor tory with
bnorm l PT nd PTT results for one of the p tients th t Cindy drew th t morning
. The results for
both tests re elev ted, but the p tient h s no signs of excessive bruising or b
leeding. These
tests were ordered s screen prior to n elec- tive surgery th t the p tient w
s to h ve done
next week. The physici n sks Cindy to cont ct the l bor tory nd see if the res
ults for the
pl telet count re v il ble. Cindy t lks to the technici n performing the hem t
ol- ogy testing,
nd she is told th t the specimen for the pl telet count needs to be redr wn bec
use it w s
clotted. 1. How do you think the specimen condition for the pl telet count nd t
he other tube
used for the PT/PTT testing might be rel ted? 2. How does this situ tion with th
e clotted tube
rel te to the elev ted results for the PT nd PTT? 1899_Ch15_313-331 21/12/11 4:
29 PM P ge 328
Ch pter 15 Co gul tion Studies 329 RESOURCES AND SUGGESTED READINGS Atri l Fibr
ill tion nd
W rf rin Excellent expl n tion of the risks involved with tri l fibril- l tion
s rel ted to
blood clots, nd the use of w rf rin for tre tment http://www.p tient.co.uk/show
doc/23068883
D-dimers nd Fibrin Degr d tion Products Inform tion bout co gul tion studies per
formed t
M ss - chusetts Gener l Hospit l; gre t inform tion bout the differ- ences betw
een FDP nd

D-dimers http://www2.m ssgener l. org/p thology/co gbook/CO002700.htm Dissemin te

d Intr v scul r
Co gul tion (DIC); Consumption Co gulop thy; Defibrin tion Syndrome Det ils bout
dissemin ted
intr v scul r co gul tion dise se. http://www.merck.com/mmpe/sec11/ch136/ch136c.
html Hemophili ,
F ctor VIII Deficiency F cts bout bleeding nd clotting disorders http://www.
hemophili .org/NHFWeb/M inPgs/M inNHF. spx? menuid=179&contentid=45&rptn me=blee
ding, W rf rin
nd Chinese Medicine Det ils bout the development of w rf rin, plus lots of info
r- m tion
rel ted to herbs nd Chinese medic tions th t ffect bleeding tendencies.
http://www.itmonline.org/ rts/ w rf rin.htm ITC, The Point of C re, Surgicutt Ble
eding Time
Device Det iled inform tion bout the Surgicutt device nd proce- dure for bleedi
ng time
testing. http://www.itcmed.com/ Products/Surgicutt 1899_Ch15_313-331 21/12/11 4:
29 PM P ge 329
1899_Ch15_313-331 21/12/11 4:29 PM P ge 330 331 Section III Hem tology nd Co gu
l tion Wh t Does
It All Me n? As you c n see, hem tology nd co gul tion testing provides inv lu
ble inform tion
to physici ns nd other prim ry he lth-c re providers. Now, let us re- visit our
C se in Point
for this section nd see wh t it ll me ns. C se in Point At the beginning of th
is section we met
M.J., 38-ye r- old m le p tient who w s worked into the doctors schedule bec us
e he felt tired
nd we k nd experi- enced bleeding gums fter brushing his teeth. P tient histo
ry reve led th t
M.J. received blood tr nsfusion following tr ctor ccident sever l weeks pri
or to this
ppointment. Upon your encounter with M.J., you noted th t he seemed very p le.
The doctor
ordered CBC, PT, nd PTT to help ssess the situ tion. Upon ex min tion of the
results obt ined
(loc ted on p ge 258), no wonder M.J. felt so poorly. M.J. is suffering from
c
ondition known s
dis- semin ted intr v scul r co gul tion (DIC). Dissemi- n ted, in this c se, me
ns widespre d
over the body. Intr v scul r refers to t king pl ce within blood vessels, nd co
gul tion me ns
the clotting of blood. Under norm l conditions, the hum n body h s built-in mech n
isms to clot
blood when injury occurs nd to dissolve clots when ppropri te. This b l nce be
tween clotting
nd bleeding is known s hemost sis. However, when the clotting nd bleed- ing b
l nce is
disrupted, individu ls experience b- norm l bleeding, s noted when M.J. bled w
hile brushing his
teeth, nd clotting. This imb l nce c n c use serious injury to the org ns of th
e body. Individu ls become nemic, s evidenced by M.J.s compl ints of being tired nd we k
, s well s
the observ tion of the p tient being p le. This nemi results bec use of the in
credible loss of
blood, which in turn results in n in bility of red blood cells to tr nsport oxy
gen to the
tissues. If the condition is left untre ted, de th m y result. Fortun tely, in M
.J.s c se, he

recognized the bnorm l situ tion t king pl ce in his body nd sought help. Alth
ough l bor tory
results re import nt in con- firming the di gnosis nd monitoring of DIC, physi
- ci ns often
m ke the initi l di gnosis b sed prim - rily on clinic l symptoms. Unfortun tely
there is no
single l bor tory test th t is di gnostic for DIC;
b ttery of tests must be pe
rformed nd the
results ex- mined in concert with e ch other r ther th n inde- pendently. In d
dition to the
tests presented in this c se study there re ddition l l bor tory tests th t m
y be performed to
provide more inform tion bout the clinic l situ tion when DIC is suspected. A f
urther discussion
of these ddition l tests is beyond the scope of this text. 1899_Ch15_313-331 21
/12/11 4:29 PM
P ge 331 332 On the Horizon A wide v riety of subst nces, often referred to s
n lytes, m ke up
the test menu v il ble in the chemistry section of the clinic l l bor tory. Lik
ewise, the test
methodologies th t m y be used to determine these n lytes re m ny. Some tests
re performed on
complex instruments, where s others re con- ducted using rel tively simple-to-o
per te equipment.
The results obt ined from such tests provide he lth- c re te m members with
we
lth of knowledge
in the di gnosis nd monitoring of numerous dise ses nd conditions. Relev nce f
or the Medic l
Assist nt Medic l ssist nts (MAs) typic lly ssume one or both of these roles
ssoci ted with
chemistry l bor tory tests: (1) specimen collection nd processing nd (2) perfo
rm nce of select
chemistry tests. In ddition to performing CLIA-w ived tests, MAs m y lso perfo
rm
moder te-complexity tests with ppropri te tr ining. Further, MAs m y lso revie
w p tient ch rts
while performing their other duties nd in the process m y ex mine l bor tory re
sults (from this
re s well s ll re s of the l bor tory). F mili rity of common l bor tory t
ests nd their
signific nce llows MAs to t ke the inform tion obt ined from such reviews into
ccount s they
work with their p tients. C se in Point You re working t he lth f ir being c
onducted t Acme
Innov tions, Inc. P rt of the he lth f ir consists of collecting blood for f s
ting blood
glucose level. The following result w s obt ined on C rrie W., 34-ye r-old fem
le Acme
employee: Questions for Consider tion: Wh t does the word f sting refer to in th
is c se? Wh t
is the purpose of the f sting blood glucose test? Wh t l bor tory test could be
ordered to help
ssess this p tient nd to monitor C rries condition? Suppose th t C rrie is preg
n nt nd her
doctor wishes to ssess her for gest tion l di betes. Wh t l bor - tory test cou
ld be ordered in
this situ tion? P tient Reference Test Result R nge F sting blood 215 mg/dL 70100
mg/dL glucose
1899_Ch16_332-348 21/12/11 5:05 PM P ge 332 333 Section IV Clinic l Chemistry On
the Horizon The

content in this section is limited to three ch pters nd serves s n overview o

f the chemistry
section of the clinic l l bor tory: Ch pter 16: Overview of Clinic l Chemistry i
ntroduces the
re der to the scope of the chemistry section of the clinic l l bor tory, includi
ng the
identific tion nd brief description of specimens upon which this testing is per
formed. A brief
overview of some of the more common individu l chemic l n lytes, including gluc
ose nd
cholesterol s well s groups of tests known s profiles, re covered. Ch pter 1
7: Glucose
Testing covers the physiology nd p thophysiology ssoci ted with blood glucose.
The v rious
glucose tests v il ble, including venous blood s mples, hemoglobin A1c, glucose
toler nce tests,
nd c pill ry puncture glucose testing, re described. Suggested procedures nd
qu lity control
consider tions re lso covered. Ch pter 18: Other Select Chemistry Tests covers
the physiology
nd p thophysiol- ogy ssoci ted with the following represent tive chemistry tes
ts: cholesterol,
lipids, nd electrolytes. Proper collection nd testing technique, reference r n
ges, qu lity
control issues, sources of error, nd test interpret tion re included. 1899_Ch1
6_332-348
21/12/11 5:05 PM P ge 333 1899_Ch16_332-348 21/12/11 5:05 PM P ge 334 335 Ch pte
r 16 Overview of
Clinic l Chemistry Const nce L. Lieseke, CMA (AAMA), MLT, PBT(ASCP) CHAPTER OUTL
INE Clinic l
Chemistry Specimen Types Used for Clinic l Chemistry An lysis Pl sm Serum Other
Specimen Types
Used for Clinic l Chemistry Testing CLIAW ived Clinic l Chemistry Tests Glucose T
esting
Cholesterol nd Lipid Testing Cholesterol Triglycerides Lipid P nels Electrolyte
s Other Common
Clinic l Chemistry Tests Blood Ure Nitrogen Cre tinine Thyroid P nels Comprehen
sive Met bolic
P nel nd B sic Met bolic P nel C rdi c Enzymes Hep tic or Liver Profile Referen
ce R nges
Potenti l Sources of Error Summ ry Time to Review C se Study Resources nd Sugge
sted Re dings
Le rning Outcomes After re ding this ch pter, the successful student will be bl
e to: 16-1 Define
the key terms. 16-2 Rel te how serum differs from pl sm . 16-3 Describe common s
ubst nces
dissolved in pl sm . 16-4 Ex mine the re sons th t glucose testing is performed
in the physici n
office l bor tory. 16-5 Cite the tests included in lipid p nel. 16-6 List comm
on n lytes
included in n electrolyte p nel. 16-7 Differenti te which org n system is ev lu
ted using
blood ure nitrogen test nd cre tinine test. 16-8 Ev lu te the purpose of order
ing tests in
p nel form t r ther th n individu lly. 16-9 Describe the tests commonly ordered
s c rdi c
enzymes. 16-10 Expl in the r tion le for seri l c rdi c enzyme blood specimen co
llections. 16-11
Rest te the liver profile tests most commonly ordered by physici ns. 16-12 Outli
ne the p r meters

th t must be t ken into ccount when considering reference r nges for clinic l c
hemistry tests.
16-13 Ex mine potenti l sources of error for chemistry testing procedures. 1899_
Ch16_332-348
21/12/11 5:05 PM P ge 335 CLINICAL CHEMISTRY When scientists first beg n to stud
y the hum n body,
their focus w s on n tomy. Science w s not ble to n lyze wh t could not be se
en with the n ked
eye, so much of the physiology (or function) of the body w s unknown. M ny hypot
heses were
formed, but it took very long time before they could be proved or disproved. I
t w s obvious
th t the hum n body functioned best when in st te of homeost sis (intern l b l
nce), nd the
scientists could recognize some of the more visible me ns by which this b l nce
w s chieved. It
w s e sy to see how the iris in the eye constricted when exposed to 336 Section
IV Clinic l
Chemistry CAAHEP/ABHES STANDARDS CAAHEP St nd rds None ABHES St nd rds None KEY
TERMS An lytes
Atherosclerosis B sic met bolic p nel (BMP) Blood ure nitrogen (BUN) Br in n tr
iuretic peptide
(BNP) Cholesterol Clinic l chemistry Comprehensive met bolic p nel (CMP) Cre tin
e kin se (CK)
Cre tinine Di betes mellitus Electrolytes Endogenous cholesterol Exogenous chole
sterol
Gest tion l di betes Glycosyl ted hemoglobin (Hb A1c) High-density lipoprotein (
HDL) Hemolysis
Hep tic function p nel Homeost sis Hyperlipidemi Hyperthyroidism Hypothyroidism
Icteric Ischemi
J undice Lipemi Lipid Lipoproteins Low-density lipoprotein (LDL) Lytes Myoc rdi
l inf rction
Myoglobin Occlude Physiology Pl que Pl sm Qu lity not sufficient (QNS) specimen
Qu lit tive
Qu ntit tive Seri lly Serum Thyroid-stimul ting hormone (TSH) Thyroxine (T4) Tri
iodothyronine
(T3) Troponin Very low-density lipoprotein (VLDL) bright light or when perspir t
ion w s formed on
the forehe d in hot we ther. However, m ny of the sm ll ch nges within the hum n
body were not so
obvious; they re b sed on djustments to the levels of chemic ls needed to keep
our body
functioning ppropri tely. It w s not until the 19th century th t scientists beg
n to re lize how
closely the ppropri te b l nce of these chemic ls in the body w s linked to ove
r ll he lth.
Clinic l chemistry includes the qu ntit tive n lysis of the v rious n lytes (s
ubst nces being
n lyzed; in this c se, chemic ls) dissolved in the fluids of our bodies. Qu nti
t tive tests
provide n ctu l number th t repre- sents the mount of
subst nce present in
the body.
1899_Ch16_332-348 21/12/11 5:05 PM P ge 336 Qu lit tive testing, which indic tes
the presence or
bsence of specific chemic ls, m y lso be performed in the clinic l chemistry d
ep rtment in the
l bor tory. Chemic l elements re present in our bodies t ll times, but incre
ses or decre ses
in the levels of cert in n lytes m y be indic tive of dise se process. Clinic
l chemistry

testing llows the he lth-c re provider to ev lu te these ch nges nd use them t

o di gnose nd
prescribe tre t- ment. Procedures used to monitor drug levels for some prescript
ion drugs or to
identify subst nces th t m y be present in the body in the c se of environment l
or drug
poisoning re lso performed in the clinic l chemistry re of the l bor tory. C
h pter 16
Overview of Clinic l Chemistry 337 Test Your Knowledge 16-1 How re qu lit tive
tests different
from qu ntit tive tests? (Outcome 16-1) Reference l bor tories m y offer hundred
s of clinic l
chemistry tests on v rious types of specimens. Although ll these tests re clin
ic lly
signific nt, m ny of them re only used in the presence of specific dise se st t
es. In this
ch pter, we concentr te on the most commonly performed clinic l chemistry tests
using blood,
urine, nd stool specimens. SPECIMEN TYPES USED FOR CLINICAL CHEMISTRY ANALYSIS
Common specimens
in clinic l chemistry testing include urine, serum, nd pl sm . M ny other fluid
specimens,
including cerebrospin l fluid, synovi l fluid t ken from the joints of the body,
semen, mniotic
fluid, nd peri- tone l fluid from the bdomin l c vity, re n lyzed for qu nti
t tive chemistry.
Occ sion lly chemistry testing m y be performed using whole blood. This is usu l
ly done in
physici n office l bor tories using CLIA-w ived testing methods. In l rger l bor
tories, most
clinic l chemistry testing is performed on pl sm or serum spec- imens sep r ted
from the s mple
fter centrifug tion. Serum is obt ined from clotted blood nd pl sm comes from
whole blood.
Pl sm As presented in Ch pter 8, pl sm is the liquid portion of the blood in o
ur body in which
the blood cells re suspended. This liquid m kes up more th n 50% of the tot l b
lood volume. We
lso use the word pl sm to describe the liquid portion of the blood when collec
ted in
tube
cont ining ntico gul nt. Pl sm is m de up of t le st 90% w ter, in which ther
e re m ny
dissolved subst nces nd g ses. There re too m ny chemic l compounds present in
pl sm to list
them ll sep r tely, but gener l c tegories include the following: Pl sm protei
ns: Pl sm
proteins re l rge mole- cules th t re not excreted s w ste products nd which
re designed to
rem in in the blood. These include ntibodies (immunoglobulins), s well s bloo
d-clotting
proteins (fibrinogen nd prothrombin) nd lbumin. Medic tions: If n individu l
must t ke
medic tion, it is tr nsported throughout the body in the pl sm . Electrolytes: E
lectrolytes re
compounds th t h ve positive or neg tive ch rge when dissolved in w ter, nd
re c p ble of
tr nsmitting n electric l impulse within the body. Hormones: Endocrine gl nds t
hroughout the
body secrete hormones directly into the bloodstre m. Hormone tests re commonly
ordered to verify

the function of the v rious endocrine gl nds, such s the pituit ry gl nd nd th

yroid gl nd.
Lipids: F t molecules such s cholesterol re tr ns- ported through the bloodstr
e m. Enzymes:
Protein-b sed molecules th t c t lyze (speed up) chemic l re ctions re known s
enzymes. Food:
When digestion is complete, the food we e t h s been broken into components th t
c n be e sily
used by our body for energy or building blocks for other molecules. These bre kd
own products re
b- sorbed into our bloodstre m nd dissolve in the pl sm for tr nsport tion. F
tty cids,
proteins, nd simple sug rs re c rried s food in the pl sm . In d- dition, es
senti l tr ce
elements such s miner ls nd vit mins re lso present. Dissolved g ses: CO 2 i
s present in
pl sm s by-product of met bolism. Other dissolved g ses include oxygen (even
though it is
tt ched to the red blood cells) nd nitrogen. W ste: Cell met bolism cre tes w
ste products
th t re processed in the liver nd removed from the body through the urin ry sy
stem. Serum Serum
is the liquid portion of blood th t h s been col- lected into tube th t does n
ot cont in
ntico gul nt. Pl sm nd serum re very simil r; however, when
specimen is dr
wn in tube
without n ntico gul nt, 1899_Ch16_332-348 21/12/11 5:05 PM P ge 337 Other Spec
imen Types Used
for Clinic l Chemistry Testing As mentioned previously in this ch pter, clinic l
chem- istry
testing m y be performed on numerous specimen types. In the physici n office l b
or tory, whole
blood m y be used for CLIA-w ived procedures such s glucose or cholesterol test
ing, providing
qu ntit tive result. Urine chemic l testing is performed s p rt of routine r
ndom urin lysis
with semiqu ntit tive results reported th t indic te
r nge for the n lyte v l
ues. In some
dise se st tes, it is necess ry to obt in results th t re more specific, with
specific number
reported for the chemic l concen- tr tion r ther th n
r nge. This type of qu n
tit tive urine
chemistry testing is performed t reference or l rge hospi- t l l bor tories, bu
t not in
physici n office l bor tories. These qu ntit tive urine tests m y be used to scr
een for kidney
d m ge c used by di betes, hypertension, or other dise se processes. Urine m y
lso be n lyzed
to rese rch the c use of ren l c lculi (kidney stone) form tion. Common qu ntit
tive tests
performed on urine specimens include micro lbumin, tot l protein, nd cre tinine
. A timed urine
specimen (such s 24-hour urine specimen) is gener lly used for these tests. F
or ll clinic l
chemistry testing, it is import nt to keep in mind th t reference r nges re b s
ed on cert in
specimen types. For inst nce, serum nd pl sm look identic l once the liquid h
s been removed
from the blood specimen, but the reference r nges for some chemic ls re very di
fferent in the

two specimen types. It is essenti l to collect the correct type of tube for the
n lysis when
performing
blood collection, nd lso to l bel the specimen type if the liquid
is removed from
the origin l collection cont iner to void ny potenti l prob- lems. Other types
of specimens m y
h ve simil r p- pe r nce if they re tr nsported in n unl beled specimen con
t iner. 338
Section IV Clinic l Chemistry CLIAWAIVED CLINICAL CHEMISTRY TESTS Glucose Testin
g The most
common type of CLIA-w ived clinic l chem- istry test performed in the clinic set
ting is glucose
testing. This test m y be used to screen for di betes mellitus (type 2 di betes)
or to monitor
the glucose levels of p tients who h ve lre dy been di gnosed nd re under tre
tment.
Gest tion l di betes in pregn nt women m y lso be di gnosed with tests performe
d in the
physici n office l bor tory. It is benefici l to the p tient to h ve these tests
performed on
site, s the results re v il ble within minutes. Abnorm l glucose levels m y b
e reported to the
he lth-c re provider immedi tely, llowing for ddition l tests to be ordered or
for further
p tient inter- ction to be initi ted if necess ry. CLIA-w ived glucose testing
methods use whole
blood specimens, usu lly obt ined from c pill ry puncture. The glucose levels
m y be ordered s
f sting, r ndom, or timed specimens. Test Your Knowledge 16-2 Which of these re
present from
centrifuged tube con- t ining no ntico gul nt? . Serum b. Pl sm c. Whole bloo
d d. None of the
bove (Outcome 16-2) the proteins nd other blood clotting f ctors re utilized
s the blood clot
forms. The l ck of co gul tion f ctors dissolved in the liquid limits some of th
e tests th t m y
be performed on serum specimen. Test Your Knowledge 16-3 List two re sons th t
glucose testing
might be performed in
physici n office l bor tory. (Outcome 16-4) Di betic p t
ients m y lso be
monitored with glyco- syl ted hemoglobin, or Hb A1c, test. Hemoglobin is prese
nt in ll the red
blood cells of the body, nd one subunit of this hemoglobin molecule is hemoglob
in A. When
hemoglobin A is exposed to excessive levels of glucose, it becomes glycosyl ted,
which me ns th t
the glucose molecules bind to the hemoglobin A irreversibly. The Hb A1c test c n
me sure the
mount of glycosyl ted hemoglobin present, nd bec use red blood cells live for
pproxim tely 3
months in the body, Hb A1c results m y be used indirectly s n indic tion of th
e over ll blood
sug r levels for the p st few months. Hb A1c m y be performed s CLIA-w ived t
est in the
physici n office l bor tory or utom ted testing m y be performed in reference
l bor tory.
Whole blood is used for this n ly- sis; c pill ry s mples re used for the CLIA
-w ived methods, nd n EDTA l vender top tube is used for the reference l bor tory methods.
Cholesterol nd

Lipid Testing Lipids re subst nces including oils nd f ts th t re insoluble i

n w ter nd
soluble in org nic solvents. Cholesterol is n ex mple of lipid, but there re
other types of
f ts in our bodies s well. Our digestive system bre ks down ingested f ts into
f tty cids,
which re 1899_Ch16_332-348 21/12/11 5:05 PM P ge 338 tr nsported through the bl
oodstre m to the
liver, where they re used to m nuf cture lipids. Bec use lipids do not dissolve
in w ter, the
body tt ches lipids to pro- tein molecule for tr nsport to the cells of the b
ody to be used.
These complexes re c lled lipoproteins. Lipids re used s n ltern tive sourc
e of energy when
glucose is not re dily v il ble, nd they re lso necess ry for hormone produc
tion, cell w ll
integrity, utiliz tion of f t-soluble vit mins, hunger s ti tion, m inten nce of
ppropri te body
temper ture, nd skin he lth. In the l bor tory, the two types of lipids most co
m- monly n lyzed
re cholesterol nd triglycerides. Tot l blood cholesterol nd tot l triglycerid
e counts provide
v lu ble inform tion to he lth-c re providers bout c rdio- v scul r he lth nd
potenti l risk
f ctors for the future. However, more inform tion c n be g ined by bre king down
the rel tive
mounts of lipids ccording to subtype. These c tegories re HDL (high-density l
ipoproteins), LDL
(low-density lipoproteins), nd VLDL (very low-density lipoproteins). Elev ted t
ot l cholesterol,
triglyceride, nd LDL levels m y re considered to be risk f ctors for coron ry
he rt dise se.
Ch pter 18 provides more in-depth inform tion bout lipid testing. Ch pter 16 O
verview of
Clinic l Chemistry 339 Test Your Knowledge 16-4 Which of these tests is included
in lipid
p nel? . LDH b. LDL c. VLDL d. ALT (Outcome 16-5) Cholesterol Cholesterol is es
senti l for the
hum n body to function properly. Cholesterol is used for hormone production, bs
orption of
vit min D, bile production, nd cellul r membr ne structure, nd is lso used s
p rt of the
covering (the myelin she th) on some of the nerves in the body. The liver cre te
s ll the
cholesterol th t we need to function norm lly. This is c lled endogenous cholesterol bec use it
is m nuf ctured within the body. Exoge- nous cholesterol comes from our diets. W
hen choles- terol
builds up in the body it c n le d to pl que form tion within the blood vessels,
condition known
s therosclerosis. Pl que buildup m y eventu lly occlude (block) blood vessels,
or pieces of
pl que m y bre k w y from the vessel lining nd tr vel s n embolus, lodging e
lsewhere in the
body nd c using blood clot. Cholesterol levels ordered individu lly do not re
quire f sting
s mples. However, cholesterol levels re often ordered s p rt of
lipid p nel
with the
triglyceride, HDL, LDL, nd VLDL levels. These ddition l tests do require f s
ting s mple, so

p tients should be dvised to bst in from e ting for 12 hours prior to the bloo
d dr w.
Triglycerides P tients who h ve diet th t is high in c rbohydr tes m y h ve el
ev ted
triglyceride levels. Most of the f t in our bodies is m de up of triglycerides.
When person
t kes in more c lories th n re needed for energy, the excess c lories re conve
rted into
triglycerides nd stored s f t for use l ter s n energy source. Those who h v
e di betes,
hypertension, or excess lcohol int ke re especi lly prone to high triglyceride
levels.
Hyperlipi- demi is the word used to describe high levels of lipids (cholesterol
nd
triglycerides) in the pl sm . P tients who h ve elev ted triglyceride levels m y
h ve pl sm or
serum th t ppe rs milky bec use of ll the f t molecules present. The presence of
the f t
molecules suspended in the blood is c lled lipemi . Bec use triglyceride levels
do rise fter
ingestion of food, triglyc- eride testing usu lly requires f sting blood dr w.
Lipid P nels A
lipid p nel commonly includes tot l cholesterol level, triglyceride level, H
DL, LDL, VLDL,
nd tot l cholesterol : HDL r tio. These v lues will provide the he lth-c re p
rovider with
v lu ble inform tion concern- ing the risk f ctors for coron ry rtery dise se.
POINT OF INTEREST
16-1 Cholesterol testing Cholesterol testing is performed to ssist the he lthc re provider in
ev lu ting the p tient for potenti l he rt dise se. The tot l cholesterol level
consists of
high-density lipoproteins (HDL) nd low-density lipoproteins (LDL). The HDL is c
onsidered to be
good cholesterol bec use it ctu lly cle ns excess cholesterol from the blood vess
els in the
body nd c r- ries it w y in the bloodstre m. Ide lly, the p tient will h ve
higher
concentr tion of HDL in the blood- stre m th n LDL. Elev ted levels of LDL m y l
e d to he rt
dise se, s the low-density lipoproteins will deposit cholesterol on the w lls o
f the blood
vessels. There is
direct correl tion of elev ted cholesterol results nd/or n
imb l nce of HDL
nd LDL results nd therosclerosis. The following individu ls re t higher ris
k th n others:
Smokers Those di gnosed with di betes mellitus Continued 1899_Ch16_332-348 21/12
/11 5:05 PM
P ge 339 OTHER COMMON CLINICAL CHEMISTRY TESTS So f r, we h ve focused on clinic
l chemistry
tests th t m y be performed in the physici n office l bor tory s well s refere
nce l bor tories.
In this section of the ch pter, we focus on some of the most commonly ordered cl
inic l chemistry
tests th t re not usu lly performed in the physici n office l bor tory. These t
ests would ll be
performed on serum or pl sm in hospit l or reference l bor tory. M ny of thes
e com- monly
performed tests re ordered s profiles or p nels r ther th n individu l tests.
The p nels re

benefici l to the he lth-c re provider bec use the tests included in p nel m y
ev lu te v rious
spects of specific org n system; in the c se of the b sic met bolic p nel (BM
P) nd
comprehensive met bolic p nel (CMP), they ev lu te p r meters of sever l org n s
ystems. Obt ining ll the results t once c n llow for differen- ti l di gnosis, nd l
so m y s ve the
p tient time nd money by not h ving to return to the l bor tory for sep r te bl
ood dr ws.
Ch rges for the tests included in Medic re- pproved p nel m y not leg lly surp
ss the costs of
ordering the tests individu lly, so it is cost effective to perform multiple tes
ts t one time.
340 Section IV Clinic l Chemistry P tients with hypertension Men over 45 nd wo
men over 55
F mily history of he rt dise se Obesity L bor tory tests usu lly pl ce the p tie
nt in one of
three c tegories: High risk: H ving tot l cholesterol level of 240 mg/dL or b
ove Borderline
high: H ving cholesterol result of 200 to 239 mg/dL. Often the he lth-c re pro
vider will order
ddition l testing to see if the elev ted level is the result of the presence of
the LDL (b d
choles- terol) or HDL (good cholesterol). Desir ble or norm l: H ving
tot l ch
olesterol level
less th n 200 mg/dL is considered norm l, nd pl ces the p tient t low risk o
f he rt dise se.
Triglyceride testing is often performed with the cholesterol ss y in the l bor
tory s p rt of
lipid p nel. Triglycerides re
form of f t, nd re often c rried by nother l
ipoprotein, very
low-density lipoprotein (VLDL). Elev ted levels of triglycerides in the bloodstr
e m m y lso le d
to he rt dise se. Poor diet nd low levels of exercise m y le d to ele- v ted tr
iglyceride
levels. Electrolytes Routine blood screening often includes n order for electro
lytes.
Electrolytes (often bbrevi ted s lytes) include sever l miner ls th t re esse
nti l for norm l
body function. They c rry n electric l ch rge (positive or neg tive ch rge) whe
n dissolved in
w ter. Sodium, pot ssium, chloride, nd CO 2 re usu lly included in n electrol
yte ss y.
Addition l tests m y lso be included by some l bor tories, such those for s m
gne- sium nd
c lcium. Electrolyte ss ys m y provide inform tion to the he lth-c re provider
bout the cidb se b l nce of the body, c uses for edem , or ddition l inform tion bout the
st tus of kidney
dysfunction. Electrolyte levels m y lso be ltered by cert in drugs, dehydr tio
n, nd
overhydr tion. The tests within the electrolyte p nel m y be ordered individu ll
y, or s group.
CLIA-w ived utom ted procedures re v il ble for electrolyte testing, but thes
e tests m y lso
be per- formed t hospit l l bor tories nd reference l bor to- ries. More infor
m tion is
v il ble bout the specific testing methods for electrolytes nd the clinic l s
ignifi- c nce of

the n lytes in Ch pter 18. Test Your Knowledge 16-5 Which of these n lytes is
not included in
n electrolyte p nel? . Sodium b. Pot ssium c. Chloride d. C dmium (Outcome 166) Test Your
Knowledge 16-6 List two dv nt ges of ordering tests s
p nel r ther th n indi
vidu lly.
(Outcome 16-8) Blood Ure Nitrogen As protein is broken down by the body, it pro
duces ure s
by-product. Nitrogen is p rt of this ure molecule. Ure should be cle red from
the blood by the
kidneys, so if the level blood ure nitrogen is elev ted, it m y be n indic tio
n th t the
p tient h s imp ired ren l function. Blood ure nitrogen (BUN) is me surement
of the mount of
ure in the bloodstre m. This test is often ordered in conjunction with cre ti
nine test.
1899_Ch16_332-348 21/12/11 5:05 PM P ge 340 Cre tinine Cre tinine is by-produc
t of muscle
met bolism. As in the c se with the blood ure nitrogen, cre tinine should be cl
e red from the
blood by the kidneys. Elev ted cre tinine levels m y indic te imp ired kidney fu
nction.
Cre tinine levels m y be performed on urine s mples to correl te the levels with
those obt ined
from testing the serum or pl sm . This provides more in-depth inform - tion bou
t potenti l
kidney dysfunction. ch nges in dise se process. The tests included in this p n
el re BUN,
cre tinine, sodium, pot ssium, chlo- ride, c rbon dioxide, c lcium, lbumin, tot
l protein,
bilirubin, lk line phosph t se (often bbrevi ted s ALP), l nine minotr nsfe
r se ( lso c lled
SGPT or ALT), sp rt te minotr nsfer se (which m y lso be known s SGOT or AST
), nd glucose.
The CMP is p nel th t h s been pproved for p yment by the Center for Medic re
& Medic id
Services (CMS), so it is ccept ble for it to be ordered s di gnostic test fo
r p tients with
Medic re cover ge. The BMP includes eight tests th t will help to iden- tify pro
blems with
electrolytes, kidney function, glucose met bolism, nd cid-b se b l nce. The b
sic met bolic
p nel m y be used s di gnostic tool, or used to mon- itor medic tion use or p
tient progress
with ongoing tre tment. The BMP includes glucose, c lcium, sodium, pot ssium, c
rbon dioxide,
BUN, nd cre tinine levels. The BMP h s lso been pproved for p yment s p ne
l by the CMS, so
p tients who h ve Medic re s their pri- m ry insur nce m y h ve this test order
ed knowing th t
its cost is reimburs ble. C rdi c Enzymes C rdi c enzymes re ordered in situ ti
ons in which the
he lth-c re provider suspects d m ge to the he rt, s in the c se of ischemi (
tempor ry
decre se of blood flow to the he rt muscle) or in the c se of tr um to the he r
t muscle from
myoc rdi l inf rction (he rt tt ck). The profile usu lly includes
tot l cre t
ine kin se (CK)
nd CK-MB, in ddition to other tests such s troponin or myoglobin. Cre tine
kin se is found

in muscles other th n the he rt muscle; therefore, if the tot l CK level is elev

ted, ddition l
testing must be performed to iden- tify the source of the bnorm l result. CK is
oenzymes re
subtypes of the cre tine kin se n lyte. The CK-MB (cre tine kin se myoc rdi l b
nd) isoenzyme is
specific m rker for he rt muscle d m ge. The CK-MB levels will st rt to rise i
n the bloodstre m
pproxim tely 4 hours f- ter
myoc rdi l inf rction, nd will pe k pproxim te
ly 18 hours fter
the event. Troponin levels will be elev ted with he rt muscle d m ge, but not wi
th other types of
muscle tr um . Troponin I levels re especi lly sensitive to myoc rdi l d m ge.
Troponin testing
m y be per- formed on STAT b sis when
myoc rdi l inf rction is suspected bec
use these levels
become elev ted sooner nd rem in elev ted longer th n the CK-MB fter he rt
tt ck. This
llows for e rlier di gnosis nd ppro- pri te tre tment. It is recommended th t
the troponin
levels re tested every 2 to 4 hours for the first 24 hours fter c rdi c even
t. Myoglobin m y
lso be used s n Ch pter 16 Overview of Clinic l Chemistry 341 Test Your Know
ledge 16-7 True
or F lse: BUN nd cre tinine tests re routinely ordered to ev lu te kidney func
tion. (Outcome
16-7) Thyroid P nels The thyroid gl nd secretes sever l very import nt hor- mone
s directly into
the bloodstre m. These hormones, thyroxine (T4) nd triiodothyronine (T3) re es
senti l for
regul tion of cellul r met bolism. The thyroid gl nd lso secretes thyroc lciton
in, which helps
to stimul te c lcium stor ge in the bones of the body. M ny l bor - tories offer
thyroid p nels
th t include the T3 nd T4. Another hormone th t ffects thyroid function is the
TSH(thyroid-stimul ting hormone), which is secreted by the pituit ry gl nd. Thyr
oid-stimul ting
hormone is necess ry for the thyroid to be stimul ted to produce the T3 nd T4. Fo
r the thyroid
gl nd to function nor- m lly, there must be source of iodine in the diet. Iodi
ne c n be
ingested with iodized s lt, se food, or veget bles th t were grown in soil with
supplement ry
iodine. Hypothyroidism is condition in which the thyroid gl nd does not produc
e enough of the
hormones neces- s ry to stimul te cell met bolism t norm l level. P tients m
y lso suffer
from hyperthyroidism, in which c se the thyroid gl nd is producing hormones t
level th t is
bove norm l, resulting in overstimul tion of cell met bolism. TSH levels outsid
e of the norm l
r nge m y c use under- or overstimul tion of the thyroid gl nd, resulting in n
imb l nce; for
this re son, the TSH m y lso be included in some thyroid p nels. Comprehensive
Met bolic P nel
nd B sic Met bolic P nel The CMP is
set of 14 tests th t screen for problems
with the kidneys,
glucose met bolism, liver, nd cid- b se b l nce of the body. The CMP m y be us
ed s gener l
screening test during routine office visit, or the p nel m y be ordered to mon

itor medic tion

use or 1899_Ch16_332-348 21/12/11 5:05 PM P ge 341 indic tor for myoc rdi l in
f rction, bec use
it will be elev ted in the bloodstre m sooner fter
c rdi c event th n troponi
n will be.
Myoglobin is found in c rdi c nd skelet l muscles, so the levels m y be elev te
d in the
bloodstre m in situ tions other th n myoc rdi l inf rc- tion bec use it is not s
pecific to the
he rt muscle. When p tient h s chest p in nd
myoc rdi l inf rction is suspe
cted, the c rdi c
enzymes re ordered seri lly, bec use the levels of the v rious components will
ch nge with time
if there w s d m ge to the he rt muscle. Specimens re usu lly collected every f
ew hours, nd the
he lth-c re provider looks for p ttern in the elev tion of the different compo
nents to rule out
or differenti lly di gnose d m ge to the he rt muscle s result of
he rt tt
ck. If the
specimens re not dr wn sever l times within the first 24 hours, it is not possi
ble to est blish
whether he rt tt ck re lly occurred. The myoglobin is usu lly the first test
to be elev ted,
but most he lth-c re providers like to h ve more inform - tion before proceeding
with
differenti l di gnosis. It is import nt to remember th t other di gnostic proced
ures (such s n
electroc rdiogr m) will lso ssist with the di gnosis s well. Another common c
rdi c n lysis
is the br in n tri- uretic peptide (BNP) test. BNP is synthesized in the ven- tr
icles of the
he rt. The BNP secretion r te is incre sed under conditions of ddition l myoc r
di l stretch nd
bnorm l w ll tension. The test is used to differenti te whether dyspne (diffic
ulty bre thing)
is the result of pulmon ry conditions or c rdi c dysfunction. An exces- sively e
lev ted BNP level
is indic tive of he rt f ilure. Hep tic or Liver Profile Disorders of hep tic (l
iver) function
m y be di gnosed using
hep tic function p nel. M ny of the hep tic enzymes re
lso found in
other tissues of the body. The use of p nel m y be helpful to the provider for
differ- enti l
di gnosis. P tients with elev ted liver enzymes often exhibit j undice (yellowin
g of the skin nd
eyes), n use nd vomiting, or urine th t is d rk in color. Specimens ob- t ined
from p tients
with liver dise se or d m ge m y h ve pl sm or serum th t ppe rs icteric. Icte
ric s mples h ve
d rk yellow or greenish tint to the fluid portion of the blood, which often co
rrel tes to n
elev ted tot l bilirubin level. Hep tic function p nels m y lso be used to moni
- tor liver
function when p tients re t king medic tion 342 Section IV Clinic l Chemistry
th t is known to
c use hep tic d m ge. This p nel usu lly includes t le st seven tests th t m y
be elev ted with
liver dysfunction: ALT ( l nine minotr nsfer se), lk line phosph t se, AST ( s
p rt te
minotr nsfer se), bilirubin, tot l protein, nd lbumin. Hep tic function p nel

s m y include
ddition l tests in some l bor tory settings. However, if there re ddi- tion l
tests dded to
those listed bove, Medic re m y not p y for the tests performed. Test Your Know
ledge 16-8 Why
re c rdi c enzymes ordered s series of blood dr ws r ther th n just once? (O
utcome 16-10)
Test Your Knowledge 16-9 Which of these tests re included in
hep tic function
p nel? . AST b.
Tot l protein c. ALT d. None of the bove e. All of the bove (Outcome 16-11) RE
FERENCE RANGES It
is import nt to re lize th t the reference r nges for clinic l chemistry tests
re b sed on the
technique used by the l bor tory performing the test, the ge nd gender of the
p tient, the test
prep r tion, nd some- times even by the time of the d y th t the specimen w s d
r wn.
Occ sion lly there m y be
difference in refer- ence r nges for the pl sm vers
us serum s mples
s well. It is import nt lw ys to document the det ils of the blood dr w nd p
tient prep r tion
c refully when col- lecting the blood s mple so th t the reference r nges will b
e ccur te. It is
lso essenti l th t the medic l ssist nt le rn how to re d the l bor tory repor
t so th t
bnorm l results re recognized immedi tely. The reference r nges for the l bor
tory tests listed
in this ch pter re included in T ble 16-1 nd T ble 16-2. POTENTIAL SOURCES OF
ERROR The most
common sources of error for clinic l chemistry tests occur in the pre n lytic l
re . These
include improper p tient prep r tion, in ppropri te specimen collection techniqu
es, nd errors in
specimen processing. Specific sources of specimen processing errors include the
following:
Hemolysis: A s mple c n be hemolyzed (the red blood cells broken open) during sp
ecimen collection
or fter- w rd during processing. Ex mples of procedures th t m y c use hemolysi
s include
tr um tic blood dr w, using
needle th t is too sm ll for the collection proces
s,
1899_Ch16_332-348 21/12/11 5:05 PM P ge 342 Ch pter 16 Overview of Clinic l Che
mistry 343 TABLE
16-1 Reference r nges for glucose testing F sting Pl sm Glucose 2-Hour Postpr n
di l Glucose
Norm l 70100 mg/dL Less th n 140 mg/dL Predi betes 101125 mg/dL 141199 mg/dL Di bet
es 126
mg/dL or bove 200 mg/dL or bove D t from Americ n Di betes Associ tion. TABLE
16-2 Reference
r nges for common chemic l n lytes (listed lph betic lly) An lyte Norm l R nge
(Adults) Albumin
(Alb) 3.55 g/dL Alk line phosph t se (ALP) 42136 U/L Al nine minotr nsfer se (ALT
) 1035 U/L
Asp rt te minotr nsfer se (AST) 035 U/L Bilirubin, tot l (TBili) 0.31 mg/dL Blood
ure
nitrogen (BUN) 1020 mg/dL Br in n triuretic peptide (BNP) 0100 ng/L C lcium (C ) 8
.210.5 mg/dL
C rbon dioxide (CO 2 ) 2230 mEq/L Chloride (Cl) 96106 mEq/L Cholesterol, tot l (Ch
ol) Less th n
200 mg/dL Cre tinine (Cre t) 0.61.2 mg/dL Cre tine kin se (CK) 55170 U/L k Cre t

ine
Phosphokin se (CPK) High-density lipoprotein (HDL) Gre ter th n 50 mg/dL L ct te
dehydrogen se
(LD, LDH) 100190 U/L Low-density lipoprotein (LDL) Less th n 100 mg/dL Myoglobin
Less th n 90
g/L Pot ssium (K) 3.55.0 mEq/L Sodium (N ) 136145 mEq/L Thyroid-stimul ting hormone
(TSH)
0.44.2 U/mL Thyroxine (T4) 4.511.2 g/dL Triglyceride (Trig) Less th n 150 mg/dL
Triiodothyronine (T3) 75220 ng/dL sh king tube fter collection r ther th n usi
ng gentle
inversion, or subjecting the whole blood s mple to extreme he t or cold temper t
ures. Hemolysis
m y lso result if tube without ntico gul nt is centrifuged before the specim
en is llowed to
clot dequ tely. Any ctivity th t c uses the red blood cells in the specimen to
be git ted
unnecess rily m y potenti lly c use the red blood cells to be broken. Hemolysis
c uses the serum
or pl sm to t ke on red color, which interferes with m ny testing methods. Fi
gure 16-1 shows
specimen 1899_Ch16_332-348 21/12/11 5:05 PM P ge 343 with visible hemolysis. Hem
olysis m y lso
incre se levels of cert in n lytes in the pl sm (pot ssium or iron, for inst n
ce) th t re not
norm lly present in high concentr tions. The reference r nges for these chemic l
s re b sed on
nonhemolyzed specimens, so it m y ppe r th t the p tient needs tre tment for n
imb l nce when
the result is erroneous due to hemolysis. Lipemic specimens: Lipemi is present
in specimen
when there re too m ny lipoproteins in the blood circul tion. The excessively h
igh levels of
lipoproteins m y be c used by heredit ry hyperlipidemi or chronic liver dise se
. M l bsorption
disorders m y lso c use lipemi to be evident. More often, lipemi results when
p tient h s
not followed the instructions for speci- men prep r tion by not f sting s direc
ted before the
blood dr w. Lipemic specimens h ve
milky ppe r- nce th t m y be visible immedi
tely fter
collection or fter centrifug tion. These f tty p rticles suspended in the speci
men will
interfere with m ny clinic l chem- istry ss ys. Some testing m y be possible if
the speci- men
is cle red using speci l centrifug tion process, but often the l bor tory will
sk th t the
specimen be redr wn if the lipemi is severe. Lipemi is evident in the specimen
included in
Figure 16-2. Specimen collection errors: The medic l ssist nt who is performing
specimen
collection needs to keep the difference between pl sm nd serum s mples in mind
. If test c lls
for serum s mple, tube with- out ntico gul nt must be used for the collecti
on. In 344
Section IV Clinic l Chemistry Figure 16-1 A centrifuged blood specimen with hem
olysis evident in
the serum. ddition, cert in test results m y lso be ffected if tube with se
rum/pl sm
sep r tor gel is used for the collection. Specifics bout the type of specimens
th t re

ccept ble nd un ccept ble for p rticul r test would be listed in the l bor t
ory directory,
which pro- vides collection specifics for the tests offered by th t l bor tory.
This SST
restriction is most common when collecting specimens for medic tion levels. Anot
her potenti l
source of error when collecting clinic l chemistry specimens is the incorrect ti
ming of the
collection. Tests m y be ordered s series of blood dr ws, s in the c se of t
he c rdi c
enzymes. Medic - tion levels m y lso be ordered t specific times s pe k nd t
rough dr ws. It
is import nt to underst nd the process involved in these timed collections so th
t the specimens
re properly l beled nd the reference r nges re m tched to the specimen type.
In the c se of
medic tion levels, it is import nt to find out if there re restrictions concern
ing the length of
time between the l st dose nd the specimen collection so th t the he lth-c re p
rovider will
receive results th t llow for proper tre tment of the p tient. In ddition to t
he incorrect type
of specimen collec- tion nd the incorrect timing, nother potenti l source of e
rror is the order
in which the tubes re collected. C rryover of ntico gul nt from one tube to n
other m y c use
ch nges in the levels of cert in n lytes when the testing procedures re perfor
med. Pot ssium
levels, for ex mple, m y be elev ted if the l vender top tube is Figure 16-2 A c
entrifuged blood
specimen with lipemi evident in the serum. 1899_Ch16_332-348 21/12/11 5:05 PM P
ge 344 collected
before the green top tube nd
c rryover of ntico gul nt results. Qu ntity not
sufficient:
L bor tory directories provide inform tion bout the volume needed for testing p
roce- dures, nd
they m y lso provide minimum volume ccepted for the test. A QNS specimen (on
e th t does not
h ve the qu ntity necess ry for testing) will require
re-collection, which del
ys potenti l
tre tment for the p tient. These volume requirements must be t ken into consider
tion before the
s mple is collected; they c n ffect the choices m de concerning which type of c
ollec- tion setup
to use nd how m ny tubes to dr w. The st ted minimum volumes usu lly llow the
test to be
performed only once; this me ns th t if there re ny errors during the n lysis
or n extremely
high or low result, retesting the s mple will not be possible. Sometimes it is n
ecess ry to
retest the s mple using dilutions to obt in true v lue, but this would lso no
t be possible if
only the minimum volume is submitted to the l bor tory. Exposure to light: Some
n lytes
(bilirubin nd ferritin, for ex mple) will deterior te when exposed to light ft
er collection.
These s mples need to be covered immedi- tely (usu lly wr pping foil round the
tube will
suffice) nd centrifuged s soon s possible. The pl sm or serum to be n lyzed
should be

sep r ted into tube designed to protect the specimen from light exposure. Figu
re 16-3 shows n
mber pl stic tr nsfer tube th t is designed to minimize the light exposure for
specimen.
Exposure to ir: Once
specimen h s been cen- trifuged, it m y be necess ry to
remove the rubber
top of the tube nd sep r te out the pl sm or serum. The exposure to ir should
be minimized, s
the concentr - tion for some n lytes will ch nge with the exposure. Alcohol n
lysis is n
excellent ex mple of this; the longer the tube is open, the lower the lcohol co
ncen- tr tion m y
become in the specimen. C rbon dioxide is nother common n lyte th t m y decre
se with continued
exposure to ir. Specimen processing: C reful dherence to specimen processing i
s essenti l for
clinic l chemistry tests. M ny of the chemic l concentr tions will ch nge when l
eft t room
temper ture for extended periods of time, so re- se rching the specimen requirem
ents prior to
processing is import nt. If there is question bout how to h ndle
specimen,
the l bor tory
directory should be consulted, nd if necess ry, the testing l bor tory should b
e con- t cted for
cl rific tion before the specimen is collected. Pl sm or serum m y require free
zing or
refriger tion within cert in mount of time fter collection to m in- t in the
integrity of the
s mple. It is lso necess ry to prechill specimen collection tubes for some n l
ytes. Del yed
processing: Blood specimens to be used for clinic l chemistry should be centrifu
ged s soon s
possi- ble so th t the pl sm or serum c n be removed from the cells in
timely
m nner. Serum
tubes must be llowed to clot completely before centrifuging. Del yed sep r tion
of cells from
pl sm or serum will llow n lytes th t re in higher concentr tion within th
e cells th n
outside the cells to le k out of the cells nd c use erroneous test results. This
c n result in
n in ccur te di gnosis nd/or unnecess ry tre tment for the p tient. Conversely
, glu- cose th t
is present in the pl sm or serum will continue to be used by the cells in the s
pecimen s n
energy source if the serum or pl sm is not removed from the cells in timely m
nner. Therefore,
the longer th t the cells re- m in in cont ct with the fluid portion of the bloo
d, the lower the
glucose levels will become in the pl sm or serum. This c n m ke it ppe r th t
the p tient h s
very low pl sm glucose level when the specimen is tested in the l bor tory. Ch
pter 16 Overview
of Clinic l Chemistry 345 Figure 16-3 Amber tr nsfer tubes designed to minimize
specimen exposure
to light. Test Your Knowledge16-10 Which of these potenti l sources of error re
rel ted to high
levels of lipids in the bloodstre m? . Lipemi b. Hemolysis c. Erroneous low gl
ucose levels d.
QNS specimens (Outcome 16-13) 1899_Ch16_332-348 21/12/11 5:05 PM P ge 345 SUMMAR
Y Clinic l

chemistry is
complex component of l bor - tory testing. There re hundreds of
tests th t m y
f ll into this c tegory, nd the specimen collection nd processing requirements
will v ry
depending on the testing method nd l bor tory policies. Some clinic l chemistry
tests m y be
performed in physici n office l bor tories; most of these will use whole blood s
pec- imens for
n lysis. Common clinic l chemistry tests performed in the physici n office l bo
r tory include
glucose nd cholesterol testing. Clinic l chemistry tests performed t reference
l bor tories re
usu lly performed on pl sm or serum specimens r ther th n whole blood specimens
. M ny of these
tests m y be ordered s p nels or profiles. There re numerous sources of error
in specimen
collection nd processing for clinic l chemistry tests, so the medic l ssist nt
h s to rem in
diligent bout specific specimen re- quirements to provide ppropri te specimens
for me ningful
l bor tory results. TIME TO REVIEW 1. Atherosclerosis is: Outcome 16-1 . H rden
ing of the
rteries due to ge b. A buildup of w xy pl que on the lining of blood vessels c
. A condition
rel ted to high glucose levels d. The presence of occult blood in the stool 2. C
re tinine is
present in the blood Outcome 16-1 s by-product of: . Protein met bolism b. H
e rt d m ge c.
Muscle met bolism d. Glucose met bolism 3. Myoglobin nd troponin re Outcome 16
-1 ex mples of:
. Tests included in typic l hep tic function p nel b. Tests included in
typ
ic l ren l
function p nel c. Tests included in the BMP d. Tests included in n order for c
rdi c enzymes 4.
True or F lse: Pl sm is the liquid Outcome 16-2 portion of the blood sep r ted
fter
centrifug tion from tube th t does not cont in ntico gul nt. 5. True or F lse
: Hemoglobin is
Outcome 16-3 subst nce th t is dissolved in blood pl sm . 6. Which of these test
s re not Outcome
16-5 included in
typic l lipid p nel? . Tot l cholesterol b. Tot l triglyceri
de c. VLDL d.
Cre tinine 7. An electrolyte p nel typic lly Outcome 16-6 includes which of thes
e tests? . BUN
b. CPK c. ALT d. Pot ssium 8. True or F lse: A p nel of l bor tory Outcome 16-8
tests costs more
for the p tient th n ordering ll the tests in the p nel individu lly. 9. Which
of these tests
re not Outcome 16-9 usu lly included in c rdi c p nel? . ALT b. CK-MB c. CK
d. Myoglobin 10.
Which of these f ctors m y be Outcome 16-12 t ken into consider tion when ev lu
ting reference
r nges for test? . Age nd gender of the p tient b. Testing methodology c. Ti
me of d y for
specimen collection d. All of the bove 11. True or F lse: Hemolysis is void bl
e Outcome 16-13
when collecting blood s mple. 346 Section IV Clinic l Chemistry C se Study 16
-1: Wh t order?
Mr. Oliver rrived e rly for his blood dr w one Mond y morning. The medic l ssi
st nt w s running

l te th t d y, nd seemed to be
bit distr cted s she prep red for the blood d
r w. Mr. Olivers
physici n h d ordered CBC (to be collected in
pot ssium EDTA tube) nd pot
ssium level (to
be collected in green top hep rinized tube). The MA completed the blood dr w,
nd th nked Mr.
Oliver for his time. The next d y, the physici ns office c lled Mr. Oliver nd s
ked him to come
in to h ve his pot ssium level 1899_Ch16_332-348 21/12/11 5:05 PM P ge 346 Ch pt
er 16 Overview
of Clinic l Chemistry 347 rechecked, s it w s elev ted on the test from the d y
before. This w s
not n expected result, s usu lly Mr. Olivers pot ssium level w s decre sed belo
w the reference
r nge. The specimen w s dr wn nd checked on STAT b sis, nd the result w s in
the low end of
the reference r nge. The physici n told Mr. Oliver th t the pre- vious result w
s elev ted
bec use of l bor tory error. 1. Wh t re two sources of error th t could c use
the pot ssium
result to be erroneously elev ted in this scen rio? RESOURCES AND SUGGESTED READ
INGS Modern
Technology Helps Shed Light on Illness in Artists of the P st A summ ry of n rt
icle by P ul L.
Wolf, MD, which p- pe red in the November 2005 edition of the Archives of P tho
logy nd
L bor tory Medicine, public tion of the College of Americ n P thologists. Very
interesting
inform tion concerning the w y th t illnesses nd drugs h ve influenced the work
of m ny f mous
rtists nd composers. http://www.newswise.com/ rticles/view/516145/ Cholesterol E
xcellent
present tion on cholesterol nd the effects th t it m y h ve on the c rdiov scul
r system; lso
includes infor- m tion bout lifestyle ch nges nd symptoms of myoc rdi l inf rc
tion nd stroke
http://www. meric nhe rt.org Dise ses nd Conditions Index, Coron ry Artery Dise
se N tion l
He rt, Lung nd Blood Institute; N tion l Institutes of He lth Excellent inform
tion bout
coron ry rtery dise se includ- ing illustr tions. http://www.nhlbi.nih.gov/he l
th/dci/
Dise ses/C d/CAD_Wh tIs.html Third Report of the Expert P nel on Detection, Ev lu
tion, nd
Tre tment of High Blood Cholesterol in Adults (Adult Tre tment P nel III) N tion
l He rt, Lung
nd Blood Institute: N tion l Institutes of He lth Includes recommend tions for
lipid testing nd
desir ble r nges nd tre tment options. http://www.nhlbi.nih.gov/
guidelines/cholesterol/index.htm 1899_Ch16_332-348 21/12/11 5:05 PM P ge 347 189
9_Ch16_332-348
21/12/11 5:05 PM P ge 348 349 Ch pter 17 Glucose Testing Const nce L. Lieseke, C
MA (AAMA), MLT,
PBT(ASCP) CHAPTER OUTLINE Glucose Utiliz tion nd Control Mech nisms P thophysio
logy of Glucose
Met bolism Predi betes Di betes Type 1 Di betes Type 2 Di betes Gest tion l Di b
etes Types of
Glucose Tests Performed F sting Blood Glucose Test R ndom Glucose Test Postpr nd
i l Glucose Test
Or l Glucose Toler nce Testing Procedures Glycosyl ted Hemoglobin Blood Ketone T

esting C pill ry
S mple Testing nd Correl tion to Pl sm Glucose Levels Urine Testing for Di bet
ics Glucose
Testing Methods Home Glucose Testing Instruments Qu lity Control nd Common Erro
rs L bor tory
Glucose Testing nd Potenti l Sources of Error Summ ry Time to Review C se Study
Resources nd
Suggested Re dings 17-1 Define the key terms. 17-2 Expl in how insulin nd gluc
gon work together
to m int in he lthy blood sug r levels. 17-3 List three w ys th t insulin secret
ion ffects the
body. 17-4 Comp re nd contr st type 1 nd type 2 di betes. 17-5 Describe how ge
st tion l
di betes is different from type 1 nd type 2 di betes. 17-6 List potenti l probl
ems th t m y
develop with uncontrolled di betes. 17-7 Expl in why it is import nt to di gnose
nd tre t
gest tion l di betes. 17-8 Ex mine the differences between the r ndom nd f stin
g glucose
testing. 17-9 Expl in the procedure for postpr ndi l glucose testing. 17-10 Desc
ribe the steps
involved in
glucose toler- nce test. 17-11 Identify the clinic l signific nce
of the Hb A1c
test. 17-12 Expl in how the results for c pill ry whole blood glucose testing m
y comp re to
those tested on pl sm s mple. 17-13 Describe common m inten nce nd qu lity c
ontrol issues
th t m y need to be ddressed in home nd l bor tory glucose testing methods. 17
-14 Perform
CLIA-w ived glucose testing. 17-15 Perform CLIA-w ived Hb A1c test. Le rning O
utcomes After
re ding this ch pter, the successful student will be ble to: 1899_Ch17_349-370
21/12/11 5:25 PM
P ge 349 350 Section IV Clinic l Chemistry KEY TERMS Albumin Auto ntibodies Aut
oimmune response
Body m ss index (BMI) C rbohydr tes Di betes Di betes insipidus Di betes mellitu
s Di betic
keto cidosis Di betic neurop thy Etiology F sting blood sug r (FBS) F sting pl s
m glucose (FPG)
Gest tion l di betes Gluc gon Glucose Glucose ch llenge test Glucosuri Glyc ted
hemoglobin
Glycemic control Glycogen Glycogenolysis Glycolysis Glycosyl ted hemoglobin Hb A
1c Hyperglycemi
Hypoglycemi Imp ired f sting glucose (IFG) Imp ired glucose toler nce (IGT) Ins
ulin Insulin
dependent Insulin resist nce Islets of L ngerh ns Ketones Ketonuri M crosomi M
et bolic syndrome
Micro lbumin Micro lbuminuri Or l glucose toler nce test (OGTT) Polydipsi Poly
ph gi Polyuri
Postpr ndi l Predi betes Type 1 di betes Type 2 di betes CAAHEP/ABHES STANDARDS
CAAHEP St nd rds
I.P.13. Perform chemistry testing ABHES St nd rds 10. Medic l L bor tory Procedu
res, b.
CLIA-w ived tests Gr du tes: b. Perform selected CLIA-w ived tests th t ssist w
ith di gnosis
nd tre tment, #3 Chemistry Testing H istory h s provided us with m ny det iled
observ - tions of
p tients with di betes. The ncient physi- ci ns documented the symptoms rel ted
to di betes,
such s frequent excessive urin tion nd weight loss; however, they were not bl

e to effectively
tre t the con- dition. In the first century AD, physici n in ncient Greece n
med this m l dy
di betes, b sed on the Greek word for siphon, s it seemed to him th t the liquid
t ken in by
the body w s just siphoned through nd c me directly out s urine. Other ncient c
iviliz tions
provide ex mples of urine from ill p tients th t ttr cted nts bec use of the s
weetness of the
fluid. In the 1700s, physici ns discovered th t the urine nd blood from p tient
s exhibiting
di betic symptoms t sted sweet, like sug r, nd this bec me n ccepted me ns of
di gnosing
di betes in symptom tic p tients. The tre tment of di betes rem ined ineffective
be- c use
physici ns could not determine the c use or source of the dysfunction responsibl
e for the
symptoms. Some thought there w s problem with digestion in these 1899_Ch17_349
-370 21/12/11
5:25 PM P ge 350 Ch pter 17 Glucose Testing 351 p tients, where s others though
t it must be
dise se of the kidneys bec use there w s so much urine produced. It w s not unti
l the l te 19th
century th t scientists dis- covered evidence th t the p ncre s w s involved in
the process. In
1889, two physici ns who were studying f t digestion nd utiliz tion discovered
th t the remov l
of the p ncre s c used the nim ls in the experiment to exhibit the symptoms of
di betes. In
1922, Frederick B nting nd Ch rles Best experimented with extr cts from the p n
cre s to isol te
insulin, n enzyme th t is necess ry for the proper utiliz tion of glucose by th
e cells of the
body. Insulin bec me v il ble in the 1920s s injected medic tion to tre t di b
etes, with
immedi te lifes ving results for those fflicted. In 1935, scientist Roger Himsw
orth presented
evi- dence th t di betes w s ctu lly two sep r te dise ses: insulin sensitive (to
d ys type 1
di betes) nd insulin insensitive (now known s type 2 di betes). This discov- ery
provided the
opportunity for deeper underst nding of the dise se nd its tre tment, s well
s the development of n or l medic tion for insulin-insensitive type of di betes, which bec me
v il ble in
the 1950s. Even though the c use nd types of di betes re now understood nd mo
re tre tment
options re v il ble, di betes is still
very serious, widespre d, nd expensi
ve he lth
problem. According to st tistics from the Centers for Dise se Control nd Preven
tion (CDC),
pproxi- m tely 8% of the popul tion of the United St tes h s di betes, nd in 2
007 it w s the
sixth le ding c use of de th. Common complic tions of di betes include c r- diov
scul r dise se,
incre sed stroke risk, poor he ling, hypertension, blindness, kidney dise se, ne
rvous system
dysfunction, mput tions, nd dent l dise se. Di betes c n lso contribute to co
mplic tions of
pregn ncy nd c uses incre sed susceptibility to other illnesses. Bec use of the

severity of this
dise se nd the number of those fflicted, glucose testing h s become
very com
mon procedure
performed in physici n office l bor tories nd reference l bor tories. He lth-c
re providers nd
p - tients must work closely together to m n ge the dise se nd provide ppropri
te tre tment to
void the onset of life-thre tening complic tions. GLUCOSE UTILIZATION AND CONTR
OL MECHANISMS
Glucose is
type of simple sug r th t is needed s n en- ergy source by ll li
ving things. When
c rbohydr tes re digested, glucose enters into the bloodstre m s by- product
. As the blood
glucose levels rise, the body re cts in sever l w ys: Some of the glucose goes d
irectly to the
br in tissues, where it is needed for norm l function. Cells of the br in do not
require insulin
to t ke in glucose for energy. The incre sed levels of glucose in the blood trig
ger the
p ncre s to rele se insulin, which is produced by clus- ters of speci lized bet
cells in the
p ncre tic islets of L ngerh ns. Insulin is required for glucose to enter most o
f the cells of
the body so th t it c n be used s n energy source. The cells of the body h ve
receptor th t
inter cts with the insulin molecule. This inter ction llows glucose to p ss thr
ough the cell
membr ne. Insulin m y be considered s key to open the doors on the cells to ll
ow the
glucose to enter. The cells ccept s much glucose s needed for norm l function
. Bec use
me l m y provide more glucose th n is needed immedi tely, insulin triggers the b
ody to store the
excess glucose in the muscles nd liver s glycogen, which is essenti lly long
string of
glucose molecules. When the dem nd for glucose incre ses p st wh t is in the blo
odstre m, this
glycogen is broken down nd re- le sed for use s glucose. The incre sed glucose
dem nd m y lso
result in the tr nsmission of
mess ge to the br in encour ging the body to t k
e in food.
Addition l unneeded glucose m y be stored s f t. Test Your Knowledge 17-1 Wh t
is glycogen?
(Outcome 17-1) Once the glucose h s entered the cells of the body, the blood glu
cose levels begin
to return to norm l. The go l of the body is to keep
consistent level of gluco
se in the
bloodstre m t ll times while providing the necess ry energy to the cells. Gluc
ose continues to
be used by the cells const ntly, nd with incre sed ctivity the glucose dem nds
re heightened.
The incre sed dem nd c uses the glucose levels in the bloodstre m to decre se be
low the norm l
r nge s the glucose mole- cules move into the cells. When this occurs, nother
cell type ( lph
cells) in the p ncre tic islets of L ngerh ns secrete
hormone c lled gluc gon,
which
counter cts the effects of insulin. (See Fig. 17-1 for more det ils bout the p
ncre s nd the
islets of L ngerh ns.) Gluc gon c uses the p ncre s to reduce insulin produc- ti

on, nd sign ls
the liver, muscles, nd dipose tissues of the body to rele se some of the gluco
se th t is stored
there into the bloodstre m to incre se blood glucose levels. This process of gly
cogen bre kdown
is c lled glycogenolysis. Figure 17-2 demonstr tes the b l nce between glucose,
insulin, nd
gluc gon. 1899_Ch17_349-370 21/12/11 5:25 PM P ge 351 The intric te b l nce of t
he blood sug r
levels, insulin secretion, nd gluc gon secretion is essenti l for the body to f
unction norm lly.
Insulin is required for most of the cells in the body to t ke in glucose to be u
sed for energy,
nd insulin lso triggers the form tion of glycogen nd triglycerides from the e
xcess blood
glucose so th t the body h s b ckup source of energy between me ls or during t
imes of incre sed
need. In ddition, the secretion of insulin stimul tes the liver nd muscle cell
s to bsorb mino
cids introduced into the bloodstre m during di- gestion nd use these to cre te
proteins.
Insulin lso stim- ul tes the cells to t ke in f tty cids from the bloodstre m
so th t there is
not n excessive buildup. PATHOPHYSIOLOGY OF GLUCOSE METABOLISM Predi betes Acco
rding to the
Americ n Di betes Associ tion, there re pproxim tely 57 million Americ ns th t
h ve predi betes, which is defined s condition in which the blood glucose level is el
ev ted, but not
high enough to be indic tive of di gnosis for type 1 or type 2 di betes. Those
who h ve
predi betes m y lre dy be experiencing some of the dverse effects of hyperglyc
emi (elev ted
blood glucose) nd re t gre tly incre sed risk of de- veloping di betes with
in the next few
ye rs. Those with predi betes h ve some degree of insulin resist nce, usu lly s
soci ted with
obesity, sedent ry lifestyle, nd poor e ting h bits. P tients with incre sed
bdomin l f t nd
n elev ted body m ss index (BMI) ( me surement of weight in rel tionship to he
ight) re t n
incre sed risk, s well s those with
history of type 2 di betes in their imme
di te f mily. In
ddition, di - betes is more common in cert in ethnic groups. L tinos, 352 Secti
on IV Clinic l
Chemistry Islet of L ngerh ns Acin r cells (secrete digestive enzymes) Bet cell
s (secrete
insulin) Delt cells (secrete som tost tin) Red blood cells Alph cells (secrete
gluc gon) Figure
17-1 P ncre s nd islets of L ngerh ns; note the lph nd bet cells. Test Your
Knowledge 17-2
Which of these processes is triggered by the secretion of insulin? . Form tion
of glycogen b.
Incre se of blood glucose c. Form tion of glucose d. Secretion of glucose (Outco
me 17-3)
1899_Ch17_349-370 21/12/11 5:25 PM P ge 352 Afric n Americ ns, N tive Americ ns,
Asi n Americ ns,
nd P cific Isl nders h ve n incre sed presence of di - betes in their popul ti
ons. The elderly
lso h ve dispro- portion te mount of di betes present. Bec use these groups

h ve more
di betes in their midst, predi betes is lso more likely. Predi betes is detecte
d by testing the
blood glucose level. The desir ble f sting pl sm glucose (FPG) re- sult tested
fter
pproxim tely 12 hours of f sting is below 100 mg/dL. Predi betes is indic ted b
y n FPG of 100
to 125 mg/dL, nd p tients with di betes usu- lly demonstr te n FPG of 126 mg/
dL or bove.
Predi betics with n FPG of 100 to 125 mg/dL re s id to h ve imp ired f sting g
lucose (IFG). The
pre- di betes di gnosis m y lso be b sed on n bnorm l or l glucose toler nce
test (OGTT)
result. The result t 2 hours during this procedure for predi betics will be bet
ween 140 nd 200
mg/dL, nd for di betics it will be over 200 mg/dL. (The OGTT procedure is de- t
iled l ter in
this ch pter.) Predi betics with glucose levels t 2 hours between 140 nd 200 m
g/dL re s id to
h ve imp ired glucose toler nce (IGT). Those di gnosed with predi betes do not
lw ys pro- ceed
to develop di betes. Studies h ve shown th t if p tients with predi betes m ke
concentr ted
effort to incre se physic l ctivity nd reduce their weight by 5% Ch pter 17 G
lucose Testing
353 REGULATION OF BLOOD GLUCOSE LEVELS Control centerP ncre s Alph cells Bet ce
lls Gluc gon
production (hormone) Insulin production (hormone) Result: Liver bre ks down glyc
ogen into
glucose; r ises blood glucose Result: Glucose upt ke by liver, f t nd muscle ti
ssue; lowers
blood glucose Lower glucose (in dequ te energy supply for cells) Higher glucose
(toxic to cells)
Glucose tr nsporter receptor Glucose tr nsporter receptor Homeost sis Glucose co
ncentr tion =
70100 mg/dL Figure 17-2 Represent tion of the b l nce between blood glucose, insu
lin, nd
gluc gon. When blood glucose is incre sed, the body produces insulin to llow th
e glucose to
enter the cells. This decre ses the blood glucose levels, which triggers gluc go
n to be rele sed
if the level drops too low. The gluc gon then decre ses the bsorption of glucos
e into the cells,
nd incre ses the bre kdown of glycogen, if necess ry. 1899_Ch17_349-370 21/12/1
1 5:25 PM P ge
353 354 Section IV Clinic l Chemistry to 10%, they m y not develop di betes, or
t the very
le st, they m y del y the onset of di betes for
few ye rs. These lifestyle ch
nges will lso
stop ny undesir ble ef- fects of the hyperglycemi on the cells of the body. Th
e Americ n
Di betes Associ tion strongly recommends counseling nd follow-up for this group
to ssist with
lifestyle ch nges. Di betes The word di betes is used to refer to group of dis
or- ders th t ll
exhibit hyperglycemi , or elev ted blood glucose. These m y lso be known s dif
ferent types of
di betes mellitus, or sweet di betes, bec use of the glucose content in the urine
of those
di gnosed. There re ctu lly three different types of di betes ssoci ted with

hyperglycemi ,
which differ by their etiology (c use) nd by their tre tment. These include typ
e 1 di betes,
which previously w s known s insulin- dependent di betes or juvenile-onset di b
etes. Type 2
di betes w s previously known s non-insulin- dependent di betes. Gest tion l di
betes is
disorder of glucose met bolism th t only ffects those who re pregn nt. A di gn
osis of type 1 or
type 2 di betes is usu lly only ssigned to
p tient fter confirm tion of the
bnorm l blood
levels. Type 1 Di betes P tients with type 1 di betes h ve
l ck of insulin. Th
e bet cells of
the islets of L ngerh ns in the p n- cre s h ve been destroyed nd re not c p b
le of cre t- ing
enough insulin to keep the body he lthy. Type 1 di betes is present in pproxim
tely 5% to 10% of
ll di betic p tients, nd presents most often in children or dolescents. Adult
s m y lso be
fflicted, lthough this is not s common s it is in those under the ge of 20.
The destruction
of the bet cells responsible for in- sulin production is most commonly ssoci t
ed with n
utoimmune response, in which the p tients body develops uto ntibodies th t tt
ck the cells in
the islets of L ngerh ns. There seems to be genetic pre- disposition to this c
ondition,
lthough it ppe rs th t there is usu lly some sort of trigger th t brings on the
uto ntibody
production. Vir l infections nd en- vironment l f ctors h ve been linked to the
progres- sion of
the dise se. Type 1 di betes m y develop over
few weeks; the onset of the dise
se is often
quite r pid s comp red to type 2 di betes, which h s gr du l progression. Typ
e 1 di betes
p tients commonly exhibit f tigue, incre sed urin tion nd incre sed thirst, n u
se nd vomiting,
nd weight loss in spite of n incre sed ppetite. Dur- ing the initi l onset of
symptoms, the
p tient m y h ve periods of hyperglycemi s well s hypoglycemi (low blood sug
r). If the
di gnosis nd tre tment re not est blished e rly in the dise se process, the bo
dy will re ct to
the short ge of insulin by using f tty cids s n energy source inste d of depe
nding on glucose.
The use of f tty cids m y c use buildup of ketones in the bloodstre m. Ketone
s re
by-product of f t met bo- lism, nd bec use they re cidic in n ture, they will
ch nge the pH of
the body over period of time. Initi l symptoms of di betic keto cidosis includ
e bdomin l p in,
n use , nd vomiting. As the condi- tion progresses, the p tient m y h ve incre
sed sh llow
respir tions, which is the bodys w y of ttempting to ch nge the cidic blood pH.
The p tient
m y h ve dif- ficulty thinking nd communic ting cle rly, nd m y eventu lly bec
ome com tose. It
is t this point th t the di gnosis of type 1 di betes is often ssigned, s the
p tient is
dmitted to the emergency room or hospit l once he or she becomes critic lly ill

. Tre tment of
type 1 di betes requires frequent insulin injections. Insulin c nnot be dminist
ered or lly, s
it is not effective once it h s been digested. There re m ny different types of
insulin; some
ct quickly nd st y in the circul tion for
short period of time, nd others
re designed to be
longer l sting. P tients who re insulin dependent monitor their blood glucose l
evel sever l
times d ily nd djust their insulin int ke ccordingly. Type 2 Di betes Type 2
di betes is
ch r cterized by l ck of insulin ctivity on the cells of the body. This m y b
e due to insulin
resist nce, in which the cells h ve dimin- ished bility to inter ct with insu
lin s they
should. Be- c use the insulin no longer cts on the cells of the body to llow t
he glucose to
p ss through into the cells, the blood glucose levels rem in elev ted. Type 2 di
betes m y lso
be the result of decre sed production of in- sulin by the bet cells of the p
ncre s. In
situ tions in which the p tient exhibits insulin resist nce, the body will try t
o produce more
insulin to overcome the resist- nce, but fter period of time the dem nd is e
xcessive nd the
production c nnot keep up with the needs of the body. Those who h ve type 2 di b
etes often h ve
high levels of insulin in the bloodstre m s well s high levels of glucose. In
ddition to the
high levels of blood glucose th t result bec use of ineffective cellul r tr nsport, the body
lso tries to ccommod te the imb l nce by bre king down ddition l glycogen in
the liver,
1899_Ch17_349-370 21/12/11 5:25 PM P ge 354 Ch pter 17 Glucose Testing 355 whic
h dds ddition l
glucose to the bloodstre m nd complic tes the situ tion further. Type 2 di bete
s is the most
common form of the dis- e se, ffecting pproxim tely 95% of ll di betics. The
CDC h s decl red
type 2 di betes to be t n epidemic level, s the numbers of those di gnosed in
cre se every
ye r. The etiology (c use) of type 2 di betes is compli- c ted. There is direc
t correl tion
with obesity nd in- dividu ls who h ve been di gnosed with met bolic syndrome (
group of risk
f ctors th t occur together nd incre se the risk of coron ry he rt dise se, str
oke, nd type 2
di betes), s well s f mily history of type 2 di betes nd sedent ry lifest
yle. Women with
his- tory of polycystic ov ry syndrome or gest tion l di - betes lso h ve n in
cre sed ch nce of
developing type 2 di betes. Those older th n ge 40 re t higher risk th n th
ose who re
younger, lthough there h s been
sh rp incre se in the number of obese childre
n di gnosed with
type 2 di betes in the p st few ye rs. Cert in ethnic groups re t higher ris
k, such s N tive
Americ ns nd those of Asi n or Afric n descent. Di gnosis of type 2 di betes m
y be del yed for
ye rs fter the first onset of symptoms s this type of di betes develops slowly

. As with type 1
di betes, m ny p tients di gnosed with type 2 di betes demonstr te incre sed uri
n tion nd
incre sed thirst. Some other common symptoms include unexpl ined weight loss or
weight g in,
flu-like symptoms with f tigue nd n use
ccom- p nied by loss of ppetite, c
h nges in vision,
nd poor he ling. P tients m y lso find th t they re more susceptible to other
illnesses, such
s the common cold. H ving frequent urin ry or ye st infections m y lso be n i
ndic tor of type
2 di betes. Another clinic l indic - tor m y be
ch nge in or l he lth, bec use
di betes m y
c use infl mm tion th t le ds to infection in the gums. In ddition, some p tien
ts experience
tingling or loss of sens tion in the fingertips or toes, which is c used by d m
ged nerve endings
from the high levels of glucose in the body. Type 2 di betes is first tre ted wi
th lifestyle
ch nges. Most p tients di gnosed with this type of di betes re overweight, so t
he first go l is
to lose pproxim tely 8% to 10% of the tot l weight. Di betics re lso encourged to exercise
for t le st 150 minutes per week to im- prove their he lth. Or l medic tions th
t enh nce the
bility of the body to re ct to insulin or stimul te the bet cells of the p ncr
e s to produce
more insulin m y lso be used. If these me sures re ineffective in ccom- plish
ing glycemic
control ( ppropri te blood glucose levels), the p tient with type 2 di betes m y
be tre ted with
insulin injections. Untre ted or uncontrolled type 1 or type 2 di betes m y le d
to hypertension
nd other serious c rdiov scu- l r dise ses, s well s di betic neurop thy; ner
vous system
d m ge; eye nd kidney tissue d m ge; poor he ling; foot nd skin complic tions;
nd
g strop resis,
disorder in which the stom ch t kes too long to empty fter e t
ing. Those with
di betes re t n incre sed risk of developing depression. P tients with type 1
di betes m y
lso h ve n incre sed risk of developing celi c dis- e se ( chronic digestive
disorder c used
by the in bility to met bolize gluten) or p inful musculoskelet l con- dition
known s frozen
shoulder, in which the indi- vidu l loses movement of the shoulder for
period o
f time. Test
Your Knowledge 17-3 List one w y th t type 1 nd type 2 di betes re simil r. (O
utcome 17-4) Test
Your Knowledge 17-4 List two potenti l consequences of uncontrolled or untre ted
di betes.
(Outcome 17-6) Gest tion l Di betes Gest tion l di betes (sometimes bbrevi ted
s GDM) is
simil r to type 2 di betes bec use it is form of glucose intoler nce r ther th
n reduction in
insulin production. Approxim tely 4% of ll pregn nt women develop gest tion l d
i betes. It is
more frequent mong Hisp nic Americ ns, Afric n Americ ns, N tive Americ ns, Asi
n Americ ns,
indigenous Austr li ns, nd P cific Isl nders. Obesity, previous delivery of n

inf nt weighing
more th n 9 pounds, nd positive f mily history of di betes lso incre se the
risk of developing gest tion l di betes. Women who h ve gest - tion l di betes will usu lly d
emonstr te it in
subse- quent pregn ncies, nd re t n incre sed risk of developing type 2 di b
etes l ter in
life. Although the ex ct c use of gest tion l di betes is not cle r, it is thoug
ht th t the
insulin resist nce present in gest tion l di betes is demonstr ted s result o
f the ddition l hormones present in the body during preg- n ncy. The pl cent produces
high levels of
hormones (such s cortisol nd estrogen) to support nd sust in the pregn ncy. T
hese hormones
block or reduce the ction of insulin on the cells of the mothers body, which c u
ses her blood
glucose levels to become elev ted. 1899_Ch17_349-370 21/12/11 5:25 PM P ge 355 3
56 Section IV
Clinic l Chemistry The high levels of hormones re not usu lly prob- lem until
l te in the
pregn ncy, s the mothers p ncre s norm lly responds to the ddition l insulin de
m nds e rly in
the pregn ncy. As the pregn ncy continues, the ddition l m tern l insulin produ
ction c nnot
overcome the effects of the hormones produced by the pl cent , nd the mother wi
ll exhibit
sust ined elev ted blood glucose levels. Gest tion l di betes is
serious he lt
h risk bec use of
the ddition l glucose in the mothers bloodstre m. Glucose p sses through the pl
cent to the
fetus, c using condition known s m crosomi . M croso- mi me ns f t b by. In th
is condition,
the ddi- tion l glucose p ssed on to the b by from the mother c uses the b bys b
ody to produce
excessive f t cells in response to the ddition l unneeded glucose. The b by m y
become
excessively l rge, which c n c use complic tions during delivery. M ny b bies bo
rn to mothers
with gest tion l di betes must be delivered using ces re n delivery, s their
excessive size
does not llow v gin l birth. If v gin l birth is t- tempted, these b bies
re t high
risk of shoulder d m ge during the delivery. Studies h ve shown th t b bies born
to mothers with
gest tion l di betes h ve incre sed risk of becoming obese s children, s well
s n incre sed
risk of developing type 2 di betes l ter in life. In ddition to the risks from
excessive size,
inf nts born to mothers with gest tion l di betes h ve n in- cre sed risk of br
e thing problems,
s well s extreme hy- poglycemi (low blood glucose levels) fter birth. During
the pregn ncy,
the inf nt h s been producing enough in- sulin to process the glucose cre ted by
his or her own
body, s well s the ddition l glucose supplied by the circul tion of the mothe
r. When the
ddition l m tern l glucose supply is discontinued t birth, there is too much i
nsulin in the
inf nts bloodstre m, resulting in low levels of blood glucose. Without c reful mo

nitoring, this
situ tion c n become life thre tening. These b bies m y lso be t n incre sed
risk for other
chemic l im- b l nces in the first few d ys of life. Test Your Knowledge 17-5 Is
gest tion l
di betes more like type 1 or type 2 di betes? Why? (Outcome 17-5) Test Your Know
ledge 17-6 How is
m crosomi rel ted to gest tion l di betes? (Outcome 17-7) POINT OF INTEREST 171 Another type of
di betes There is nother dise se th t sh res the n me di - betes, but it is not
ssoci ted with
hyperglycemi . Di betes insipidus is n endocrine dise se ch r cter- ized by l
ck of the
hormone v sopressin, which cts on the kidneys to reduce urin ry output nd llo
w for
concentr tion of the urine. V sopressin is produced by the pituit ry gl nd, nd
those with this
dise se ei- ther do not produce enough v sopressin, or they h ve developed res
ist nce to the
ctions of v sopressin to concentr te urine. A p tient with di betes insipidus p
roduces excessive
mounts of urine e ch d y, nd of- ten sees the physici n bec use of symptoms s
soci ted with
bed-wetting, dehydr tion, nd/or electrolyte imb l nces. Di betes insipidus h s
very little in
com- mon with the other forms of di betes discussed in this text, except for the
initi l common
symptoms of incre sed urin tion nd incre sed thirst. TYPES OF GLUCOSE TESTS PER
FORMED The role
of the l bor tory in di betes c re is to ssist the he lth-c re provider in the
initi l
di gnosis, differenti - tion bout the type of di betes present, nd monitoring
the progress of
the tre tment once it h s st rted for the p tient. There re sever l types of gl
ucose test
procedures performed th t provide necess ry inform tion to the he lth-c re provi
der. F sting
Blood Glucose Test The glucose level performed in l bor tory on f sting bloo
d specimen is
known s f sting pl sm glucose (FPG). The term f sting blood sug r (FBS) m y
lso be used.
Most l bor tories perform blood glucose levels on pl sm or serum, r ther th n o
n whole blood. To
prep re for this test, the p tient needs to f st for 12 hours nd should not smo
ke, drink
nything but w ter, or t ke medic tion before the test. (Sometimes the medic tio
n is must; this
should be cle red with the physici n before the specimen is dr wn.) The World He
lth Org niz tion recommends the use of pl sm obt ined from venipuncture for this te
st. If the test
c nnot be per- formed within n hour of the blood dr w,
gr y top tube should b
e used for the
specimen. The dditives in the gr y top tube reduce glycolysis (utiliz tion of t
he glucose in the
specimen by the living cells present) for up to 24 hours t room temper ture. Th
e desir ble
f sting pl sm or serum glucose level is 70 to 100 mg/dL 1899_Ch17_349-370 21/12
/11 5:26 PM P ge
356 Ch pter 17 Glucose Testing 357 P tients with FPG of 100 to 125 mg/dL h ve i

mp ired f sting
glucose, nd re predi betic. A result equ l to or bove 125 mg/dL is indic tive
of di betes.
R ndom Glucose Test A r ndom blood glucose test is one th t is t ken t ny time
of the d y
without reg rd for the time of the l st me l. A p tient who is symptom tic for d
i betes, perh ps
exhibiting polyuri , (excessive urin tion) polyph gi , (excessive hunger), or po
lydipsi
(excessive thirst) nd unexpl ined weight loss m y h ve
r ndom glucose test or
dered. According
to the criteri est blished by the Americ n Di betes Associ tion, if the r ndom
glucose re- sult
for symptom tic p tient is equ l to or gre ter th n 200 mg/dL, then the p tien
t is cl ssified
s di betic. solution. P tients with gest tion l di betes will demon- str te
postpr ndi l
blood glucose level t 1 hour th t is gre ter th n or equ l to 140 mg/dL. If thi
s glucose ch llenge result is elev ted, then the he lth-c re provider will usu lly order 3-h
our or l glucose
toler nce test. Test Your Knowledge 17-7 Which of these best describes r ndom
glucose? . A
glucose level dr wn 1 hour fter e ting b. A glucose level dr wn fter 12 hours
of f sting c. A
glucose level dr wn t ny time of the d y without ny previous prep r tion d. A
glucose level
dr wn just before e ting (Outcome 17-8) Test Your Knowledge 17-8 True or F lse:
A l bor tory
postpr ndi l glucose test is dr wn t
specific time interv l fter ingestion o
f drink high in
glucose or ingestion of me l. (Outcome 17-9) Postpr ndi l Glucose Test Postpr
ndi l refers to
something done fter e ting or f- ter me ltime. Glucose testing th t is perform
ed post- pr ndi l
m y me n th t the blood specimen w s col- lected specific mount of time fter
me l, or it
m y me n th t the specimen w s dr wn t cert in interv l fter ingestion of
glucose-rich
bever ge. Di betics who re striving to chieve close glycemic control will test
their blood
glucose levels t home 1 or 2 hours postpr n- di l to see how their body h s h n
dled the me l.
Most di betic educ tion l m teri ls provide t rget r nges for 2-hour postpr ndi
l blood glucose
levels. Ide lly, the blood glucose should not go bove 140 mg/dL for non- di bet
ic p tients; for
di betics the level should rem in below 180 mg/dL 2 hours fter e ting. Initi l
screening
procedures for gest tion l di betes m y lso use postpr ndi l glucose testing. T
his m y be c lled
glucose ch llenge test. P tients do not need to f st before this procedure. Wh
en they rrive t
the l bo- r tory or physici n office, they re given
drink th t con- t ins 50
g of glucose.
This drink must be ingested within 5 minutes for the test to be v lid. A blood s
pecimen is dr wn
ex ctly 1 hour fter ingestion of the glucose Or l Glucose Toler nce Testing Pro
cedures According
to the N tion l Institutes of He lth, the or l glucose toler nce test is more se

nsitive to the
detection of predi betes th n the f sting glucose test level. The OGTT is used p
rim rily for the
di gnosis of di betes mellitus. This test m y be performed on p tient with n
bnorm l FPG,
ssuming th t the result of the FPG w s less th n 200 mg/dL. If the f sting resu
lt w s equ l to
or more th n 200 mg/dL, n or l glucose toler nce test is not indic ted bec use
the high FPG
level is indic tive of di betes. This test m y lso be ordered for p tients who
re being
ev lu ted for gest tion l di betes, or those who h d n bnorm l 1-hour postpr n
di l glucose
result. A p tient prep ring for n or l glucose toler nce test should h ve c r
bohydr te-rich
diet for t le st 3 d ys prior to the scheduled test. Diets th t restrict c rboh
y- dr te int ke
m y produce erroneous results. The p - tient must f st for 12 hours prior to the
test. During
this time, no food or liquid other th n w ter is to be consumed. The p tient sho
uld lso void
smoking nd strenuous exercise. Upon rriv l t the l bor tory or the clinic, th
e p tient will
h ve f sting pl sm glucose specimen dr wn. This specimen should be n lyzed f
or glucose
content before continuing with the process; if the f sting pl sm glucose result
s re elev ted
bove 126 mg/dL, the test will not continue. Also, some l bor tories will collec
t urine
specimen with e ch blood dr w; this helps to provide more inform tion bout the
glucose th t m y
be spilled into the urine specimen. Usu lly blood glucose of 170 mg/dL or gre te
r will c use
glucose to be present in the urine specimen, s the body c nnot h ndle these hig
h levels. After
the f sting specimen h s been dr wn, the p tient will be given solution with 7
5 or 100 g of
glucose dissolved in w ter. (For p tient who is not pregn nt, 1899_Ch17_349-37
0 21/12/11 5:26
PM P ge 357 75 g re used; when testing for gest tion l di betes, 100 g re used
.) Blood
specimens ( nd urine if th t is the policy of the l bor tory) will be collected
t le st three
more times during the procedure: 1 hour, 2 hours, nd 3 hours fter the initi l
dose of glucose
drink h s been ingested. Some l bor tories will lso collect blood specimen h
lf n hour fter
ingestion to provide more inform tion bout how the body is utilizing the glucos
e in the
specimen. Occ sion lly, p tients will feel n useous, tired, cold, nd perspire w
hile undergoing
this test. It is import nt th t p tients re kept c lm, nd th t they st y in n
re where they
c n be monitored while w iting. Sometimes p tient will vomit shortly fter ing
estion of the
glucose solution; if this occurs e rly in the process (prior to 1 hour fter dri
nking the
sweetened drink), then the procedure should be discontinued nd rescheduled, s
the results m y
be in ccur te. Also, if p tient loses consciousness or exhibits symptoms of sl

urred speech nd
imp ired thought processes, the test should be dis- continued nd the physici n
or emergency
personnel should be notified immedi tely. These could be signs of hypoglycemi t
h t require
immedi te tre tment. The interpret tion of the test results is different when sc
reening for
di betes mellitus th n it is for gest tion l di betes. For gest tion l di betes
screening with
100-g glucose solution, if there re two bnorm l results in the v rious timed b
lood dr ws, the
p tient is di gnosed with gest tion l di betes, whether or not she is symptom ti
c. According to
the Americ n Di betes Associ tion, these results re considered bnorm l for p
regn nt wom n:
F sting pl sm glucose: gre ter th n or equ l to 95 mg/dL 1-hour pl sm glucose:
gre ter th n
or equ l to 180 mg/dL 2-hour pl sm glucose: gre ter th n or equ l to 155 mg/dL
3-hour pl sm
glucose: gre ter th n or equ l to 140 mg/dL For suspected di betes mellitus in p
tients who re
not pregn nt, 75-g glucose solution is used. The Americ n Di betes Associ tion
h s est blished
these p r meters for
di gnosis of di betes in nonpregn nt individu ls: F sting
pl sm
glucose: gre ter th n or equ l to 126 mg/dL 1-hour pl sm glucose: gre ter th n
or equ l to 200
mg/dL 2-hour pl sm glucose: gre ter th n or equ l to 200 mg/dL 358 Section IV
Clinic l
Chemistry 3-hour pl sm glucose: gre ter th n or equ l to 200 mg/dL (the 3-hour
s mple is not
lw ys included in the procedure for non-gest tion l-di betes p tients) Test You
r Knowledge 17-9
How m ny times ( t minimum) is the blood dr wn for
p tient completing
3-ho
ur glucose
toler nce test? (Outcome 17-10) Glycosyl ted Hemoglobin As presented in Ch pter
16, elev ted
blood glucose lev- els will eventu lly ch nge the hemoglobin molecule present in
the red cells of
the body by irreversibly binding glucose to the hemoglobin A subunit. This compo
und is known s
glycosyl ted or glyc ted hemo- globin, nd is bbrevi ted s Hb A1c. The typic l
red blood cell
survives in the body for 90 to 120 d ys. Bec use the ch nges to the hemoglobin m
olecule re
const ntly occurring whenever the blood glucose level becomes elev ted (whether
the p tient is
w re of the elev tion or not) the Hb A1c level is n excellent w y to me sure g
lycemic control
over 2- to 3-month period. The Hb A1c test is not recommended s di gnostic
tool for
di betes, but is n excellent tool for monitoring the m n gement of the dise se.
The Americ n
Di betes Associ tion h s provided guid nce reg rding the frequency of this test
nd the
interpret tion of the results. A nondi betic p tient will h ve Hb A1c levels bel
ow 6%. For
di betic p tients, the go l is to rem in below 7%, s it is understood th t ther
e m y be spikes
in the blood glucose th t re un void ble. As p rt of the m n gement of di betes

, those who h ve
unst ble blood sug rs should h ve their Hb A1c tested qu rterly; those who ppe
r to h ve good
glycemic con- trol should be checked t le st two times per ye r. In ddition, t
he recommend tion
includes perform nce of n nnu l lipid profile nd urine micro lbumin testing t
o screen for
ren l d m ge. Micro lbumin testing is dis- cussed in more det il l ter in this c
h pter. Test Your
Knowledge 17-10 The Hb A1c test m y be used to monitor the over ll glycemic cont
rol for p tient
for which of these time interv ls? . 1 month b. 6 weeks c. 3 months d. 6 months
(Outcome 17-11)
1899_Ch17_349-370 21/12/11 5:26 PM P ge 358 Ch pter 17 Glucose Testing 359 TABL
E 17-1 Types of
di betes, di gnostic test procedures, nd tre tment methods Type of Di betes Sym
ptoms Clinic l
Present tion Di gnostic Test Procedures Tre tment Di betes insipidus Type 1 di b
etes Type 2
di betes Gest tion l di betes Excessive mount of urine production; dehydr tion
nd electrolyte
imb l- nce s result of fluid loss Hyperglycemi , f tigue, dehydr tion, n use
, vomiting,
weight loss M y be sympto- m tic for ye rs; usu lly develops slowly. Hyper- gly
cemi , f tigue,
dehydr tion, n u- se , vomiting, weight loss Often symptom tic; m y develop sym
p- toms like
those of di betes mellitus L ck of v sopressin production by pitu- it ry gl nd o
r kid- ney
resist nce to v sopressin Auto ntibodies destroy p ncre tic cells th t produce i
nsulin, resulting
in reduced or bsence of insulin Cells of the body develop resist nce to insulin
; keeps glu- cose
from entering cells so the pl sm glucose levels become elev ted Incre sed level
s of hormones
from pregn ncy incre se cellul r resist nce to insulin Medic l history, physic l
ex min tion,
urin lysis, m gnetic reson nce im ging nd/or CAT sc n of the br in, fluid depri
v tion testing
Medic l history, physic l ex min tion, bnorm l blood glucose levels with verifi
c tion of f sting pl sm glucose bove 126 mg/dL or r ndom pl sm glu- cose bove 200 mg/dL Me
dic l history,
physic l ex min tion, bnorm l blood glucose levels with f sting pl sm glucose
or glucose toler nce test Abnorm l glucose ch l- lenge test nd/or bnorm l glucose toler nce
test V sopressin
(usu lly n s l spr y) nd fluid repl cement if neces- s ry Insulin injections
Lifestyle
ch nges, or l medic tion; insulin injections m y become necess ry if or l medic
tions dont
ccomplish desired glycemic control Lifestyle ch nges, or l medic tions, or insu
lin injections
(if needed for glycemic control) until birth of inf nt POINT OF INTEREST 17-2 Ne
w Testing
procedures for monitoring di betes There is
new procedure v il ble for monito
ring the glycemic
control of di betes p tients. The Gly- coM rk blood test me sures the level of
subst nce
n tur lly present t consistent level in the blood- stre m. This molecule is k

nown s
1,5- nhydro- D-glucitol (1,5 AG), which is monos cch ride th t is very close i
n chemic l
structure to glucose. When the glucose level of di betic p tient rises bove 1
80 mg/dL, the
kidneys re not ble to re b- sorb the 1,5 AG molecule bec use the glucose block
s the sites for
this molecule to be re bsorbed. Thus, when the glucose level rises (with poor gl
ycemic control)
the 1,5 AG concentr tion de- cre ses below the reference r nge. This procedure p
rovides n
opportunity to moni- tor the glycemic control for di betic p tients for the p st
1 to 2 weeks. As
comp rison, the Hb A1c test provides me surement of the glycemic control ove
r the p st 3
months. M ny physici ns feel th t this new testing method m y llow them to tre
t their newly
di gnosed di betics more efficiently, bec use the re- sults will be ffected by
poor glycemic
control very quickly. Blood Ketone Testing M ny home glucose meters re now c p
ble of testing
ketones s well s glucose levels in the bloodstre m. Elv ted levels of ketones
in the blood re
indic tive of fluctu tions in the blood glucose levels. Although close ttention
to diet,
exercise, nd medic tion will help to ensure th t di betic 1899_Ch17_349-370 2
1/12/11 5:26 PM
P ge 359 p tient m int ins ppropri te glycemic control, there m y be situ tions
th t stress the
body nd llow the di betes to become out of control, such s the following: P t
ients with
preexisting di betes who become pregn nt P tients who re ill for sever l d ys,
especi lly if
they re vomiting or h ve di rrhe Situ tions of unusu lly high stress Blood glu
cose levels
equ l to or gre ter th n 300 mg/dL Symptoms of hyperglycemi such s n use , f t
igue, nd
vomiting th t re not ssoci ted with nother dis- e se process Some ketone test
ing procedures
will provide qu lit tive results indic ting the presence or bsence of ketones i
n the blood.
Other testing methods provide qu ntit tive results, indic ting the level of keto
nes present.
P tients should dis- cuss their situ tion with he lth-c re provider before tes
t- ing for the
presence of blood ketones. C pill ry S mple Testing nd Correl tion to Pl sm Gl
ucose Levels The
World He lth Org niz tion recommends th t the pl sm glucose level (r ther th n
whole blood
testing) is used for di gnosis nd monitoring of di betic p tients. However, thi
s is not lw ys
possible, even in l bor tory or clinic setting. Some rur l re s in the United
St tes do not
h ve l bor tory f cilities th t meet these st nd rds. Outside of the United St t
es it c n become
even more problem tic. These rur l or underserved re s often h ve
glucose met
er v il ble,
which is designed to perform whole blood glucose testing r ther th n pl sm gluc
ose testing.
Pl sm glucose levels re 10% to 15% higher th n those of whole blood obt ined v

i
c pill ry
procedure. Bec use the glucose levels for di gnosis of predi betes nd di betes
re very
specific, it m y be necess ry to c l- cul te the pl sm glucose level using
wh
ole blood c pill ry result. M ny of the new glucose meters include this c lcul tion in their
results when
reported; for inst nce, inste d of the number on the screen indic ting the glucose level in the
whole blood specimen th t w s just tested,
c lcul tion will h ve lre dy been
included nd the
number is ctu lly indic tive of the pl sm glucose level. If the meter in use d
oes not use this
c lcul tion, m ny of the glucose meter m nuf cturers websites will provide more i
nform tion to
correl te whole blood glu- cose to pl sm glucose levels. This discrep ncy betwe
en pl sm nd
whole blood glucose is not often expl ined to p tients who re self-monitoring t
heir levels t
home. It is import nt to mention th t their results m y not comp re to the l bor
tory results
bec use the reference r nges nd test- ing methods re different. The he lth-c r
e provider nd
ny di betes educ tors who re working with the p tients need to help them devel
op p r meters to
use for self-monitoring from the testing instrument th t they re using t home.
Glucose m y lso
be tested using serum s mples. This is not recommended for di betes screening be
c use the glucose
level in the specimen c n ch nge slightly during the time period required for th
e blood to clot.
If the specimen is centrifuged immedi tely fter clotting, with immedi te sep r
tion of the serum
from the cells, then the glucose result will be very simil r to th t of pl sm
specimen.
However, if there is
del y in the processing of the specimen, the serum glucos
e result will be
much lower th n pl sm result would h ve been for th t p tient. 360 Section IV
Clinic l
Chemistry Test Your Knowledge 17-11 If
whole blood glucose nd
pl sm glucos
e were collected
on the s me p tient t the s me time, which of the results would be expected to
be higher?
(Outcome 17-12) Urine Testing for Di betics Urine testing is not used s di gn
osis tool for
di betes or predi betes. The threshold for e ch individu l for the mount of glu
cose toler ted in
the bloodstre m m y be different. Usu lly nyone who h s blood glucose level
bove 170 mg/dL
will h ve glucose present in the urine s well, condition known s glucosuri .
The urine of
di betic p tients m y lso be monitored for other chemic l subst nces. The prese
nce of ketones in
the urine (ketonuri ) m y be n indic tor of poor glycemic control. When the glu
cose in the
bloodstre m c nnot enter the cells of the body to be used for energy, the body w
ill bre k down
f tty cids s n ltern tive en- ergy source. This process is n tur l, nd occu
rs in our body
during f sting periods nd times when our energy needs re cceler ted. Ketones

re by-product
of f tty cid met bolism, nd if they re present in the urine, it m y indic te
excessive use of
f tty cids for energy. This me ns th t there is not enough insulin (or the cell
s re resisting
the insulin th t is present) to llow the glucose to be met bolized s it should
by the cells of
the body. Glucose molecules re l rge, nd re not designed to be p ssed into th
e urine in
me sur ble mounts. When 1899_Ch17_349-370 21/12/11 5:26 PM P ge 360
p tient h
s high levels of
blood glucose over n ex- tended period of time, these l rge molecules re force
d through the
filtr tion system of the nephron, c using d m ge bec use of their l rge size. Th
e d m ged
glomerulus will now llow other l rge molecules pres- ent in the blood to enter
the urine. The
presence of these subst nces in the urine is considered to be bnor- m l nd ind
ic tive of d m ge
to the kidney. One of these l rge molecules is pl sm protein c lled lbu- min
. Approxim tely
20% to 40% of ll di betics de- velop ren l dise se, nd the first sign th t the
kidneys h ve
been d m ged m y be the presence of micro lbu- minuri . This me ns th t there r
e sm ll mounts
of lbumin present in the urine; the levels re just bove norm l r nges. When t
he lbumin levels
in the urine re still low, it m y be possible to elimin te further kid- ney d m
ge by incre sing
efforts for glycemic control. If the levels incre se to m cro lbuminuri (l rge
mounts of
lbumin in the urine), it is sign th t the ren l dise se h s progressed with m
ore severe d m ge
to the filtr tion system of the kidneys. It is recom- mended th t ll di betics
be tested for
urine micro lbu- min levels t le st nnu lly. GLUCOSE TESTING METHODS There re
m ny different
types of instruments used to perform glucose testing. The equipment v ries from
m chines th t
n lyze hundreds of specimens per hour to those th t test one specimen t
time
s CLIAw ived test. Home Glucose Testing Instruments Blood glucose monitors re the mos
t common
self-testing products sold in the world. They re n essenti l p rt of di betes
educ tion nd
monitoring, nd llow di betic p tients
degree of freedom nd control of their
dise se th t
previously w s not possible. Blood glucose meters re ll simil r in function;
sm ll testing
strip is inserted into the instrument,
drop of blood is pplied, nd result
ppe rs on the
screen on the front of the instrument within seconds. However, these instruments
m y v ry in
size, complexity, cost of oper tion, nd necess ry qu lity control me sures. The
se re some
consider tions to t ke into ccount when choosing n instrument for home glucose
monitoring,
including the following: 1. Wh t type of di betes is being monitored? For those
who h ve type 1
di betes nd use n insulin pump, continuous glucose monitor m y be the most

ppropri te choice
of device. These monitors h ve sensor th t is pl ced just under the surf ce of
the skin th t
s mples the blood glucose level 24 hours per d y. These results re tr nsmitted
to recording
device with memory, or to n insulin pump. If the continuous glucose monitor i
s p ired with n
insulin pump, the mount of insulin in- jected will be utom tic lly m tched to
the glucose
re dings. A he lth-c re provider nd/or di betes educ tor would be ble to help
the p tient
decide if this is the best method for p rticul r p tient. 2. A p tient should
not t ke the
first testing instru- ment th t is offered nd ssume th t they re ll like. S
ome instruments
require l rger specimen volume th n do others, nd other m chines h ve code
th t must be
verified whenever new bottle of test strips re opened. Some p tients prefer i
nstru- ments th t
dont need code to be entered, nd some re most interested in sm ll instrumen
t th t c n t ke
s mples from different re s of the body in ddition to the fingertips. If possi
ble, p tients
should s mple sever l types of instruments when they meet with their he lth-c re
provider to
discuss the need for blood glucose testing. Di betes educ - tors re nother goo
d resource. 3.
Instruments m y v ry by cost of oper tion. The blood glucose meters themselves
re often quite
inexpensive; sometimes they re even free. However, the testing strips c n be qu
ite expensive. A
typic l di betic p tient who is self-monitoring will use t le st two or three s
trips per d y.
Some insur nce pl ns will help to p y only for specific br nds of instruments n
d strips, so it
is best to investig te this e rly in the process. 4. P tients should be cert in
th t they c n
re d the results displ yed on the instrument used. For those with imp ired visio
n, meters re
v il ble th t dis- pl y the result in l rger numbers. Also, the lighting on the
screen m y v ry,
which might m ke cert in models less ppe ling for some p tients with specific v
ision needs.
Qu lity Control nd Common Errors M ny di betic p tients h ve been self-monitori
ng for more th n
dec de. Unfortun tely, they m y not h ve been offered the resources th t re n
ow v il ble when
they st rted the process, nd their home testing methods m y not be providing c
cur te results.
It is import nt to remember th t the glucose meters used by p tients t home re
n essenti l
tool for their he lth m inten nce. Educ tion bout qu lity control methods Ch pt
er 17 Glucose
Testing 361 1899_Ch17_349-370 21/12/11 5:26 PM P ge 361 for the instrument, stor
ge nd use of
strips, nd record- keeping options should be offered. Periodic lly, p tients sh
ould bring in
their home glu- cose meter nd comp re pl sm glucose levels from the l bor tory
to those th t
they obt in t the s me time using their own instrument. Although these results

m y v ry s much
s 10% to 15% from one nother, this process c n identify meters th t re not te
sting ccur tely,
or help the clinic st ff to identify problems with the w y the p tient is perfor
ming the test on
his or her meter while observing the p tient. Qu lity control solution m y be pu
rch sed nd
tested periodic lly to ssure th t the results obt ined by the meter re ccur t
e. Desir ble
r nges for the qu lity control solution re usu lly printed on the box or bottle
cont ining the
solution, nd the p tient c n immedi tely verify the ccur cy of the result. Exp
l in to p tients
th t if the m chine is not testing within these r nges, they need to correct the
situ tion before
continuing use of the meter. Cle ning nd proper stor ge of the instrument is es
senti l, but
often overlooked. Re gent strips must be stored s directed by the m n- uf cture
r, nd need to
be disc rded if they re discol- ored or expired. M ny p tients le ve the bottle
open between
tests, which c uses the strips to bsorb mois- ture nd provide erroneous result
s. Reviewing
the troubleshooting section of the meter instructions with p tients c n help the
m to under- st nd
error codes nd possible courses of ction when the instrument is not performing
s expected.
Much of this inform tion is v il ble online s well. P tients who re self-moni
toring blood
glucose levels must keep c reful records in order for their efforts to be me nin
gful to their
c re. Educ ting the p tients bout different w ys to ccomplish this go l c n be
benefici l. Some
of the meters v il ble on the m rket h ve the c p city to store gre t de l of
inform tion th t
m y be downlo ded to
computer to be printed or tr nsmitted to
he lth-c re pr
ovider. P tients
m y prefer to keep h ndwritten log; if so, they should be provided with bl nk
copies for their
use. Ask p tients bout the type of l ncet they re using, nd how they re disp
osing of the
used devices. M ny of the newer utom tic l ncets m y be djusted ccording to t
he depth of the
puncture, which is ben- efici l to those who test often. L ncets should never be
used more th n
once, nd should not be disposed of in the regul r home tr sh. Some offices llo
w the p tients to
bring in their l ncets in n ppropri te bioh z rdous sh rps cont iner for dispo
s l; others do
not. To ssist p tients with proper dispos l methods, find out wh t the recommen
d tions re in
your re for dispos l of this type of w ste, nd provide th t inform tion to yo
ur di betic
p tients. 362 Section IV Clinic l Chemistry Test Your Knowledge 17-12 Wh t is o
ne re in which
medic l ssist nt m y need to offer educ tion nd ssist nce for di betics who
re performing
home monitoring of their glucose levels? (Outcome 17-13) L bor tory Glucose Test
ing nd Potenti l
Sources of Error When glucose testing is performed in l rge l bor tory on n

utom ted
instrument, pl sm or serum is tested. There re sever l different enzym tic met
hods v il ble
for glucose testing with simil r reference r nges b sed on the type of specimen.
F sting s mples
will h ve different results from r ndom specimens or those th t were dr wn s p
rt of glucose
toler nce test. Glucose testing m y lso be ordered on cerebrospin l fluid (CSF)
. The reference
r nge for this test is pproxi- m tely two-thirds of the blood glucose level for
the s me p tient
collected t the s me time s the cerebr l spin l fluid s mple. When the CSF glu
cose levels re
low s comp red to the pl sm glucose, it m y be indic tive of meningitis. Bec u
se specimen
dr wn for pl sm or serum glu- cose testing in l bor tory must be processed be
fore it is
n lyzed, there exists opportunities for error in the pre- n lytic l ph se. The
following re
some consider tions th t must be ddressed to void potenti l problems: The timi
ng of the blood
dr w is critic l. For inst nce, if the specimen is to be dr wn f sting, it is im
per tive th t the
p tient is informed nd the prep r tion is ver- ified before the collection occu
rs. Glucose
continues to be met bolized by the cells pres- ent in the blood specimen fter i
t is dded to the
collection tube. If the specimen is not processed by centrifug tion nd tested w
ithin 1 hour of
collection, the pl sm or serum glucose level m y not indic te the ctu l mount
of glucose
present in the bloodstre m of the p tient; inste d, it will be indic tive of the
mount left in
the tube fter the glucose h s been uti- lized by the cells. If there will be mo
re th n 1-hour
del y in testing fter collection,
tube with sodium fluoride or pot ssium ox l
te dditives
should be used for the specimen collection. This slows down the utiliz tion of g
lucose by the
cells, nd llows the 1899_Ch17_349-370 21/12/11 5:26 PM P ge 362 pl sm glucose
to rem in st ble
for pproxim tely 24 hours t room temper ture. Reference r nges for glucose lev
els re
gener lly st ted s pl sm levels. However, serum m y lso be dr wn for glucose
testing, s long
s the serum is sep r ted from the cells within 1 hour. The reference r nges re
usu lly the s me
for pl sm nd serum glucose. CLIA-w ived testing for blood glucose is not desig
ned to be
performed with pl sm s mples. It is import nt to re d the directions for the CL
IA-w ived methods
to ensure th t the results will be ccur te. Ch pter 17 Glucose Testing 363 Pro
cedure 17-1:
Perform nce of Hb A1c Test Using B yers A1c Now+ System CAAHEP/ABHES STANDARDS CA
AHEP St nd rds
I.P. An tomy nd Physiology, #13 Perform chemistry testing ABHES St nd rds 10. M
edic l
L bor tory Procedures, b. CLIA-w ived tests Gr du tes: b. Perform selected CLIAw ived tests
th t ssist with di gnosis nd tre tment, #3 Chem- istry Testing 1. Greet nd th

en identify
p tient using t le st two unique identifiers. 2. Verify test ordered, nd expl
in procedure to
p tient. 3. Verify th t ll s mples, re gents, nd monitor re t room temper tu
re. 4. W sh h nds
nd pply gloves. 5. Assemble necess ry equipment. All p tients must be identifi
ed properly
before collect- ing s mples or performing l bor tory testing. All l bor tory tes
t orders should
be verified by check- ing the ch rt nd/or requisition form more th n once. A qu
ick expl n tion
of the procedure for the p tient will ensure more cooper tion. Test results m y
not be v lid if
the s mple nd/or re gents re not t room temper ture. H nds should lw ys be w
shed between
p tients nd before st rting ny procedures. Gloves re ppropri te person l pro
tective equipment
(PPE) for this procedure. V rious steps in this procedure require c reful dherence to limits
in time. M teri ls th t re org nized will ssist in the process of following th
e directions
properly. TASK Correctly perform n Hb A1c test using B yers A1c Now+ testing sys
tem. CONDITIONS
Gloves L bor tory co t H nd s nitiz tion supplies A1c Now plus monitor S mple di
lution
kit pouch Test c rtridge pouch Whole blood from c pill ry puncture or well-mixed
hep rinized
blood s mple G uze p d Bioh z rdous w ste cont iner Qu lity control m teri ls Pr
ocedure
R tion le Continued 1899_Ch17_349-370 21/12/11 5:26 PM P ge 363 364 Section IV
Clinic l
Chemistry Procedure 17-1: Perform nce of Hb A1c Test Using B yers A1c Now+ Systemc
ontd
Procedure R tion le 6. Prior to perform nce of test, verify whether qu l- ity
control (QC)
specimen needs to be tested, nd if so, complete th t test before the p tients te
st is
performed. 7. Verify th t ll lot numbers m tch on the monitor, the s mple dilut
ion kit pouch,
nd the test c r- tridge pouch. 8. Verify th t the kit h s not expired. 9. Open
the s mple
dilution pouch nd remove the dilution device. 10. Perform the c pill ry punctur
e following
ppro- pri te procedure, or mix the whole blood s mple to prep re for next step.
11. Add 5-L
blood s mple to blood collection device. 12. Plug blood collection device into t
he s mpler body.
Push firmly so th t there is no g p on insertion. Liquid QC should be used to ve
rify the test
results t these times: . With new shipment b. Whenever new lot number of r
e gents or QC is
put into use c. New oper tor; someone who is being tr ined on the procedure d. P
roblems with
stor ge, instrument, re gents, etc. e. To ensure th t stor ge conditions re fin
e, QC should be
performed t le st once monthly. If the lot numbers do not m tch, the monitor wi
ll not provide
v lid test result upon completion of the test. The B yers A1c Now+ kit m y be kep
t t room temper ture for 4 months, but then ny unused m teri- ls must be disc rded. If kep

t refriger ted,
the sup- plies m y ll be used until the printed d te of expir tion. The dilutio
n device should
not be removed until just before the test is performed. Whole blood specimen m y
be obt ined from
finger- stick c pill ry puncture, or green top hep rinized s mple m y be used
s long s it h s
not been t room temper ture for more th n 8 hours, or refrig- er ted for more t
h n 14 d ys.
Lithium hep rin or sodium hep rin re ccept ble s mple types. It is not necess
ry to me sure the
blood dded to the collection device; however, t ke c re th t the s mple re on
the collection
device is filled, but not over- filled. If it ppe rs to be underfilled, dd mor
e s m- ple; if
overfilled, wipe w y excess. Do not llow excess blood to rem in on the outside
of the collection device. If g p is present, the s mple will not combine with the dilution
solution inside
the s mpler body, nd the results will be inv lid. 1899_Ch17_349-370 21/12/11 5:
26 PM P ge 364
Procedure R tion le Ch pter 17 Glucose Testing 365 13. Sh ke the device six to
eight times to
mix the dilution solution with the s mple thoroughly. 14. Set s mple ssembly on
the t bletop s
the test c rtridge is prep red. 15. Te r open the test c rtridge pouch nd ensur
e th t the code
number on the c rtridge m tches the code number printed on the instrument. 16. I
nsert the test
c rtridge into the monitor until it is se ted firmly nd n udible click is he
rd. 17. Verify
th t the instrument screen displ y re ds WAIT. 18. When the instrument screen di
spl ys SMPL, pick
up the s mpler device nd remove the b se piece, exposing the plunger. 19. Deliv
er the s mple by
pressing the plunger gently nd firmly into the corresponding s mple pplic - ti
on re on the
c rtridge. Remove fter 1 second. 20. The instrument screen will displ y count
down from 5
minutes to 0. Do not move the monitor during this time. 21. The results will dis
pl y s
percent ge on the screen. Record results ppropri tely in computer, on log sheet
, nd/or in ch rt
if v il ble. 22. Following office protocol, llow the p tient to le ve the test
ing re , or
consult with the he lth- c re provider. 23. Dispose of s mple dilution c rtridge
nd test
c rtridge s bioh z rdous tr sh, nd disinfect work re . 24. Remove gloves nd
s nitize h nds.
25. Document the test results in p tient ch rt. Solution must be well mixed to b
re k down the
blood s mple for ppropri te testing. This system is set up so th t the monitor
h s definitive number of uses v il ble; ll the supplies need to be from the s me seri l
number nd
c rtridge code numbers for the results to be v lid. If the test c rtridge is not
se ted firmly,
no test proce- dure will occur. The instrument undergoes
series of intern l se
lf- checks before
the testing process proceeds. The b se piece must be removed so th t the s mple

c n be dded to
the testing device. The s mple must be dded within 2 minutes. The s mple pplic
tion must occur
ll t once, but ex- cessive force is not necess ry. The pplic tion device must
be removed for
the testing process to proceed. The testing process t kes 5 minutes to complete.
Mov- ing the
monitor m y c use in ccur te or inv lid test results. Results must be recorded i
mmedi tely so
th t they re reported correctly. If results re f r outside of the norm l r nge
, it m y be
office policy th t the he lth-c re provider spe ks with the p tient before he or
she le ves the
office. The work re must lw ys be cle n nd disinfected fter e ch procedure.
H nds must
lw ys be s nitized fter removing gloves. All results must be documented in the
p tients ch rt.
D te 8/30/2014: Hb A1c 6.9%
Connie Lieseke, CMA (AAMA) 12:45 p.m.
1899_Ch17_349-370 21/12/11 5:26 PM P ge 365 366 Section IV Clinic l Che
mistry Procedure
17-2: Perform nce of Whole Blood Glucose Testing TASK Correctly perform blood
glucose test
using the HemoCue Glucose 201 An lyzer. CONDITIONS Gloves L bor tory co t H nd s
nitiz tion
supplies HemoCue Glucose 201 An lyzer HemoCue Glucose microcuvettes HemoCue Gluc
ose Control
Cuvette C pill ry puncture supplies Bioh z rd sh rps cont iner G uze or l bor to
ry wipes
Bioh z rdous w ste cont iner Qu lity control m teri ls CAAHEP/ABHES STANDARDS CA
AHEP St nd rds
I.P. An tomy nd Physiology, #13 Perform chemistry testing ABHES St nd rds 10. M
edic l
L bor tory Procedures, b. CLIA-w ived tests Gr du tes: b. Perform selected CLIAw ived tests
th t ssist with di gnosis nd tre tment, #3 Chemistry Testing Procedure R tion
le 1. Greet nd
then identify p tient using t le st two unique identifiers. 2. Verify test orde
red, nd expl in
procedure to p tient. 3. W sh h nds nd pply gloves. 4. Assemble necess ry equi
pment, nd verify
th t ll re gents re within the posted expir tion d tes. 5. Turn on the HemoCue
instrument. When
the LCD displ y re ds READY, the instrument is re dy to be used. 6. Pl ce the He
moCue Control
Cuvette on the cuvette holder nd push the holder into the instrument. All p tie
nts must be
identified properly before collect- ing s mples or performing l bor tory testing
. All l bor tory
test orders should be verified by check- ing the ch rt nd/or requisition form m
ore th n once. A
quick expl n tion of the procedure for the p tient will ensure more cooper tion.
H nds should
lw ys be w shed between p tients nd before st rting ny procedures. Gloves re
ppropri- te
person l protective equipment (PPE) for this procedure. Glucose microcuvettes mu
st be stored
refriger ted, s well s the glucose control solution, but they must be removed

from the
refriger tor nd pl ced within re ch before the process begins. M teri ls th t
re org nized will
ssist in the process of following the directions properly. The HemoCue instrume
nt undergoes
series of self- checks when it is turned on. The control cuvette is designed to
check the
function of the instrument nd detect ny interference with the testing method.
It should be used
t le st once per d y. 1899_Ch17_349-370 21/12/11 5:26 PM P ge 366 Ch pter 17 G
lucose Testing
367 Procedure R tion le 7. Verify th t the v lues displ yed on the instrument sc
reen re within
the ccept ble r nges provided with the Control Cuvette. 8. Prior to perform nce
of test, verify
whether qu l- ity control (QC) specimen needs to be tested, nd if so, complet
e th t test
before the p tients test is performed. 9. Perform c pill ry puncture, using pp
ropri te
technique. Wipe w y the first drop of blood. 10. Remove microcuvette from the
cont iner. Hold
the open end of the microcuvette to the drop of blood obt ined from the c pill r
y punc- ture.
Approxim tely 5 L of blood will enter the microcuvette. 11. Wipe w y ny excess
blood on the
outside of the microcuvette. 12. Pl ce the filled microcuvette on the holder nd
push it into the
instrument for processing. 13. Within few seconds, the glucose result will pp
e r on the
displ y screen in mg/dL. Record this result ppropri tely, in the computer, the
p tient log
sheet, nd/or the p tients ch rt. 14. Following office protocol, llow the p tien
t to le ve the
testing re , or consult with the he lth- c re provider. 15. Pull the microcuvet
te holder b ck
out, remove the microcuvette, nd disc rd in the bioh z rdous tr sh. The r nges
re specific per
cuvette nd re designed specific lly for e ch instrument. If the results re ou
t of r nge, try
cle ning the cuvette nd testing g in. If they continue to be out of r nge, the
instrument
c nnot be used for p tient testing nd the m nuf c- turer must be notified. Liqu
id QC should be
tested following l bor tory pro- tocol nd m nuf cturers recommend tions. Ex m- p
les of when QC
should be used to verify the test results include the following: . With new s
hipment b.
Whenever
new lot number of re gents or QC is put into use c. New oper tor; som
eone who is being
tr ined on the procedure d. Problems with stor ge, instrument, re gents, etc. e.
To ensure th t
stor ge conditions re fine, QC should be performed t le st once monthly The fi
rst drop of blood
should be disc rded, s it m y be cont min ted with interstiti l fluids resultin
g in n erroneous
result. The blood will enter the microcuvette by c pill ry ction. It is not pos
sible to overfill
the microcuvette. Avoid ir bubbles s the microvuvette is filled. If excess blo
od is present on
the outside of the microcu- vette, it m y interfere with the testing process nd

c use erroneous
results or n instrument error while processing the specimen. The microcuvette w
ill fit only when
pl ced on the holder in cert in direction. The result will st y on the screen
until the
microcuvette holder is pulled from the instrument for the next s mple to be dde
d. It is
import nt to record it s soon s it is evident on the screen. If results re f
r outside of the
norm l r nge, it m y be of- fice policy th t the he lth-c re provider spe k with
the p tient
before he or she le ves the office. The microcuvette cont ins blood, so it must
be dis- c rded s
bioh z rdous subst nce. Continued 1899_Ch17_349-370 21/12/11 5:26 PM P ge 367
SUMMARY Di betes
is dise se th t h s re ched epidemic propor- tions. It requires e rly di gnosis
nd consistent
mon- itoring for successful tre tment. Consequences of untre ted di betes includ
e c rdiov scul r
dise se, loss of vision, poor he ling, di betic neurop thy, nd perm nent ren l
d m ge.
Predi betes c n now be identified, nd e rly intervention h s helped to stop the
progression of
the dise se for those who m ke ppropri te ch nges to their diet nd exercise h
bits. There re
v rious testing procedures th t m y be used to di gnose predi betes nd di betes
, nd to monitor
tre tment once it is under w y. Type 1 di - betes must be tre ted with insulin i
njections, nd
the dos ge is directly rel ted to the mount of glucose present in the body t t
he time. Type 2
di betes is m n ged with lifestyle ch nges nd or l medic tion. Frequent blood g
lucose monitoring
ssists with tre t- ment for this type of di betes s well. Gest tion l di betes
is developed by
pregn nt women nd m y be identified tow rd the end of the pregn ncy. Gest tion
l di betes th t
is untre ted m y le d to pregn ncy complic tions s well s serious he lth issue
s for the unborn
child. Sever l different timed 368 Section IV Clinic l Chemistry Procedure 17-2
: Perform nce of
Whole Blood Glucose Testingcontd Procedure R tion le 16. Turn off the instrument,
nd disinfect
the mic- rocuvette holder. 17. Be sure to dispose of the c pill ry puncture devi
ce in sh rps
cont iner nd ny other equipment th t m y be cont min ted with blood in bioh
z- rdous
cont iner. 18. Disinfect the work re . 19. Remove gloves nd s nitize h nds. 20
. Document the
test results in the p tients ch rt. The microcuvette holder c n be completely rem
oved from the
instrument for cle ning with lcohol or so p nd w ter. It is vit l to lw ys pr
operly dispose of
bioh z rds. It is import nt to keep the work re cle n nd org nized. H nds mus
t lw ys be
s nitized fter removing gloves. All results must be documented in the p tients c
h rt. D te
8/17/2014: F sting blood glucose 85 mg/dL
Connie Lieseke, CMA (AAMA) 10:50

.m.

glucose tests llow n opportunity to identify nd cl ssify the di betic

p tient, including
f sting pl sm glucose, nd postpr ndi l glucose testing. Hb A1c testing is lso
useful to
monitor the progress of the dise se. Self-m n gement testing performed t home b
y di betic
p tients helps to chieve glycemic control between visits to the he lth-c re pro
vider. TIME TO
REVIEW 1. Glycogenolysis is: Outcome 17-1 . The bre kdown of glycogen to be use
d for energy b.
The form tion of glycogen s me ns of storing energy for l ter use c. The bre
kdown of glucose
d. The bre kdown of gluc gon 2. Wh t does
BMI tell us bout Outcome 17-1 p t
ient? . A
c lcul tion comp ring the height nd weight of
p tient b. A c lcul tion used t
o comp re glucose
nd body weight 1899_Ch17_349-370 21/12/11 5:26 PM P ge 368 c. A c lcul tion of
Hb A1c d. None of
the bove 3. When is the term imp ired Outcome 17-1 f sting glucose used? . Whe
n the f sting
glucose level is over 200 mg/dL b. When the f sting glucose level is between 100
to 125 mg/dL c.
When the f sting glucose level is below 100 mg/dL d. When the f sting glucose le
vel is between
100 to 124 mg/dL 4. Does the rele se of gluc gon Outcome 17-2 r ise or lower blo
od glucose
levels? . Gluc gon r ises blood glucose levels b. Gluc gon decre ses blood gluc
ose levels 5.
True or F lse: Type 1 di betes Outcome 17-4 is tre ted with insulin injections w
here s type 2
di - betes is tre ted with or l medic tions nd lifestyle ch nges. 6. True or F
lse: A p tient
who is Outcome 17-5 di gnosed with gest tion l di betes h d di betes before she
bec me pregn nt.
7. Which of these body systems m y Outcome 17-6 be ffected by di betes? . C rd
iov scul r b.
Integument ry c. Nervous d. Eye e. All of the bove 8. How long should p tient
go Outcome 17-8
without food nd drink before f sting pl sm glucose is dr wn? . 8 hours b. 1
6 hours c. 12
hours d. 10 hours 9. True or F lse: A postpr ndi l Outcome 17-9 glucose s mple i
s lw ys dr wn
fter drinking glucose-rich bever ge. 10. Wh t is the correct number of Outcom
e 17-10 times
th t p tient drinks the glucose solution while completing
3-hour glucose tol
er nce test
procedure? . One b. Two c. Three d. Four Ch pter 17 Glucose Testing 369 11. Tr
ue or F lse: The
Hb A1c Outcome 17-11 test is used to est blish di gnosis of di betes. 12. How
m y the serum
glucose Outcome 17-13 level be ffected if the s mple is dr wn into tube with
no dditive nd
the tube is llowed to sit for 3 hours before centrifug tion nd processing? .
The glucose level
m y incre se b. The glucose level m y decre se c. There will be no effect on the
glucose level d.
It will be impossible to test the glucose level C se Study 17-1: Use of the Hb A
1c Rose Gr ce is
p tient who h s been tre ted success- fully for type 2 di betes for m ny ye rs

with or l medic tion nd lifestyle ch nges. The p st few months h ve been especi lly stressfu
l for her, nd
she h s not been monitoring her diet, exercise, or blood glucose levels consiste
ntly during this
time. A week before her qu r- terly ppointment with her physici n she st rts to
w tch her diet
c refully nd c tch up with some of her glucose monitoring to prep re for the vi
sit. When she
sees the physici n, she is ple sed to h ve her r ndom glucose t 145 mg/dL, nd
she does not
sh re ll the ctivities of the p st few months with her he lth-c re provider,
s it ppe rs th t
her blood glucose is fine. However, when the Hb A1c result is v il ble, Roses ph
ysici n c lls
her nd tells her th t she needs to come in for nother visit to discuss dditio
n l tre tment
options. 1. Wh t did the Hb A1c result tell the he lth-c re provider th t w s no
t pp rent with
the blood test performed t the initi l visit? RESOURCES AND SUGGESTED READINGS N
tion l
Di betes Inform tion Cle ringhouse Provides in-depth inform tion bout the v riou
s types of
di betes, di gnosis, nd m n gement http://www.di betes. niddk.nih.gov/ Americ n
Di betes
Associ tion website Inform tion bout risk f ctors, m n ging di betes, nd suppor
t for those who
h ve di betes; website provides inform tion for providers, p tients, nd f mily
members
http://www. di betes.org Executive Summ ry: St nd rds of Medic l C re in Di betes
2009
Di betes C re 32, no. S1 (J nu ry 2009): S6S12, doi: 10.2337/dc09-S006. 1899_Ch17
_349-370
21/12/11 5:26 PM P ge 369 2007 Di betes F ct Sheet N tion l Center for Chronic Dis
e se
Prevention nd He lth Promotion; Provides st tistics for di betes morbidity nd
mort lity in 2007
http://www.cdc.gov/di betes 370 Section IV Clinic l Chemistry St nd rds of di b
etic medic l c re
developed by world- wide consensus nd dopted by the World He lth Org ni- z tio
n, N tion l
Institutes of He lth, nd the Americ n Di betes Associ tion. Includes p r meters
for di gnosis
nd tre tment. 1899_Ch17_349-370 21/12/11 5:26 PM P ge 370 371 Ch pter 18 Other
Select Chemistry
Tests Const nce L. Lieseke, CMA (AAMA), MLT, PBT(ASCP) CHAPTER OUTLINE Lipid Tes
ting Cholesterol
Cholesterol Met bolism Within the Body Types of Cholesterol Risk F ctors, Desire
d R nges, nd
Clinic l Interpret tion of Abnorm l Lipid Results Triglycerides Met bolic Syndro
me Reference
R nges nd Clinic l Interpret tion of Abnorm l Results Lipid P nels Electrolytes
Function of
Electrolytes nd Consequences of Electrolyte Imb l nces Testing Prep r tion nd
Common Testing
Methods Reference R nges Summ ry Time to Review C se Study Resources nd Suggest
ed Re dings
Le rning Outcomes After re ding this ch pter, the successful student will be bl
e to: 18-1 Define
the key terms. 18-2 Identify diet ry sources of cholesterol. 18-3 Comp re nd co

ntr st the
different types of lipoproteins tested in lipid p nel. 18-4 Provide the desire
d r nge for
cholesterol levels. 18-5 Describe the effects of elev ted cholesterol levels on
the body. 18-6
Expl in how the body uses triglycerides. 18-7 Describe the ppe r nce of lipemi
in blood
specimen. 18-8 Ev lu te the potenti l he lth issues th t re c used by high leve
ls of
triglycerides. 18-9 List the components of common lipid p nels. 18-10 Expl in th
e p tient
prep r tion necess ry be- fore specimen is collected for
lipid n lysis. 1811 Perform
CLIA-w ived cholesterol test. 18-12 Describe how electrolytes re used by the bo
dy. 18-13
Summ rize the consequences of untre ted electrolyte imb l nces. 18-14 List the c
ommon n lytes
included in n electrolyte p nel. 18-15 Perform CLIA-w ived electrolyte test.
CAAHEP/ABHES
STANDARDS CAAHEP 2008 St nd rds I.P.I.13. Perform Chemistry Testing I.A.I.2. Use
l ngu ge/verb l
skills th t en ble p tients underst nding ABHES St nd rds 10. Medic l L bor tory
Procedures,
b. CLIA-w ived tests 10. Medic l L bor tory Procedures, b. 3) Chemistry Testing
1899_Ch18_371-387 26/12/11 2:15 PM P ge 371 C linic l chemistry includes the qu
ntit tive
chemic l n lysis of v rious body fluids, s introduced in Ch pters 16 nd 17 in
this text.
Bec use this re of the l bor tory performs so m ny different testing proce- du
res, it is not
possible to cover them ll in det il in this book. This ch pter provides more de
t ils bout lipid
testing nd provides ddition l inform tion bout the role of electrolytes in th
e body.
Cholesterol n lysis nd some electrolyte testing re commonly performed in phys
ici n office
l bor tories, s well s hospit l nd ref- erence l bor tories. LIPID TESTING Li
pid testing
includes the qu ntit tive n lysis of choles- terol levels, differenti tion of t
he different
types of lipoproteins th t tr nsport cholesterol in the body, nd n lysis of to
t l triglyceride
levels. He rt dise se is the most common c use of de th in the United St tes, n
d bec use the
presence of elev ted cholesterol (hypercho- lesterolemi ) or hyperlipidemi is
risk f ctor for
m ny serious c rdiov scul r complic tions, frequent monitor- ing of lipid levels
is very
import nt. Cholesterol Cholesterol is
white, soft, w xy subst nce th t is pres
- ent in ll the
cells of hum ns. Although hum ns use cholesterol to form cell membr nes, cre te
hormones, nd
perform other vit l body functions, too much cholesterol is very d m ging to the
blood vessels
within our body. It is recommended by the N tion l Choles- terol Educ tion Progr
m th t ll
dults h ve their cholesterol levels checked t le st once every 5 ye rs. The ch
olesterol level
for ny individu l is dependent on m ny f ctors, including genetics, sex, diet,
level of physic l

ctivity, soci l h bits, nd ge. Cholesterol Met bolism Within the Body The cho
lesterol th t is
needed by our body is m nuf c- tured in the liver, but cholesterol is lso inges
ted with nim l
products, d iry products, nd hidden in processed foods. This excess cholesterol
is deposited
within the blood vessels, c using pl que buildup. The pl que on the interior of
the rteries
c uses them to h rden nd lose el sticity,
condition known s ther- osclerosi
s. The vessels
m y eventu lly fill with sticky, h rd cholesterol nd become occluded (blocked )
so th t the
blood flow is disrupted. The blood th t is tr pped by the pl que buildup m y bec
ome clotted.
Pieces of the pl que m y lso bre k w y from the vessel w lls nd tr vel to oth
er re s of the
body s emboli. 372 Section IV Clinic l Chemistry Test Your Knowledge 18-1 The
hum n body
produces dequ te cholesterol to meet its needs. Addition l cholesterol is dded
s p rt of our
diets. Wh t is one prim ry source of ingested cholesterol? (Outcome 18-2) KEY TE
RMS Acidosis
Alk losis Anions Apolipoproteins Buffer C tions Extr cellul r Fibr tes Hyperk le
mi Hypern tremi
Hypok lemi Hypon tremi Intr cellul r Ions Lipemi Lipoproteins M l bsorption M
et bolic syndrome
Ni cin St tins Types of Cholesterol Cholesterol is
type of lipid th t does not
dissolve in
blood pl sm . It must be tt ched to nother molecule for tr nsport throughout t
he body. The
molecules used for cholesterol tr nsport re lso cre ted in the liver, nd re
c lled
polipoproteins. These re speci l types of protein th t re designed to tt ch
to lipid
molecule, becoming
lipoprotein. As introduced in Ch pter 16, 1899_Ch18_371-387
26/12/11 2:15 PM
P ge 372 sedent ry lifestyle, poor diet, cig rette smoking, heredity, nd obesit
y. The presence
of two or more risk f ctors for specific p tient m y double the risk of
he r
t tt ck. N tive
Americ ns nd Afric n Americ ns re t n ex- ception lly high risk bec use of g
enetic f ctors.
HDL levels m y be incre sed in women bec use of the n tur l presence of estrogen
in their bodies.
Testosterone h s been shown to lower HDL levels. Cig rette smoking, sedent ry li
festyles, nd
obesity ll contribute to lower HDL levels. It is possible to ch nge the rel tiv
e levels of LDL
nd HDL in the body through diet nd exercise. The go l of tre tment is to decre
se tot l
cholesterol, incre se HDL levels nd decre se LDL levels. Incre sed exercise, sm
oking cess tion,
nd weight loss c n elev te HDL levels nd decre se LDL levels. E rly detection,
immedi te
lifestyle ch nges, nd or l medic tions m y h ve pro- found effect on these n
lytes. LDL
levels m y be decre sed with the use of cl ss of medic tions c lled st tins. C
h pter 18 Other
Select Chemistry Tests 373 there re three types of lipoproteins present to tr n
sport cholesterol

in the bloodstre m: High-density lipoprotein (HDL): A c rrier molecule th t is k

nown s the
good cholesterol bec use it tr nsports cholesterol through the v scul r system wit
hout
contributing to the buildup on the vessel w lls. In f ct, HDL h s been shown to
help remove some
of the cholesterol th t h s ccumul ted in the v scul r system. A high level of
HDL ppe rs to
protect the body from he rt dise se, nd low level (below 40 mg/dL for men nd
50 mg/dL for
women) incre ses the risk for he rt dise se nd stroke. Low-density lipoprotein
(LDL): The
m jor lipopro- tein cholesterol tr nsport molecule present in the bloodstre m. T
his is often
referred to s the b d cholesterol bec use the lipoprotein h s higher f t conten
t th n does
the HDL nd ctu lly sticks to the blood vessel w lls nd dheres to the w xy bu
ildup, le ding to
vessel occlusion. This w xy buildup (pl que) cre tes unique environment in whi
ch blood cells
m y bind to one nother nd form blood clot. When
blood clot or n occlusion
occurs in one of
the coron ry vessels th t supplies blood to the he rt, he rt tt ck m y result
. Blocked blood
flow to the br in results in stroke ( lso known s cerebrov scu- l r cciden
t [CVA]).
According to the Americ n He rt Associ tion, LDL cholesterol levels bove 160 mg
/dL gre tly
incre se the ch nce of he rt dise se. Very Low-Density Lipoprotein (VLDL): Prese
nt in sm ller
mounts th n the other tr nsport molecules. Elev ted VLDL levels re directly re
l ted to the
form - tion of pl que from sticky cholesterol deposits, which incre ses the risk
of he rt dise se
nd stroke. Test Your Knowledge 18-2 Which cl ssific tions of lipoproteins re c
onsidered s
contributors to pl que buildup? (Outcome 18-3) Test Your Knowledge 18-3 True or
F lse: Elev ted
HDL levels re desir ble in he lthy dult. (Outcome 18-4) Test Your Knowledge
18-4 S lly
Se shore h s her f sting cholesterol test performed s p rt of her ye rly phys
ic l. Her tot l
cholesterol level w s 205 mg/dL. Is this within the desir ble r nge? (Outcome 18
-4) Test Your
Knowledge 18-5 Why re elev ted LDL levels considered to be he lth risk? (Outc
ome 18-5) Risk
F ctors, Desired R nges, nd Clinic l Interpret tion of Abnorm l Lipid Results T
ot l cholesterol
screening ssists with identific tion of those who re t high risk for c rdiov
scul r dise se.
According to the Centers for Dise se Control nd Pre- vention (CDC), pproxim te
ly 17% of the
dults in the United St tes h ve tot l cholesterol levels bove the de- sired r
nge. Cholesterol
levels m y be elev ted in cert in dise ses, such s di betes, hypothyroidism, n
d kidney or ren l
dise se. However, more commonly the elev tion of tot l cholesterol is the result
of risk f ctors
such s Cholesterol reference r nges re b sed on f sting specimens. According
to the CDC, the

recommended cholesterol levels re the following: Tot l cholesterol levels below

200 mg/dL
LDL cholesterol level below 100 mg/dL HDL cholesterol t 40 mg/dL or bove Trigl
ycerides
below 150 mg/dL It is not only dults who h ve elev ted cholesterol levels. Chil
dren who h ve
p rents or gr ndp rents who developed he rt dise se before they were ge 55, or
those who h ve
other risk f ctors such s r ce nd obesity should h ve their cholesterol levels
monitored
closely, s it is now cle r th t the development of pl que buildup in the blood
vessels m y begin
very e rly in life. 1899_Ch18_371-387 26/12/11 2:15 PM P ge 373 Procedure 18-1:
Cholesterol
Testing Using the Cholestech LDX System 374 Section IV Clinic l Chemistry TASK
Perform
CLIA-w ived cholesterol testing using the Cholestech LDX System CONDITIONS Glove
s L bor tory
co t H nd s nitiz tion supplies Cholestech LDX n lyzer Cholestech therm l l bel
printer
Liquid controls (level 1 nd level 2) Test c ssettes in foil wr p Optics test c
ssette nd
holder C pill ry puncture supplies Cholestech c pill ry tubes nd bl ck plungers
for
collection nd pplic tion of blood s mples Bioh z rdous sh rps cont iner G uze
or l bor tory
wipes Bioh z rdous w ste cont iner Liquid qu lity control m teri ls (two levels)
Acrylic
s fety shield (if using lithium hep rin v cuum tubes r ther th n c pill ry s mpl
es for the
testing process) CAAHEP/ABHES STANDARDS CAAHEP St nd rds I.P.I. An tomy nd Phys
iology, #13.
Perform Chemistry Testing I.A.I. An tomy nd Physiology, #2. Use l ngu ge/ verb
l skills th t
en ble p tients underst nding ABHES St nd rds 10. Medic l L bor tory Procedures,
b.
CLIA-w ived tests 10. Medic l L bor tory Procedures, b. 3) Chemistry Testing Pro
cedure
R tion le 1. Greet nd then identify p tient using t le st two unique identifie
rs. 2. Verify
test ordered, nd expl in procedure to p - tient. Verify whether p tient h s pre
p red properly.
3. W sh h nds nd pply gloves. 4. Assemble necess ry equipment, nd verify th t
ll re gents re
within the posted expir tion d tes. Allow ll re gents to come to room temper tu
re. All p tients
must be identified properly before collect- ing s mples or performing l bor tory
testing. All
l bor tory test orders should be verified by check- ing the ch rt nd/or requisi
tion form more
th n once. A quick expl n tion of the procedure for the p tient will ensure more
cooper tion.
Cholesterol testing requires the p tient to f st for t le st 12 hours prior to
the blood dr w.
It is import nt th t the p tient underst nds the me ning of 12-hour f st to ve
rify whether he
or she h s followed the necess ry prep r tion instructions. H nds should lw ys
be w shed between
p tients nd before st rting ny procedures. Gloves re ppropri- te person l p
rotection

equipment (PPE) for this procedure, s well s l bor tory co t. The Cholestech
LDX c ssettes
re stored in the refriger- tor, but must come to room temper ture before use.
It is recommended
th t they be removed from the refriger tor for t le st 10 minutes prior to use.
Org - niz tion
of m teri ls will m ke it e sier to follow the procedure specified by the m nuf
cturer properly.
1899_Ch18_371-387 26/12/11 2:15 PM P ge 374 Procedure R tion le Ch pter 18 Othe
r Select
Chemistry Tests 375 5. Plug in the n lyzer nd llow it to initi lize. Verify t
h t the printer
h s p per tt ched to the testing instrument correctly. 6. Perform n optics che
ck using n
optics check c ssette. When testing the optics test c ssette, the following proc
edures re
followed: . Press RUN. The n lyzer will then perform self-test, nd displ y
Self-Test OK
mess ge on the screen. The dr wer will then utom tic lly open, nd
mess ge of
Lo d C ssette
nd Press Run will ppe r on the screen. b. Use the optics check c ssette by ins
erting the
c ssette into the open dr wer of the instrument. Be c reful not to touch the d r
k re s of the
c s- sette; it should be h ndled only by the edges nd by touching the cle r p r
ts of the
c ssette. c. Press RUN g in. The dr wer will shut nd the testing process for t
he optics check
will begin. d. A series of numbers will be displ yed on the screen. These re th
e results of the
optics check. The results must ll f ll between 80 nd 105, nd they must lso b
e within the
r nges pro- vided with purch se of the optics check to be v lid test. e. Verif
y th t the
results re s desired before con- tinuing with the testing process. If the resu
lts re not
within r nge, the instrument will dis- pl y n error code (Optics Test F il), n
d it will not be
possible to process p tient s mples until v lid optics check is performed. 7.
Remove the optics
check cuvette from the instru- ment nd pl ce it b ck in the design ted cont ine
r. 8. Prior to
p tient testing, verify whether qu lity control (QC) specimen needs to be test
ed, nd if so,
complete th t process before the p tients test is performed. P tient testing c nn
ot be performed
unless the qu lity control v lues re within the est blished r nges. 9. Te r ope
n the foil
p ck ge nd set the testing c s- sette on
level non bsorbent surf ce. The n l
yzer must be
llowed to initi lize before use. The optics check c ssette is to be used s dir
ected by the
m nuf cturer nd l bor tory policy to verify th t the four optic ch nnels of the
instrument re
working correctly. This should be used t le st once d ily before p tient s mple
s or qu lity
control s mples re tested. An optics test should lso be completed fter the m
chine is moved or
cle ned. Accept ble r nges will be provided with the cuvette upon purch se. If t
he results do not

f ll within the ccept ble r nge, the instrument m y not be used for specimen te
sting until the
c use h s been identi- fied nd the problem h s been identified nd solved. Trou
bleshooting tips
will be v il ble in the user m n- u l nd/or m nuf cturer insert. The cuvette m
ust be stored in
the design ted cont iner to keep it from being d m ged. Exposure to moisture or
d m ging the
cuvette m y ffect the perform nce. Liquid QC should be tested following l bor t
ory pro- tocol
nd m nuf cturers recommend tions. Ex m- ples of when QC m y be utilized to verif
y the test
results include the following: . With new shipment b. Whenever new lot numb
er of re gents or
QC is put into use c. New oper tor; someone who is being tr ined on the procedur
e d. Problems
with stor ge, instrument, re gents, etc. The c ssette needs to be re dy for the
pplic tion of
the s mple s soon s the blood collection is complete. Continued 1899_Ch18_371387 26/12/11 2:15
PM P ge 375 376 Section IV Clinic l Chemistry Procedure R tion le 10. Perform
c pill ry
puncture, using ppropri te technique. Wipe w y the first drop of blood. 11. Re
move c pill ry
tube nd bl ck plunger from the cont iner. Insert the bl ck plunger into the c
pill ry tube,
nd then hold the open end of the c pill ry tube to the drop of blood obt ined f
rom the c pill ry
puncture. The c pill ry tube will fill with s mple, nd this should be completed
within
pproxim tely 10 seconds. 12. Introduce the blood into the s mple well on the c
ssette. Be
c reful not to touch the d rk re s of the c ssette. Use the bl ck plunger to em
pty the c pill ry
tube into the testing well. 13. Pl ce the filled c ssette into the dr wer s soo
n s the s mple
h s been dded. If the dr wer h s closed, press the RUN button g in nd the dr
wer will open.
14. Within
few seconds, the cholesterol result will ppe r on the displ y scre
en in mg/dL.
Record this result on the p tient log sheet. 15. Following office protocol, llo
w the p tient to
le ve the testing re , or consult with the he lth- c re provider bout the test
results. 16.
Disc rd the c pill ry tube nd plunger nd con- t min ted c ssette in the bioh z
rdous g rb ge.
17. Turn off the instrument if there re no further tests needed nd disinfect t
he work re .
Disc rd ny other w ste ppropri tely. 18. Remove gloves nd s nitize h nds. 19.
Document the
test results in p tient ch rt. The first drop of blood should be disc rded, s i
t m y be
cont min ted with interstiti l fluids resulting in n erroneous result. The bloo
d will enter the
c pill ry tube without further ction if the c pill ry tube is kept level while
the end is
immersed in drop of blood. Avoid ir bubbles s the c pill ry tube is filled.
Blood on other
re s of the c ssette p rt from the s m- ple well m y interfere with the testin
g process. The

c ssette needs to be processed immedi tely for ccur te results. Do not llow th
e filled c ssette
to be moved excessively. It should be kept horizont l s it is pl ced in the dr
wer. The result
will st y on the screen until the RUN button is pushed to open the dr wer for th
e next test
s mple to be dded. It is import nt to record the result s soon s it is eviden
t on the screen.
The result will print if the instrument is tt ched to printer. If results re
f r outside of
the norm l r nge, the office policy m y be th t the he lth-c re provider spe ks
with the p tient
before he or she le ves the office. The c pill ry tube, plunger, nd c ssette co
nt in blood, so
they must be disc rded s bioh z rdous subst nce. The work re should lw ys
be disinfected
fter use. H nds must lw ys be s nitized fter removing gloves. All results mus
t be documented
in the p tients ch rt. Procedure 18-1: Cholesterol Testing Using the Cholestech L
DX
Systemcontd D te 8/17/2014: F sting cholesterol 195 mg/dL
2:15 p.m.
Connie Lieseke, CMA (AAMA) 1899_Ch18_371-387 26/12/11 2:15 PM P ge 376 T
riglycerides
Triglyceride levels re usu lly included in lipid p nels s n ddition l indic
tor for
ev lu ting the risk of c rdiov scul r dise se. Triglycerides re the end prod- u
ct of the f ts
th t we ingest. When person t kes in more c lories th n re needed for energy,
some of the
excess c lories re lso turned into triglycerides nd stored s f t for use l t
er s n energy
source. These re then stored in the liver nd the dipose cells of our body, n
d m y lso
sometimes be stored in the muscle tissue. A p tient who often e ts more c lories
th n those used
by the body m y develop elev ted blood triglyceride levels. Met bolic Syndrome E
lev ted
triglyceride levels un ccomp nied by other risk f ctors re not linked s closel
y to
c rdiov scul r dise se s re high cholesterol levels. However, the high triglyc
- eride levels
m y be p rt of group of conditions th t re known s met bolic syndrome. Met b
olic syndrome
includes hypertension, hyperglycemi , excessive f t de- posits round the w istl
ine, low HDL
levels, nd high triglyceride levels. P tients who simult neously exhibit most o
f these
conditions in the met bolic syndrome h ve n incre sed risk for c rdiov scul r d
ise se, s well
s gre ter potenti l for developing di betes. Or l medic - tions m y be prescr
ibed to lower
triglyceride levels. Ni cin is commonly used, s is cl ssific tion of drugs c
lled fibr tes. If
the triglyceride levels re elev ted s well s tot l cholesterol nd LDL levels
, combin tion
of drugs m y be used to lower the v rious lipid levels. Reference R nges nd Cli
nic l

Interpret tion of Abnorm l Results Hyperlipidemi is the word used to describe e

lev ted levels of
cholesterol nd triglycerides in the bloodstre m, nd s introduced in Ch pter 1
6, p tients with
hyperlipidemi m y h ve cloudy or milky pl sm nd/or serum pp r- ent fter
s m
ple of their
blood is spun in
centrifuge. According to the CDC, triglyceride levels should
be dr wn s
f sting s mples, bec use the blood levels be- come elev ted with the ingestion o
f food.
Triglyceride levels m y be c tegorized s the following: Norm l: below 150 mg/dL
Borderline
high: 150 to 199 mg/dL High: 200 to 499 mg/dL Very high: equ l to or gre ter th
n 500 mg/dL
Lipid P nels A lipid p nel commonly includes tot l cholesterol level;
trigly
ceride level; the
HDL, LDL, VLDL; nd
tot l cholesterol/HDL r tio. These v lues provide the he l
th-c re provider
with v lu ble inform tion to determine whether the cholesterol levels for
p ti
ent indic te
risk f ctor for coron ry rtery dise se. The lipid p nel lso provides inform ti
on th t is useful
for monitoring p tients who re t king medic tion to tre t high cholesterol or t
riglycerides.
Current recom- mend tions from the N tion l Institutes of He lths N tion l Choles
terol Educ tion
Progr m include the perform nce of
screening f sting ( t le st 12 hours) lipid
p nel t le st
once every 5 ye rs. For p tients with elev ted LDL levels nd/or triglyceride or
tot l
cholesterol levels th t re too high, lifestyle ch nges nd possible drug tre tm
ent should be
st rted imme- di tely. The f sting lipid p nel should be rechecked once every 6
weeks until the
est blished go ls h ve been met for p tient, nd f sting lipid p nel should
continue to be
performed every 4 to 6 months while completing tre tment. This ppe r nce is kno
wn s lipemi ,
nd it is c used by suspended f t p rticles, which c n c use interference for m
ny testing
procedures. L rge reference l bor tories m y h ve speci lized centrifuges design
ed to cle r the
excess f ts from the pl sm or serum so th t testing c n continue on these speci
mens. Ch pter 18
Other Select Chemistry Tests 377 Test Your Knowledge 18-6 Wh t le ds to buildu
p of
triglycerides in the dipose tissue of the body? . Consumption of excess c lori
es b.
P ncre titis c. Elev ted LDL levels d. Pl que buildup (Outcome 18-6) Test Your K
nowledge 18-7
Lipemi is suspension of ______________ , visu lized in the liquid portion of
the blood fter
centrifug tion: . Hemolyzed red blood cells b. Excess f t p rticles c. Pl que d
. Milk (Outcome
18-7) 1899_Ch18_371-387 26/12/11 2:15 PM P ge 377 ELECTROLYTES In Ch pter 16, el
ectrolytes re
defined s subst nces th t re c p ble of conducting n electric l ch rge when d
is- solved in
w ter. P rticles th t re positively or neg tively ch rged bec use of the loss o
r g in of

electrons re c lled ions, nd ll electrolytes f ll within this description. Po

sitively ch rged
ions re c lled c tions, nd those ions with
neg tive ch rge re c lled nions
. The most common c tions in the body re sodium nd pot ssium. Sodium h s high extr cellul
r concentr tion,
which me ns th t it h s higher concentr tion outside the bodys cells, in the pl
sm . Pot ssium
is higher in con- centr tion inside the cells, in the intr cellul r environ- men
t. The most
common nions present in the body re chloride nd bic rbon te. Bic rbon te (HCO
3 ) is n ion
cre ted when c rbon dioxide re cts with w ter. Most electrolyte p nels me sure N
, K , Cl
nd bic rbon te. Figure 18-1 illustr tes the distribution of the most common ele
ctrolytes inside
nd outside red blood cells. Bic rbon te m y be me sured directly or by n lysis
of tot l CO 2 ,
s most of the c rbon dioxide present in the blood is found s bic rbon te molec
ules. Addition l
electrolytes present in the body include m gnesium, c lcium, phosph te, nd sulf
te; however,
these re not included in most electrolyte p nels. 378 Section IV Clinic l Chem
istry Test Your
Knowledge 18-8 True or F lse: Electrolytes re neutr l; they neither exhibit p
ositive nor
neg tive ch rge when dissolved in w ter. (Outcome 18-1) the int ke of s tur ted
f t will lso
help to control cholesterol in the diet bec use they ppe r in simi- l r foods.
Remember,
genetics lso pl ys role in tot l blood cholesterol content; m ny p tients wil
l h ve high
levels of cholesterol even with excellent diets nd ctive lifestyles. In this c
se, p tients
will usu lly need to be tre ted with or l medic tions to keep their cholesterol
level t
re son ble level. Monouns tur ted nd polyuns tur ted f ts: These f ts re consi
dered the most
he lthy f ts. They come from ingestion of fish, veget ble oils, nd nuts. All sour
ces of f t
re high in c lories, but polyuns tur ted nd monouns tur ted f ts do not pose
s high
c rdiov scul r thre t s do the other types. POINT OF INTEREST 18-1 Types of f t
s F ts re
essenti l to homeost sis, but ingestion of too much c n be quite h rmful. Most A
meric ns t ke in
n excess of f t on d ily b sis. According to the Centers for Dise se Control
nd Prevention
(CDC), f ts should not m ke up more th n 35% of our c loric int ke e ch d y. In
ddition to
controlling the mount of f t ingested, we c n benefit from moni- toring the typ
es of f ts we
e t, bec use cert in types of f ts c use much more h rm to our c rdiov scul r sy
stems th n
others. Polyuns tur ted nd monoun- s tur ted f ts re he lthier for the body th
n tr ns f ts,
s tur ted f ts, nd cholesterol. The unhe lthy f ts re hidden in m ny of the proc
essed foods
th t we e t. To void n unhe lthy diet, it is import nt to be educ ted bout th
e types of f ts

in our diets: Tr ns f ts: It is required th t ll products cont in- ing tr ns f

ts h ve them
listed on their nutrition l bels. This type of f t ctu lly st rts s liquid;
process c lled
hydrogen tion ch nges the oils into solid f t. Tr ns f t helps processed foods
l st longer
without spoil ge, but the presence of tr ns f ts incre ses LDL cholesterol level
s nd de- cre ses
HDL cholesterol levels. M ny processed b ked goods (such s pies, cookies, cr ck
ers, nd c kes)
include tr ns f ts to extend their shelf life. Tr ns f ts m y lso be present in
solid m rg rine
products. Nutritionists recommend soft m rg rine over solid m rg rine whenever p
ossible.
S tur ted f ts: The current recommend tion is to restrict our d ily c loric int
ke from s tur ted
f ts to less th n 10%. This type of f t comes from me t nd high-f t d iry produ
cts. It is lso
present in p lm nd coconut oils, which c n be included in m ny processed food
s. Choosing
low-f t products, f t-free milk, nd le n me ts c n help to control the mount o
f s tur ted f ts
ingested. Check l bels to reduce the mount of s tur ted f ts ( nd tr ns f ts) w
henever possible.
Removing the skin from me ts before cooking, nd skimming off visible f t from s
oups nd stews
c n lso help to reduce diet ry int ke. Diets th t re high in s tur ted f t re
believed to
contribute to c rdiov scul r dise se. Cholesterol: Cholesterol is usu lly found
in the s me
type of products s those h ving high levels of s tur ted f t. Me t, eggs, nd d
iry products
cont in high levels of cholesterol. Steps th t lower 1899_Ch18_371-387 26/12/11
2:15 PM P ge 378
Function of Electrolytes nd Consequences of Electrolyte Imb l nces Appropri te
mounts of the
v rious electrolytes in the body re essenti l to m int in homeost sis nd cidb se b l nce. The
electrolytes re lso responsible for tr nsmission of nervous impulses, nd they
pl y m jor
role in contr ction nd rel x tion of the mus- cle fibers present throughout the
body. The
presence of the v rious intr cellul r nd extr cellul r elec- trolytes in pprop
ri te
concentr tions lso llows for cells to keep their sh pe so th t they c n functi
on properly. More
specific electrolyte functions include the following: Sodium (N
): Sodium is th
e electrolyte
found in highest concentr tion outside the cells of the body. We t ke in sodium
through our
diets, nd the mount ret ined by the body is controlled by the kidneys. Sodium
loss lso occurs
through perspir - tion. Sodium is essenti l for controlling the mount of fluid
ret ined in the
cells of the body. When the sodium levels re too low ( condition known s hypo
n tremi ) in
rel tion to the mount of fluid present in the body, the p tient m y exhibit dro
wsi- ness nd
confusion. If the condition worsens, it c n le d to muscle twitches, seizures, c
om , nd even

de th. Hypon tremi c n occur with v rious ren l disorders, endocrine imb l nces
th t the mount
of ntidiuretic hormone (ADH) produced, excessive w ter int ke, or retention of
fluids from
v rious dis- e se processes. Cert in prescription drugs m y lso contribute to l
ow sodium levels.
Hypern tremi (elev ted sodium levels) results when the concentr tion of sodium
is elev ted s
comp red to the mount of fluid in the body. Essenti lly,
p tient with hypern
- tremi h s too
little w ter in the body for the mount of sodium th t is present. This c n be t
he result of
severe vomiting nd/or di rrhe with fluid loss, or excessive swe ting without f
luid repl cement.
Hyper- n tremi m y lso occur with severe burns, nd is risk for those with d
ise se st tes
th t c use excessive urine to be produced. Sodium levels th t re outside the re
ference r nge m y
le d to leth rgy, confusion, muscle twitches, seizures, com , nd de th if not t
re ted promptly.
Pot ssium (K
): Pot ssium is present in high con- centr tions within the cells o
f the body,
but norm lly is quite low in the blood pl sm . The kidneys control the mount of
pot ssium
excreted from the body, nd diet ry int ke helps to keep the necess ry b l- nce
for he lthy
function. The presence of pot ssium is essenti l for c rdi c function, s well
s the tr nsmission of nervous impulses to other muscles of the body. Hyperk lemi is the wo
rd used to
describe elev ted levels of pot ssium in the blood, nd hypok lemi is the word
used to describe
dimin- ished levels of pot ssium. Both conditions m y be c used by ren l dysfunc
tion or cert in
hormon l imb l nces. Reduced diet ry int ke m y lso con- tribute to hypok lemi
, s well s use
of prescription medic tions th t contribute to incre sed urin tion. Dise ses th
t c use
g strointestin l m l bsorption (problems with the bsorption of nutrients from f
ood ingested)
will lso c use hypok lemi . Pot s- sium imb l nces re not toler ted well by th
e body, nd m y
result in c rdi c rrhythmi s or other symp- toms of muscle we kness. Chloride (
Cl ):
Chloride is n nion, which me ns th t it h s neg tive ch rge when dissolved i
n w ter. It is
very import nt extr cellul r presence, s chlo- ride contributes to homeost sis
by p rticip tion
in cid-b se b l nce. Chloride moves into nd out of the cells of the body in re
sponse to the
tr nsfer of hydrogen nd c rbon dioxide through the cellul r membr ne. When chlo
ride levels
become imb l- nced, the cid-b se neutr lity of the bodys tissues m y be ffecte
d, nd cidosis
(incre se in cidity of the blood) or lk losis (incre se in lk linity of the b
lood) m y result.
Bic rbon te (HCO 3 ): Bic rbon te is formed when c rbon dioxide combines with w
ter present
in blood pl sm . As is the c se with chloride, bic rbon te pl ys Ch pter 18 Oth
er Select

Chemistry Tests 379 Extr cellul r Fluid Intr cellul r Fluid Sodium Chloride Bic
rbon te C lcium
Pot ssium M gnesium 136 mEq/L 96 mEq/L 22 mmol/L 8.2 mg/dL 3.5 mmol/L 3 mEq/L 14
5 mEq/L 106 mEq/L
30 mmol/L 10.5 mg/dL 5.0 mmol/L 50 mEq/L Figure 18-1 M jor intr cellul r nd ext
r cellul r
electrolytes. 1899_Ch18_371-387 26/12/11 2:15 PM P ge 379 n essenti l role in
cid-b se b l nce
of the body. It cts s buffer, which me ns th t the presence of bic rbon te h
elps to keep the
bodys pH t neutr l level by inter cting with subst nces c p ble of ch ng- ing
the pH. Most of
the bic rbon te in the body is found outside the cells, but there is sm ll mo
unt present
intr cellul rly. Bic rbon te m y be indirectly me sured in the l bor tory by n
lyzing the mount
of tot l CO 2 present in the blood. Abnorm l mounts of bic rbon te (directly te
sted or n lyzed
by me sur- ing tot l c rbon dioxide levels) m y contribute to ci- dosis or lk
losis. possible
to determine whether
s mple is hemolyzed t the time of the blood dr w by look
ing t the whole
blood specimen; hemolysis does not become pp rent until the s mple h s been spu
n in centrifuge
or un- til it h s s t long enough for the pl sm nd/or serum to begin to sep r
te visibly from
the cells. This me ns th t it is especi lly critic l to void d m ge to the spec
imen when it will
be used for whole blood test- ing, bec use it will not be evident th t the cells
h ve been
hemolyzed, which could c use erroneous test results for pot ssium nd possibly f
or the other
elec- trolytes. The phlebotomist must implement ppropri- te venipuncture techn
ique, including
the use of the correct needle size, with complete insertion of the bevel into th
e interior of the
vein. The tourniquet should not be pplied for longer th n 1 minute, nd pumping
of the fist
should not be encour ged. Also, the blood s mple should be gently inverted (not
sh ken). There
re m ny instruments th t h ve been pproved for CLIA-w ived electrolyte testing
. These
instruments re c p ble of performing ll the tests included in most electrolyte
p nels,
including sodium, pot ssium, chloride, nd bic rbon te. The testing instruments
re present in
physici n office l bor tories, but m y lso be used s STAT testing method in
other
environments. These in- clude the Ab xis Piccolo Blood Chemistry An lyzer nd th
e Abbott i-STAT
System. (See Fig. 18-2.) 380 Section IV Clinic l Chemistry Test Your Knowledge
18-9 A p tient
who h s been tre ted with diuretics for the p st few months develops n rrhythm
i nd is seen in
the ER. When the p tient h s his blood tested, which electrolyte level m y be ou
tside of the
reference r nge? (Outcome 18-13) Testing Prep r tion nd Common Testing Methods
Specimen
collection for electrolyte testing does not require ny specific prep r tion, bu
t it is import nt

to collect the s mple using ppropri te phlebotomy technique to void erroneous

results.
Electrolyte test- ing performed in hospit l nd reference l bor tories usu lly r
equires pl sm or
serum s mples, which need to be sep r ted from the blood cells in the specimen w
ithin n hour of
collection. Electrolyte results c n e sily be ffected by poor pre n lytic l pro
cedures. Bec use
pot ssium is t such
high concentr tion within blood cells nd exhibits such
low extr cellul r concentr tion, ny specimen collection or process- ing errors th t contribut
e to hemolysis
will c use the pl sm pot ssium v lues to be f lsely elev ted. Exces- sive hemol
ysis m y lso
c use the pl sm sodium nd chloride results to be decre sed bec use of
diluti
on effect from
ll the intr cellul r contents rele sed when the cells re broken. Cont min tion
of the specimen
with IV fluids will lso lter the pl sm electrolyte results; the effects will
v ry depending on
the type of fluids being dministered. CLIA-w ived electrolyte procedures use wh
ole blood for
testing. The s mples m y be obt ined by c pill ry puncture or by venipunc- ture,
using lithium
hep rin (light green top tube) or sodium hep rin (d rk green top tube). It is no
t Figure 18-2
Abbott i-STAT n lyzer. Courtesy of Abbott Point of C re, Princeton, NJ. 1899_Ch
18_371-387
26/12/11 2:15 PM P ge 380 Ch pter 18 Other Select Chemistry Tests 381 Test Your
Knowledge 18-10
Which of these tests is not p rt of typic l electrolyte p nel? . Sodium b. Po
t ssium c.
Nitrogen d. Chloride (Outcome 18-14) Procedure 18-2: Electrolyte Testing Using
n Abbott i-STAT
Chemistry An lyzer TASK Perform CLIA-w ived whole blood electrolyte testing usin
g n i-STAT
n lyzer. CONDITIONS Gloves L bor tory co t H nd s nitiz tion supplies I-STAT ch
emistry
n lyzer I-STAT n lyzer electrolyte (p nel or individu l test) c rtridges C pil
l ry puncture
supplies or venipuncture supplies nd green top tubes Bioh z rdous sh rps cont i
ner G uze or
l bor tory wipes Bioh z rdous w ste cont iner Qu lity control m teri ls CAAHEP/A
BHES
STANDARDS CAAHEP St nd rds I.P.I. An tomy nd Physiology, #13. Perform Chem- ist
ry Testing
I.A.I. An tomy nd Physiology, #2. Use l ngu ge/verb l skills th t en ble p tien
ts underst nding ABHES St nd rds 10. Medic l L bor tory Procedures, b. CLIA-w ived tests
10. Medic l
L bor tory Procedures, b. 3) Chemistry Testing Reference R nges It is import nt
to re lize th t
the reference r nges for ny n lyte m y v ry ccording to the method used for t
est- ing. The
following re pproxim te r nges est blished for dults for pl sm s mples: Sodi
um: 135 to 145
mmol/L Pot ssium: 3.5 to 5.0 mmol/L Chloride: 98 to 108 mmol/L Bic rbon te: 22 t
o 30 mmol/L
1. Greet nd then identify p tient using t le st two unique identifiers. 2. Ver
ify test ordered,

nd expl in the testing proce- dure to the p tient. All p tients must be identif
ied properly
before collect- ing s mples or performing l bor tory testing. All l bor tory tes
t orders should
be verified by check- ing the ch rt nd/or requisition form more th n once. A qu
ick expl n tion
of the procedure for the p tient will ensure more cooper tion. Procedure R tion
le Continued
1899_Ch18_371-387 26/12/11 2:15 PM P ge 381 382 Section IV Clinic l Chemistry P
rocedure
R tion le Procedure 18-2: Electrolyte Testing Using n Abbott i-STAT Chemistry A
n lyzercontd 3.
Assemble necess ry equipment, nd verify th t ll re gents re within their expi
r tion d tes. For
n electrolyte p nel to be performed, it m y be neces- s ry to use c rtridge t
h t tests for
other n lytes in ddition to those in the electrolyte p nel, due to the c rtrid
ge p ck ging. 4.
W sh h nds nd pply gloves. 5. Turn on the n lyzer. If necess ry, use the elec
- tronic
simul tor c rtridge to verify th t the instru- ment is oper ting correctly. 6. P
rior to
perform nce of test, verify whether qu l- ity control (QC) specimen needs to b
e tested, nd if
so, complete th t test before the p tients test is performed. It is recommended t
h t two levels
of qu lity control be tested every time QC is run. 7. Remove the c rtridge from
the foil pouch.
Be c re- ful to h ndle the c rtridge only by the edges, nd pl ce it on level,
cle n surf ce
until use. 8. Perform c pill ry puncture, using ppropri te technique. Wipe w
y the first drop
of blood. Use hep rinized c pill ry tube to collect
blood s mple, voiding t
he form tion of
ir bubbles in the tube. i-STAT c rtridges re to be stored t 2 to 8C until their
printed
expir tion. C rtridges must be removed from the refriger tor nd llowed to be
t room
temper ture for t le st 5 minutes before use. A c rtridge expires 2 weeks fter
it is removed
from the refriger tor, nd it is not to be put b ck in the refriger tor once it
h s re ched room
temper ture. M teri ls th t re org nized will s- sist in the process of follow
ing the
directions properly. H nds should lw ys be w shed between p tients nd before s
t rting ny
procedures. Gloves re ppropri- te person l protective equipment (PPE) for thi
s procedure. An
intern l electronic simul tion occurs fter every 8 hours th t the instrument is
in use. It m y
lso be necess ry to use n extern l electronic simul tor c r- tridge if the int
ern l test is not
successful or if the l bor tory policy dict tes the use of this ddition l step.
This c rtridge
is stored t room temper ture. To use, insert the c rtridge into the instrument
with the I f cing
upw rd. If the test is successful, the LED screen will displ y PASS mess ge. L
iquid QC should
be tested following l bor tory protocol nd m nuf cturers recommend tions. Ex mpl
es of when QC

should be used to verify the test results include the following: . With new s
hipment b.
Whenever
new lot number of re gents or QC is put into use c. New oper tor; som
eone who is being
tr ined on the procedure d. Problems with stor ge, instrument, re gents, etc. e.
To ensure th t
stor ge conditions re fine, QC should be performed t le st once monthly If the
cont ct points
of the c rtridge re scr tched or d m ged before the test is performed, it m y h
ve n dverse
effect on the test results. The c rtridge should be removed from the pouch befor
e the s m- ple is
collected just to s ve time. The first drop of blood should be disc rded, s it
m y be
cont min ted with interstiti l fluids, resulting in n erroneous result. 1899_Ch
18_371-387
26/12/11 2:15 PM P ge 382 D te 8/17/2014: Electrolyte test performed: Sodium 140
mmol/L,
Pot ssium 3.7 mmol/L, Chloride 100 mmol/L, TCO2 25 mmol/L 11:29 .m.
Connie Lieseke, CMA (AAMA) Procedure R tion le Ch pter 18 Other Select
Chemistry Tests 383
9. Hold the end of the filled c pill ry tube to the s mple well. The well will f
ill with blood
through c pill ry ction. Fill the well to the indic ted fill m rk. The s mple m
y lso be t ken
from sodium hep rin or lithium hep rinev cu ted blood tube, or from sterile sy
ringe without
dditives. 10. The n lyzer will request n oper tor ID nd
specimen/p tient i
dentific tion
number. Enter these ccording to l bor tory policy. 11. After the n lysis h s c
ompleted, the
result will be displ yed on the LED screen for 45 seconds. It m y be recorded di
rectly on the
p tient log sheet nd tr nsferred to the p tient ch rt when re dy. 12. Following
office protocol,
llow the p tient to le ve testing re , or consult with the he lth-c re provide
r. 13. Remove the
used c rtridge from the instrument, nd disc rd it s bioh z rdous tr sh. 14. Tu
rn off the
instrument or prep re to run the next specimen. 15. Dispose of the c pill ry pun
cture device or
used venipuncture supplies in sh rps cont iner imme- di tely fter use. Any ot
her equipment
th t m y be cont min ted with blood must be disposed of s bioh z rd. 16. Disi
nfect the work
re . 17. Remove gloves nd s nitize h nds. 18. Document the test results in p t
ient ch rt. The
blood will enter the c rtridge well by c pill ry ction. It is ccept ble to sli
ghtly overfill
the well, but if the well is grossly overfilled or if blood is sme red on the c
rtridge outside
of the well, the instrument will give n ERROR code when the ss y is per- forme
d. Avoid ir
bubbles s the s mple well is filled. If n ev cu ted blood tube is used, pl i
n pl stic c pill ry tube c n be used to tr nsfer the specimen to the c rtridge. If
sterile sy
ringe is used for
the venipunc- ture, it is import nt to pply the s mple immedi tely to the c rtr
idge to void

clots in the specimen. These identific tion methods llow for better docu- ment
tion nd
tr cking. The result m y be rec lled before running the next specimen by pushing
DIS (displ y) on
the instru- ment. S mple results re lso kept in the n lyzer memory, nd some
l bor tories will
h ve the instru- ment interf ced with their p tient d t system for direct docum
ent tion in the
p tient record. If results re f r outside of the norm l r nge, office pol- icy
m y be th t the
he lth-c re provider spe ks with the p tient before he or she le ves the office.
The c rtridge
cont ins blood, so it must be disc rded s bioh z rdous subst nce. If numerous
specimens re
w iting to be ss yed, le ve the instrument turned on between s mples. It is vit
l to lw ys
properly dispose of bioh z rds. It is import nt to keep the work re cle n nd
org n- ized.
Prompt disinfection helps to stop the cycle of infection. H nds must lw ys be s
nitized fter
removing gloves. All results must be documented in the p tients ch rt. 1899_Ch18_
371-387
26/12/11 2:15 PM P ge 383 6. Elev ted lipid levels in the Outcome 18-8 bloodstre
m incre se the
ch nce of: . Pl que form tion on the blood vessel w lls b. Myoc rdi l inf rctio
n c. Liver d m ge
d. Electrolyte imb l nces 7. Which of these re included in the Outcome 18-1 met
bolic syndrome?
. Elev ted triglyceride levels b. Hypertension c. Hyperglycemi d. Excessive f
t deposits round
the w istline d. All of the bove 8. Which tests re included in lipid Outcome
18-9 p nel? .
Tot l cholesterol, HDL, LDL, VLDL, triglyceride b. HDL, GLDL, LDL, BUN c. Tot l
cholesterol,
triglyceride, HDL, nion g p d. None of the bove 9. How should
p tient prep r
e for Outcome
18-10 lipid p nel specimen collection? . No prep r tion is necess ry b. The p t
ient must f st
for 12 hours c. The p tient should follow c rbohydr te- restrictive diet for
week prior d.
The p tient should follow protein-rich diet for week prior 10. Wh t is
con
sequence of
elev ted Outcome 18-13 or decre sed bic rbon te levels? . Loss of cellul r memb
r ne sh pe b.
C rdi c rrhythmi c. Acidosis or lk losis d. Muscle tremors 384 Section IV Cl
inic l Chemistry
SUMMARY Clinic l chemistry is
complex l bor tory dep rtment where wide v rie
ty of tests m y
be performed. This ch pter focused on some of the clinic l chemistry tests th t
might be
performed in
physici n office l bor - tory s well s in l rger reference l bo
r tories. These
include lipid p nels, electrolyte n lysis, nd fec l occult blood testing. Lipi
d testing is very
import nt, s elev ted levels of tot l cholesterol, LDL, nd triglyc- erides m y
be indic tive of
potenti l d m ge to the c rdiov scul r system nd subsequent myoc rdi l inf rcti
on or stroke.
Electrolytes re responsible for conduction of nerve impulses nd m inten nce of
homeost sis with

cid-b se b l nce. Imb l nces of sodium, pot ssium, chloride, nd bic rbon te c
n be life
thre tening, nd m y indic te n ongoing dise se process elsewhere in the body.
TIME TO REVIEW 1.
Hypern tremi is: Outcome 18-1 . Elev ted sodium concentr tion in the blood b.
Elev ted
pot ssium concentr tion in the blood c. Decre sed sodium concentr tion in the bl
ood d. Decre sed
pot ssium concentr tion in the blood 2. St tins re used to tre t: Outcome 18-1
. Electrolyte
imb l nces b. Anemi c. Elev ted triglyceride levels d. Elev ted cholesterol lev
els 3. True or
F lse: Cholesterol levels re Outcome 18-2 incre sed by excessive ingestion of c
rbohydr tes. 4.
True or F lse: When ev lu ting Outcome 18-9 cholesterol levels, the tot l choles
terol is not the
only level considered by the pr ctitioner. 5. Which type of lipoprotein is Outco
me 18-3
considered to be the good cholesterol? . HDL b. VLDL c. Triglyceride d. LDL 1899_
Ch18_371-387
26/12/11 2:15 PM P ge 384 Ch pter 18 Other Select Chemistry Tests 385 C se Stud
y 18-1: Difficult
dr w Kim B b do, CMA (AAMA), is working in the l bor - tory re of n intern l
medicine clinic.
She h s the re- sponsibility of dr wing blood on most of the p tients in the pr
ctice, performing
some point-of-c re testing, nd processing blood nd other s mples to prep re th
em for tr nsport
to l rge reference l bor tory cross town. The second p tient of the morning h
s n order for
n electrolyte p nel. When Kim ex mines the p - tients rm, she h s difficult t
ime finding
suit ble site for the blood dr w. The p tient h s very sm ll veins th t seem to
roll w y every
time Kim touches them. Kims first ttempt is unsuccessful. On her second try, Kim
does
successfully puncture the vein, but obt ins slow blood flow th t fills the tub
e pproxim tely
h lf full. After the blood specimen is spun in the centrifuge, Kim notes light
pink sh de to
the pl sm . 1. Do you think th t the specimen is ppropri te for electrolyte tes
ting? C se Study
18-2: Diet ry effects A p tient h s lipid p nel dr wn on Mond y fter- noon,
nd his results
include n elev ted triglyceride level. The ordering physici n sks for the spec
imen to be
redr wn to verify the results before meeting g in with the p tient. 1. Wh t is
possible
expl n tion for the elev ted triglyceride level for this p tient? 2. Wh t might
be import nt
inform tion to give the p tient before the next blood dr w? RESOURCES AND SUGGES
TED READINGS
Colorect l C ncer Screening Colorect l c ncer screening inform tion nd recommend
- tions from
the Centers for Dise se Control nd Prevention
http://www.cdc.gov/c ncer/colorect l/b sic_info/screening/ Hemoccults Newest Gold
St nd rd in
FOBTs-Hemoccult ICT Beckm n Coulter Hemoccult ICT test inform tion http://
www.hemocultfobt.com/s les/s les_Hemo_ICT.htm Hemoccult Fec l Occult Blood Tests P
rovides links

to overview for ll of Beckm n Coulter Hemo- ccult products http://www.hemoccult

fobt.com/ Tests
Gr nted W ived St tus Under CLIA List of ll CLIA-w ived tests, including CPT cod
e for
reimbursement http://www.cms.hhs.gov/CLIA/downlo ds/ w ivetbl.pdf Cholestech Det i
led
inform tion bout the Cholestech n lyzers v il- ble for lipid testing. http:/
/cholestech.com
Abbott Point of C re Det iled inform tion bout the Abbott i-STAT n lyzer nd oth
er
point-of-c re testing instruments m nuf ctured by Abbott http:// bbottpointofc r
e.com
1899_Ch18_371-387 26/12/11 2:15 PM P ge 385 1899_Ch18_371-387 26/12/11 2:15 PM P
ge 386 387
Section IV Clinic l Chemistry Wh t Does It All Me n? As the ch pters in this sec
tion cle rly
point out, there is plethor of tests th t re typic lly performed in the clin
ic l chemistry
re of the l bor tory. These tests m y be ordered nd performed on n individu l b sis or m y
be ordered nd tested in groups known s profiles. Physici ns nd other prim ry
c re providers
such s nurse pr ctitioners nd physici n ssist nts m ke these import nt orderi
ng decisions.
C se in Point At the beginning of this section we met 34-ye r-old C rrie W. A f
sting blood
glucose test w s per- formed on her s p rt of he lth f ir sponsored by C rries
employer, Acme
Innov tions, Inc. Her v lue w s signific ntly higher th n the highest number in
the norm l r nge
for this test. The f ct th t this test w s done fter
period of f sting indic
tes th t her
bility to process glucose is likely imp ired. Glucose serves s the bodys m in s
ource of
energy. Under norm l circumst nces, glucose is met bolized nd the resulting pro
ducts re used by
the body for the m ny functions it performs on d ily b sis. An unusu lly high
glucose level
suggests th t the body is un ble to met bolize glucose properly. The most likely
condition
ssoci ted with this scen rio is di betes mellitus. Individu ls with di betes me
llitus typic lly
either do not produce the subst nce insulin th t is necess ry for glucose met bo
lism or they
produce insulin but its function is imp ired. In either event, glucose is not be
ing prop- erly
used nd eventu lly builds up in the body, thus c using incre sed blood glucose
levels. Bec use
the body c n count on glucose for energy, it resorts to f t. Incomplete f t met
bolism ensues. A
by-product of incomplete f t met bolism is subst nce known s ketone. Once the
body h s re ched
its s tur tion point of glucose nd ketones, excess mounts of both sub- st nces
re deposited
into the urine for dispos l from the body. Thus, long with high blood glucose l
evels,
individu ls with di betes mellitus typic lly lso h ve high levels of glucose n
d ketones in the
urine (urine testing is covered in det il in Ch pter 21). In some inst nces
ch
nge in diet

st bilizes the blood glucose levels to the point th t the di betes mellitus c n
be m n ge ble
without t king other steps. However, there re inst nces when tre tment with ins
ulin is
indic ted. 1899_Ch18_371-387 26/12/11 2:16 PM P ge 387 388 On the Horizon Perh p
s the e siest,
most noninv sive specimen type for n lysis from hum ns is urine. In f ct, the c
oncept of
n lyzing urine h s been noted in dr wings on ncient history w lls. E rly n ly
zers determined
th t if urine from di betic individu l is spre d on the ground, then bec use o
f its sweet
smell, nts would gr vit te to it. At one point, group of so- c lled self-t ug
ht urine
n lyzers, known s the pisse prophets, m rketed their services to individu- ls.
P tients who
submitted their urine nd p id
fee received n n lysis of their urine without
ever being
ex mined by physici n. There h ve been m ny dv nces in urine n lysis over th
e ye rs, one of
the more not ble being the d- vent of pl stic strips impregn ted with chemic l
p ds, known s
dipstick. Tod y, test th t incorpor tes the dipstick technology, known s ur
in lysis, screens
for number of bnorm lities. In m ny inst nces, such bnorm lities m y be dete
cted through
urin lysis testing, often before the p tient experiences ny symptoms. This sect
ion focuses on
the urin lysis test, s it is cruci l in the di gnosis nd monitoring of dise se
s well s in
the monitoring of select tre tment regimens. The occult blood test is lso cover
ed in this
section. Relev nce for the Medic l Assist nt (He lth-C re Provider) As with so m
ny other spects
of l bor tory testing, medic l ssist nts nd other he lth-c re support per- son
nel re often
involved in the collection of s mples for urin lysis testing by ssisting the p
tient in the
process or providing the p tient with collection in- structions. Furthermore, me
dic l ssist nts
often per- form urin lysis nd occult blood testing long with ppropri te qu li
ty control.
Medic l ssist nts re lso responsible for completing the document tion ssoci
ted with this
testing. Continued on p ge 390. 1899_Ch19_388-400 26/12/11 2:27 PM P ge 388 Sect
ion V Urin lysis
389 On the Horizon Ch pter 19: Urin lysis introduces the re der to key n tomic
l p rts
ssoci ted with the urin ry system. A brief overview of the form tion of urine d
et iling the
func- tions of the n tomic l p rts of the urin ry system is presented. An overv
iew of the
routine urin lysis test including qu lity control is described. Ch pter 20: Phys
ic l
Ch r cteristics of Urine covers the color, cl rity, volume, nd odor of urine s
mples. The
me surement of specific gr vity nd testing for it using urinometer nd refr c
tometer re
introduced. Proper technique, norm l test refer- ence r nge, sources of error n
d interference,

nd test interpret tion re described. Ch pter 21: Chemic l Ex min tion of Urine
nd Feces
identifies nd describes 10 chemic l tests th t comprise typic l urine dipstic
k. The occult
blood test is in- troduced nd described. Proper technique, norm l test referenc
e r nge, sources
of error nd interference, nd test interpret tion re covered. Ch pter 22: Micr
oscopic
Ex min tion of Urine introduces the re der to the most commonly seen microscopic
formed
elements found in urine. Proper technique, norm l test reference r nge, sources o
f error nd
interference, nd test interpret - tion re covered. 1899_Ch19_388-400 26/12/11
2:27 PM P ge 389
390 Urin lysis Physic l Ex min tion Component Result Reference R nge Color Amber
Yellow Cl rity
Cloudy Cle r Urin lysis Chemic l Ex min tion (Dipstick) Component Result Referen
ce R nge Glucose
Neg tive Neg tive Bilirubin Neg tive Neg tive Ketone Neg tive Neg tive Specific
gr vity 1.005
1.0051.030 Blood Tr ce Neg tive pH 6.0 4.58.0 Protein 100 mg/dL Neg tivetr ce Urobi
linogen 0.2
mg/dL 0.21 mg/dL Nitrite Neg tive Neg tive Leukocyte ester se Neg tive Neg tive Q
uestions for
Consider tion: Wh t key points would you m ke when giving direc- tions to Johnnys
mother when
she helps Johnny collect
urine s mple? Wh t is the purpose of the physic l ex
min tion of
urine? Wh t is the purpose of the chemic l ex min tion of urine? Wh t is the thi
rd portion of
the urin lysis test th t h s not yet been done? Wh t is the purpose of the chemi
c l ex min tion
por- tion of the urin lysis test? C se in Point Three-ye r-old Johnny is rushed
to the doctors
office fter he dr nk ntifreeze in the f mily g r ge. As the medic l ssist nt
on duty t the
time, you re sked to give in- structions to Johnnys mother so she c n help the
young boy
collect
urine s mple. Once the s mple is collected, you re sked to conduct t
he physic l nd
chemic l ex- min tion portions of urin lysis test on it. You obt in the follo
wing results:
Continued from p ge 388. 1899_Ch19_388-400 26/12/11 2:27 PM P ge 390 Ch pter 19
Urin lysis
Const nce L. Lieseke, CMA (AAMA), MLT, PBT(ASCP) CHAPTER OUTLINE Historic l Pers
pective of
Urin lysis An tomy nd Physiology of the Urin ry System The Kidneys Ureters Bl d
der Urethr
Sequence of Urine Production nd Excretion Clinic l Signific nce of Urine Testin
g Results
Physic l Ex min tion Chemic l Ex min tion Microscopic Ex min tion Qu lity Assur
nce for Urine
Testing Procedures St nd rd Prec utions Used When An lyzing Urine Specimens Type
s of Urine
Specimens Summ ry Time to Review C se Study Resources nd Suggested Re dings Le
rning Outcomes
After re ding this ch pter, the successful student will be ble to: 19-1 Define
the key terms.
19-2 Describe the function of the urin ry system. 19-3 Differenti te the p rts o
f the urin ry

system. 19-4 Expl in how urine is formed in the kidneys. 19-5 Describe the route
followed s
urine is excreted from the body. 19-6 Discuss the clinic l signific nce of urin
lysis results.
19-7 Comp re nd contr st the different types of testing involved in routine uri
n lysis. 19-8
Describe common qu lity ssur nce procedures used for the n lysis of urine. 199 Describe the
person l protective equipment necess ry to process urine s mples. CAAHEP/ABHES S
TANDARDS CAAHEP
St nd rds I.C.I.5: Describe the norm l function of e ch body system. ABHES St nd
rds None 391
1899_Ch19_388-400 26/12/11 2:27 PM P ge 391 HISTORICAL PERSPECTIVE OF URINALYSIS
Urine h s been
used s prim ry di gnostic tool by those who pr ctice medicine for thous nds o
f ye rs. The
first recorded observ tion of the ch r cteristics of urine w s written over 6,00
0 ye rs go.
Ancient physici ns could only m ke ssumptions utilizing the color, ppe r- nce
, smell, nd
sometimes t ste of urine bec use their knowledge of hum n n tomy nd physiology
w s very
limited. Urine observ tion nd n lysis w s known s uroscopy. Some of these e r
ly di gnostic
theories result- ing from uroscopy proved to be quite ccur te, where s others w
ere l ter shown
to be complete f ll cies. Unfortun tely, the type nd mount of inform tion th t
could be derived
from urine bec me ex gger ted, nd ex min tion of urine without the presence of
the p tient or
ny other clinic l inform tion bec me popul r. The n lysis of urine lost medic
l credibility for
time, s the ex min tion of urine bec me
tool used by unedu- c ted individu
ls who pretended
to di gnose dise se nd predict the future using urine specimens. This type of u
roscopy w s
profit ble venture until 1637, when Thom s Bri n published book th t l beled t
hese pr ctitioners s pisse prophets. The book discredited their pr ctices nd led to the
demise of this
profession. Tod y, the n lysis of urine is v lu ble tool used by he lth-c re
pr ctitioners to
screen for potenti l bnorm lities or monitor dise se processes nd the effic cy
of tre tment. A
urin lysis m y provide impor- t nt inform tion to ssist with the di gnosis of d
i betes or kidney
d m ge, or detect potenti l urin ry tr ct infection. Urin lysis is
rel tivel
y inexpensive,
nonin- v sive CLIA-w ived procedure th t is commonly per- formed in physici n of
fices by medic l
ssist nts. The n lysis of urine includes observ tion of the physic l ch r cter
istics of the
urine specimen th t m y be seen or me sured with the n ked eye. The physic l ch
r cter- istics of
the urine include document tion of the color nd ppe r nce of the urine specime
n. Urin lysis
proce- dures lso include procedures such s the me surement of urine specific g
r vity (
me surement of the density or concentr tion of the urine specimen), or me surement of the

specimen volume when needed for refer- ence. Addition l n lysis for the presenc
e of v rious
chemic l components is nother p rt of the testing process. An lysis of urine m
y lso include
micro- scopic component, which uses microscope to look for formed elements in
the urine
specimen. Urine micro- scopic n lysis is not CLIA-w ived test, but medic l s
sist nts often
prep re nd set up the specimen on the microscope for ex min tion by pr ctitio
ner or other
qu lified profession l. Addition l tr ining m y llow for medic l ssist nts to
perform
microscopic ex min - tion of urine specimens s well. 392 Section V Urin lysis
KEY TERMS
Afferent rteriole Aliquot Anterior Bl dder Bowm ns c psule C lyx Dist l convolut
ed tubule
Efferent rteriole Filtr tion Glomerul r filtr tion Glomerulus Hilum Kidneys Loo
p of Henle
M croscopic Microscopic Micturition Nephrons Peritoneum Pisse prophets Proxim l
convoluted tubule
Re bsorption Re gent dipstick Ren l cortex Ren l medull Ren l pelvis Ren l tubu
le
Retroperitone l Rug e Secretion Specific gr vity Ureters Urethr Urin lysis Urin
ry me tus Urine
microscopic Uroscopy 1899_Ch19_388-400 26/12/11 2:27 PM P ge 392 nd f t surroun
ds nd protects
e ch kidney. The in- dented (conc ve) portion of the kidney is known s the hilu
m, the region
where the ren l rtery enters the kid- ney nd the ren l vein nd ureter le ve t
he kidney.
Ch pter 19 Urin lysis 393 It is import nt to dhere to the proper collection pr
ocedure for
urin lysis specimens. Ide lly, urin lysis is performed on cle n-c tch midstre m
urine specimen
s mples, nd if the procedures for this collection re not followed c refully, e
rroneous results
m y be reported to the physici n. In dequ te cle nsing before collection will in
troduce
cont min nts into the specimen th t c n lter the results. In ddition, if cul
ture is dded to
the specimen fter initi l testing, it is import nt th t the specimen be collect
ed using the
cle n-c tch midstre m method. Ide lly, pproxim tely 50 mL of urine will be subm
itted for
urin lysis testing, but ccording to the Clinic l L bor tory nd St nd rds Insti
tute, the minimum volume for ccur te results is 12 mL. ANATOMY AND PHYSIOLOGY OF THE URINARY
SYSTEM The
urin ry system includes two kidneys, two ureters, the bl dder, nd the urethr .
(These structures
c n be seen in Fig. 19-1.) The functions of the urin ry system include filtr tio
n of the blood,
excretion of excess w ste, nd the regul tion of fluid nd cid-b se b l nce wit
hin the body. The
kidneys lso help to regul te blood pres- sure, nd they produce erythropoietin,
hormone th t
stimul tes production of red blood cells. Test Your Knowledge 19-1 How re proce
dures used to
document the physic l ch r- cteristics of the urine different from the microsco
pic procedures?

(Outcome 19-7) Test Your Knowledge 19-2 Wh t is the function of the urin ry syst
em? (Outcome
19-2) Inferior ven c v Aort Ren l rtery nd vein Kidney Kidney Ureters Bl dd
er Urethr
Sphincter Test Your Knowledge 19-3 Which of these best describes the kidneys? .
Loc ted in front
of the peritoneum b. Pe r-sh ped org ns c. Loc ted on either side of the vertebr
l column with
one slightly lower th n the other d. Covered with hilum (Outcome 19-3) Figure 19
-1 The p rts of
the urin ry system, including the kidneys, ureters, urin ry bl dder, nd the ure
thr . The Kidneys
The kidneys re considered the most import nt org ns of the urin ry system bec u
se they re
responsible for the form tion of urine. They re be n-sh ped structures loc ted
to the b ck of
the bdomin l c vity on either side of the vertebr l column. The peritoneum, or
mem- br ne th t
lines the bdomin l c vity, covers only the nterior (front) side of the kidneys
, which me ns
th t they re retroperitone l, or behind the peritoneum. The left kidney is loc
ted bit higher
th n the right kid- ney. A thick ren l c psule consisting of connective tissue T
he kidneys re
m de up of n outer ren l cortex nd n inner ren l medull . The ren l medull m
y be visu lized
s series of structures known s pyr mids, s is evident in Figure 19-2. E ch
pyr mid dr ins
into c lyx, which serves s collection tubule for the urine s it is cre ted
. The re of the
kidney where the c lyces join is c lled the ren l pelvis, which is connected to
the ureter
le ving the kidney. E ch kidney cont ins pproxim tely 1 million neph- rons. Nep
hrons re known
s the function l unit of the 1899_Ch19_388-400 26/12/11 2:27 PM P ge 393 kidney
s, bec use these
microscopic structures filter the blood nd cre te urine utilizing filtr tion, r
e bsorption, nd
secretion, s described l ter in this ch pter. The v st m jority of the nephrons
in the kidneys
re cortic l nephrons, loc ted in the outer cortex l yer of the kidney. All neph
rons function to
filter blood nd cre te urine, but the cortic l nephrons re responsible prim ri
ly for remov l of
w ste products nd re bsorption of nutrients. Juxt medull ry nephrons re longer
, nd extend deep
into the medull . These nephrons speci lize in concentr tion of the urine. Almos
t one-qu rter of
the bodys blood supply is in the kidneys t ny given time. The kidneys re incre
di- bly
v scul r to llow for dequ te processing of the blood supply nd production of
t le st 1 liter
of urine e ch d y. To underst nd how this process occurs, it is impor- t nt to l
ook closely t
the n tomy nd physiology of the nephrons, s they perform filtr tion, re bsorp
tion, nd
secretion to cre te urine. A nephron is shown in Figure 19-3. Blood enters the n
ephrons through
sm ll vessel c lled the fferent rteriole. The blood continues to flow through
complex t ngled

tuft of c pill ries th t m kes up the glomerulus. The c pill ries rejoin, nd th
e blood p sses
through the efferent rteriole s it le ves the glomerulus. The efferent rterio
le is much
sm ller th n the fferent rteriole, which c uses gre t de l of pressure to bu
ild up within the
glomerulus. This hydrost tic pressure pushes out fluid from the blood s it tr v
els through the
tuft of c pill ries. The cell lining of these c pill ries is different from thos
e in other pl ces
in the body, s it cont ins pores th t llow sm ll molecules to p ss through nd
f cilit tes the
p s- s ge of fluid t high r te. This process is c lled glomerul r filtr tion.
The fluid th t
is forced from the c pill ries during glomerul r filtr tion is collected by
tu
bule th t
surrounds the tuft of c pill ries. This is c lled the Bowm ns c psule. The Bowm ns
c psule is
the beginning of the ren l tubule, hollow structure th t cont ins the blood fi
ltr te. Not ll
the fluid forced from the c pill ries is excreted from the body s urine; if it
were, the body
would be depleted of vit l elec- trolytes nd fluid very quickly. Approxim tely
99% of the fluid
nd electrolytes re re bsorbed by c pill ries th t surround the ren l tubules.
Addition l
subst nces re lso secreted into the filtr te before it le ves the kidneys s u
rine. The ren l
tubules form V-sh ped complex, includ- ing the proxim l convoluted tubule, the
loop of Henle,
nd fin lly the dist l convoluted tubule on the other side of the V. (See Fig. 1
9-3.) This
complex of tubules is surrounded by c pill ries, which llows for essenti l exch
nges to occur
between the blood nd the filtr te within the tubules. The prim ry re bsorption
of fluid nd
electrolytes occurs in the proxim l convoluted tubule. More w ter, sodium, nd c
hloride re
re bsorbed into the blood from the filtr te in the loop of Henle t the bottom o
f the V-sh ped
complex. Most of the fi- n l djustments re ccomplished in the dist l convo- l
uted tubule to
cre te urine from the glomerul r filtr te. Urine th t h s p ssed through the ren
l tubules flows
into the collecting duct, which then dr ins into the c lyx re of the kidney. T
he c lyces open
up to form the ren l pelvis, nd the urine le ves the kidneys through the ureter
. 394 Section V
Urin lysis C lyces Ren l rtery Ren l vein Ureter Ren l pelvis Ren l medull Ren
l cortex Pyr mid
Figure 19-2 A cross section of
kidney, showing the ren l vein nd rtery, uret
er, ren l pelvis,
ren l medull , ren l pyr mids, nd ren l cortex. Test Your Knowledge 19-4 Why r
e the nephrons
c lled the function l units of the kidneys? (Outcome 19-3) Test Your Knowledge 1
9-5 Wh t
processes occur in the ren l tubules? (Outcome 19-4) 1899_Ch19_388-400 26/12/11
2:27 PM P ge 394
Ureters The ureters re flexible hollow tubes th t connect the kidneys to the bl
dder. Urine

flows from e ch ren l pelvis through the ureter by perist ltic w ves cre ted by
the muscul r
ureter w lls. E ch ureter is pproxim tely 12 in. long, which llows enough leng
th for them to
p ss behind the bdomin l c vity before entering the bl dder. Bl dder The bl dde
r is hollow
muscul r s c th t is designed to store urine. The size nd sh pe of the bl dder
differ ccording
to the mount of urine being stored t ny time. The interior lining of the empt
y bl dder forms
rug e, which re folds th t llow for the bl dder to exp nd when filled with uri
ne. Typic lly,
the dult bl dder c n hold bout 500 mL of urine, but the urge to urin te c n be
felt when the
bl dder cont ins p- proxim tely 150 mL of urine. The rele se of urine from the
bl dder
(micturition) involves the inter ction of the micturition reflex center in the s
cr l region of
the spin l cord nd the volunt ry muscles th t surround the urethr . Ch pter 19
Urin lysis 395
Bowm ns c psule Arteriole from ren l rtery Arteriole from glomerulus Glomerulus
Proxim l tubule
Dist l tubule From nother nephron Collecting duct Br nch of ren l vein Loop of
Henle with
c pill ry network Cortex Medull Figure 19-3 The components of the nephron, incl
uding the
glomerulus, Bowm n
s c psule, proxim l convoluted tubule, loop of Henle, nd dis
t l convoluted
tubule. Test Your Knowledge 19-6 Are the ureters involved in the production of u
rine? (Outcome
19-4) 1899_Ch19_388-400 26/12/11 2:27 PM P ge 395 Urethr When the urine le ves
the bl dder, it
tr vels through hollow tube c lled the urethr s it le ves the body. The uret
hr v ries in
length ccording to the p tients gender. The m le urethr is pproxim tely 21 cm
in length,
where s the fem le urethr ver ges only 4 cm. In m les the urethr lso is used
by the
reproductive system to tr nsport semen. The opening t the dist l (f r) end of t
he urethr where
it le ves the body is c lled the urin ry me tus. SEQUENCE OF URINE PRODUCTION AN
D EXCRETION E ch
p rt of the urin ry system pl ys n import nt role in the form tion nd excretio
n of urine. The
process be- gins s the blood is filtered in the glomerul r c pill ries nd ends
s the urine
p sses through the urin ry me tus. Blood is forced through the glomerul r c pill
ries with
sufficient pressure to force most of the liquid portion of the blood out through
the pores in the
c pill ries to form the glomerul r filtr te. The glomerul r filtr te is collecte
d in the
Bowm ns c psule th t surrounds the glomerulus. The glomerul r filtr te continues
to p ss
through the ren l tubules, including the proxim l convoluted tubule, the loop of
Henle, nd the
dist l convoluted tubule. The refined filtr te (now known s urine) enters the c
ollecting
ducts. The collecting ducts join to dr in into the c lyces, which re p rt of th
e ren l pelvis.

 The urine le ves the ren l pelvis through the hilum into the ureter. The ureter
tr nsports
the urine into the urin ry bl dder. Urine le ves the body through the urethr . T
he dist l end
of the urethr where the urine le ves the body is known s the urin ry me tus. C
LINICAL
SIGNIFICANCE OF URINE TESTING RESULTS Urin lysis is one of the most common tests
performed in
physici n offices nd l bor tories. The test is f st, simple, nd rel tively ine
xpensive to
perform. Urine testing is considered reli ble to detect or monitor the progress
of numerous
dise se st tes. Disorders of c rbo- hydr te met bolism, urin ry tr ct infections
, nd b- norm l
pH ch nges in the body m y ll be detected through n lysis of urine. The m lfun
ction of the kidneys or liver m y lso be evident in urine specimen. Urin lysis is lso common
ly performed s
screening procedure for symptom tic dise se. The n lysis of urine h s sever l
p rts: physic l
ex min tion, chemic l testing, nd
microscopic ex min tion of the urine sed- i
ment for
detection of formed elements present in the specimen. 396 Section V Urin lysis
Test Your
Knowledge 19-7 True or F lse: Urin lysis is performed only to confirm clinic l
di gnosis.
(Outcome 19-6) POINT OF INTEREST 19-1 Bl dder c ncer testing Bl dder c ncer is o
ne of the most
prev lent c ncers in the United St tes. It is most common in men over the ge of
60. The risk of
developing bl dder c ncer is gre tly elev ted in those who smoke, nd p tients w
ho h ve
experienced chemic l exposure (such s dry cle ning chemic ls) re lso t hig
h risk for
bl dder c ncer. One of the first symptoms of bl dder c ncer m y be the presence
of blood in the
urine (hem - turi ), s well s incre sed urin ry frequency, irrit bil- ity, nd
pelvic p in. If
detected e rly, bl dder c ncer is highly tre t ble. As of June 2004 the Dep rtme
nt of He lth nd
Hum n Services U.S. Preventive Services T sk Force recommends g inst routine sc
reening for
bl dder c ncer for symptom tic p tients without the pres- ence of risk f ctors.
However, there
re v rious tests for p tients who show symptoms of bl dder c ncer, or for those
who h ve
multiple risk f ctors. One of these is cystoscopy, which is visu l ex min tion
of the bl dder
using scope. Biopsies th t re ob- t ined during cystoscopy m y lso provide
v lu- ble
inform tion. In ddition to these screening procedures, the he lth-c re provider
m y choose to
test the p tients urine specimen for the presence of the nucle r m trix protein,
which is often
elev ted in the presence of bl dder c ncer. The NMP22 Bl dder Chek test (m nuf c
tured by
M tritech Corpor tion) is the only U.S. Food nd Drug Administr tion pproved, CLI
A-w ived test
for the screening of urine for potenti l bl dder c ncer. For p tients who h ve b
een previously

di gnosed with bl dder c ncer, the BTA St t test (m nuf ctured by Polymedco) m y
be used
1899_Ch19_388-400 26/12/11 2:27 PM P ge 396 Physic l Ex min tion The first step
t ken when
n lyzing urine specimen is to perform direct observ tion of the urine speci
men. The color
nd ppe r nce of the urine specimen m y be noted, depending on the policies nd
procedures of
the l bor tory. Some l bor tories will lso llow for docu- ment tion of ny unu
su l specimen
odor, bec use n mmoni -like odor m y indic te n old urine specimen th t h s n
ot been properly
preserved. In ddition, the physic l ex min tion m y include the document tion o
f the urine
specific gr vity, using refr ctometer. The spe- cific gr vity me surement prov
ides inform tion
bout the mount of dissolved subst nces present in the urine specimen. The phys
ic l ex min tion,
s well s the rest of the procedures included in urin lysis, should be per- f
ormed on fresh
urine specimens within 1 hour of collec- tion. If there will be del y in the t
esting, the
specimen needs to be refriger ted t 4 to 6C or dded to pre- serv tive tube s
directed by
l bor tory policy. If refrig- er ted, the specimen needs to be brought b ck to r
oom temper ture
before testing. nd ssign v lues. More det ils bout the chemic l test- ing of
urine re
presented in Ch pter 21. Microscopic Ex min tion The fin l test performed s p r
t of urin lysis
is the urine microscopic ex min tion. An liquot (sm ll s m- ple) of the urine s
pecimen is
centrifuged. At le st 12 mL of urine re required to obt in n ppropri te speci
men for
microscopic ex min tion. The sediment formed t the bottom of the tube during ce
ntrifug tion is
pl ced on slide nd viewed under the microscope. The l bor - tory profession l
will document
the formed elements present when the specimen is ex mined. Cells com- monly pres
ent in the urine
specimen include squ mous epitheli l cells s well s red nd white blood cells.
B c- teri nd
fungi m y be observed long with m ny other microscopic structures. Ch pter 22 f
ocuses more
specif- ic lly on the microscopic urine ex min tion nd the sig- nific nce of th
e results.
Ch pter 19 Urin lysis 397 Test Your Knowledge 19-8 Wh t is observed nd recorde
d during the
physic l ex min tion of urine specimen? (Outcome 19-7) Test Your Knowledge 199 Which p rt of
the urin lysis procedure uses re gent test strips? . Observ tion of color nd c
l rity b.
Microscopic ex min tion c. Chemic l n lysis d. Culture (Outcome 19-7) POINT OF
INTEREST 19-2 HIV
urine testing According to the Centers for Dise se Control nd Prevention, every
ye r there re
more th n 16 million people in the United St tes who re tested for poten- ti l
HIV infection.
M ny of these p tients will h ve r pid test performed in the physici n office,
using n or l

s mple (from the mucos l surf ce of the mouth) or c pill ry blood s mple. Most
p tients re not
w re th t urine m y lso be tested for HIV ntibod- ies. Urine HIV testing h s
not been pproved
s r pid test method, but C lypte Biomedic l Corpor - tion m nuf ctures
urin
e screening test
th t h s been pproved by the U.S. Food nd Drug Administr tion for HIV testing.
It is import nt
to remember th t urine is not considered to be n infectious m teri l for HIV; h
owever,
ntibodies m y be present in urine. Urine testing for HIV h s been shown to be
little less
sensitive nd specific for HIV ntibodies to detect bl dder c ncer cells. The BT
A St t test h s
not been pproved for use s screening mech nism. A positive result with eithe
r of these tests
will le d to further investig tive procedures to est blish the pres- ence of c n
cer cells nd
define the severity of the condition. Chemic l Ex min tion After the initi l phy
sic l ex min tion
h s been per- formed nd recorded, the urine specimen will be tested with re g
ent dipstick,
thin piece of pl stic covered with re gent p ds th t will ch nge color depending
on the
concentr tion of specific chemic ls in the urine spec- imen. Re gent dipsticks
re commonly used
to test for glucose, ketones, pH, bilirubin, urobilinogen, red blood cells, whit
e blood cells,
nitrites, lbumin, nd protein. Specific gr vity m y lso be me sured using this
method. Chemic l
testing m y be performed m nu lly with visu- liz tion of the color ch nges on t
he re gent p ds,
or n instrument m y be used to ev lu te the ch nges in color Continued 1899_Ch1
9_388-400
26/12/11 2:27 PM P ge 397 QUALITY ASSURANCE FOR URINE TESTING PROCEDURES Urine
n lysis involves
sever l different processes, some of which m y be performed m nu lly or by me ns
of instrument tion. Qu lity ssur nce methods for h ndling nd testing urine specimen
s include the
following: Appropri te expl n tion of collection techniques should be provided t
o p tients. A
cle n-c tch mid- stre m urine collection technique is best for urin ly- sis test
ing to provide
s mple th t is cont min nt free. A sterile collection cont iner with ppropri te
l beling
should be provided to the p tient. This llows the specimen to rem in cont min n
t free in c se
there is culture dded to the specimen fter the urin lysis is performed. Test
ing should
occur within 1 hour of collection whenever possible. If this is not fe sible, re
friger tion or
preserv tion of the s mple t 4 to 6C must occur within 1 hour. C libr tion of nd
use of
qu lity control specimens on the refr ctometer if used for specific gr vity test
ing must be
implemented. St ff tr ining must be ongoing for st nd rdiz tion of terms used to
report the
physic l ex min tion nd other results. Use of extern l qu lity control specimen
s must occur;

positive nd neg tive qu lity control specimen should be processed for ll p r m

eters reported on
p tient specimens. The frequency of testing is dependent on the number of urin l
ysis tests
performed, the m nuf c- turers recommend tions, nd the dopted l bor tory polici
es. Re gent
strips must be stored properly; they re to re- m in in the origin l cont iner w
ith the dessic nt
s p ck ged, nd they should rem in out of direct light nd be protected from hu
mid environments.
The c p must st y on the cont iner to keep moisture from ffecting the strips, w
hich would result
in erroneous results. Centrifuges used to spin urine specimens should be c libr
ted regul rly.
Commerci l qu lity control specimens should be processed by ll who perform urin
e microscopic
ex m- in tion. Slides nd pictures used for proficiency testing m y lso be usef
ul. STANDARD
PRECAUTIONS USED WHEN ANALYZING URINE SPECIMENS As introduced in Ch pte 3, St nd
rd Prec utions
com- bine the principles of Univers l Prec utions with those of Body Subst nce I
sol tion.
Univers l Prec utions st te th t ll blood nd other potenti l infectious body f
luid specimens
should be tre ted s if they re infectious for HIV, hep titis B, nd other bloo
dborne p thogens.
Body Subst nce Isol tion procedures specify how em- ployees re to be protected
from other
p thogens th t m y be present in specimen. Essenti lly, when testing urine usi
ng the St nd rd
Prec utions, it is import nt for the employee to be shielded from potenti l expo
sure to the
p thogens th t m y be present in the urine spec- imen. This protection m y be c
complished by use
of gloves when h ndling the urine specimens nd by we r- ing l bor tory co t t
o protect g inst
potenti l spl shes or spills. Eye protection should be worn when removing the co
ver from the tube
to protect g inst erosols or spl shing. 398 Section V Urin lysis th n the tes
ting performed on
blood or or l s mples. Any positive results should be rechecked two times, nd i
f the result is
positive, the specimen must be sent out for confirm tion with western blot con
firm - tory test
before the p tient is to be considered HIV positive. Test Your Knowledge 19-10 W
hich of these is
type of person l protective equipment (PPE) th t should be worn while
medic
l ssist nt performs urin lysis test? . L bor tory co t b. Gloves c. Respir tory protection
d.
nd b e. ,
b, nd c (Outcome 19-9) TYPES OF URINE SPECIMENS This ch pter nd the others in
this section
focus on the collection, processing, nd testing of urin lysis s mples. A urin l
ysis should be
performed using cle n-c tch midstre m urine specimen, prefer bly collected wit
h the first
morning void. However, s presented in Ch pter 9, urine specimens m y be used fo
r other types of
testing s well. These s mples differ in their collection require- ments, n lys
is procedures,

nd the clinic l signific nce 1899_Ch19_388-400 26/12/11 2:27 PM P ge 398 c. Ent

er nd exit the
ureters d. Enter nd exit the glomerulus 4. True or F lse: The urin ry system Ou
tcome 19-2 is
very import nt for m inten nce of the bodys norm l pH. 5. The urin ry bl dder: Ou
tcome 19-3 .
Helps to concentr te the urine b. Serves s stor ge recept cle c. C n stretch
to hold more th n
1 L of fluid d. Is superior to the kidneys in the body 6. The initi l filtr tion
of the blood:
Outcome 19-4 . Occurs in the dist l convoluted tubule b. Occurs s the blood en
ters the kidney
c. Occurs s the blood p sses through the glomerulus d. Occurs in the ureters 7.
True or F lse:
Microscopic Outcome 19-7 ex min tion of urine specimens is n utom ted procedur
e. 8. Wh t is the
recommend tion for Outcome 19-8 the use of qu lity control m teri ls for the re
gent strip
testing portion of the urin lysis? . Test positive controls only b. Test neg ti
ve controls only
c. Test positive nd neg tive controls d. No qu lity control m teri ls need to b
e used for this
p rt of the n lysis 9. Why should l bor tory co t be Outcome 19-9 worn when p
erforming
urin lysis testing? 10. True or F lse: Bec use blood is Outcome 19-9 not usu lly
present in urine
specimens, it is not necess ry to we r gloves when processing urine s mples. Ch
pter 19
Urin lysis 399 C se Study 19-1: Re gent stor ge requirements When John rrives
t work in the
office l bor tory on Mond y morning, he finds th t the lid for the urine re gent
strips is not on
the cont iner. There w s no one in the office over the weekend, nd John w s not
the l st person
in the l bor tory t the end of the d y on Frid y. 1. Should John use these stri
ps for urine
testing? Why or why not? of the results. Ex mples of ltern tive urine specimens
include the
following: Timed specimens, such s postpr ndi l specimens or those collected du
ring
glucose
toler nce testing procedure 24-hour urine specimens used for specific chemic l
n lysis
Postprost tic m ss ge specimens Urine collected for Chl mydi testing Urine coll
ected for
drug testing SUMMARY For m ny ye rs n lysis of urine specimens h s been n inv
lu ble tool for
providing import nt clinic l inform tion. The urin ry system is complex, nd is
responsible for
the filtr tion of toxins from the body, s well s the cid-b se nd over ll flu
id b l- nce th t
is necess ry for homeost sis. The techno- logic l dv nces in testing methods r
e dr m tic, nd
urine m y now be used to identify nd/or mon- itor the progress of m ny dise se
st tes.
Urin lysis is commonly performed in physici n offices s well s l rge reference
l bor tories. A
typic l urin lysis test includes m croscopic, physic l, chemic l, nd microscopi
c components.
Qu lity control pl ys very import nt role in every p rt of urine testing proce
dures. TIME TO

REVIEW 1. The ren l c lyx is: Outcome 19-1 . A cup-like extension of the ren l
pelvis b. P rt of
the nephron c. The membr ne th t covers the kidney d. A vessel in the Bowm ns c p
sule 2.
Specific gr vity is r tio th t Outcome 19-1 comp res: . The weight of the uri
ne specimen to
norm l urine specimen b. The weight of the urine specimen to the p tients blood c.
The weight
of the urine specimen to distilled w ter d. None of the bove 3. The fferent n
d efferent
rterioles: Outcome 19-2 . Enter nd exit the bl dder b. Enter nd exit the kid
ney
1899_Ch19_388-400 26/12/11 2:27 PM P ge 399 400 Section V Urin lysis RESOURCES
AND SUGGESTED
READINGS Clinic l nd L bor tory St nd rds Institute, Urin lysis: Approved Guide
line, ed. 3. CLSI
document G16-A3. W yne, PA, 2009 Approved l bor tory st nd rds for collecting, p
rocessing, nd
testing urin lysis s mples Becton, Dickinson, Best Pr ctice: Tips for Urin lysis.
L b- Notes,
13, no. 2, 2003 Online newsletter from Becton, Dickinson nd Comp ny. Includes d
et ils bout
urine processing for urin lysis nd urine cultures, including inform tion bout
preserv tive
tubes http://www.bd.com/v cut iner/l bnotes/2003 spring/best_pr ctice. sp 1899_C
h19_388-400
26/12/11 2:27 PM P ge 400 401 Ch pter 20 Physic l Ch r cteristics of Urine Const
nce L. Lieseke,
CMA (AAMA), MLT, PBT(ASCP) CHAPTER OUTLINE Physic l Ch r cteristics of Urine Uri
ne Color Urine
Cl rity Specimen Volume Urine Odor Specific Gr vity Refr ctometer Me surement Te
chnique
Urinometer Me surement Technique Re gent Strip Methodology Procedure for Recordi
ng Physic l
Ch r cteristics of Urine Specimen Potenti l Sources of Error Summ ry Time to R
eview C se Study
Resources nd Suggested Re dings 20-1 Define the key terms. 20-2 Describe the cl
inic l
signific nce of bnorm l urine color. 20-3 Expl in how urine cl rity is interpre
ted nd reported.
20-4 Discuss the clinic l signific nce of urine volume nd odor. 20-5 Describe t
he clinic l
signific nce of specific gr vity results. 20-6 Comp re nd contr st the differen
t methods used to
perform urine specific gr vity testing. 20-7 Provide the units used to report sp
ecific gr vity
results. 20-8 List potenti l sources of error for urine physic l ex min tion pro
cedures. 20-9
An lyze nd document the physic l ch r cteristics of urine specimen. Le rning
Outcomes After
re ding this ch pter, the successful student will be ble to: CAAHEP/ABHES STAND
ARDS CAAHEP
St nd rds I.P.I.13. Perform Urin lysis ABHES St nd rds 10. Medic l L bor tory Pr
ocedures, b.
Perform selected CLIA-w ived tests th t ssist with di gnosis nd tre t- ment, #
1: Urin lysis
1899_Ch20_401-412 26/12/11 5:38 PM P ge 401 402 Section V Urin lysis PHYSICAL C
HARACTERISTICS OF
URINE There re sever l steps involved in n lyzing
urine specimen. An lysis
nd document tion

of the physic l properties of urine m ke up the first procedur l step. This n l

ysis includes
observ tion nd document tion of the color, ppe r nce, nd specific gr vity of
the urine
specimen. Urine odor m y lso be noted in some c ses, but is not p rt of the st
nd rdized
reporting procedure. The physic l ch r cteristics of urine m y provide infor- m
tion for the
he lth-c re provider bout kidney func- tion nd the st tus of other body system
s. M ny times the
bnorm l color or ppe r nce of urine specimen is the first sign of
serious
disorder. Urine
Color Norm lly, urine specimens m y ppe r p le yellow ( lso known s str w) to
mber in color.
Urochrome is the subst nce th t provides the tr dition l yellow color observed i
n urine.
Urochrome is pigment th t is rele sed continuously s
product of hemoglobin
bre kdown nd
norm l met bolism. Bec use the mount of urochrome is consistent, the intensity
of the yellow
color in the specimen will v ry with the p tients hydr tion st tus. Urine specime
ns th t re
more concentr ted (such s the first morning void specimen) will h ve
d rker y
ellow color th n
those th t re obt ined l ter in the d y, s the p tient becomes more hydr ted.
The terms used to
describe the color of urine m y v ry slightly mong l bor tories, but it is impo
rt nt th t they
re st nd rdized within e ch f cility. Simple descriptive terms re best, such
s str w, yellow,
d rk yellow, nd mber. Employees should be tr ined to rec- ognize these colors
so th t the
reporting methods re consistent. It is lso import nt to ev lu te urine color o
n well-mixed
specimen in cle r cont iner, so th t the true color c n be ev lu ted. Figure 2
0-1 shows v rious
colors of urine specimens. A notice ble ch nge in urine color m y be c used by
p thologic l
condition. However, cert in foods, vit - mins, or medic tions m y lso c use n
bnorm l color.
T ble 20-1 lists potenti l c uses for v rious urine colors. The most commonly en
countered
bnorm l colors nd their signific nce re listed here: D rk yellow to mber: Al
though these
colors re tech- nic lly within the norm l r nge, sometimes urine will KEY TERMS
Anuri Amorphous
phosph tes Amorphous ur tes Cl rity Enuresis Glycosuri Hem turi Meniscus Myogl
obin Nocturi
Oliguri Polyuri Pyuri Refr ctive index Refr ctometer Specific gr vity Urin ry
frequency
Urin ry incontinence Urinometer Urochrome Test Your Knowledge 20-1 How is urochr
ome rel ted to
urine color? (Outcome 20-1) Figure 20-1 Urine color: left to right, str w; yell
ow; d rk yellow;
mber. 1899_Ch20_401-412 26/12/11 5:38 PM P ge 402 Ch pter 20 Physic l Ch r cte
ristics of Urine
403 ppe r d rk yellow or mber when bilirubin is present in the specimen. This
m y indic te
liver dysfunction, such s in hep titis, or other conditions th t le d to in- cr
e sed red blood

cell destruction. Recent strenuous exercise m y lso c use urine to ppe r d rk

yellow. Or nge:
Urine m y lso ppe r or nge when biliru- bin levels re elev ted in the specime
n. However,
more common c use of bright or nge urine is the presence of Pyridium (phen zopyr
idine),
medic tion used to tre t recurrent urin ry tr ct infections. This medic tion produces
potent or nge
pigment th t will interfere with m ny of the testing proce- dures included in
urin lysis. Red
to brown: The presence of red blood cells (hem - turi ) in the urine specimen m
y c use it to
ppe r pink, red, or even brown. Urin ry tr ct infections or ren l dysfunction m
y llow red
blood cells to enter the urin ry tr ct. The presence of hemoglobin from incre se
d red blood cell
lysis elsewhere in the body lso le ds to red urine specimens, lthough the urin
e is cle rer th n
it is when int ct red blood cells re present. Myoglobin is by-product of musc
le destruction,
nd elev ted levels m y lso c use the urine to ppe r reddish in color. M ny me
dic tions, fresh
beets, nd fresh bl ckberries m y lso contribute to red urine specimen. Blue
or green:
Urin ry tr ct infections c used by Pseudomon s b cteri l genus m y c use the p t
ients urine to
ppe r green in color. V rious medic tions m y lso c use green or blue hue. F
luorescence:
Multivit mins m y c use the urine to fluoresce, lthough the urine color m y be no
rm l. Brown
or bl ck: Hemoglobin m y turn brown in cidic urine th t h s been left st nding
for n extended
period of time. Brown or bl ck urine m y be evident for p tients th t h ve mel n
om . This is
c used by the presence of mel nin nd mel nogen in the specimen. Test Your Knowl
edge 20-2 Ms.
Jones h s h d recurrent urin ry tr ct infections for most of the p st ye r. Her
physici n h s
prescribed
med- ic tion to tre t these infections. On Mond y morning, Ms. Jone
s t kes her first
dose of the medic tion. L ter th t fternoon, Ms. Jones goes to the restroom nd
is l rmed to
see th t her urine is bright or nge. Is the bright or nge color indic tive of
serious problem?
Wh t is the prob ble c use of the bnorm l color in her urine? (Outcome 20-2) TA
BLE 20-1 Urine
Colors nd Possible C uses Urine Color Possible C uses More Inform tion Colorles
s to p le yellow
Recent fluid int ke, P le yellow nd/or colorless urine re not di betes mellitu
s, polyuri
necess rily bnorm l, but m y be present in some dise se st tes D rk yellow Firs
t morning
specimen, Usu lly norm l; fluorescent, d rk yellow urine recent strenuous exerci
se m y be due to
ingestion of multivit mins Yellow/brown/ mber Hep titis, dehydr tion Green Prese
nce of
Pseudomon s b cteri l The culture reports will confirm the presence species in u
rine specimen of
this b cterium type. Blue or green Cert in types of drugs or dyes used for contr
st studies;

ingestion of Clorets bre th mints Pink or red Red blood cells, myoglobin, ingest
ion of fresh
beets or fresh bl ckberries Brown or bl ck Hemoglobin in urine th t h s Mel nin
m y be present in
p tients with been st nding or mel nin mel nom 1899_Ch20_401-412 26/12/11 5:38
PM P ge 403 404
Section V Urin lysis Urine Cl rity The word cl rity is used to describe the tr
nsp rency of the
urine specimen. A norm l urine specimen will be cle r when ex mined in cle r c
ont iner. The
color nd the cl r- ity of the specimen re usu lly ev lu ted t the s me time.
As w s expl ined
in the section Urine Color, the terms used to describe urine cl rity need to be
st nd rdized
within
l bor tory. Common descriptive terms used include cle r, h zy, cloudy,
or turbid. Figure
20-2 shows the difference in specimen urine cl rity. When ev lu ting urine cl ri
ty, it c n be
helpful to use n object or print behind the specimen; the visibility of the obj
ect or print when
viewed through the urine specimen will help to determine the cl rity th t should
be reported.
Common terms used to describe urine cl rity nd their clinic l signific nce re
listed here:
Cle r: A cle r specimen h s no visible p rticles nd is tr nsp rent. Most norm l
urine specimens
ppe r cle r. H zy: H zy specimens m y h ve few p rticles flo t- ing in the sp
ecimen nd re
not completely tr nsp r- ent. However, it is still rel tively e sy to see throug
h h zy
specimen. Mucus nd other cellul r elements m y c use the urine to ppe r h zy.
Cloudy: A
cloudy specimen will be difficult to see through bec use of the p rticles th t
re suspended in
the specimen. Recently voided specimens m y ppe r cloudy bec use of pyuri (the
presence of
white blood cells or pus), b cteri , mucus, red blood cells, sperm, ye st, or c
sts in the
specimen. F t p rticles suspended in the urine specimen will c use it to be exce
ssively cloudy.
Cont min tion c used by v gin l cre ms m y lso c use the urine specimen to ppe
r cloudy. In
ddi- tion, specimens th t h ve been llowed to st nd t room temper ture for ex
tended periods of
time m y develop cloudy ppe r nce bec use of the incre se in the num- ber of
b cteri present
in the specimen. Refriger ted specimens m y lso become cloudy; this is due to t
he presence of
ur tes nd phosph tes in the urine specimen. When the specimen is llowed to coo
l, these w ste
products become visible s diffuse ( morphous) p r- ticles throughout the specim
en, known s
morphous ur tes or morphous phosph tes. Amorphous ur tes re present in cidic
urine, nd m y
c use the cloudy urine to ppe r slightly pink. If there re so m ny morphous u
r tes present
th t the specimen c nnot be viewed under the microscope, the urine c n be w rmed
to 60C to cle r
the urine. Alk line urine will result in the form tion of mor- phous phosph tes
, with white,

cloudy ppe r nce. The morphous phosph tes c n be cle red from the specimen if
needed for
microscopic ex min tion by dding drop of cetic cid to the specimen. Urine c
l rity provides
clues concerning the type nd number of formed elements present in the specimen.
A cloudy
specimen h s high concentr tion of formed elements, where s
cle r specimen u
su lly h s low
concentr tion. The chemic l n lysis nd microscopic ex min tion provide dditio
n l inform tion
bout ny chemic ls or structures present in the specimen. A cle r urine specime
n is not lw ys
norm l, s there m y be bnorm l chemic l constituents present th t dont c use th
e urine to
ppe r bnorm lly cloudy. Figure 20-2 Urine cl rity: left to right, cle r; h zy;
cloudy. Test
Your Knowledge 20-3 Why is it import nt to pl ce print or something simil r behi
nd the urine
specimen when ev lu ting the urine cl rity? (Outcome 20-3) Specimen Volume The v
olume of urine
produced in 24-hour period will v ry depending on f ctors such s the hydr tio
n st tus, gener l
ren l he lth, nd diet ry h bits of p tient. The norm l dult urine volume for
24-hour period
is 1899_Ch20_401-412 26/12/11 5:38 PM P ge 404 Ch pter 20 Physic l Ch r cterist
ics of Urine 405
between 750 nd 2,000 mL per d y. Terms used to describe bnorm lities in urine
volume or urin ry
frequency re listed below: Anuri : The bsence of urine production Urin ry freq
uency: An
incre se in the urge to urin te Oliguri : Diminished urin ry output of less th n
400 mL per d y
Polyuri : Excessive urin tion Enuresis: The in bility to control the flow of uri
ne. This term
is used for p tients who h ve involunt ry urin tion fter the ge t which bl dd
er control should
h ve been est blished. Nocturi : Excessive or frequent urin tion t night Urin r
y
incontinence: Involunt ry urin tion To perform complete urin lysis, most l bor
tories prefer
specimen of pproxim tely 50 mL; the minimum ccept ble volume is usu lly 12 mL.
Those performing
the testing procedures on urine specimens with
volume less th n 12 mL will nee
d to be mindful
of the limited v il bility for rechecking the results of the n lysis if needed
. Test Your
Knowledge 20-4 A p tient h s been ill with vomiting nd di rrhe for sev- er l d
ys. His urine
volume over 24 hours is likely to be: . Incre sed b. Decre sed (Outcome 20-4) U
rine Odor Routine
urin lysis procedures do not include the docu- ment tion of urine odor. A norm l
, recently voided
urine specimen h s n rom tic odor th t is not unple s- nt. Abnorm l urine odo
rs re gener lly
not considered to be clinic lly signific nt, but they m y still be ssoci- ted
with cert in
conditions or ch r cteristics of the urine specimen. Urine specimens th t re le
ft t room
temper ture for n extended period of time will develop n mmoni odor s the u
re present in

the specimen de- gr des. B cteri l infections of the urin ry tr ct will result i
n urine
specimen with strong foul-smelling odor. A urine specimen with fruity, sweet
odor m y
indic te the presence of ketones in the urine in di betic p tient. Other met b
olic disorders
m y give the urine ch r c- teristic odor. For ex mple, p tients with phenylket
onuri will
excrete urine with
ch r cteristic mousy or musty odor. Ingestion of cert in fo
ods (such s
sp r gus, g r- lic, or onions) c n lso c use the urine specimen to h ve n unu
su l smell. Test
Your Knowledge 20-5 True or F lse: A urine specimen with strong odor is lw ys
indic tive of
urin ry tr ct infection. (Outcome 20-4) POINT OF INTEREST 20-1 The odoriferous
sp r gus The odor
ssoci ted with urine specimen m y be ttributed to its volume nd the concent
r tion of the
chemic ls present in the urine specimen. For ex m- ple, within
short period of
time fter
ingesting sp r gus, m ny people h ve reported th t their urine h s sulfur smell
. It is
thought th t this distinctive odor is c used by the bre kdown of mino cid compounds in the
sp r gus s it is digested. However, there is continuing deb te over the prod
uction of
odoriferous urine bec use it does not ppe r to be univers l. Some studies h ve
shown th t less
th n h lf of the popul tion ctu lly excretes sulfurous-smelling urine fter sp
r gus ingestion.
It w s thought th t genetic lly the two groups differed, nd they were l beled
s excretors nd
nonexcre- tors, b sed on whether they smelled the sulfur in their urine fter sp
r gus
ingestion. This belief is still held by m ny. However, other scientists believe
th t ll
individu ls ctu lly excrete the sulfurous odor, but only some individu ls re
ble to detect the
odor. Those who c nnot detect the smell re not w re of its presence, nd m y h
ve been
miscl ssi- fied s nonexcretors in the origin l studies. There is not enough scien
tific
evidence v il ble to prove or disprove either hypothesis. Specific Gr vity Spec
ific gr vity
me surements re one of the physic l ex min tions performed during
routine uri
n lysis. Urine
specific gr vity is defined s the density (or weight) of the urine specimen s
comp red to the
den- sity (weight) of distilled w ter t the s me temper ture. The density of th
e urine specimen
is dependent on the mount nd size of the dissolved subst nces present in the u
rine specimen.
These include such subst nces s glucose, proteins, nd electrolytes. The kidney
s re responsible
for selective re bsorption of essenti l chem- ic ls nd fluid fter the blood is
filtered.
Abnorm l spe- cific gr vity v lues m y be n e rly indic tion of ren l dysfuncti
on. Low specific
gr vity urine is considered to be dilute with very few dissolved subst nces, whe
re s

1899_Ch20_401-412 26/12/11 5:38 PM P ge 405 urine with high specific gr vity i

ndic tes th t the
urine is concentr ted with incre sed mounts of dissolved subst nces. 406 Sectio
n V Urin lysis
Refr ctometers re port ble, rel tively inexpensive, nd e sily c libr ted. This
method of
me surement uses only drop of urine, which c n be benefici l s comp red to ot
her methods.
Refr ctometers must be c libr ted regul rly with distilled w ter to chieve
re
sult of 1.000.
Five percent N Cl m y lso be used to check the c libr - tion, nd it should re
d 1.022. Urine
qu lity control s m- ples should lso be used to verify th t the refr ctometer i
s working
correctly nd th t the oper tor knows how to Test Your Knowledge 20-6 True or F
lse: Urine
specimens with high specific gr vity results re lw ys cloudy. (Outcome 20-5) B
ec use urine
specific gr vity is me sured g inst dis- tilled w ter, the results re reported
using units th t
reflect this comp rison. Urine specific gr vity is reported in units beginning w
ith 1.000 (for
distilled w ter) to mounts bove 1.030 (for highly concentr ted urine specimens
). Urine
concentr tion ( s me sured by the specific gr vity of the urine specimen) m y be
elev ted with
congestive he rt f ilure, dehydr tion, dren l gl nd dysfunction, glycosuri (th
e presence of
glucose in the urine), high levels of urine protein, or recent use of high molec
ul r weight IV
fluids. The urine specific gr vity m y lso be elev ted in situ tions in which t
he p tient h s
become dehydr ted s result of excessive vomiting or di rrhe . Decre sed urine
specific gr vity
m y be present in di betes insipidus, excessive fluid int ke, or ren l f ilure.
The norm l urine
specific gr vity is 1.005 to 1.030. Test Your Knowledge 20-7 A urine specific gr
vity is
documented on the p tients ch rt s 1.25. Is this correct? (Outcome 20-7) Specifi
c gr vity m y
be me sured in sever l w ys, but there re three methods used most often in phys
ici n of- fice
l bor tories. These include the use of refr ctome- ter,
urinometer, or re
gent dipstick.
Refr ctometer Me surement Technique An instrument c lled refr ctometer me sure
s the refr ctive
index of
solution. This is me surement of the velocity of light in ir s co
mp red to the
velocity of light in
solution. The number of dissolved p rticles present in th
e solution ffect
the velocity nd the ngle t which the light p sses through
urine specimen. C
linic l
refr ctometers (see Fig. 20-3) used for urine n lysis use prism to direct one
distinct
w velength of light for comp rison to speci l sc le. The concentr - tion of th
e urine specimen
h s direct effect on the ngle of the light s it p sses through to the prism.
The refr ctive
index is not identic l to the specific gr vity of urine, but refr ctometers re
c libr ted to

provide specific gr vity re dings. Look t the sc le through the eyepiece. Re d

the sc le where
the bound ry line intercepts it. Close the d ylight pl te gently. 1.050 1.040 1.
030 1.020 1.010
1.000 1.355 1.350 1.345 1.340 1.335 1.333 nD U.G. 20C Figure 20-3 Steps to be t k
en when
determining urine specific gr vity with refr ctometer. Courtesy of NSG Precisi
on Cells.
www.precisioncells.com 1899_Ch20_401-412 26/12/11 5:38 PM P ge 406 Ch pter 20 P
hysic l
Ch r cteristics of Urine 407 re d the results ppropri tely. Procedure 20-1 prov
ides det iled
instructions for the use of refr ctometer to me sure urine specific gr vity. U
rinometer
Me surement Technique A urinometer is device th t uses weighted flo t tt ch
ed to sc le.
This weighted flo t will displ ce volume of liquid rel tive to its weight. Whe
n used with
distilled w ter, the weight will sink until the c libr ted sc le re ds ex ctly 1
.000. Bec use
urine h s more dis- solved subst nces present th n does distilled w ter, the uri
nometer flo t
will displ ce less fluid. This will result in
higher re ding on the urinometer
sc le. Figure
20-4 includes n ex mple of urinometer. Urinometers re r rely used for specif
ic gr vity testing. The Clinic l nd L bor tory St nd rds Institute does not recommend their us
e for urine
specific gr vity, but they m y still be used in sm ll physici n office l bor tor
ies. There re
sever l dis dv nt ges to the urinometer method, including the l rge volume of ur
ine required for
the procedure (10 to 15 mL), the fr gility of the weighted flo t/sc le, nd the
need for
specific cont iner th t llows for the displ cement of the fluid during the proc
ess. In ddition,
the specific gr vity is me sured t the meniscus (the bottom of the curve t the
top of the urine
column) of the fluid fter the flo t is dded to the urine specimen; the reporte
d results m y
sometimes be in ccur te bec use of problems with re d- ing the meniscus properly
. Re gent Strip
Methodology Specific gr vity me surements performed by using re gent strips re
nother indirect
me surement of the mount of dissolved subst nces in the urine specimen. Re gent
strip re ctions
re b sed on the rele se of ionic solutes in the specimen. These ions re rele s
ed for
me surement when exposed to the re gent p d on the strip s it is dipped into th
e urine specimen.
A color ch nge occurs on the re gent p ds, which c n be me sured in 0.005 interv
ls from 1.000 to
1.030. M ny f cilities h ve dopted this method of me suring specific gr vity be
c use it does not
involve n ddition l instrument for the procedure, s the results re re d for
specific gr vity
while re ding those for other chemic l n lytes on the re gent strip. Figure 204 A urinometer.
The result is re d t the top of the urine column ( t the meniscus) on the me su
rement sc le

printed on the urinometer. Test Your Knowledge 20-8 Wh t re three dv nt ges of

using the
refr ctometer method for specific gr vity testing? (Outcome 20-6) POTENTIAL SOUR
CES OF ERROR
Numerous pre n lytic l v ri bles m y ffect the physic l ch r cteristics of urin
e specimens. The
ssessment proce- dures for color, cl rity, nd specific gr vity m y lso be per
formed
incorrectly. The following re some of the most common sources of error: Incorre
ct or missing
identific tion on the specimen: Urine specimens must be l beled with the p tients
n me, birth
d te, nd specimen number or other unique identifier. The d te nd time of colle
ction must lso
be noted on the requisition form nd on the specimen. In ppropri te specimen sto
r ge: Urine
specimens re to be n lyzed within 2 hours of collection. If this is not possib
le, the specimen
must be refriger ted or ppro- pri tely preserved within 2 hours of collection.
Ide lly, the
color nd cl rity of the specimen should be determined, but if they were not, th
e specimen must
be llowed to re ch room temper ture g in before ssessment. 1899_Ch20_401-412
26/12/11 5:38 PM
P ge 407 408 Section V Urin lysis Procedure 20-1: Observ tion nd Document tion
of Urine
Physic l Properties TASK The student will perform n ssessment of the phys- ic
l properties of
urine specimen, including the color, ppe r nce, nd specific gr vity. A h ndhel
d refr ctometer
will be used for the specific gr vity me surement. CONDITIONS Gloves, l bor tory
co t, nd
protective eyewe r Freshly voided urine specimen Tr nsfer tube Refr ctometer Gr
ph p per
to be used s print for urine cl rity comp rison Distilled w ter Tr nsfer pipettes

Kimwipes Perm nent fine-tip pen for m rking identific tion on the tr nsfer tube
Bl ck pen for
document tion on the p tients ch rt P tients ch rt Bioh z rdous w ste cont iner
CAAHEP/ABHES STANDARDS CAAHEP St nd rds I.P.I. An tomy nd Physiology, #13. Perf
orm Urin lysis
ABHES St nd rds 10. Medic l L bor tory Procedures, b. Perform selected CLIA-w iv
ed tests th t
ssist with di gnosis nd tre tment, #1: Urin lysis Procedure R tion le 1. W sh
h nds 2. Put on
gloves. 3. Verify test order nd ssemble necess ry equipment nd specimen. 4. V
erify specimen
l beling nd identific tion. 5. Verify th t specimen collection w s less th n 1
hour before
testing or th t it w s refriger ted nd/or preserved ppropri tely fter collect
ion. 6. Allow ny
refriger ted specimens to come to room temper ture before proceeding. H nd w shi
ng bre ks the
cycle of infection. We ring proper person l protective equipment (PPE) protects
employees from
potenti l exposure to p thogens present in the specimen. Verific tion of test or
der elimin tes
potenti l errors, nd org niz tion of supplies s ves time. Urine specimens need
to be l beled
with the n me of the p tient, the birth d te, nd the ccount or spec- imen numb

er. The d te nd
time of the collection must lso be documented. Specimens th t re llowed to st
y t room
temper ture for more th n 1 hour fter collection without the ddition of preser
v tive m y yield
in ccur te results bec use of ch nges in pH, bilirubin or urobilinogen concentr
tion, glucose
levels, nd b cteri l cont m- in tion. Specimens th t re colder th n room tempe
r ture m y
exhibit cryst lliz tion of morphous ur tes or phos- ph tes, which c n interfere
with me surement
of ll the physic l ch r cteristics of the urine specimen. 1899_Ch20_401-412 26/
12/11 5:38 PM
P ge 408 Ch pter 20 Physic l Ch r cteristics of Urine 409 7. Mix specimen well.
8. Observe the
color of the specimen by visu l obser- v tion. Report s str w, light yellow, ye
llow, d rk
yellow, or mber. 9. Pl ce
printed piece of p per behind the specimen to me su
re the cl rity.
Report s cle r, h zy, cloudy, or turbid. 10. Pour sm ll mount of the urine s
pecimen (less
th n 50 mL) into tr nsfer tube th t h s been l beled with the p tients n me nd
/or ID number.
11. Using distilled w ter, verify the function of the refr ctometer: . Open the
refr ctometer
cover nd pl ce one drop of distilled w ter on the prism under the cover using
cle n tr nsfer
pipette. b. Close the cover, nd verify th t the s mple h s spre d over the enti
re prism surf ce.
c. Look t the sc le through the eyepiece; bright light in the vicinity helps wi
th visu liz tion.
d. Re d the sc le where the line intercepts it. This is where the colors ch nge
with sh rp line
of division. e. Wipe the s mple w y from the f ce of the prism with
Kimwipe l
bor tory tissue
nd w ter. Urine specimens must be mixed well to judge their color nd ppe r nc
e ccur tely, s
well s the spe- cific gr vity re ding. Without mixing, the formed elements in t
he specimen will
settle to the bottom of the cont iner nd m y not be considered when determining
whether
specimen h s n bnorm l color or cl rity. These subst nces will lso not be ref
lected in the
specific gr vity re ding. The terms used to describe specimen color need to be s
t nd rdized
throughout the l bor tory. Abnorm l urine ppe r nce m y be linked to p tholog
ic l condition.
Use of st nd rdized terms is import nt throughout the l bor tory. The urine spec
imen m y need to
h ve culture performed on it; this decision is often not m de until the routin
e urin lysis h s
been completed. By pouring off specimen into tr nsfer tube r ther th n inserti
ng the pipette
directly into the urine cont iner, cont min tion is voided. The refr ctometer s
hould re d 1.000
when the specific gr vity of distilled w ter is tested. If this is not the re di
ng chieved,
follow the m nuf cturers direc- tions for c libr tion of the refr ctometer before
test- ing the
urine specimen. Re d the sc le where the bound ry line intercepts it. 1.050 1.04

0 1.030 1.020
1.010 1.000 1.355 1.350 1.345 1.340 1.335 1.333 nD U.G. 20C Procedure R tion le C
ontinued
1899_Ch20_401-412 26/12/11 5:38 PM P ge 409 D te 10/24/2013 Urine color: yellow,
Cl rity: cle r,
Specific gr vity: 1.015
11:58 .m.
Connie Lieseke, CMA (AAMA) Procedure 20-1: Observ tion nd Document tion
of Urine Physic l
Propertiescontd 410 Section V Urin lysis 12. Following l bor tory protocol, test
qu lity
control specimen using the refr ctometer. Use the s me procedure outlined in ste
p 10. Ch rt the
results on the qu lity control log. 13. Using cle n tr nsfer pipette, pl ce on
e to two drops of
the urine specimen (from the tr nsfer tube) on the f ce of the prism. Following
the pro- cedure
outlined in step 10 bove, re d the specific gr vity of the specimen. 14. Dispos
e of the urine
left in the tr nsfer tube by pouring it down the sink nd flushing it with plent
y of w ter.
Dispose of the tube nd tr nsfer pipette used for the urine in bioh z rd dispo
s l b g. If the
urine is not to undergo ddition l testing immedi tely, refriger te it or preser
ve it
ccordingly. 15. Cle n the instrument using distilled w ter nd
Kimwipe. 16. R
emove gloves nd
s nitize h nds. 17. Document results for p tient specimen on the ch rt (if v il
ble) nd testing
log sheet. Be cert in to use the correct digits for the document tion. The frequ
ency of the
qu lity control me surement will be dependent on the number of tests performed i
n most
l bor tories. Be cert in th t the qu lity control m teri l re ding f lls within
the ccept ble
r nge; if the results re outside the ccept ble r nge, do not use the refr ctom
eter for testing
the specific gr vity of the urine speci- men until the ccur cy of the instrumen
t h s been
verified. Reference r nges for urine specific gr vity re pproxi- m tely 1.005
to 1.030. Do not
llow the urine specimen to dry on the prism. Do not use h rsh cle ners or br s
ives to cle n the
prism or it will become scr tched nd unus ble. Refer to the m nuf cturers instru
ctions for more
cle ning procedures. Gloves should lw ys be removed immedi tely fter
procedu
re is performed.
H nd s nitiz tion is ppro- pri te before nd fter gloves re worn. Document ti
on needs to occur
immedi tely fter the specimen testing is complete. Procedure R tion le 1899_Ch2
0_401-412
26/12/11 5:38 PM P ge 410 Insufficient specimen volume: There must be
mini- mu
m of 12 to 15
mL of urine submitted for routine urin lysis to be performed. Use of nonst nd
rdized terms
for reporting: Although there m y be v rious terms used to describe the color n
d/or cl rity of
the urine specimen, ll l bo- r tory personnel must use the s me st nd rd terms

within their
institution. This llows for norm l r nges to be est blished, nd is import nt w
hen reporting
results. L ck of personnel tr ining: Although the ssessment of the urine physic
l properties
is rel tively simple process, there must be documented tr ining for those who
perform this
t sk. Use of nonc libr ted equipment: Refr ctometers must be c libr ted regul rl
y using
distilled w ter, nd qu l- ity control m teri ls should be tested to verify th t
they re working
ppropri tely. TIME TO REVIEW 1. Which of the following words is Outcome 20-1 us
ed to describe
blood in the urine? . Glycosuri b. Hem turi c. Pyuri d. Oliguri 2. Which of
the following
words is Outcome 20-1 used to describe slightly cloudy urine specimen? . H zy
b. Cle r c.
Turbid d. Amber 3. Which of the following is n Outcome 20-1 instrument used to
me sure the
specific gr vity of urine specimen? . Hemoglobinometer b. Urochrome meter c.
Refr ctometer d.
None of the bove 4. Which of the following m y c use Outcome 20-2 urine specime
ns to exhibit n
bnorm l color? . Ingestion of r re me t b. Ingestion of broccoli c. Aspirin us
e d. Ingestion
of fresh beets 5. Which of the following is used to Outcome 20-3 describe urine
cl rity when the
specimen h s p rticu- l te m tter suspended in it? . H zy b. Cloudy c. Turbid d
. All of the
bove 6. A urine specimen with n Outcome 20-4 mmoni -like odor m y be c used b
y: . B cteri in
the specimen b. Asp r gus ingestion c. Multivit min use d. Dye studies 7. A urin
e specimen with
specific Outcome 20-5 gr vity re ding of 1.035 will demonstr te: . High levels
of dissolved
subst nces b. Low levels of dissolved subst nces c. An mber color d. A foul odo
r Ch pter 20
Physic l Ch r cteristics of Urine 411 Test Your Knowledge 20-9 A medic l ssist
nt performing
urin lysis reported the urine cl rity for specimen s p rtly h zy. If the l bo
- r tory where
she works uses the s me criteri s th t noted in this textbook for specimen cl
rity, is this the
correct w y to report this test result? (Outcome 20-8) SUMMARY The physic l ex m
in tion of urine
will provide infor- m tion bout the color, cl rity, nd specific gr vity of the
specimen.
Occ sion lly, n unusu l odor m y lso be noted during this p rt of the urine n
lysis. Results
th t re outside the reference r nge for these physic l ch r cteristics m y be t
he result of
p thologic l conditions, or they m y be c used by medic tion use or ingestion of
cert in foods.
Accur te results must begin with specimen th t h s been collected properly, id
en- tified
ppropri tely, nd preserved or refriger ted within 2 hours of collection. When
reporting the
color nd cl rity of specimen, it is import nt to use terms th t h ve been pp
roved by the
f cility so th t the reporting methods re st nd rdized. Instruments used for sp

ecific gr vity
re dings must be c libr ted nd qu lity control m teri l must be tested t regul
r interv ls to
verify the ccur cy of the me surement. Medic l ssist nts must lso be w re of
potenti l
sources of error when per- forming n ssessment of the physic l properties of
urine specimen
to void in ccur te results. 1899_Ch20_401-412 26/12/11 5:38 PM P ge 411 412 Sec
tion V
Urin lysis C se Study 20-1: Too much to do Cindy Collier, CMA (AAMA), is working
in the office
l bor tory for busy intern l medicine clinic. She is bout to perform urin l
ysis on
specimen th t w s collected from
p tient who is in to see the physici n bec us
e of blood in her
urine. Cindy verifies the identi- fic tion on the specimen nd pl ces it on the
counter in the
l bor tory re . Before she h s ch nce to do ny- thing else, she is c lled w
y to perform
venipuncture nd PT/INR on nother p tient. Approxim tely 1 hour l ter, Cindy hu
rries into the
l bor tory so th t she c n st rt to n lyze the urine specimen. She picks up the
cup, nd
documents th t the specimen is cle r nd ppe rs yellow in color. She lso notes
th t there is
red ring round the bottom interior of the cup. 1. Wh t did Cindy forget to do bef
ore ssessing
the color nd cl rity of the specimen? 2. Is her ssessment of the specimens bein
g yellow nd
cle r correct result for this specimen? RESOURCES AND SUGGESTED READINGS Clini
c l nd
L bor tory St nd rds Institute, Urin lysis: Approved Guideline, ed. 3. CLSI docu
ment G16-A3.
W yne, PA, 2009 Approved l bor tory st nd rds for collecting, processing, nd te
sting urin lysis
s mples 8. Which of the following is not Outcome 20-8 potenti l source of erro
r for urine
testing? . A urine specimen received without p tient n me b. Observ tion nd
document tion of
urine color nd cl rity upon specimen receipt c. Observ tion nd document tion o
f urine color nd
cl rity immedi tely fter t king the specimen from the refriger tor d. Use of
cont iner th t
w s not provided by the l bor tory for the urine collection 1899_Ch20_401-412 26
/12/11 5:38 PM
P ge 412 Ch pter 21 Chemic l Ex min tion of Urine nd Feces Const nce L. Lieseke
, CMA (AAMA),
MLT, PBT(ASCP) 413 CHAPTER OUTLINE Urine An lytes nd Their Clinic l Signific nc
e Bilirubin Blood
Glucose Ketones Leukocytes Nitrite pH Protein Urobilinogen Specific Gr vity Pote
nti l Sources of
Error S fety Prec utions Qu lity Control Procedures Urine Testing Methods Confir
m tory Urine
Testing Fec l Occult Blood Testing Summ ry Time to Review C se Study Resources
nd Suggested
Re dings 21-1 Define the key terms. 21-2 Differenti te v rious dise se st tes re
l ted to bnorm l
urine chemistry results. 21-3 Identify bnorm l v lues for the n lytes tested w
ith urine
chemistry n lysis. 21-4 List potenti l sources of error for urine chem- istry t

esting, nd
describe how these errors m y be voided. 21-5 Describe ppropri te s fety prec
utions implemented when testing urine. 21-6 Comp re the testing methods v il ble for urine
chemistry
n lysis. 21-7 Perform CLIA-w ived urine chemistry n lysis using m nu l nd
n utom ted
testing method. 21-8 Provide ex mples of confirm tory tests performed on urine s
pecimens. 21-9
Expl in the import nce of fec l occult blood testing. 21-10 Det il the necess ry
p tient
prep r tion for fec l occult blood specimen collection. 21-11 Perform CLIA-w i
ved fec l occult
blood test. Le rning Outcomes After re ding this ch pter, the successful student
will be ble to:
1899_Ch21_413-438 22/12/11 11:14 AM P ge 413 414 Section V Urin lysis KEY TERMS
Acidosis
Alk losis Bence Jones protein Bilirubin Conjug ted bilirubin Fec l occult blood
testing (FOBT)
Glucosuri Glycosuri Gu i c method Hem turi Hemoglobinuri iFOB Intr v scul r
lysis J undice
Ketones Ketonuri Leukocyte ester se Leukocytes Micro lbuminuri Multiple myelom
Myoglobin
Myoglobinuri Nitrite Proteinuri Semiqu ntit tive Sulfos licylic cid precipit
tion test
Urobilinogen CAAHEP/ABHES STANDARDS CAAHEP St nd rds III.P.III.2. Pr ctice St nd
rd Prec utions
I.P.I.14. Perform Urin lysis ABHES St nd rds Apply principles of septic techniq
ues nd
infection control. Use st nd rd prec utions. Perform CLIA-w ived tests th t ssi
st with
di gnosis nd tre tment, Urin lysis. Instruct p tients in the collection of fe
c l specimen. T
he chemic l testing of urine specimens is the sec- ond component included in c
omplete
urin lysis. There h ve been numerous ch nges to chemic l urine testing procedure
s through the
ye rs, nd the most sig- nific nt ch nges occurred with the development of re ge
nt test strips.
Since the 1950s it h s been possible to test numerous chemic l n lytes t once
with dispos- ble
re gent test strips. These strips re m de of pl s- tic with bsorbent p ds t
t ched. (An
ex mple is shown in Fig. 21-1.) The p ds re impregn ted with v rious chemic ls,
nd e ch p d is
designed to ch nge color s it re cts with specific n lyte present in the uri
ne spec- imen.
The resulting colors on the p ds re interpreted by comp ring the individu l p d
to ch rt
supplied with the re gent strips. An ex mple of ch rt used for comp rison is s
hown in Figure
21-1. By comp ring the color ch nges with the reference ch rt it is possible to
perform
semiqu ntit tive me surement, providing n pproxim te v lue for e ch of the che
mic ls being
tested. The results m y be reported s the milligr ms per deciliter present, or
by using
semiqu ntit tive re- porting method of tr ce, 1+, 2+, 3+, or 4+. Some of the res
ults m y lso be
reported s positive or neg tive, which is n ex mple of qu lit tive test resu

lt. URINE
ANALYTES AND THEIR CLINICAL SIGNIFICANCE A routine urin lysis usu lly includes t
esting for
biliru- bin, blood, glucose, ketones, leukocytes, nitrites, pH, protein, nd uro
bilinogen. The
re gent strips most commonly used include testing for specific gr vity s well.
M ny of these
chemic l subst nces re norm lly present in the urine specimen, but the mount o
f the individu l
n lyte present m y ch nge with cert in dise se st tes. Other chemic ls re not
present in the
urine specimen norm lly, nd their detection m y 1899_Ch21_413-438 22/12/11 11:1
4 AM P ge 414
Ch pter 21 Chemic l Ex min tion of Urine nd Feces 415 be clinic lly signific n
t. Chemic l
n lysis of urine spec- imens m y detect dysfunction of c rbohydr te met bo- lis
m, pH imb l nces,
red blood cell hemolysis, nd liver or kidney problems. The perform nce of urine
chemic l testing
in the physici n office l bor tory is benefici l for the p tient bec use bnorm
lities re
quickly detected nd ppropri te tre tment or follow-up testing c n be t ken c r
e of immedi tely
while the p tient is still in the presence of the he lth-c re provider. There r
e two prim ry
m nuf cturers for urine re gent strips. Multistix is m nuf ctured by Siemens Med
ic l Solutions
Di gnostics, nd Chemstrip is m n- uf ctured by Roche Di gnostics. The strips r
e v il- ble
with v rious types of re gent p ds, depending on the needs of the he lth-c re pr
ovider ordering
the urine tests. If testing is performed with n utom ted system, there m y be
recommend tion
for one br nd r ther th n the other. The m nuf cturers insert will include instru
ctions for use
nd will lso include interfering subst nces for e ch n lyte. Bilirubin Norm ll
y, bilirubin is
not present in the urine. The presence of bilirubin in the urine specimen m y be
n e rly
indic tion of liver dise se or bile obstruction. Bilirubin is by-product of re
d blood cell
destruction. As red blood cells re broken down t the end of their 120-d y life
cycle,
hemoglobin is rele sed. This decomposition of red blood cells occurs in the sple
en nd liver. As
the hemoglobin molecules rele sed from the red blood cells degr de further, they
re split into
sm ller components. Bilirubin is cre ted from hemo- globin s p rt of this degr
d tion process.
To tr vel through the bloodstre m, bilirubin must be c rried by molecules of lb
umin ( type of
protein) bec use the bilirubin is not w ter soluble. The bilirubin- lbumin molec
ule is too l rge
to enter the urine within the kidneys. Inste d, the bilirubin- lbumin complex is
re- turned for
processing in the liver, where the bilirubin becomes w ter soluble nd is sep r
ted from the
lbu- min. This w ter-soluble bilirubin is c lled conjug ted bilirubin. Conjug t
ed bilirubin is
not usu lly detected in the urine bec use it is p ssed from the liver directly i

nto the bile duct

to be secreted into the intestines. The intestin l b cteri further lter the bi
lirubin, ch nging
it into compound known s urobilinogen. Bile obstruction m y le d to the prese
nce of conjug ted bilirubin in the urine, nd liver dysfunction m y lso c use bilirubin to
be detected in
the urine specimen. Bilirubin is h s strong yellow-or nge color. When it becom
es elev ted in
the bloodstre m, the p tients skin, scler of the eye, nd pl sm reflect this in
tense yellow
color, known s j undice. Excessive hemolysis, liver dysfunction, or bile obstru
ction m y c use
j un- dice. Just s the bilirubin is elev ted in the bloodstre m with bile obstr
uction or liver
dysfunction, the levels m y lso be elev ted in the urine specimen, llowing for
detection with
chemic l n lysis. Test Your Knowledge 21-1 True or F lse: All n lytes tested b
y the urine
re gent strips re present in me sur ble qu ntities in
norm l urine specimen.
(Outcome 21-3)
Test Your Knowledge 21-2 Wh t clinic l dysfunction will c use urine specimen t
o test positive
for bilirubin? (Outcome 21-2) Figure 21-1 Urine chemic l re gent testing strip
nd ch rt used
for comp rison when re ding urine chemic l re gent strip results. 1899_Ch21_413438 22/12/11
11:14 AM P ge 415 Blood There re three re sons th t urine s mple m y show
p
ositive result
for blood. The presence of int ct red blood cells, known s hem turi , will c us
e pos- itive
re ction. Hem turi will often present with
cloudy, red urine specimen with l
rge mounts of
red blood cells present. Microscopic ex min tion of the urine specimen will dete
ct red blood
cells in the urine sediment. The presence of hemoglobin without the presence of
int ct red blood
cells (hemoglobinuri ) will lso c use positive result for blood in
urine s
mple. Hemoglobinuri m y be the result of red blood cell lysis th t occurs in the urin ry tr ct,
or it c n be
c used by intr v scul r lysis, which is the bre kdown of red blood cells within
the vessels.
Intr v scul r lysis occurs in hemolytic tr ns- fusion re ctions. Hemoglobinuri
m y lso be
present with severe burns, m l ri , hemolytic nemi s, or with some spider or sn
ke bites th t
c use hemolysis within the blood vessels. The presence of blood in the urine spe
cimen is not
norm l, except in the c se of specimen cont min tion with menstru l blood or tr
um c used by
c theter insertion. Fin lly, the presence of myoglobin in the urine, known s my
oglobinuri , will
result in positive result for blood. Myoglobin is present in muscle tis- sues,
where it serves
s n oxygen-storing molecule. When present in urine, it m y c use the urine to
ppe r red-brown
in color, but the specimen cl rity will rem in cle r. Myoglobin m y be present i
n the urine when
there is tr um to the muscles, convul- sions, lcoholism, electrocution, or exc

essive exercise.
Myoglobin is ctu lly toxic to the kidneys; therefore, high mounts present in t
he urine m y be
n indic tor of concurrent kidney d m ge. There re m ny testing methods nd com
p risons between
urine nd pl sm th t m y differenti te
positive urine blood result due to hem
oglobin from one
th t is due to myoglobin, be- c use there re very few int ct red blood cells pr
esent in the
urine in both c ses. Glucose The presence of glucose in the urine is not norm
l result. Blood
glucose is norm lly regul ted through hormon l ch nges nd kidney function, incl
uding the
re bsorption of lmost ll the glucose filtered out by the glomeruli. However, w
hen the blood
glucose concentr tion becomes excessively elev ted ( t levels between 160 nd 18
0 mg/dL) the
glucose concentr - tion is too high for most of it to be re bsorbed by the tubul
es, nd the
glucose spills into the urine. Glycosuri is word used to describe the presence
of sug r in
the urine; glucosuri is used when the sug r in the urine is identified s gluco
se. Glucose is
the most common c use of glycosuri , nd most re gent strip methods test positiv
e only in the
presence of glucose; they do not re ct with other sug rs. How- ever, g l ctose,
l ctose,
fructose, nd pentose re other sug rs th t m y be present in the urine. Point o
f Interest 21-1
provides more inform tion bout ddition l test procedures th t m y be performed
on the urine
specimen to llow for detection of sug rs other th n glucose. Elev ted levels of
g l ctose in the
urine of inf nts m y be indic tive of serious condi- tion th t needs immedi te
intervention;
therefore, ltern tive testing methods re often used for urine testing on inf n
ts to provide n
opportunity to detect g l ctosuri . Urine glucose testing c n be n inv lu ble p
rt of di betes
screening. Bec use the symptoms of di betes re not cle rly defined nd do not p
resent themselves
in the s me w y for e ch individu l, there re m ny p tients who re un w re th
t they re
di betic. For this re son, glucose testing is one of the most common tests perfo
rmed on urine
specimens. Bec use the blood glucose concentr tion c n fluctu te throughout the
d y, urine
glucose testing done for the purpose of di - betes screening should be performed
on f sting
speci- mens. Di betic p tients m y lso use urine glucose testing to monitor the
ir dise se
progress; this testing is usu lly performed on postpr ndi l specimens. Gluco- su
ri m y lso be
present when the re bsorption of the kidney tubules h s been compromised, s in
the c se of ren l
f ilure. 416 Section V Urin lysis Test Your Knowledge 21-3 Which of the followi
ng will result in
positive test for blood in the urine specimen? . Int ct red blood cells b. El
ev ted levels of
iron in the blood c. Pus in the urine d. None of the bove (Outcome 21-3) Test Y

our Knowledge
21-4 True or F lse: All di betic p tients will h ve
positive urine glucose res
ult t ll times.
(Outcome 21-2) 1899_Ch21_413-438 22/12/11 11:14 AM P ge 416 Ketones Ketones re
product of f t
met bolism, nd their presence in urine is not considered norm l result. When
f t is
met bolized, the process usu lly continues to the point t which the ketones re
fully broken
down nd undetect ble. However, if the glucose in the body c nnot be re dily use
d for energy,
then f t met bolism is incre sed, nd ketones m y be present in the blood nd in
the urine.
Uncontrolled di betes mellitus, m l- bsorption syndromes, excessive reduction i
n c rbohy- dr te
int ke, nd vomiting m y ll le d to the presence of ketones in the urine (keton
uri ) bec use
these con- ditions dont llow glucose to be used efficiently s source of energ
y. The word
ketones is used to describe three different products rele sed into the bloodstre
m s f t is
met bo- lized: cetone, ceto cetic cid, nd bet -hydroxybutyric cid. Re gent
strips test
specific lly for ceto cetic cid. The other two ketone types re ctu lly cre t
ed by ceto cetic cid, so detection of this compound will provide clinic lly signific
nt result,
indic ting the presence of ny type of ketone product. Urine ketones re often m
onitored in
p tients with type 1 di betes mellitus. When the body does not h ve enough insul
in, the glucose
present in the bloodstre m c nnot be used, nd the body will begin to met bolize
incre sing
mounts of f t for energy. If the ketones c n be detected e rly (in the blood n
d in the urine),
the p - tient m y be w re of n impending crisis nd the dos ge of insulin c n
be regul ted to
llow for more efficient glucose met bolism. Leukocytes Leukocytes re white blo
od cells. Their
presence in the urine in sm ll mounts is not n bnorm l result, but when the n
umber of
leukocytes becomes elev ted, it is indic tive of infl mm tion or infection of th
e urin ry Ch pter
21 Chemic l Ex min tion of Urine nd Feces 417 POINT OF INTEREST 21-1 G l ctose
mi The glucose
test p d on the urine chemic l re gent strip is specific for glucose only; other
types of sug rs
th t m y be present in the urine re not detected by the enzym tic chemic l re c
tion th t occurs
when this p d is exposed to the urine specimen. However, for inf nts, this re ge
nt p d test does
not provide enough inform tion. Urine specimens th t test neg - tive for n inf
nt should h ve n
ddition l test per- formed th t will detect other types of sug rs th t m y be p
resent in the
urine. When n inf nt ingests l c- tose ( type of sug r commonly found both in
bre st milk nd
formul ), the l ctose inter cts with n tu- r lly occurring enzyme, l ct se. L
ct se splits the
l c- tose molecule into two sm ller sug r molecules, glu- cose nd g l ctose. Gl

ucose is e sily
used by the body for energy, but g l ctose must be met bolized further before th
e body c n m ke
use of it. Heredit ry g l c- tosemi is
condition in which the inf nt is not c
- p ble of
met bolizing the g l ctose. The g l ctose levels in the bloodstre m begin to cli
mb, c using initi l symptoms of convulsions, irrit bility, leth rgy, poor weight g in, j undice
, nd vomiting.
If the ele- v ted levels of g l ctose continue to incre se, the liver, br in, ki
dneys, nd eyes
m y be ffected irre- versibly. Detection of g l ctosemi within the first few d
ys of life is
critic l, s the tre tment involves the complete remov l of this sug r type from
the diet, nd
these ch nges must begin immedi tely. To ensure th t elev ted levels of other su
g rs such s
g l ctose ( lso known s reducing subst nces) re detected in urine specimens fo
r inf nts, n
ltern te form of testing is used. The Clinitest test m nuf c- tured by B yer Co
rpor tion uses
copper reduction testing method, in contr st to the enzym tic method used on tes
t strip re gent
p ds. The copper reduction test method will detect the presence of ll types of
sug r, not just
glucose. In this test,
few drops of the urine specimen re mixed with few dr
ops of w ter, nd
re gent t blet is dropped into the tube. A vio- lent re ction ensues, nd the
resulting color
of the mixture in the tube is comp red to
ch rt (provided with the t blets) to
interpret the
mount of reducing subst nces present in the specimen. If the test result for th
e Clinitest is
positive, it is ssumed th t the sug r present is not glucose, s this would h v
e lso c used
positive result on the re gent p d re ction. C re should be t ken when performin
g the Clin- itest
procedure. Gloves, eye protection, nd skin pro- tection need to be worn, s the
re ction th t
occurs within the tube involves boiling the mixture nd it is possible to c use
d m ge to the
skin, eyes, or mucous membr nes. It is import nt to dispose of the mixture prope
rly s well, s
it cont ins sodium hydroxide nd citric cid. The procedure nd prec utions outl
ined in the
p ck ge insert should be followed c refully. 1899_Ch21_413-438 22/12/11 11:14 AM
P ge 417 418
Section V Urin lysis tr ct. Re gent strips test for the presence of leukocyte e
ster se,
subst nce present in gr nulocytic white blood cells (those th t h ve gr nules in
their
cytopl sm), such s neutrophils, b sophils, nd eosinophils. Leukocyte es- ter s
e is lso present
in monocytes. Neutrophils re the white blood cell type th t is most commonly el
ev ted in urin ry
tr ct infections. Leukocytes m y be visu lized with microscopic ex min tion of t
he urine, but
bec use leukocyte ester se is present even with lysed white blood cells, the pre
sence of
leukocytes in the urine specimen m y be overlooked if only the microscopic resul

ts re considered
in the p tient ssessment. nd the pH of subst nce is the me surement of how
cidic or lk line
th t subst nce is, b sed on the concen- tr tion of hydrogen ions present. The lu
ngs nd the
exch nge of ions in the urin ry tubules of the kidneys pri- m rily control the p
H of the hum n
body. The pH of the blood must be m int ined between 7.35 nd 7.45. Urin ry pH m
y be bnorm l
when the body is in st te of cidosis ( blood pH of 7.35 or below) or when th
e blood pH is
elev ted bove 7.45 (known s lk lo- sis). Met bolic issues not rel ted to kidn
ey function m y
c use n bnorm l urine pH. Kidney dysfunction m y lso le d to lk line or cid
ic urine bec use
the exch nge of ions occurs in the ren l tubules. Medic tions or nutri- tive sup
plements m y be
used for p tients with chronic urin ry tr ct infections to keep the urine slight
ly cidic, s
this environment is not supportive of b cteri l growth. This m y c use urine pH
results th t re
outside of the norm l r nge, but will not necess rily be inter- preted s bnorm
l for the
p tient who is undergoing tre tment. Protein The presence of protein in the urin
e (proteinuri )
is most commonly ssoci ted with ren l dise se. A posi- tive result for protein
does not lw ys
indic te kidney d m ge, but there should lw ys be ddition l testing performed
to determine
whether the proteinuri is indic tive of p thologic l condition. Norm l urine
h s very little
protein present, s most protein mole- cules re not llowed to enter the urine
through the
glomerulus bec use the molecules re too l rge to le ve the pl sm . Any th t re
filtered out re
usu lly re b- sorbed by the ren l tubules nd re not present in the urine speci
men. Protein m y
be present in the urine when there is no ren l dise se or d m ge. This occurs wh
en the tot l
protein level of the pl sm is elev ted. This elev tion is the result of the inc
re sed presence
of sm ll protein molecules in the pl sm th t re c p ble of p ssing through the
pores in the
glomerulus. The kidneys will filter out the excess protein, but when they h ve r
e ched their
c p city for protein re bsorption in the ren l tubules, protein will be present
in the urine
spec- imen. Muscle tr um , fever, or excessive intr v scul r hemolysis will elev
te the blood
protein levels. This is usu lly tr nsient result th t will not continue once t
he underlying
condition h s been resolved. P tients with multiple myelom ( c ncer of the bon
e m rrow) m y
present elev ted mounts of Bence Jones protein in their pl sm . This specific t
ype of Test Your
Knowledge 21-5 True or F lse: The leukocyte ester se result will lw ys be posit
ive when white
blood cells re present in the urine specimen. (Outcome 21-3) Nitrite Some types
of b cteri re
c p ble of converting ni- tr te, which is norm lly present in urine, to nitrite,

which is not
usu lly detect ble. Escherichi coli, which is the most common c use of b cteri
l urin ry tr ct
in- fection, is c p ble of producing nitrites. M ny other gr m-neg tive org nism
s re lso
c p ble of this con- version, such s those of the Klebsiell , Proteus, nd Serr ti gener . A
positive nitrite result is indic tive of the presence of b cteri in the urine.
However, there
re two f ctors th t must be considered when interpreting this result. First of
ll, not ll
b cteri re c p ble of converting nitr te to nitrite, so neg tive result does
not necess rily
me n th t the specimen is b cteri free. Second, the b cteri must be present in
the urine specimen long enough to ccomplish the conversion, nd this usu lly t kes 4 to 6 hou
rs. If
nitrite
test is to be used s screening tool for potenti l urin ry tr ct infection,
first morning
void specimen should be used for the test, bec use the urine collected with this
type of specimen
h s been in the bl dder ll night with the b cteri , llowing for n opportunity
for the conversion to occur. Specimens collected t other times of the d y m y or m y not h ve
been in the
bl dder for long enough period of time for this result to be positive one, e
ven if the
b cteri present re c p ble of convert- ing nitr te to nitrite. pH The pH of no
rm l freshly
voided urine m y v ry from 4.6 to 8.0. The bbrevi tion pH st nds for p rts hydro
gen,
1899_Ch21_413-438 22/12/11 11:14 AM P ge 418 Ch pter 21 Chemic l Ex min tion of
Urine nd Feces
419 protein will be filtered out of the blood, nd when the tubul r re bsorption
c p city h s
been surp ssed, Bence Jones protein will be present in the urine speci- men. It
is possible to
differenti te Bence Jones protein from other types of protein by t king dv nt g
e of the
different re ction of this specific type of protein when exposed to he t. The Be
nce Jones protein
will co gul te (clump up) when exposed to temper tures between 40C nd 60C, but it
will
dissolve b ck into the solution when exposed to temper tures of 100C. Other prote
ins will
co gul te t simil r tem- per ture, but will not dissolve t the higher temper
- tures. The
bsence of Bence Jones protein in the urine is not v lid me ns of ruling out m
ultiple myelom ,
s m ny p tients with this dise se do not excrete levels high enough to be detec
ted in the urine
specimen. Protein electrophoresis is
more specific test used for di gnosis. Th
e most common
type of protein present in the urine s result of d m ge to the kidneys is lb
umin. It m y be
indic tive of d m ge to the glomeruli or to the ren l tubules. The presence of
lbumin m y be
tr nsient condition, s in the c se of strenuous exercise or dehydr tion. P tien
ts with
hypertension m y lso present with proteinuri . Positive protein tests in preg-

n nt women
(especi lly in the l st trimester of preg- n ncy) m y be indic tive of preecl mp
si , serious
condition th t must be tre ted immedi tely. Micro l- buminuri , or the chronic p
resence of sm ll
mounts of lbumin in the urine, is common occurrence in di- betic p tients.
It is n
indic tion th t the glucose lev- els in the blood re not st bilized, nd the in
cre sed worklo d
required of the kidneys to filter out these l rge molecules h s c used the glome
ruli to become
d m ged. The d m ged glomerulus llows protein molecules to le k into the urine
specimen,
presenting s micro lbuminuri . Most re gent strips detect only the presence of
lbumin. If other
types of protein re suspected, it m y be necess ry to use other testing methods
to detect their
presence. The sulfos licylic cid precipit tion test (SSA test) is test th t w
ill detect ll
forms of protein in the urine specimen. In this procedure, 3 mL of 3% sulfos lic
ylic cid is
dded to n equ l volume of centrifuged urine. The specimen is mixed well with t
he cid, nd the
degree of turbidity (cloudiness) is me sured. The gr de or degree of turbidity i
s corre- l ted to
the prob ble mount of protein present in the specimen. This test m y be useful
when there is
color interference in the urine specimen nd protein test is desired, or when
the urine
specimen h s very lk line pH, s this c n interfere with the re gent strip re
sults for
protein. Test Your Knowledge 21-6 Which of these re nonp thogenic c uses of pro
teinuri ? .
F tigue b. Fever c. Vomiting d. Ingestion of red me t (Outcome 21-3) Urobilinoge
n The presence of
sm ll mount of urobilinogen in the urine is norm l. However, incre sed levels
m y be
indic tive of liver dise se (such s hep titis or cirrhosis) or hemolytic disord
ers. Urobilinogen
is produced in the intestines by the intestin l b cteri s bilirubin is broken
down. Once
formed, either it will be re bsorbed into the bloodstre m (where it will eventu
lly p ss through
the kidneys) or it m y be excreted in the feces. Some of the urobilinogen in the
intestines is
further broken down by intestin l b cteri to form urobilin, pigmented subst n
ce th t dds
color to feces. Urine urobilinogen levels m y be elev ted bec use the liver is i
nc p ble of
processing the urobilinogen in the blood or bec use there re elev ted levels of
bilirubin
present. In the c se of bile duct obstruction, the urine will be positive for bi
lirubin, but the
urobilinogen levels will be norm l. Hemolytic dise ses m y produce neg tive bi
lirubin result
with positive urobilinogen re ction. Specific Gr vity The clinic l signific nc
e of the specific
gr vity test is presented in Ch pter 20, s well s sever l testing meth- ods th
t re used for
specific gr vity me surements. Spe- cific gr vity tests m y be useful in monitor

ing the hydr tion st tus of p tients or to me sure the bility of the ren l tubules to con
centr te the
urine specimen s needed. The specific gr vity p d on the re gent strip t kes d
v nt ge of the
incre sed mount of ions present in urine specimens h ving higher concentr tions
. The gre ter the
number of ions th t re present in the urine, the more the color ch nges when ex
posed to the
speci- men. The specific gr vity re gent p ds re usu lly sensi- tive from 1.000
to 1.030 nd re
semiqu ntit tive. The results m y be in ccur te with lk line urine specimens (f
lsely decre sed
results) or when high concentr tions of protein re present in the urine specime
n (f lsely elev ted results). 1899_Ch21_413-438 22/12/11 11:14 AM P ge 419 420 Section V Urin
lysis POINT OF
INTEREST 21-2 CLIAw ived drug screening tests M ny employers now require their po
tenti l employees to h ve
urine drug screening test performed prior to n offer of employmen
t. These drug
screen- ing collections re becoming common p rt of the duties for medic l ss
ist nts nd
phlebotomists in m ny offices. In some c ses, the drug screenings m y be feder l
ly m nd ted.
Other employers h ve devel- oped drug screening policy to keep the workpl ce s
fer. If drug
screening collection is ordered by n employer, the medic l ssist nt will be in
volved in the
collection process, nd
ch in of custody will be st rted to document the tr ns
port tion of the
speci- men until it is tested in
reference l bor tory th t speci lizes in this
type of testing.
This process requires specific tr ining nd gre t de l of ttention to det il.
The employment
st tus of the client depends on these results. Urine drug screenings m y lso be
ordered to check
for illeg l drug use in p tients for whom this is suspected s p rt of their cli
nic l di gnosis.
These tests m y be performed in the office, using CLIA- w ived urine drug screen
ing kits. They
re v il ble to test for m ny different drugs of buse, such s m riju n , coc
ine,
mphet mines, opi tes, oxy- codone, nd PCP. These tests re gener lly per- form
ed by pplying
the urine specimen to re gent stick th t will ch nge color if the met bolite o
f th t specific
drug is present. In ddition, employers who would like to h ve immedi te results
m y sk for
quick screening test to be performed in the office using these CLIA-w ived kits.
This is not
lw ys conclusive; sometimes the p tient m y be t king pre- scription drugs th t
will c use the
screening tests to be positive, bec use the urine tests re designed to identify
the met bolites
(bre kdown products) of the drug th t w s ingested, not the drug itself. If p
tient h s
positive result, it is imper tive to follow the office protocol for sending out
the specimen for
confirm tory testing. A urine drug screening test m y not lw ys detect the pres

ence of the drugs

in the system even if the p tient h s been exposed recently. E ch drug h s dif
ferent time
interv l for which it c n be detected. This c n v ry depending on the mount of
exposure, the
size of the individu l, his or her unique met - bolic r te, the pH of the urine
specimen, nd the
type of drug. Drugs th t re lipid soluble (such s m riju n ) re detect ble fo
r longer periods
of time th n re m ny other drugs th t re considered to be more d ngerous. The
product
liter ture for the CLIA-w ived testing kit used in the office should be consulte
d for more
inform tion bout the sensitivity of the test. Some f cilities now request testi
ng of h ir
s mples, s the retention time for the drug in the h ir follicles is much longer
th n its
presence in the urine. There re currently no CLIA-w ived proce- dures for h ir
testing. In
ddition, if the urine specimen is very dilute, it is possible th t the test m y
be f lsely
neg tive. Most offices th t perform drug screening collections nd/or testing wi
ll h ve
est blished policies in which speci- mens th t re too dilute will need to be re
collected. This
decision is b sed on the specific gr vity v lue of the specimen. Another CLIA-w
ived test th t
m y be requested by employers nd/or he lth-c re providers tests for the presenc
e of lcohol by
testing s liv s mple. Or sure Technologies m nuf ctures
CLIA-w ived qu ntit
tive s liv
lcohol test. If n employer sus- pects th t n employee h s been ingesting lco
hol while t
work, th t employer m y request this test be performed s screening tool. A bl
ood lcohol test
would be more sensitive, nd m y lso be requested. This would require testing
t reference or
hospit l l bor tory, s there re no CLIA-w ived tests v il- ble to screen blo
od for lcohol.
POTENTIAL SOURCES OF ERROR Some of the most common errors encountered while perf
orming urine
chemic l testing re the following: Incorrect specimen l beling: Urine specimens
must h ve the
l bels ffixed to the specimen cont iner, not to the lid of the cont iner. Lids
m y be removed
from multi- ple specimen cont iners t once, llowing for confu- sion when ttem
pting to identify
the correct p tient n me for e ch specimen. L beling errors lso include specime
ns th t re
misl beled or not l beled t the time of collection. Improper stor ge: The re g
ent strips must
be protected from direct light, moisture, nd excessive he t. They should lso n
ot be stored in
n re ne r vol tile liq- uids, s the p ds on the strip m y bsorb some of the
chemic ls
present in the environment. Strips should not be removed from the bottle until j
ust before use,
nd the desicc nt provided needs to rem in in the bot- tle of strips until they
re ll used. If
the re gent strips 1899_Ch21_413-438 22/12/11 11:14 AM P ge 420 Ch pter 21 Chem

ic l Ex min tion
of Urine nd Feces 421 re exposed to moisture, they will become discolored nd
must be
disc rded. The lid for the bottle must be repl ced immedi tely fter removing re
gent strips. The
bottles re to be stored t room temper ture, nd c re should be t ken not to us
e the strips
fter the expir tion d te printed on the bottle. Re gent strips should never be
cut in h lf or
ltered in ny w y. Improper technique: The m nuf cturers instructions st te th t
the urine
re gent strip is to be dipped com- pletely into
well-mixed specimen nd remove
d immedi tely.
Excess urine is to be removed from the strip by sliding the edge of the strip l
ong the side of
the cont iner s it is withdr wn from the specimen. In ccur te results re produ
ced when the
re gent strip is llowed to rem in in the urine for n extended period of time,
s the chemic ls
in the re gent p ds will erode, cont min ting the urine specimen to pro- duce in
ccur te color
ch nges. Once the strip is removed from the urine, it is recommended th t ny ex
cess urine still
present be blotted w y with n bsorbent p d. Also, m ny formed elements in the
urine specimen
will settle to the bottom of the con- t iner if the specimen is not well mixed,
llowing for
potenti l f lse-neg tive results when the strip is inserted into the specimen. I
ncorrect timing
of re ctions: Incorrect timing of re c- tions is prob bly the most common error
in re gent strip
n lysis. E ch br nd of test strips will specify how long the urine should rem i
n in cont ct with
the testing strip before the result is to be re d by observ- ing the color ch ng
e on the p d.
This time v ries mong tests, but ll test p ds should usu lly be re d within 12
0 seconds.
Unfortun tely, the person per- forming the test commonly dips the re gent strip
into the urine
specimen, but doesnt follow the timing rec- ommend tions when re ding the results
. This results
in n inconsistency within the l bor tory nd m y le d to f lse-positive test re
sults bec use of
incre sed re ction times, or f lse-neg tive test results bec use of in dequ te r
e ction times.
Incorrect result interpret tion: The re gent strips nd color ch rts used to re
d the re ctions
re not interch nge ble mong m nuf cturers. For m nu l procedures, it is import
nt to line up
the re gent strip ppropri tely to the color ch rt used for comp rison, nd to r
eport the n lyte
using the units nd reporting methods suggested by e ch m nuf cturer. Some tests
re reported s
qu li- t tive results in which the result is either positive or neg tive, where
s other tests re
reported using
sc le of 1+, 2+, nd so on. Other n lytes re reported using u
nits of
me surement, such s 20 mg/dL. Test interference: Bec use every re gent p d on t
he test strip
is impregn ted with
different chemic l, e ch p d m y be ffected by different

types of interfering subst nces. Urines th t re very lk line m y interfere with sever l of t
he p ds, s will
strong col- ors (such s those with Pyridium [phen zopyridine] use), the presenc
e of detergents
or ntiseptics, or high specific gr vity. High levels of scorbic cid (vit min
C) m y c use
f lse-neg tive results for blood, glucose, bilirubin, nitrite nd leukocyte este
r se. The
presence of menstru l blood m y c use f lse-positive results for blood th t re
not clinic lly
signific nt. M ny di gnostic dyes nd medic tions lso c n c use interference fo
r some of the
testing methods. The m nuf cturers insert will provide more det iled inform tion
bout
interfering sub- st nces for the v rious tests. Incorrect urine stor ge or prep
r tion:
Although this is not technic lly potenti l source of error only for re gent st
rip testing, it
is common problem th t c n ffect ll the urin lysis results. Urine s mples sh
ould be
refriger ted, tested, or properly preserved within 1 hour of collection. Urine t
h t is llowed to
rem in t room temper ture for extended periods of time c n undergo chemic l ch
nges th t were
not present t the time of collection. F ilure to perform m inten nce, c libr ti
on, or qu lity
control: Whether the method used in the l bor tory is m nu l or utom ted, qu li
ty control
testing should t le st be performed t the frequency specified by the m nuf ctu
rer. In ddition,
utom ted instruments h ve requirements for c libr tion nd m inten nce, nd the
se
recommend tions must be followed nd documented ppropri tely. Test Your Knowled
ge 21-7 Wh t re
three w ys th t re gent strips c n be h ndled incorrectly? (Outcome 21-4) Test Y
our Knowledge
21-8 Which of these is n ex mple of n improper urine chemistry testing techniq
ue th t m y
ffect results? . Performing the test without we ring gloves b. Allowing the re
gent strip to
rem in in the urine for 60 seconds before remov l c. Mixing the specimen just pr
ior to testing d.
Allowing the urine specimen to re ch room tem- per ture before testing (Outcome
21- 4)
1899_Ch21_413-438 22/12/11 11:14 AM P ge 421 SAFETY PRECAUTIONS Urine is not con
sidered to be n
infectious gent for HIV nd other bloodborne p thogens unless it is visi- bly c
ont min ted with
blood. However, it m y still be infectious bec use it is cont min ted with other
microorg nisms, such s b cteri . Mucous membr ne ex- posure is the route of infec
tion most
re son bly ntici- p ted for urine specimens being tested for chemic l n lytes,
bec use of the
potenti l for spl shing the urine into the eyes or mouth s the specimen is h ndled. St nd rd
prec utions should be used when h n- dling urine specimens, nd ppropri te cti
ons should be
t ken to void spl shing, spilling, or form tion of erosols when h ndling the u

rine specimen.
Applic - tion of st nd rd prec utions for urine specimens include the following:
Appropri te
h nd hygiene procedures before nd fter pplic tion of gloves. Also, if cciden
t l exposure to
b re skin does occur, this site should be disinfected s soon s possible. Glove
use when
performing testing procedures. Gloves should be removed when le ving the testing
re nd
ppro ching cle n re of the l bor tory or physici n office. We ring of longsleeved,
fluid-resist nt l bor tory co ts th t re completely buttoned or sn pped. Occlus
ive dressings
or b nd ges used over broken skin. Use of eye protection nd/or f ce shield when
expo- sure is
nticip ted. N il biting, smoking, e ting, drinking, or m nipul t- ing cont ct l
enses is
prohibited when h ndling urine specimens. Covering urine specimens before centri
fuging. s mples
be checked e ch d y or e ch shift, depending on worklo d nd/or l bor tory polic
y. Most
l bor tories will require qu lity control testing d ily. The frequency recom- me
nd tion for
utom ted urine chemistry testing m y be different from the dvice given for m n
u l urine
testing. There m y lso be unexpected situ tions (such s the exposure of the st
rips to extreme
he t nd/or cold) th t will w rr nt qu lity control testing before p tient speci
- mens c n be
n lyzed. Commerci l qu lity control m teri ls re v il ble for purch se. Ex mp
les of these
include Lyphochek Qu ntit tive Urine Control by Bio R d, nd KOVA- Trol (m nuf c
tured by Hycor
Biomedic l, Inc.). It is suggested th t the positive control used for urin ly- s
is procedures be
we kly positive specimen, so th t the sensitivity of the testing process c n b
e ch llenged.
(Altern tively, three levels of control c n be imple- mented to verify the sensi
tivity of the
testing process.) It is import nt to note th t w ter should never be used s n
eg tive control
bec use it does not re lly resem- ble urine enough to test the procedure. Some l
bor to- ries
will freeze liquots of positive nd neg tive urine specimens to be used s qu l
ity control
specimens; this is ppropri te s long s the desired results re verified with
multiple testing
procedures nd ccept ble r nges re est blished for e ch test. Ide lly, e ch l
bor tory will
lso p rticip te in n extern l qu lity ssessment survey to ev lu te its perfor
m nce s comp red
to other l bor tories utilizing the s me testing procedures. This is not requi
red component for
CLIA-w ived tests, but the comp rison with other l bor tories will llow for mor
e confidence in
the test results. It is import nt to remember th t p tient testing should be per
formed only if
the urine qu lity control results re within the ccept ble r nge. If the result
s re not s
expected, then p tient results c nnot be n lyzed until the re son for the discr

ep ncy h s been
identified. Troubleshooting steps m y include using new bottle of control m te
ri l or using
new testing strip from
dif- ferent bottle or lot number. URINE TESTING METHODS
Urine re gent
strip testing is considered one of the e siest l bor tory tests performed. Howev
er, it is import nt to follow the instructions provided by the m nuf cturer precisely the w
y th t they re
written to ensure th t the p tient results re v lid. The strips must be stored
properly, nd
must not be exposed to moisture. Re gent strips must be disc rded fter their 42
2 Section V
Urin lysis Test Your Knowledge 21-9 Wh t is the most common route of ccident l
exposure to urine
specimens? (Outcome 21-5) QUALITY CONTROL PROCEDURES The chemic l n lysis of ur
ine is
CLIA-w ived testing procedure. This does not me n, however, th t qu lity con- tr
ol is not n
import nt p rt of the process. For inst nce, the p ck ge insert for the B yer Mu
ltistix urin lysis test strips suggests th t positive nd neg tive qu lity control should be
tested whenever
new bottle of strips is put into use. This is
minimum frequency suggestion;
individu l
l bor tories m y require th t qu lity control 1899_Ch21_413-438 22/12/11 11:14 A
M P ge 422
expir tion d te, nd must be used only once. In ddi- tion, it is import nt to
dhere to the
instructions for timing the re ctions nd interpreting the results. The color ch
nges for e ch
test p d must be re d indi- vidu lly t different time interv ls, r nging from 3
0 to 120 seconds.
The m nuf cturers insert for the re gent strips lso provides inform tion bout p
otenti l c uses
of interfer- ence. An ex mple is scorbic cid (vit min C), which c n c use f ls
e-neg tive
results for glucose, blood, nd other subst nces on some re gent strips. St ff w
ho perform
chemic l urine n lysis need to be f mili r with the p ck ge insert provided for
the re gent
strips used by their f cility, nd
copy should be v il ble for reference t
ll times. Re gent
strips re lso v il ble to test for one or two chemic l n lytes, r ther th n
the entire
spectrum th t is usu lly included in routine urin lysis. Ketones nd glu- cose
re some of the
most common n lytes included on these limited test strips. These c n be benefic
i l for those
with type 1 di betes or for monitoring pregn nt women for potenti l gest tion l
di betes. Other
test strips m y be used to monitor protein nd cre tinine levels in the urine, w
hich c n help to
detect kidney dysfunction in high-risk p tients, or c n be used to monitor the p
rogress of kidney
dise se for p tients who h ve lre dy been di gnosed. Micro lbuminuri m y be de
tected by strips
designed to pick up very low levels of protein in the urine. The presence of mic
ro lbuminuri is
signif- ic nt f ctor in the progression of di betes. color ch nges on the re g

ent p ds. Some of

the uto- m ted instruments re designed to re d one strip t time, where s ot
hers re c p ble
of processing numerous re gent strips t once. B yer nd Roche Di gnostics both
m nuf cture
utom ted urin lysis instruments, including the B yer Clinitek models nd the Ro
che Urisys
instruments (Fig. 21-2). V rious models re v il- ble from both of these m nuf
cturers.
C libr tion nd Ch pter 21 Chemic l Ex min tion of Urine nd Feces 423 Test You
r Knowledge 21-10
True or F lse: Urine re gent strips m nuf ctured by different comp nies m y be
v il ble with
different test c p bilities. The reference v lues for urine chemic l strips re
the s me whether
the test is performed m nu lly or by u- tom tion. These results re summ rized
on T ble 21-1. It
is import nt to remember th t these reference v lues re obt ined by following t
he m nuf cturers
instruc- tions precisely; speci l ttention should be given to the timing interv
ls for re ding
the results. Autom ted urin lysis instruments re designed to re d re gent strip
re ctions t the
ppropri te interv ls. The results re usu lly printed out nd c n lso be sent
uto- m tic lly
through computer interf ce for m ny instru- ments. The use of utom ted urin l
ysis instruments
m y help reduce errors by elimin ting potenti l sources of er- ror with the timi
ng of re ctions
nd the interpret tion of TABLE 21-1 Reference r nges for urine chemistry result
s Chemic l
An lyte Norm l Finding pH 4.68.0 Protein 28 mg/dL (neg tive to tr ce) Specific gr
vity
1.0051.030 Leukocyte ester se Neg tive Nitrite Neg tive Glucose Neg tive Ketones
Neg tive
Leukocytes Neg tive Blood Neg tive Urobilinogen 0.11.0 mg/dL Figure 21-2 B yer C
linitek urine
n lyzer with printed results. From E gle, S, Br ssington, C, D iley, C, nd Gor
etti, C: The
Profession l Medic l Assist nt: An Integr - tive, Te mwork-B sed Appro ch. FA D
vis,
Phil delphi , 2009, with permission 1899_Ch21_413-438 22/12/11 11:14 AM P ge 423
424 Section V
Urin lysis Urin lysis Report Form P tient N me: P tient ID: D te: Time: An lyte
Result Observed
Reference V lue Glucose Bilirubin Ketones Blood pH Protein Urobilinogen Nitrite
Leukocyte
ester se Specific gr vity Comments: Sign ture/Initi l of Oper tor: Neg tive Neg
tive Neg tive
Neg tive 4.6 to 8.0 Neg tive to tr ce 0.1 to 1.0 mg/dL Neg tive Neg tive 1.005 t
o 1.030 CB
LABORATORY Figure 21-3 Urin lysis report form. m inten nce re necess ry for bot
h of these
m chines, in ddition to the testing of qu lity control specimens t specified i
nterv ls. Results
re then recorded on urin l- ysis report form (Fig. 21-3). Test Your Knowledge
21-11 Wh t is n
dv nt ge of utom ted urine chemistry testing procedures over m nu l testing pr
ocedures?
(Outcome 21-6) types of confirm tory tests to provide some reli ble inform tion

to the
pr ctitioner. The following re the most common confirm tory tests performed: Ac
etest (B yer
Corpor tion): The Acetest is used to test for the presence of ketones in the uri
ne specimen.
These re gents m y be used to test other body fluids if necess ry. The Acetest t
blet re ction is
less ffected by the inherent color of the urine specimen, nd the color ch nges
re less subtle
th n they re on the re gent p ds on the urine dipsticks. The testing process re
- quires t blet
nd n bsorbent p d. Ictotest (Ames Corpor tion): The Ictotest is used to de- t
ect the
presence of bilirubin in the urine specimen. This procedure is more sensitive to
the presence of
bilirubin th n the re gent p d test, nd is ffected less by the strong colors p
resent in some
urine specimens. The test involves t blet nd n bsorbent p d. CONFIRMATORY U
RINE TESTING
Sometimes the color of urine specimen m y c use color interference with the re
gent strip test
p ds, producing inv lid results. It m y then be necess ry to perform other 1899_
Ch21_413-438
22/12/11 11:14 AM P ge 424 Ch pter 21 Chemic l Ex min tion of Urine nd Feces 4
25 Procedure
21-1: CLIA-W ived Chemic l Ex min tion of Urine Using M nu l Re gent Strip Metho
d CAAHEP/ABHES
STANDARDS CAAHEP St nd rds III.P. Psychomotor Skills, III. Applied Microbiology
/ Infection
Control, #2. Pr ctice St nd rd Prec utions I.P. Psychomotor Skills, I. An tomy
nd Physiology,
#
14. Perform Urin lysis
ABHES St nd rds Apply principles of septic techniques nd infection con
trol. Use
st nd rd prec utions. Perform CLIA-w ived tests th t ssist with di gnosis nd t
re tment,
Urin lysis. Procedure R tion le 1. Assemble necess ry equipment. Put on eye prot
ec- tion, or
position pl stic shield in w y th t the procedure m y be performed behind the
shield. 2. W sh
h nds. 3. Verify test order nd specimen l beling nd identi- fic tion. 4. Verif
y th t specimen
collection w s less th n 1 hour before testing or th t it w s refriger ted nd/o
r pre- served
ppropri tely fter collection. 5. Allow ny refriger ted specimens to come to r
oom temper ture
before proceeding. Org niz tion of supplies s ves time nd helps to void errors
. Eye protection
shields employees from po- tenti l bioh z rd exposure. H nd w shing bre ks the c
ycle of
infection. Verific tion of test order nd specimen identific tion elimin tes pot
enti l errors.
Specimens th t re llowed to st y t room temper - ture for more th n 1 hour f
ter collection
without the ddition of preserv tive m y yield in ccur te results bec use of ch
nges in pH,
bilirubin or uro- bilinogen concentr tion, glucose levels, nd b cter- i l cont
min tion.
Specimens th t re colder th n room temper ture m y exhibit cryst lliz tion of
morphous ur tes

or phos- ph tes, which c n interfere with me surement of ll the physic l ch r c

teristics of the
urine specimen, s well s c use potenti l interference with the chemi- c l n l
ysis. TASK
Perform nce of CLIA-w ived chemic l ex min tion of urine specimen utilizing
the m nu l
re gent strip method. CONDITIONS Gloves, l bor tory co t, nd protective eyewe r
Urine
specimen freshly voided or ppropri tely pre- served Cle r conic l pl stic tr ns
fer tube
Re gent strips with color comp rison ch rt for re d- ing results Norm l nd bno
rm l qu lity
control specimens Test tube r ck Kimwipes or p per towels Perm nent fine-tip pen
for
m rking identific tion on the tr nsfer tube Urin lysis report form Bl ck pen for
document tion on the p tients ch rt P tients ch rt Bioh z rdous w ste cont iner Co
ntinued
1899_Ch21_413-438 22/12/11 11:15 AM P ge 425 Procedure R tion le 426 Section V
Urin lysis
Procedure 21-1: CLIA-W ived Chemic l Ex min tion of Urine Using M nu l Re gent S
trip
Methodcontd 6. Mix specimen well with gentle swirling motion. 7. Pour some of th
e urine
specimen into l beled cle r conic l tr nsfer tube. The tr nsfer tube should be
t le st h lf
full. Pl ce the tr nsfer tube in the tube r ck. 8. Prior to perform nce of p tie
nt testing,
verify whether qu lity control (QC) specimen needs to be tested, nd if so, co
mplete th t
process before the p tients test is performed. P tient testing c n- not be perfor
med unless the
qu lity control v lues re within the est blished r nges. 9. Perform the re gent
strip test
following these pro- cedures: . Dip the re gent strip into the well-mixed urine
in the tr nsfer
tube. M ke cert in th t ll the re gent p ds re moistened. b. Remove the re gen
t strip from the
urine imme- di tely, running the str ight edge of the re gent strip long the to
p of the tube to
remove excess urine. c. Immedi tely blot the edge of the re gent strip on p pe
r towel or
l bor tory wipes. d. Begin the timing for the p d development s the re gent str
ip is removed
from the tube. e. Observe the color ch nges on the re gent p d t the ppropri t
e time interv ls
s directed by the m nuf cturer. Comp re the colors to the provided ch rt for ob
serv tion, or to
the ch rt provided on the re gent strip bottle. f. Record the results on the uri
n lysis report
form. g. Disc rd the used re gent strip into bioh z rd w ste cont iner. Urine
specimens must be
mixed well to provide ccu- r te chemistry results. Using tr nsfer tube for th
e urine to be
chemic lly n- lyzed elimin tes potenti l cont min tion of the origin l specime
n by dipping in
the re gent strip. If
urine culture is necess ry, the origin l urine speci- me
n will not be
cont min ted. Liquid QC should be tested following l bor tory pro- tocol nd m n
uf cturers
recommend tions. Ex m- ples of when QC m y be used to verify the test results in

clude the
following: . With new shipment of re gent strips b. Whenever new lot number
of re gents or
QC is put into use c. New oper tor; someone who is being tr ined on the procedur
e d. Problems
with stor ge, instrument, re gents, etc. C reful dherence to the procedure will
llow for ccur cy of results. 1899_Ch21_413-438 22/12/11 11:15 AM P ge 426 Procedure R tion l
e Ch pter 21
Chemic l Ex min tion of Urine nd Feces 427 10. Dispose of the urine left in the
tr nsfer tube by
pouring it down the sink nd flushing it with plenty of w ter. Dispose of the tu
be nd tr nsfer
pipette used for the urine in bioh z rdous dispos l b g. If the urine is not t
o undergo
ddition l testing imme- di tely, refriger te it or preserve it ccordingly. 11.
S nitize the
work re , remove gloves, nd s nitize h nds. 12. Document results for p tient s
pecimen on the
ch rt (if v il ble) nd testing log sheet. Be cert in to use the correct digits
for the
document tion. Gloves should lw ys be removed immedi tely fter
procedure is
performed. H nd
s nitiz tion is ppro- pri te before nd fter gloves re worn. Results must be
recorded
immedi tely fter the testing process is complete. D te 10/24/2014: Chemic l Uri
n lysis: Glucose:
neg tive, Bilirubin: neg tive, Ketones: neg tive, Blood: neg tive, pH: 6.0, Prot
ein: neg tive,
Urobilinogen: 0.1 mg/dL, Nitrite: neg tive, Leukocyte ester se: neg tive, Specif
ic gr vity: 1.020
11:58 .m.
Connie Lieseke, CMA (AAMA) Procedure 21-2: Chemic l Ex min tion of Urine
Using Autom ted
Re gent Strip Method TASK Perform chemic l ex min tion of urine specimen uti
lizing n
utom ted urin lysis instrument. CONDITIONS Gloves, l bor tory co t, nd protect
ive eyewe r
Urine specimen freshly voided or ppropri tely pre- served Cle r conic l pl stic
tr nsfer tube
Re gent strips nd utom ted testing instrument with p per for result recording
Norm l nd
bnorm l qu lity control specimens Test tube r ck Kimwipes or p per towels Perm
nent
fine-tip pen for m rking identific tion on the tr nsfer tube Urin lysis report f
orm Bl ck pen
for document tion on the p tients ch rt P tients ch rt Bioh z rdous w ste cont ine
r
CAAHEP/ABHES STANDARDS CAAHEP St nd rds III.P. Psychomotor Skills, III. Applied
Microbiology/
Infection Control, #2. Pr ctice St nd rd Prec utions I.P. Psychomotor Skills, I.
An tomy nd
Physiology,
#
14. Perform Urin lysis
ABHES St nd rds Apply principles of septic techniques nd infection con
trol. Use
st nd rd prec utions Perform CLIA-w ived tests th t ssist with di gnosis nd tr
e tment,

Urin lysis. Continued 1899_Ch21_413-438 22/12/11 11:15 AM P ge 427 Procedure R t

ion le 428
Section V Urin lysis Procedure 21-2: Chemic l Ex min tion of Urine Using Autom
ted Re gent Strip
Methodcontd 1. Assemble necess ry equipment. Put on eye protec- tion or position p
l stic shield
in w y th t the procedure m y be performed behind the shield. 2. W sh h nds. 3
. Verify test
order nd specimen l beling nd identi- fic tion. 4. Verify th t specimen collec
tion w s less
th n 1 hour before testing or th t it w s refriger ted nd/or preserved ppropri
tely fter
collection. 5. Allow ny refriger ted specimens to come to room temper ture befo
re proceeding. 6.
Mix specimen well with
gentle swirling motion. 7. Pour some of the urine speci
men into
l beled cle r conic l tr nsfer tube. The tr nsfer tube should be t le st 1
/
2 full. Pl ce the tr nsfer tube in the tube r ck. 8. Prior to perform nc
e of p tient testing,
verify whether
qu lity control (QC) specimen needs to be tested, nd if so, co
mplete th t
process before the p tients test is performed. P tient testing c n- not be perfor
med unless the
qu lity control v lues re within the est blished r nges. Org niz tion of suppli
es s ves time nd
helps to void errors. Eye protection protects employees from potenti l bioh z r
d exposure. H nd
w shing bre ks the cycle of infection. Verific tion of test order nd specimen i
dentific tion
elimin tes potenti l errors. Specimens th t re llowed to st y t room temper ture for more
th n 1 hour fter collection without the ddition of preserv tive m y yield in c
cur te results
bec use of ch nges in pH, bilirubin or urobilinogen concentr tion, glucose level
s, nd b cteri l
cont min tion. Specimens th t re colder th n room temper ture m y exhibit cryst
lliz tion of
morphous ur tes or phos- ph tes, which c n interfere with me surement of ll th
e physic l
ch r cteristics of the urine specimen, s well s c use potenti l interference w
ith the chemic l n lysis. Urine specimens must be mixed well to provide ccur te chemistry r
esults. Use of
tr nsfer tube for the urine to be chemic lly n lyzed elimin tes potenti l cont
min tion of the
origin l specimen by dipping in the re gent strip. If urine culture is necess
ry, the origin l
urine spec- imen will not be cont min ted. Liquid QC should be tested following
l bor tory
protocol nd m nuf cturer recommend tions. Ex mples of when QC m y be used to ve
rify the test
results include the following: . With new shipment of re gent strips b. Whene
ver new lot
number of re gents or QC is put into use c. New oper tor; someone who is being t
r ined on the
procedure d. Problems with stor ge, instrument, re gents, etc. 1899_Ch21_413-438
22/12/11 11:15
AM P ge 428 Procedure R tion le Ch pter 21 Chemic l Ex min tion of Urine nd Fe
ces 429 9.

Perform the re gent strip test following these pro- cedures: . Dip the re gent
strip into the
well-mixed urine in the tr nsfer tube. M ke cert in th t ll the re gent p ds r
e moistened. b.
Remove the re gent strip from the urine imme- di tely, running the str ight edge
of the re gent
strip long the top of the tube to remove excess urine. c. Immedi tely blot the
edge of the
re gent strip on p per towel or l bor tory wipes. d. Pl ce the re gent test stri
p onto the
ppropri te re to be fed into the urin lysis instrument. Input ny specimen ID
necess ry into
the in- strument, if possible. e. Monitor the instrument s the test is com- ple
ted, w tching for
possible errors. f. Record the results on the urin lysis report form fter they
re printed. Some
models displ y the results on
screen; if so, it will be necess ry for them to
be tr nsposed
onto the report form. g. Disc rd the used re gent strip into bioh z- rdous w
ste cont iner.
10. Dispose of the urine left in the tr nsfer tube by pouring it down the sink
nd flushing it
with plenty of w ter. Dispose of the tube nd tr nsfer pipette used for the urin
e in
bioh z rdous dispos l b g. If the urine is not to undergo ddition l testing imm
e- di tely,
refriger te it or preserve it ccordingly. 11. S nitize the work re , remove gl
oves, nd
s nitize h nds. 12. Document results for p tient specimen on the ch rt (if v il
ble) nd testing
log sheet. Be cert in to use the correct digits for the document tion. C reful
dherence to the
procedure will llow for ccur cy of results. Urine does not need to be disposed
of in the
bioh z- rdous g rb ge, but it is import nt to flush the sink well fter dispos
l. Gloves should
lw ys be removed immedi tely fter
procedure is performed. H nd s nitiz tion
is ppro- pri te
before nd fter gloves re worn. Results must be recorded immedi tely fter the
testing process
is complete. D te 10/24/2009: Chemic l urin lysis using B yer Clinitek 500; Qu l
ity control
results within r nge: Glucose: neg tive, Bilirubin: neg tive, Ketones: neg tive,
Blood: neg tive,
pH: 6.0, Protein: neg tive, Urobilinogen: 0.1 mg/dL, Nitrite: neg tive, Leukocyt
e ester se:
neg tive, Specific gr vity: 1.020
11:58 .m.
Connie Lieseke, CMA (AAMA) 1899_Ch21_413-438 22/12/11 11:15 AM P ge 429
Sulfos licylic cid
precipit tion test: This test involves the ddition of n cid to the urine spec
imen nd n
observ tion for the mount of turbidity c used when the cid is dded. A semiqu
ntit tive
ssessment of the mount of protein present in the urine specimen m y result by
me suring the
turbidity present. The SSA precipit tion test is not ffected by the color of th
e specimen, s

the me surement involves the turbidity present, not

color ch nge re ction. Cli
nitest (B yer
Corpor tion): This test is used s confirm tory test for the presence of gluco
se nd other
sug rs in the urine specimen. It is not ffected s much by the origin l color o
f the specimen,
lthough some subst nces (such s mpicillin nd vit min C) c n c use in ccur te
results.
Microscopic ex min tion: Ch pter 22 det ils the process used for urine microscop
ic ex min tions.
In situ tions in which the color of the specimen prohibits v lid results for blo
od, leukocyte
ester se, or nitrites, the ex min tion of the urine sediment for these formed el
ements m y
provide ddition l inform tion for the pr ctitioner. FECAL OCCULT BLOOD TESTING
Fec l occult
blood testing (FOBT) detects blood th t is hid- den in or on feces. Blood in the s
tool m y be
clinic lly sig- nific nt even though there re only sm ll mounts present. It is
not unusu l for
dults to shed few milliliters e ch d y in their feces s result of the n tu
r l processes
occurring in the stom ch nd intestines. However, incre sed blood loss m y be du
e to
p thologic l condition th t needs medic l ttention. Blood m y be present in the
stool in the
following situ tions: Bleeding hemorrhoids Ulcers nd/or infl mm tion of the sto
m ch or
duode- num Presence of polyps, lesions, or tumors in the intestines Nosebleeds B
leeding
gums Diverticulitis, colitis, nd/or Crohns dise se P r sitic infection Colorect
l c ncer
Stool testing for the presence of occult blood is sim- ple, noninv sive, nd r
el tively
inexpensive screening test. The fec l occult blood test is not specific for ny
dise se process,
but positive result will indic te need for further investig tion with
colo
noscopy,
proctosigmoidoscopy, or lower g strointestin l x-r y th t uses b rium to visu
lize the
digestive tr ct. Most commonly this test is ordered s screen for symptom tic
p tients, but it
m y lso be used when there is nemi present with no identifi ble c use or when
the p tient
exhibits symptoms of other dis- orders th t m y result in positive screen. Acc
ording to the
Centers for Dise se Control nd Prevention (CDC), colorect l c ncer is the secon
d le d- ing
c ncer killer in the United St tes. E rly st ges of this dise se re usu lly sy
mptom tic;
therefore, colorect l c ncer is often overlooked until it h s progressed to po
int t which
tre tment options re limited. The CDC nd the Americ n C ncer Society recommend
th t ll dults
who re 50 to 75 ye rs of ge h ve
ye rly fec l occult blood screening test pe
rformed. Those
p st the ge of 75 should discuss the necessity of further testing with their ph
ysici n. E rlier
(before the ge of 50) or more frequent screening tests m y be necess ry if p
tient h s

f mily history of colorect l c ncer or if the p tient h s infl mm tory bowel dis
e se. For
p tients who re covered by Medic re, ye rly fec l occult blood screening is s
ervice th t is
covered for p yment. 430 Section V Urin lysis Test Your Knowledge 21-12 Why doe
s the Americ n
C ncer Society recommend ye rly fec l occult blood screening? (Outcome 21-9) T
here re two
types of fec l occult blood screening kits v il ble. The gu i c method, usu lly
referred to s
the FOBT (for fec l occult blood test), uses c rdbo rd specimen holder cont in
ing speci l
gu i c p per inside. This p per is used for pplic tion of the specimen nd the
developer. If
there is blood present in the stool, it ox- idizes the gu i c, nd when the deve
loper (hydrogen
per- oxide solution) is dded, the surrounding test p per turns blue where blood
is present (Fig.
21-4). The gu - i c re cts with heme present in the blood cells. This method h s
been v il ble
for m ny ye rs, nd is consid- ered reli ble if the p tient follows the diet ry
restrictions nd
collection procedures s instructed. The gu i c method is not s sensitive or sp
ecific s the
newer meth- ods, but it is inexpensive, so m ny f cilities still use it for thei
r screening.
Hemoccult (m nuf ctured by Beckm n Coulter) is most commonly used. Ser cult (m n
uf c- tured by
Propper) is nother screening kit th t is v il- ble. To perform the collection
process properly
using gu i c-b sed kits, keep the following key points in mind: 1. Seven d ys pr
ior to nd during
the collection, ll NSAIDs (such s n proxen or ibuprofen) must be discontinued.
One dult
spirin per d y is llowed. Tylenol is lso llowed. 1899_Ch21_413-438 22/12/11
11:15 AM P ge 430
The other fec l occult blood testing method, the iFOB, which st nds for immunoch
emic l fec l
occult blood, uses n immunochemic l test to detect the pres- ence of globin, p
rt of the
hemoglobin molecule. This test re cts only with hum n blood, nd is more sensitive nd specific
th n is the gu i c testing method. The iFOB h s been shown to detect
positive
result with less
blood present in the stool, nd to h ve fewer f lse- positives due to interferin
g subst nces.
There re fewer diet ry restrictions ssoci ted with this testing method; theref
ore, p tient
compli nce m y incre se. The iFOB test m y be v il ble s kit cont ining indi
vidu l test- ing
c rtridges or s slides simil r to the other type of fe- c l occult blood tests.
It is still
recommended th t the s mple be collected over three consecutive bowel move- ment
s over three
d ys, s polyps nd lesions in the GI tr ct m y bleed intermittently, nd this m
ethod of collection incre ses the opportunity to detect bleeding if present. Hemoccult ICT (
m nuf ctured by
Beckm n Coulter) is one ex mple of this immunochemic l test- ing method. Other m
nuf cturers,

such s Quidel, lso produce CLIA-w ived r pid test th t provides

qu l- it t
ive result for
the presence of fec l occult blood. The immunochemic l tests for occult blood r
e much more
expensive th n re the gu i c tests, nd re not com- monly found in the physici
n office
l bor tory. Reg rdless of the type of test used, the desired result is neg tiv
e one, indic ting
th t no me sur ble occult blood is present in the stool. However,
positive res
ult does not
necess rily indic te colorect l c ncer, or even
prec ncerous condition. The fe
c l occult blood
test procedure is to be used s screening tool only, nd further testing is l
w ys necess ry to
identify the c use of ny positive results. The test results for the FOBT nd th
e iFOB re
reported s positive or neg tive re- sult, indic ting the presence or bsence
of occult blood
in the specimen. Ch pter 21 Chemic l Ex min tion of Urine nd Feces 431 Figure
21-4 Positive
fec l occult blood test result using gu i c method. Note the blue re round th
e specimens,
which indic tes positive result nd the presence of occult blood in the stool.
In ddition,
there is positive result on the control re of the slide. Courtesy of Beckm n
Coulter. 2.
Three d ys before nd then during the collection, ll vit min C supplements must
be discontinued,
s well s citrus fruits or juices. For some test kits, turnips, broccoli, melon
s, r dishes, nd
fresh fruit should lso be discontinued. During this time, ingestion of red me t
(beef, l mb, or
liver) must be discontinued s well. Antico gul nt use m y lso c use f lse-posi
tive test
results, but p tients must consult their he lth- c re provider before discontinu
ing these drugs.
3. The stool specimens should be collected from three consecutive bowel movement
s, prefer bly on
three consecutive d ys. Follow directions provided con- cerning the volume of st
ool to pply, nd
to which side of the slide to pply it. 4. 5. Test Your Knowledge 21-13 Which of
these subst nces
should be voided for 7 d ys prior to nd then during the collection period for
FOBT? . Red
me t b. C ffeine c. Sodium d. NSAIDs (Outcome 21-10) 1899_Ch21_413-438 22/12/11
11:15 AM P ge 431
432 Section V Urin lysis Procedure 21-3: Fec l Occult Blood Testing Using Gu i
c Method TASK
Provide p tient instruction for the collection of the s mple necess ry nd perfo
rm test to
detect the pres- ence of fec l occult blood using the Hemoccult Sens test c rds
nd developer.
CONDITIONS Gloves L bor tory co t Hemoccult Sens test c rds Hemoccult Sens dev
eloper
Stool specimens Bioh z rdous w ste cont iner CAAHEP/ABHES STANDARDS CAAHEP St nd
rds III.P.
Psychomotor Skills, III. Applied Microbiology/ Infection Control, #2. Pr ctice S
t nd rd
Prec utions ABHES St nd rds Apply principles of septic techniques nd infection
control. Use

st nd rd prec utions Instruct p tients in the collection of

fec l specimen Pro
cedure
R tion le 1. Greet nd then identify p tient using t le st two unique identifie
rs. 2. Verify
test ordered, nd expl in the specimen collection requirements to the p tient. A
ll p tients must
be identified properly before collecting s mples or performing l bor tory testin
g. All l bor tory
test orders should be verified by checking the ch rt nd/or requisition form mor
e th n once. A
thorough expl n tion of the collection procedure for the p tient will ensure mor
e cooper tion.
Written liter ture should lso be provided so th t the p tient knows how to prep
re ppropri tely
nd collect the specimens correctly. Prep r tion nd collection instructions inc
lude the
following: Collect nd pply s mples from bowel movements from three different d
ys to the
slide. This in- cre ses the opportunity to detect blood th t m y be intermittent
ly present from
polyps or c ncer present in the GI system. Do not collect s mple if fr nk (obv
ious) blood is
present in the stool. For best results, collect the s mple before the stool m ke
s cont ct with
the w ter present in the toilet. Stool specimens th t re retrieved from toilet
w ter with
chemic l dditives re un ccept ble. Protect slides from he t, bright lights, n
d exposure to
strong household chemic ls such s mmoni . For 7 d ys before nd during the sto
ol collection
period, void NSAIDs such s spirin nd ibupro- fen. One dult spirin per d y
is ccept ble.
For 3 d ys before nd during the stool collection period, void vit min C in exc
ess of 250 mg/d y
nd red me ts. E t well-b l nced diet. 1899_Ch21_413-438 22/12/11 11:15 AM P g
e 432 Ch pter
21 Chemic l Ex min tion of Urine nd Feces 433 Procedure R tion le 3. Provide t
he p tient with
set of three slides, n p- plic tor, collection tissues, nd written instruc- t
ions for
collection. Let the p tient know how nd when to bring the specimens b ck to the
l bor - tory.
M ke cert in th t the slides re correctly identified with the p tients n me nd
ccount number.
4. When the slides rrive b ck t the l bor tory, w sh h nds nd pply gloves be
fore touching the
slides. 5. Assemble the developer, nd verify th t ll re gents re within the p
osted expir tion
d tes. 6. Verify the p tient identific tion on the c rds. 7. Open the b ck of th
e slide. Pl ce
two drops of Hemoccult developer directly over the specimens in box A nd box B.
Results re to
be re d t 60 seconds fter pplic tion of the developer. Any blue on or t the
edges of the
slide is considered to be positive result for the presence of occult blood. 8.
M ke note of
the result t 60 seconds. 9. Before the results re considered to be v lid, the
qu lity control
re of the slide must be developed. 10. Repe t the testing process nd qu lity
control

ssessment on the other slides. Slides must be returned for testing within 14 d
ys of collection.
It is import nt th t the d te of e ch col- lection is recorded on the outside fr
ont of the slide.
To pply the specimen to the slide, follow these steps: 1. Open the front of the
slide. Using the
pplic tor provided, pl ce sm ll mount of stool specimen s thin sme r cove
ring box A. Using
the s me pplic tor, choose different p rt of the stool specimen nd t ke not
her sm ll mount
to sme r on box B. 2. Dispose of the pplic tor nd close the front of the slide
. 3. P tients
must not open the b ck of the slide. This is for l bor tory use only. H nds shou
ld lw ys be
w shed between p tients nd before st rting ny procedures. Gloves re pproprite person l
protective equipment (PPE) for this procedure. The developer should be stored t
room temper ture
nd must be used before the expir tion d te. Alw ys verify th t the correct spec
imen is in h nd
before completing the testing process. Gu i c occult blood test results should n
ot be re d by
those who h ve color blindness, s they m y not recognize the development of the
blue color with
positive result. The result must not be re d before llowing 60 seconds for de
velopment or
fter 60 seconds h s el psed. Apply one drop of developer between the positive
nd neg tive
design tion of the QC testing re . Re d the results t 10 seconds. The positive
re will turn
blue, nd no blue will develop in the neg tive re . If results re not s expec
ted when
performing qu l- ity control, the p tient results c nnot be reported. The proced
ure is the s me
for e ch slide. Continued 1899_Ch21_413-438 22/12/11 11:15 AM P ge 433 Procedure
R tion le 434
Section V Urin lysis Procedure 21-3: Fec l Occult Blood Testing Using Gu i c Me
thodcontd 11.
Dispose of the slide in the bioh z rdous dispos l cont iner. 12. Put w y develo
per, remove
gloves, w sh h nds, nd record specimen results. Bioh z rdous specimens must be
disposed of
properly. H nds must lw ys be w shed fter removing gloves. D te 8/19/2014: Hem
occult slides
tested; neg tive X3
11:50 .m.
Connie Lieseke, CMA (AAMA) TASK Perform fec l occult blood test using
the Quickvue
immuno ss y method. CONDITIONS Gloves L bor tory co t H nd s nitiz tion supplies
Specimen
pouch cont ining QuickVue collection tube (covered with identific - tion l bel)
cont ined in
bsorbent sleeve Collection p per with dhesive P tient instructions Return m il
er
QuickVue test c ssette Absorbent l bor tory wipes or g uze p ds Timer Qu lity co
ntrol
m teri l (if necess ry) Bioh z rdous w ste cont iner CAAHEP/ABHES STANDARDS CAAH
EP St nd rds

III.P. Psychomotor Skills, III. Applied Microbiology/ Infection Control, #2. Pr

ctice St nd rd
Prec utions ABHES St nd rds Apply principles of septic techniques nd infection
control. Use
st nd rd prec utions. Instruct p tients in the collection of fec l specimen. P
rocedure
R tion le 1. Greet nd then identify p tient using t le st two unique identifie
rs. 2. Verify the
test ordered, nd expl in the collection procedure to the p tient. Enter the p t
ient identific tion inform tion on the collection tube l bel. All p tients must be identifi
ed properly
before collect- ing s mples or performing l bor tory testing. All l bor tory tes
t orders should
be verified by check- ing the ch rt nd/or requisition form more th n once. The
collection
process for this procedure is very specific, nd must be followed c refully. P t
ient instructions
include the following: During the collection process, do not llow the fec l spe
cimen to
cont ct the toilet w ter. The specimen must lso be protected from urine. Proced
ure 21-4: Fec l
Occult Blood Testing Using iFOB Quickvue Method 1899_Ch21_413-438 22/12/11 11:15
AM P ge 434
Ch pter 21 Chemic l Ex min tion of Urine nd Feces 435 Procedure R tion le 3. E
xpl in to the
p tient how to return the specimen to the l bor tory for testing. 4. When the sp
ecimen is
returned to the l bor tory, verify th t the identific tion is ppropri te nd th
t the p tient
followed the correct collection procedure. 5. S nitize h nds nd pply gloves. 6
. Assemble
necess ry equipment, nd verify th t ll re gents re within the posted expir ti
on d tes. 7.
Remove the test c ssette from the foil wr pper nd pl ce it on
level surf ce.
8. Remove the
bsorbent sleeve from the specimen pouch, nd remove the collection tube from th
e bsorbent
sleeve. 9. Sh ke the collection tube well to mix the s mple nd the buffer solut
ion. When re dy
to begin the collection, tt ch the col- lection p per to the toilet se t by rem
oving the t pe
cover from the ends of the collection p per nd t- t ching the dhesive m teri
l to the toilet
se t cross the b ck of the toilet. Att ch the p per in such w y th t it s gs
in the middle of
the toilet. Defec te on the collection p per. Do not remove the fec l specimen o
r the
collection p per from the toilet se t t this point. Unscrew the s mpler from th
e collection
tube. Pierce the fec l specimen (while still on the col- lection p per) with the
grooved end of
the s m- pler device t le st five times in different re s of the specimen. Ins
ert the s mpler
into the collection tube nd close the c p securely. Sh ke the tube to mix the b
uffer provided
in the tube with the s mple just dded to the tube. Flush the rem ining collecti
on p per nd
the fec l s mple down the toilet. The specimens m y be m iled using the provided
m iler, or they

m y be delivered b ck to the l bor - tory. Specimens m y be kept t room temper

ture for up to 8
d ys fter collection. The specimen is inv lid if the collection procedure is no
t followed. H nds
should lw ys be w shed between p tients nd before st rting ny procedures. Glo
ves re pproprite person l protective equipment (PPE) for this procedure. The only ddition l
equipment for
this test would be the timer nd the test c ssette. The test c ssette should not
be removed until
right before use. The bsorbent sleeve is provided in c se of specimen le k ge d
uring tr nsport.
The specimen nd buffer must be well mixed for v lid test results. Continued 189
9_Ch21_413-438
22/12/11 11:15 AM P ge 435 436 Section V Urin lysis Procedure 21-4: Fec l Occul
t Blood Testing
Using iFOB Quickvue Methodcontd 10. Prior to perform nce of test, verify whether
qu l- ity
control (QC) specimen needs to be tested, nd if so, complete th t test before t
he p tients test
is performed. 11. Hold the collection tube upright nd remove the light blue c p
t the top of
the tube. 12. Completely cover the exposed tip of the collection tube with the
bsorbent p d. 13.
Without twisting, quickly sn p off the tip of the collection cont iner. 14. Turn
the collection
tube upside down into verti- c l position. Dispense six drops into the well of
the testing
c ssette. 15. Re d the results in 5 to 10 minutes. 16. Dispose of the testing c
ssette nd s mple
tube in the bioh z rdous dispos l cont iner. Extern l QC m teri l should be test
ed following
l bor - tory protocol nd m nuf cturers recommend tions. Ex mples of when QC shou
ld be used to
verify the test results include the following: . With new shipment of the tes
ting m teri ls b.
Whenever
new lot number of re gents or QC is put into use c. New oper tor; som
eone who is being
tr ined on the procedure d. Problems with stor ge, instrument, re gents, etc. e.
To ensure th t
stor ge conditions re fine, QC should be performed t le st once monthly It is
import nt to hold
the tube upright for this step. It is import nt to completely cover the exposed
tip to void
potenti l exposure to the specimen during the next step. The tip will not sn p o
ff if twisting
motion is used. The tube should be held vertic lly to dispense the cor- rect siz
e of drop into
the well. Some positive results will be evident t 5 minutes, where s others m y
t ke up to 10
minutes to develop s positive. Neg tive results should be reported within 10
minutes. Do not
re d the results fter 10 minutes. Results re interpreted s follows: M roon li
nes will ppe r
t the C nd T re of the test c ssette when the result is positive for the pre
s- ence of occult
blood. Neg tive results will only exhibit
line t the C re . If
line ppe r
s only t the
T re of the test c ssette or if no lines ppe r, the test results re inv lid.
These should ll

be disposed of s bioh z rdous m te- ri ls bec use of the potenti l for the pres
ence of blood or
other biologic l h z rds in the specimen. Procedure R tion le 1899_Ch21_413-438
22/12/11 11:15 AM
P ge 436 Procedure R tion le Ch pter 21 Chemic l Ex min tion of Urine nd Feces
437 17.
Disinfect the work re . 18. Remove gloves nd s nitize h nds. 19. Document the
test results in
p tient ch rt nd/or log sheet. The work re should lw ys be disinfected fter
potenti l
exposure to biologic l subst nces. H nds must lw ys be s nitized fter removing
gloves. All
results must be documented in the p tients ch rt. D te 8/17/2014: IFOB test neg t
ive for occult
blood
12:50 p.m.
Connie Lieseke, CMA (AAMA) SUMMARY The comprehensive chemic l n lysis o
f urine is
frequently performed procedure s p rt of routine uri- n lysis. Chemic l n lyses
m y lso be
limited to
few n lytes, testing for the presence of subst nces such s glucos
e, ketones, nd
micro lbumin. Urine re gent test strips cont in p ds th t ch nge color in the pr
es- ence of
v rious chemic ls present in the urine speci- men. The mount of color ch nge is
observed nd
recorded, either m nu lly or utom tic lly using n instrument. These color ch n
ges provide
qu lit tive or semiqu ntit tive results for the chemic l n lytes on the strip.
V lu ble
inform tion for the di gnosis nd m n gement of v rious ren l dise ses nd other
body system
dysfunctions m y be obt ined by performing chemic l urine testing. Fec l occult
blood testing is
performed s screening test for the presence of col- orect l c ncer, llowing
for e rly
identific tion nd tre tment of th t dise se. TIME TO REVIEW 1. Wh t is the diff
erence between
Outcome 21-1 glucosuri nd glycosuri ? 2. J undice m y include : Outcome 21-1
. Yellow scler
of the eye b. Red, bloody urine c. Light-colored feces d. Pus in the urine 3. Th
e sulfos licylic
cid precipit tion Outcome 21-8 test is used to detect which of these in the uri
ne? . Glucose b.
Ketones c. Bilirubin d. Protein 4. True or F lse: A positive blood Outcome 21-2
test on urine
specimen is lw ys indic tive of int ct red blood cells in the urine. 5. The pre
sence of ketones
in the Outcome 21-2 urine specimen is indic tive of: . High blood sug r b. Bile
obstruction c.
Incre sed f t met bolism d. Urin ry tr ct infection 6. A positive nitrite result
in the Outcome
21-2 urine specimen m y be indic tive of: . Hem turi b. White blood cells in t
he urine specimen
c. Elev ted specific gr vity results d. B cteri in the specimen 7. True or F ls
e: A urine
specimen Outcome 21-3 with
pH of 4.0 is considered to be outside of the refere
nce r nge. 8.

True or F lse: Medic tion th t Outcome 21-4 c uses the urine to ppe r bright or
nge is likely to
c use interference on urine chemistry test. 1899_Ch21_413-438 22/12/11 11:15 A
M P ge 437 438
Section V Urin lysis 9. Which of the following m y Outcome 21-4 c use test inte
rference on the
urine chemistry tests? . Vit min C ingestion b. D iry products c. Cold medic ti
on d. Excessive
c ffeine int ke 10. List three s fety prec utions Outcome 21-5 pplic ble to uri
ne chemistry
testing procedures. 11. True or F lse: A positive fec l Outcome 21-9 occult bloo
d test is lw ys
indic tive of colorect l c ncer. C se Study 21-1: Exceptions to the rule? S lly
Steiner is t the
physici ns office bec use symp- toms th t m y be indic tive of urin ry tr ct in
fection. She
h s been urin ting frequently nd experiences p in when voiding. When the medic
l ssist nt in
the l bor tory performs the chemic l n lysis on her urine specimen, the nitrite
test is
neg tive. 1. Does this result elimin te the possibility th t there m y be b cter
i present in the
urine specimen? Why or why not? RESOURCES AND SUGGESTED READINGS Clinic l nd L
bor tory
St nd rds Institute, Urin lysis: Approved Guideline, ed. 3. CLSI document G16-A3
. W yne, PA, 2009
Approved l bor tory st nd rds for collecting, processing, nd testing urin lysis
s mples
G l ctosemi The U.S. Libr ry of Medicine, Genetic Home Reference, expl ins how g
l ctosemi is
p ssed genetic lly nd the ef- fect th t it m y h ve on the body http://ghr.nlm.
nih.gov/
condition=g l ctosemi Urin lysis,
Comprehensive Review In-depth rticle from th
e Americ n
Associ tion of F mily Pr ctitioners bout the c uses of urin lysis results, s w
ell s
inform tion bout f lse-positives nd f lse-neg tives http://
www. fp.org/ fp/2005/0315/p1153.html 1899_Ch21_413-438 22/12/11 11:15 AM P ge 4
38 Ch pter 22
Microscopic Ex min tion of Urine Const nce L. Lieseke, CMA (AAMA), MLT, PBT(ASCP
) 439 CHAPTER
OUTLINE Re sons for Performing Urine Microscopic Ex min tions Common Formed Elem
ents in the Urine
nd Their Clinic l Signific nce Epitheli l Cells Mucus Blood Cells Sperm tozo A
rtif cts C sts
Cryst ls Microorg nisms Methods Used for Urine Microscopic Ex min tions Reportin
g Urine
Microscopic Results Role of Medic l Assist nts in Microscopic Urine Ex min tion
Procedures
Qu lity Control nd Qu lity Assur nce Procedures for Urine Microscopic Ex min ti
ons Summ ry Time
to Review C se Study Resources nd Suggested Re dings 22-1 Define the key terms.
22-2 Expl in why
urine microscopic ex min tion pro- cedures re performed. 22-3 List the v rious
formed elements
identified in urine specimens. 22-4 Describe the clinic l signific nce of the fo
rmed elements in
urine specimen. 22-5 Contr st the st nd rd methods used to prep re
urine spe
cimen for
microscopic n lysis. 22-6 Describe how to focus the urine sediment speci- men

ppropri tely on
the microscope for viewing. 22-7 Summ rize the procedures for reporting formed e
lements in urine
specimens. 22-8 Describe how medic l ssist nt m y be involved in the perform
nce of
urine
micro- scopic n lysis. 22-9 Det il wh t type of qu lity ssur nce nd qu l- ity
control
procedures re necess ry to perform with urine microscopic n lysis. 22-10 Prep
re urine
specimen for microscopic n lysis. Le rning Outcomes After re ding this ch pter,
the successful
student will be ble to: CAAHEP/ABHES STANDARDS CAAHEP 2008 St nd rds I.P.I.14.
Perform
Urin lysis III,P.III.2. Pr ctice St nd rd Prec utions ABHES St nd rds Medic l Of
fice Clinic l
Procedures: b. Apply princi- ples of septic techniques nd infection control, i
. Use st nd rd
prec utions Perform Urin lysis 1899_Ch22_439-455 22/12/11 11:40 AM P ge 439 T he
fin l step in
complete urin lysis is the micro- scopic ex min tion of the urine sediment. Th
is procedure is
performed to visu lize nd identify the formed elements th t m y be present. The
se micro- scopic
structures m y enter the urine while it is in the kidneys or s the urine p sses
through the
lower urin ry tr ct. The microscopic ex min tion c n detect infection, tr um , o
r d m ge to the
urin ry system, or provide inform tion used to monitor cert in dise se st tes. I
n ddition, some
met bolic disorders m y be detected bec use of the presence of p thologic l crys
t ls in the urine
specimen. Bec use the presence of the formed elements is not lw ys clinic lly s
ignific nt when
they re present in sm ll mounts, the micro- scopic ex min tion provides qu nti
t tive
inform tion bout the elements present in ddition to the identifi- c tion of th
e structures.
REASONS FOR PERFORMING URINE MICROSCOPIC EXAMINATIONS The Clinic l nd L bor tor
y St nd rds
Institute recommends the perform nce of
urine microscopic ex- min tion whenev
er the chemic l
or physic l testing is bnorm l on the urine specimen. Bec use of this recom- me
nd tion, some
l bor tories lw ys perform urine mi- croscopic ex min tions when the chemic l
n lysis or
physic l ex min tion of the urine specimen is bnorm l. This is known s reflexi
ve testing. The
decision for dding urine microscopic ex min tion m y lso be b sed on the pp
e r nce of the
specimen; for ex mple, if the specimen ppe rs cloudy or bloody, then micro- s
copic ex min tion
m y be dded. In ddition, the urine microscopic ex min tion m y be ordered by
he lth- c re
pr ctitioner to screen for dise se process or to monitor the progress of tre t
ment. For
ex mple, the pr ctitioner m y need qu ntit tive inform tion bout the mount of
b cteri present
in s mple in order to prescribe ppropri te medic tion, or it m y be necess ry
to determine if
cert in types of cryst ls re present in the specimen for
definitive di gnosis

. COMMON FORMED
ELEMENTS IN THE URINE AND THEIR CLINICAL SIGNIFICANCE The formed elements th t m
y be present in
urine specimen include epitheli l cells, mucus, blood cells, sper- m tozo , r
tif cts, c sts,
cryst ls, nd v rious microorg n- isms. These structures re identified nd the
pproxim te
mount present in the urine sediment is estim ted nd reported. Some of the stru
ctures re
identified using the low-power objective on the microscope (10X), where s others
require the
high-power objective (40X) for visu liz tion. M ny norm l urine specimens cont i
n few formed
elements. It is import nt to ppropri tely report the qu ntity observed, bec use
the presence of
very sm ll mounts of some structures m y h ve clinic l signifi- c nce. The refe
rence r nges nd
clinic l signific nce of e ch formed element v ry, s expl ined in the following
sections.
Epitheli l Cells A common cell identified in the urine specimen is n epitheli l
cell. These
cells re const ntly dded to the urine s they re shed from the lining of the
urin ry 440
Section V Urin lysis KEY TERMS Artif cts C sts Cryst ls Epitheli l cell Fungus
Hem turi Mucus
Provider performed microscopy (PPM) Pyuri Reflexive Sediment Sperm tozo Supern
t nt Test Your
Knowledge 22-1 Provide one re son th t urine microscopic ex min - tion m y be
performed.
(Outcome 22-2) 1899_Ch22_439-455 22/12/11 11:40 AM P ge 440 tr ct. There re thr
ee types of
epitheli l cells th t m y be present, nd they re n med ccording to the re w
here they
origin te within the urin ry tr ct: Squ mous epitheli l cells: These re the mos
t common
epitheli l cells present in the urine. Their presence is not considered to be cl
inic lly
signific nt, s the cells n tur lly slough off from the lining of the lower urin ry tr ct in
both m les nd fem les, nd from the v gin in fem les. Squ mous epitheli l cell
s re l rge,
fl t, nd irregul r in sh pe, with
l rge nucleus nd bund nt cytopl sm. Their
sh pe m y be
described s h ving fried egg ppe r nce. Squ mous epitheli l cells re often th
e first
formed element th t is visible when focusing the microscope. They re reported u
s- ing the
low-power objective s r re, few, moder te, or m ny per low-power field. Usu lly
there re t
le st few squ mous epitheli l cells present in ny urine sediment (Fig. 22-1).
Tr nsition l
epitheli l cells: These cells origin te from the structures of the kidneys nd t
he ureters,
bl dder, nd upper urethr in m les. They line the urin ry tr ct in these loc ti
ons, nd their
presence in sm ll numbers in the urine is not considered bnorm l. However, if t
he number of
tr nsition l epitheli l cells is elev ted, it m y be indic tive of p thologic
l condition such
s m lign ncy. Tr nsition l epitheli l cells m y lso p- pe r in incre sed nu

mbers fter
urin ry c theteriz tion or other inv sive urologic l procedures. These cells re
identified using
the high-power objective nd reported s r re, few, moder te, or m ny per high-p
ower field. A
norm l urine s mple should not exhibit more th n the r re tr nsition l epitheli
l cell. Ren l
tubul r epitheli l cells: As the n me implies, the ren l tubul r epitheli l cell
s come from the
ren l tubules in the kidneys. The size nd sh pe of the ren l tubul r epitheli l
cells differ,
depending on the re of the tubules from which they origin te. They re sm ller
th n the other
epitheli l cells, nd their ppe r nce c n v ry from round to column r. The pres
ence of ren l
tubul r epitheli l cells in the urine specimen is clinic lly signific nt, s it
m y indic te
conditions in which d m ge is occurring to the ren l tubules. Ex mples include
glomerulonephritis, vir l infections, chronic or cute kidney dise se, nd other
dise se st tes
th t c use necrosis of the kidney tubules. Ren l tubul r epitheli l cells re id
entified using
the high-power objective, nd reported s number per high-power field. The pre
sence of ren l
tubul r epithe- li l cells in the urine sediment is lw ys considered to be n
bnorm l result.
Mucus The presence of mucus in the urine specimen is very common. Mucus ppe rs
s thre d-like
str nds m de of protein. Figure 22-2 shows n ex mple of mucus. The mucous membr
nes th t line
the lower urin ry tr ct nd the ren l epitheli l cells norm lly produce mucus. T
he str nds m y be
difficult to visu lize when the mi- croscopic light source is t its brightest;
it is often necess ry to reduce light intensity to see mucus cle rly. Mucus is not indic tive o
f p thologic l
condition in the body, nd h s no clinic l signific nce. L rge mounts of mucus
in the specimen
m y produce pos- itive protein result on the chemic l urine n lysis. Mu- cus
is identified
using the low-power objective, nd is reported s r re, few, moder te, or m ny p
er low-power
field. Norm l urine specimens m y include moder te mount of mucus. Blood Cell
s Red blood cells
nd white blood cells re often identified s p rt of the urine microscopic ex m
in tion. Their
clin- ic l signific nce v ries with the number present nd the type of blood cel
l visu lized.
Ch pter 22 Microscopic Ex min tion of Urine 441 Figure 22-1 Squ mous epitheli l
cells in urine
sediment. From Str singer, SK, nd Di Lorenzo, MS: Urin lysis nd Body Fluids, e
d. 5. FA D vis,
Phil delphi , 2008, with permission. Test Your Knowledge 22-2 Is the presence of
epitheli l cells
in urine specimen lw ys clinic lly signific nt? (Outcome 22-4) 1899_Ch22_439455 22/12/11
11:41 AM P ge 441 Red blood cells: It is not uncommon to see one or two red bloo
d cells when
ex mining urine sediment with high-power m gnific tion. When the number of red
blood cells is

elev ted, it is indic tive of d m ge to the glomeruli of the kidney or tr um to

the vessels surrounding the urin ry tr ct. The presence of red blood cells in the urine is c
lled hem turi .
The number of red blood cells present in the specimen is rel tive to the severit
y of the d m ge
to the glomerulus or the vessels. Red blood cells m y lso be present in the uri
ne specimen fter
strenuous exercise. Red blood cells m y be difficult to identify when viewed in
the urine
specimen. They re colorless, smooth, nd h ve no nucleus. Red blood cells ppe
r s round
biconc ve disks th t re difficult to distinguish from ir bubbles, budding ye s
t, oil droplets,
or rtif cts in the specimen. The ddition of st in to the specimen m y id in t
he identific tion
nd counting of the red blood cells. Figure 22-3 shows how red blood cells p- p
e r in the urine.
Red blood cells re identified using the high-power objective, nd re reported
s the number
seen per high-power field. White blood cells: A few white blood cells m y be evident in
norm l cle n-c tch midstre m urine speci- men when viewed under the microscope.
Elev ted numbers
of white blood cells in the urine is c lled pyuri , which indic tes infection or
infl mm tion of
the urin ry tr ct. Prost titis, pyelonephritis, nd cysti- tis m y c use elev te
d white blood
cell counts in the urine specimen. Pyuri m y lso be present when there re tum
ors in the
urin ry tr ct, nd other sys- temic infl mm tory conditions. It is e sier to ide
ntify white blood
cells in the urine spec- imen th n it is to identify red blood cells. The white
blood cells re
l rger, h ve
gr nul r ppe r nce, nd cont in nucleus (Fig. 22-4). Most of t
hose present in
the urine spec- imen re neutrophils, lthough eosinophils or mononucle r cells
m y be elev ted
in cert in situ tions. White blood cells re identified using the high-power obj
ective nd
reported s the number visu lized per high-power field. Sperm tozo Occ sion lly
, sperm tozo m y
be present in urine specimens from both m les nd fem les fter sexu l intercour
se. The
sperm tozo will be identified by their distinctive sh pe, s they h ve n ov l
he d th t is 442
Section V Urin lysis Figure 22-2 Thre ds of mucus; note the stringy ppe r- nc
e. From
Str singer, SK, nd Di Lorenzo, MS: Urin lysis nd Body Fluids, ed. 5. FA D vis,
Phil delphi ,
2008, with permission. Figure 22-3 Red blood cells (erythrocytes) s they ppe r
in urine
sediment. From Str singer, SK, nd Di Lorenzo, MS: Urin lysis nd Body Fluids, e
d. 5. FA D vis,
Phil delphi , 2008, with permission. Figure 22-4 White blood cells. Note the pre
sence of the
nucleus nd the cytopl smic gr nules. From Str singer, SK, nd Di Lorenzo, MS: U
rin lysis nd
Body Fluids, ed. 5. FA D vis, Phil delphi , 2008, with permission. 1899_Ch22_439
-455 22/12/11

11:41 AM P ge 442 somewh t te rdrop sh ped, nd long t il. Urine is toxic to s

perm tozo , so it
is unusu l for these cells to exhibit the s me mount of motility s they would
in semen
specimen. The clinic l signific nce of sperm tozo in
urine specimen is limite
d to situ tions
of m le infertility nd retrogr de ej cul tion in which the sperm is rele sed in
to the bl dder
inste d of into the urethr . The pres- ence of sperm tozo should be reported in
ny situ tion,
whether or not the clinic l signific nce is cle r. Elev ted mounts of sperm toz
o in the urine
specimen m y c use the urine dipstick to test positive for protein. The presence
of sperm tozo
is noted with the rest of the mi- croscopic ex min tion results, but the m nner
in which is it
reported is l bor tory specific. Artif cts Artif cts re cont min nts th t re v
isu lized in the
urine specimen. These m y include fec l m teri l, toilet p per, ir bubbles, st
rch or powder,
nd clothing fibers. Artif cts re not usu lly reported s p rt of the urine mic
roscopic
ex min tion, bec use they re not clinic lly signific nt. These structures re d
ifficult to
identify nd m y be con- fused with other formed elements in the urine specimen
bec use of
simil rities in their sh pe nd size. C sts The kidney tubules norm lly secrete
subst nce
c lled the T mm-Horsf ll protein. This protein is not clini- c lly signific nt u
nless cert in
conditions exist within the tubules th t llow the T mm-Horsf ll protein to gel
d form
protein-b sed mold of the tubule. Reduced urine flow, incre sed mounts of disso
lved subst nces
in the glomerul r filtr te, nd cidic urine conditions contribute to the form t
ion of these
c sts. The c sts ssume the sh pe of the tubule or collecting duct in which they
were formed. Any
structures or sub- st nces th t were present within the tubule or collect- ing d
uct when the c st
w s formed re tr pped within the c st. These tr pped subst nces m y include b c
te- ri , cells,
or diffuse gr nules. Eventu lly, the protein m king up the c st bre ks w y from
the lumen of the
tubules nd flushes out with the urine. These c sts c n then be identified in th
e urine sediment
when viewed under the microscope. C sts re cylindric l bec use of the sh pe of
the struc- ture
in which they were origin lly formed in the nephron tubules. They re cl ssified
using the n mes
of the tr pped subst nces within the protein structures. To visu lize c sts, the
intensity of the
light source on the mi- croscope must be decre sed, nd the urine must be ex- m
ined with the
low-power objective. The presence of
few hy line c sts in
urine specimen is
not considered
bnorm l, but the presence of ny other type of c st m y indic te d m ge to the
kidney tubules.
Some common types of c sts identified in the urine sediment include the followin
g: Hy line

c sts: Cle r, colorless, tr nsp rent. Hy line c sts m y be difficult to see nd

to differenti te
from thre ds of mucus. Figure 22-5 shows hy line c st. Strenuous exercise, he
t exposure, or
dehydr tion m y c use n incre sed number of hy line c sts. Elev ted numbers of
hy line c sts m y
lso be indic tive of pyelonephritis, glomerulonephritis, or chronic ren l dise
se. It is norm l
to see
few hy line c sts when Ch pter 22 Microscopic Ex min tion of Urine 443
POINT OF
INTEREST 22-1 Clue cells Occ sion lly the urine microscopic report for
fem le
p tient m y
include the presence of clue cells. This term is used to describe v gin l epithe
li l cells th t
re co ted with the G rdnerell v gin lis b c- terium. The clue cells re simil
r in ppe r nce
to the squ mous epitheli l cells, except th t the clue cell borders re ill defi
ned or completely
obliter ted with co ting of b cteri . The presence of these cells in the urine
specimen m y be
indic tive of n infection known s b cteri l v ginosis, nd they must be noted
if viewed in the
urine specimen. There re numerous types of b cteri present s norm l flor in
the v gin t ll
times. B cteri l v gi- nosis is the result of n overgrowth of G. v gin lis when
the b l nce of
norm l flor is disrupted. The use of bro d-spectrum ntibiotics m y destroy he
lthy b cteri nd
llow the G. v gin lis to incre se in number. Douching, ret ined t mpons, use of
in- tr uterine
devices for contr ception, nd use of prod- ucts th t cont in nonoxynol-9 m y l
so c use the
b cteri l b l nce to shift in the v gin l tissues. B cteri l v ginosis is the c
use of 60% of
vulvo- v gin l infections. It is import nt to di gnose nd tre t this condition
promptly bec use
it h s been linked to n incre sed risk of pelvic infl mm tory dis- e se (PID).
Pelvic
infl mm tory dise se is serious condition th t m y le d to infertility s well
s being
component of m ny other dise se processes. Test Your Knowledge 22-3 Is it possib
le to see
sperm tozo in the urine of fem le p tient? (Outcome 22-3) 1899_Ch22_439-455 2
2/12/11 11:41 AM
P ge 443 ex mining the urine under low m gnific tion. Hy - line c sts re report
ed s the number
visu lized per low-power field. Gr nul r c sts: Gr nul r c sts cont in fine or c
o rse gr nules.
These gr nules re disintegr ted structures th t were tr pped in the ren l tubul
e t the time
th t the c st w s formed. Gr nul r c sts m y be present in the urine sediment wi
th stress or
strenuous exercise, but they m y lso be evident with glomerulonephritis or pyel
onephritis.
Gr nul r c sts re identified using the low-power objective nd reported s the
number visu lized
per low-power field. Cellul r c sts: Cellul r c sts cont in ren l epitheli l cel
ls, red blood
cells, or white blood cells. Ren l ep- itheli l cell c sts re indic tive of d m
ge to the re-

n l tubules nd re not present in norm l urine specimen. Red blood cell c sts
m y be seen
fter strenuous exercise, but their presence m y lso be indic tive of bleeding
within the
nephron structure s in the c se of glomerulonephritis. The red blood cell c sts
h ve distinct
or nge-red color. White blood cell c sts re present when there is infl mm - tio
n or infection
within the nephron. There m y lso be b cteri present in
white blood cell c s
t. Pyelonephritis
is often ch r cterized by the presence of white blood cell c sts in the urine se
diment. Cellul r c sts re identified using the low-power objec- tive nd re reported s t
he number
visu lized per low-power field. W xy c sts: W xy c sts ppe r smooth with n irr
egu- l r
outline. They re very refr ctive when ex mined with decre sed light under low-p
ower
m gnific tion. There re no tr pped subst nces within the c st, but the outline
is e sier to see
th n th t of
hy line c st. W xy c sts re indic tive of n extreme decre se in
the urine flow
through the tubules th t ccomp nies re- n l f ilure, nd re not present in n
orm l urine
specimen. They re identified using the low-power objective nd reported s the
number visu lized
per low-power field. Cryst ls The presence of cryst ls in norm l urine sediment
is common.
Although m ny types of cryst ls re consid- ered norm l, it is import nt to repo
rt them when
iden- tified bec use their presence in incre sed numbers m y be clinic lly signi
fic nt. Cryst ls
re formed from the dissolved subst nces (especi lly s lts) in the urine. The pr
ecipit tion of
these dissolved subst nces into cryst ls is ffected by the pH of the urine, s
well s reduced
temper ture nd incre sed specific gr vity. Urine th t h s been t room temper t
ure or
refriger ted for pe- riod of time will often cont in bund nt cryst ls in the
urine sediment.
In ddition, highly concentr ted urine (urine with high specific gr vity) with
m ny dissolved
subst nces will cryst llize re dily. The pH of the urine specimen pl ys
v lu b
le role when
ttempting to iden- tify cryst ls under the microscope, s cert in types of crys
t ls re evident
in cidic urine, where s others re present in lk line urine. V rious cryst ls
c n be seen in
Figure 22-6. Norm l cryst ls m y be present in cidic or lk line urine specimen
s. These include
the following: Amorphous (without distinct sh pe) ur tes re pres- ent in cid
ic urine. The
refriger tion of the specimen signific ntly contributes to the form tion of mor
- phous ur tes in
the specimen. The urine sediment m y ppe r pink, nd the morphous cryst ls wil
l ppe r s
yellow-brown diffuse gr nules throughout the speci- men when viewed under the mi
croscope.
Amorphous ur te cryst ls m y return to solution with the pplic - tion of he t o
r ddition of

sodium hydroxide to the specimen. Uric cid cryst ls re evident in cidic urine
, nd p- pe r
with numerous sh pes nd
yellow-brown color. They m y be present in incre sed
numbers with
leukemi when the p tient is receiving chemother py, nd occ sion lly in p tient
s with gout.
C lcium ox l te cryst ls re occ sion lly found in cidic urine or, more commonl
y, in urine with
neu- tr l pH. They re seldom found in lk line urine. These cryst ls ppe r
s envelopes nd
re very re- fr ctive when viewed under the microscope. 444 Section V Urin lysi
s Figure 22-5
Hy line c st. These c sts re hollow nd h ve no structures filling their core. Fr
om
Str singer, SK, nd Di Lorenzo, MS: Urin lysis nd Body Fluids, ed. 5. FA D vis,
Phil delphi ,
2008, with permission. 1899_Ch22_439-455 22/12/11 11:41 AM P ge 444 Amorphous ph
osph tes re
present in lk line urine. This cryst lliz tion is especi lly evident fter refr
iger - tion of
the specimen. The morphous phosph te cryst ls ppe r s diffuse gr nul r p rtic
les th t m y
obscure the other structures present in the sediment when viewed under the micro
scope. The urine
speci- men m y t ke on white color if morphous phos- ph tes re present. Amor
phous phosph tes
dissolve with the ddition of 10% cetic cid. Triple phosph te cryst ls re pre
sent in neutr l
or lk line urine. They re colorless, nd very refr ctive when viewed under the
microscope. They
re often described s coffin lid, sh ped like
six-sided prism. Their presence
is not
clinic lly signific nt. The presence of other cryst ls considered bnorm l in th
e urine sediment
m y be indic tive of met bolic dis- e ses. Use of cert in drugs (such s sulfon
mides or
mpicillin) m y lso result in cryst l form tion. Urine specimens with lk line
or neutr l pH
v lues r rely con- t in bnorm l cryst ls. Fortun tely, the bnorm l urine cryst
ls ll h ve very
ch r cteristic sh pes th t re e sily recogniz ble. Cryst ls th t re considered
bnorm l include
the following: Cystine cryst ls re present in p tients with cystinuri , met b
olic disorder
in which individu ls re not ble to re bsorb cystine in the ren l tubules s
norm l individu l
would. Cystine cryst ls re hex gon l. Cholesterol cryst ls re not usu lly visu
lized unless
the urine specimen h s been refriger ted. When they re present, they ppe r s
fl t rect ngles
with notches out of the corners of the structure. Their presence in- dic tes d
isorder th t
includes lipiduri (the presence of lipids in the urine), such s nephrotic synd
rome. Tyrosine,
leucine, nd bilirubin cryst ls m y be pres- ent in the urine of p tients with l
iver disorders.
Tyro- sine needles look like clumps of needles, where s leucine cryst ls look li
ke yellow-brown,
oily spheres. Bilirubin cryst ls re lso described s lumps of nee- dle structu
res, but they re

yellow (like the color of bilirubin). Ch pter 22 Microscopic Ex min tion of Uri
ne 445 Figure
22-6 V rious cryst ls. A. Amorphous ur tes. B. Amorphous phosph tes. C. Triple p
hosph te
cryst ls. D. C lcium ox l te cryst ls. From Str singer, SK, nd Di Lorenzo, MS:
Urin lysis nd
Body Fluids, ed. 5. FA D vis, Phil delphi , 2008, with permission. A C D B 1899
_Ch22_439-455
22/12/11 11:41 AM P ge 445 Sulfon mide cryst ls h ve historic lly been present i
n urine
sediment in p tients undergoing sulf drug tre tment. However, the newer sulfon
mide drugs re
designed to be more soluble, which me ns th t these cryst ls re r rely present
now. If there re
sulfon mide cryst ls present in the urine specimen, it m y me n th t the p tient
is not
dequ tely hydr ted. These cryst ls ppe r s bundles of needles or designs th t
resemble she ves
of whe t. Ampicillin cryst ls m y lso be present in urine when p tients receive
very l rge
doses of the medic tion without dequ te hydr tion. They lso ppe r s col- orl
ess bundles of
needles. Hippuric cid is incre sed in the urine when xylene nd toluene re met
bolized.
Xylene nd toluene re common industri l chemic ls. Hippuric cid crys- t ls m y
be n indic tion
of incre sed exposure to these chemic ls, s in workpl ce exposure or in those w
ho buse
chemic ls, such s sniffing glue products. Microorg nisms When viewed with com
pound microscope,
v rious mi- croorg nisms m y be visu lized in the urine sediment. These include
b cteri , fungi,
nd p r sites. Sm ller mi- croorg nisms such s viruses re not visible in the u
rine sediment
with this type of m gnific tion. B cteri : It is not uncommon to see few b cte
ri in urine
specimens th t re collected using the cle n-c tch midstre m method. (See Fig. 2
2-7.) The
presence of b cteri is usu lly the result of extern l cont min tion, especi lly
in women. These
b cteri l cont min nts multiply quickly fter the urine is collected, nd m y c
use the nitrite
on the re gent stick to test positive if the urine is llowed to sit for more th
n n hour. When
present in elev ted numbers, the presence of b cteri will c use the urine pH to
become more
lk line. (A pH bove 8 m y indic te the presence of excess b c- teri l cont min
tion.) B cteri
must be visu lized by using the high-power microscope objective bec use of their
sm ll size. The
methods of reporting b cteri m y v ry mong l bs. Most commonly, b cteri is re
ported s few,
moder te, or m ny, but qu ntit tive system of 1+, 2+, or 3+ m y be used. Urin
ry tr ct
infections m y be c used by b cilli or cocci. When b cteri re present in the u
rine specimen in
high numbers nd white blood cells re evident, the urin lysis is gener lly foll
owed up with
culture for positive identific tion of the b cteri nd n ntibiotic sensitivit
y. Fungi:

C ndid lbic ns is the most common type of fungi (ye st) present in urine. Ye s
t is commonly
present in the urine of di betic p tients or those who re immunocompromised. Wo
men who h ve the
v gi- n l infection c ndidi sis m y lso h ve ye st present in their urine speci
men. Ye st m y be
difficult to differ- enti te microscopic lly from red blood cells, s their size
nd sh pe re
simil r. Adv nced ye st infections m y present with ye st th t is budding from sto
cks or
br nches s it multiplies nd m tures. The presence of ye st is reported in the
s me w y th t the
presence of b cteri is reported. P r sites: The most common p r site present in
the urine
specimen is Trichomon s v gin lis. This is sex- u lly tr nsmitted p thogenic m
icroorg nism th t
c uses v gin l infl mm tion in fem les. Infection in m les is often symptom tic
. T. v gin lis is
often motile when viewed under the microscope in the urine sediment, nd it m y
be recognized by
the fl gell th t provides its movement. The motility of the org nism is necess
ry for positive
identific tion of the p r site. The presence of T. v gin lis is determined using
the high-power
objective nd is reported s r re, few, moder te, or m ny per high-power field.
446 Section V
Urin lysis Figure 22-7 B cteri s they ppe r in the urine sediment. From Str s
inger, SK, nd Di
Lorenzo, MS: Urin lysis nd Body Fluids, ed. 5. FA D vis, Phil delphi , 2008, wi
th permission.
Test Your Knowledge 22-4 Which of the following microorg nisms is not visu lized
in urine
sediment specimen using compound microscope? . Viruses b. B cteri c. Fungi d
. P r sites
(Outcome 22-4) 1899_Ch22_439-455 22/12/11 11:41 AM P ge 446 METHODS USED FOR URI
NE MICROSCOPIC
EXAMINATION The urine microscopic ex min tion is the p rt of the routine urin ly
sis th t is the
le st st nd rdized from one l bor tory to nother. E ch site m y v ry in the w y
th t the
specimen is prep red, in how much urine is used for prep r tion of the sediment,
or by the w y
th t the specimen is visu lized during the ex min - tion. All procedures include
the
centrifug tion of specified volume of urine, sep r tion of the super- n t nt (
the fluid from
the top of the specimen) from the sediment (the formed elements th t h ve been c
omp cted to the
bottom of the tube), nd ex min - tion of the urine sediment under microscope.
The formed
elements re then ex mined using the low- power nd/or high-power outcomes, nd
the results re
reported. The results of the microscopic ex min tion m y be ffected by sever l
f ctors. The ge
of the specimen nd the conditions under which the specimen w s stored c n ffec
t the integrity
of the structures to be visu lized. The volume of specimen centrifuged, the time
of centrifug tion, nd the force of the centrifug tion will determine the mount of sediment
produced for the

microscopic ex min tion. The results m y lso be ffected by the mount of super
n t nt disc rded
nd the mount of sed- iment dded to the slide for ex min tion. The m nner in w
hich the results
re reported m y lso differ ccording to l bor tory protocol. Bec use of these
v ri bles, the
Clinic l nd L bor tory St nd rds Institute h s recom- mended th t the process f
or prep ring nd
performing urine microscopic ex min tions be st nd rdized with use of commerci l
systems th t
minimize the v ri bles in the process. The KOVA system (m nuf ctured by Hycor Bi
o- medic l, Inc.)
is n ex mple of commerci l urin lysis microscopic kit th t uses speci l pip
ette to st nd rdize the mount of sediment prep red, h s specific in- structions concerning the
rot tions per
minute nd length of centrifug tion to be used, nd cont ins spe- ci l slide w
ell used for
ex min tion of the sediment th t dict tes the mount of sediment used for the ex
min - tion. The
KOVA system lso includes
st in th t en- h nces the contr st of the formed ele
ments to ssist
with identific tion. Procedure 22-1 det ils the use of the KOVA method for
mic
roscopic
ex min tion. There re other commerci l systems v il ble, includ- ing the Urisy
stem m nuf ctured
by ThermoFisher Scientific nd the Count-10 system m nuf ctured by V-Tech, Incor
por ted.
Reg rdless of the system used to process the urine nd set up the microscopic ex
min tion, it is
imper tive th t fresh or properly stored urine specimen is used. If the urine
specimen is
llowed to rem in t room temper ture for n extended period of time (more th n
n hour), it m y
ffect the results of the urine microscopic ex min - tion, in ddition to the ch
emic l n lysis
of the speicmen. The formed elements present in the specimen will disintegr te
nd become
distorted in specimens th t re stored t room temper ture for n extended perio
d. The red blood
cells, white blood cells, nd hy line c sts re most ffected. Specimens th t r
e not n lyzed
within n hour m y lso exhibit n incre se in b cteri l growth, ccomp nied by
n incre se in
pH. Urine th t is refriger ted prior to the perform nce of microscopic ex min
tion will need to
re ch room tem- per ture before the procedure is performed. If the urine is stil
l very cold t
the time of the ex min tion, the precip- it tion of cryst ls will be visu lized
when viewed under
the microscope. The presence of morphous phosph tes nd morphous ur tes in the
refriger ted
urine m y obscure other clinic lly signific nt structures present in the specime
n. Medic l
ssist nts re often involved in the prep r - tion of the urine sediment for the
microscopic
ex min - tion. In ddition, the medic l ssist nt m y be sked to pl ce the slid
e on the
microscope st ge nd focus it p- propri tely so th t the he lth-c re provider (
or nother

qu lified l bor tory profession l) m y perform the ex- min tion. To ccomplish
this, it is
import nt th t the medic l ssist nt le rn how to focus the microscope so th t t
he formed
elements re visible. Procedure 22-2 outlines the import nt concepts necess ry t
o ccom- plish
this t sk. REPORTING URINE MICROSCOPIC RESULTS As the v rious formed elements h
ve been presented
in this ch pter, the reference r nges h ve been presented s well. It is import
nt to remember
th t m ny norm l urine specimens will include very few formed elements. If there
re structures
present in the urine sediment, it is import nt to report them in w y th t is e
sy to interpret.
The ex ct r nges nd terminology used for Ch pter 22 Microscopic Ex min tion of
Urine 447 Test
Your Knowledge 22-5 Why might the KOVA system be used to prep re urine microsc
opic specimen for
ex min tion? (Outcome 22-5) 1899_Ch22_439-455 22/12/11 11:41 AM P ge 447 448 Sec
tion V
Urin lysis TASK Prep re slide for urine microscopic ex min tion using the KOVA
system. Complete
ll steps within 15 minutes. CONDITIONS H nd s nitiz tion supplies Gloves L bor
tory co t
F ce Shield Conic l tube Freshly voided urine specimen KOVA System supplies, inc
luding tube
c p, KOVA pipette, slide, nd st in Centrifuge Test tube r ck Microscope Bioh z
rdous
dispos l cont iner CAAHEP/ABHES STANDARDS CAAHEP St nd rds I.P.I.14. Perform Uri
n lysis
III,P.III.2. Pr ctice St nd rd Prec utions ABHES St nd rds Medic l Office Clinic
l Procedures:
b. Apply princi- ples of septic techniques nd infection control, i. Use st nd
rd prec utions
Perform Urin lysis Procedure 22-1: Prep r tion of Urine Sediment for Microscopic
Ex min tion
Procedure R tion le 1. S nitize h nds, llow them to dry, nd pply gloves. 2. G
ther necess ry
supplies. Urine must be t room temper ture prior to use. 3. Apply f ce shield
nd mix urine well
by gently rot ting the specimen cup or inverting the cup if necess ry. Pour 12 m
L of the specimen
into the KOVA conic l tube. 4. Apply the supplied c p to the tube, nd centrifug
e the specimen t
1,500 revolutions per minute for 5 minutes. 5. When the centrifuge h s come to
complete stop,
remove the conic l tube c refully. 6. Remove the c p nd c refully insert the pet
ter pipette
included with the system into the urine specimen. M ke sure the hook t the top
of the pipette is
settled into pl ce over the edge of the conic l tube. Gloves protect the h nds f
rom exposure to
potenti l bloodborne p thogens. Gloves should lw ys be pplied in the presence
of the p tient.
All supplies must be within re ch so th t the process c n be completed in time
ly m nner. The
urine must be t room temper ture to void excess cryst l- liz tion of the speci
men. The
pplic tion of the f ce shield protects the eyes nd mucous membr nes from poten
ti l spl sh nd

erosol of the specimen. The urine must be well mixed for the results to be ccu
r te, nd the
KOVA system instruc- tions require 12 mL of urine to be dded to the tube. Centr
ifug tion is
necess ry for the solid subst nces in the specimen to settle to the bottom of th
e tube so th t
they c n be sep r ted from the liquid t the top of the tube. The protective f c
e shield c n be
removed t this time until the specimen is t ken from the centrifuge, t which p
oint it should be
put on g in. T ke c re not to disturb the sediment in the bottom of the tube wh
en h ndling the
specimen. The KOVA pipette is designed with speci l hook device t the top of
the pp r tus.
When the petter pipette is inserted correctly into the speci- men, the hook will b
e firmly
se ted over the side of the conic l tube. 1899_Ch22_439-455 22/12/11 11:41 AM P
ge 448 Procedure
R tion le Ch pter 22 Microscopic Ex min tion of Urine 449 The KOVA pipette is s
peci lly designed
with bulb t the bottom of the pipette th t holds the urine sedi- ment in pl c
e s the
supern t nt is poured out of the tube. Approxim tely 1 mL of sediment is left in
the bottom of
the tube. Only one drop of st in should be dded so th t the sed- iment is not d
iluted. The st in
nd the sediment must be thoroughly mixed, but excessive form tion of ir bubble
s should be
voided. 7. With the pipette in pl ce, c refully pour off the supern t nt by inv
erting the tube
over the sink to llow the liquid to pour out of the tube. 8. Remove the pipette
from the tube,
but do not dis- c rd it t this time. Insert one drop of KOVA st in into the con
ic l urine tube.
9. Reinsert the pipette into the tube nd mix the st in with the sediment by pp
lic tion of
gentle pressure on the bulb t the top of the pipette. Squeeze nd rele se the b
ulb until the
specimen is uniformly mixed. Courtesy of Fisher He lthC re, Inc. Continued 1899_
Ch22_439-455
22/12/11 11:41 AM P ge 449 450 Section V Urin lysis Procedure R tion le If the
slide is
overfilled or underfilled, the results of the microscopic ex min tion m y be err
oneous. When
filling the slide, void the form tion of ir bubbles s much s possible. Focus
ing on the
specimen too soon will m ke it diffi- cult to identify or qu ntit te the formed
elements
correctly. The medic l ssist nt m y be involved in the focusing of the specimen
, lthough he or
she will not be per- forming the ctu l microscopic ex min tion. 10. Use the pip
ette to dd
drop of the st ined sed- iment to the KOVA slide. The slide is cre ted with n o
pening t the top
where the sediment c n be dded. The slide must not be overfilled or underfilled
. At this point
in the procedure, the protective f ce shield c n be removed. Disc rd the pipette
into the
bioh z rdous dispos l cont iner. 11. Allow the specimen in the slide to settle f
or t le st 1

minute before proceeding to the microscopic ex min tion. 12. Complete the proced
ure necess ry to
focus the slide under the microscope. Procedure 22-1: Prep r tion of Urine Sedim
ent for
Microscopic Ex min tioncontd Courtesy of Fisher He lthC re, Inc. Procedure 22-2: F
ocusing the
Urine Sediment Under the Microscope TASK Focus the urine sediment under the micr
oscope to prep re it for identific tion nd qu ntit tion of formed elements. The process shou
ld be completed
in less th n 5 minutes. CONDITIONS H nd s nitiz tion supplies Gloves L bor tory
co t KOVA
slide with st ined sediment dded Bioh z rdous dispos l cont iner 1899_Ch22_439455 22/12/11
11:41 AM P ge 450 Ch pter 22 Microscopic Ex min tion of Urine 451 CAAHEP/ABHES
STANDARDS CAAHEP
St nd rds I.P.I.14. Perform Urin lysis III,P.III.2. Pr ctice St nd rd Prec utio
ns ABHES
St nd rds Medic l Office Clinic l Procedures: b. Apply princi- ples of septic t
echniques nd
infection control, i. Use st nd rd prec utions Perform Urin lysis Procedure R ti
on le 1.
S nitize h nds, llow them to dry, nd pply gloves. 2. Move the mech nic l st g
e ll the w y
down, w y from the microscope outcomes. Pl ce the filled KOVA slide on the mech
nic l st ge of
the micro- scope. Use the clips on the st ge to st bilize the slide. 3. Move the
10X outcome into
pl ce for viewing. Min- imize the light by using the djustment knob t the b se
of the
microscope nd/or by closing the perture opening where the light comes through
to the slide. 4.
Use the co rse djustment knob to bring the st ge s close s possible to the ou
tcomes. 5. Look
through the eyepieces, nd use the co rse nd fine djustment knobs s needed to
bring the specimen into focus. If necess ry, move the slide cross the st ge to find formed
element to use s
refer- ence while focusing. Squ mous epitheli l cells re often present nd e si
ly identifi ble.
6. Inform the he lth-c re pr ctitioner or technologist th t the slide is re dy t
o be viewed. The
microscopic ex min tion should be completed within 5 minutes of the initi l focu
s so th t the
specimen does not become dried out on the slide. 7. When the procedure is comple
ted, disc rd the
slide in the bioh z rdous dispos l cont iner, disc rd the tube with the rest of
the st ined
sediment in the bioh z rdous w ste cont iner, disinfect the work site nd micros
cope s needed,
nd remove gloves. S nitize h nds. Gloves protect the h nds from exposure to pot
enti l bloodborne
p thogens. Gloves should lw ys be pplied in the presence of the p tient. The s
t ge is moved
w y from the outcomes so th t there is room to pl ce the slide on the st ge. Al
l microscopic
specimens re pl ced on the st ge for ex min tion. The clips llow the slides to
be moved s
needed for ex min tion. Reduction of the light using the low-power outcome llow
s for better

focus on the formed elements in the specimen. This will bring the slide into pp
roxim te focus
when viewed through the eyepieces. Some specimens h ve very few formed elements;
there- fore, it
m y be necess ry to sc n sever l fields before point of reference m y be ident
ified. If the
specimen dries out, it could le d to erroneous results bec use the concentr tion
of formed elements on the slide c n ch nge with ev por tion, nd the ppe r nce of the elemen
ts m y ch nge. It
is import nt to disinfect work re s nd ppropri- tely dispose of ll l bor to
ry specimens for
infection control. 1899_Ch22_439-455 22/12/11 11:41 AM P ge 451 reporting m y v
ry mong
l bor tories. The differences in reporting methods m y be the result of the syst
em used for the
ex min tion (for inst nce, the commerci l systems m y h ve grid th t is used f
or counting nd
reporting the elements), or the differences m y be the result of l bor tory pref
erence. Cert in
structures re reported s the number present per low-power field, where s other
s report the
number per high-power field. In ddition, some of the formed elements re qu nti
t - tively
reported s r re, few, moder te, nd m ny, where s others re reported using re
l numbers, such
s 0 to 5, 5 to 10, nd so on. T ble 22-1 lists common formed elements nd the u
nits used for
reporting. ROLE OF THE MEDICAL ASSISTANT IN MICROSCOPIC URINE PROCEDURES The ex
min tion of urine
sediment is not CLIA- w ived procedure. Medic l ssist nts who perform this pr
ocedure in
physici n office or other l bor tory set- ting must possess the ppropri te tr i
ning nd
educ tion to perform this moder tely complex procedure. Urine microscopy ex min
tion m y lso be
performed by the he lth-c re provider in
physici n office l bor tory, s long
s th t
l bor tory h s been registered ppropri tely with the Centers for Medic re & Med
ic id Services s
site th t is performing provider performed microscopy (PPM). As p rt of the PP
M process, the
medic l ssis- t nt will centrifuge the urine s mple with dded st in if necess
ry, pl ce the
sediment on the slide, nd focus the specimen to prep re for the providers micros
copic ex min tion. The medic l ssist nt m y lso perform routine m inten nce on the micro
scope. QUALITY
CONTROL AND QUALITY ASSURANCE PROCEDURES FOR URINE MICROSCOPIC EXAMINATIONS Qu l
ity ssur nce is
bro d term used to describe the policies nd procedures th t ensure qu lity l
bor tory
processes nd p tient c re. For urine microscopic ex m- in tions, these p r mete
rs include the
following compo- nents of the pre n lytic l ph se of l bor tory testing: Providi
ng ppropri te
p tient instructions for the collection of the specimen Ensuring dequ te specim
en volume
Storing specimens correctly Using cle n supplies C libr ting the centrifuge used
to spin the

specimen Sep r ting the urine supern t nt correctly Setting up the urine sedimen
t correctly
on the slide with the ppropri te volume Focusing the specimen correctly in prep
r tion for
ex min tion by qu lified l bor tory profession l 452 Section V Urin lysis Tes
t Your Knowledge
22-6 True or F lse: All norm l urine specimens cont in high number of formed e
lements. (Outcome
22-7) Test Your Knowledge 22-7 List one duty th t medic l ssist nt might perf
orm in reference
to the urine microscopic ex min tion. (Outcome 22-8) TABLE 22-1 Common formed el
ements nd method
of reporting Common Formed Elements Units Used for Reporting Squ mous epitheli l
cells R re, few,
moder te, or m ny report per low-power field (lpf) Mucus Not reported by ll l b
or tories; if
reported, use r re, few, moder te, or m ny per low-power field (lpf) Red blood c
ells Aver ge
number visu lized fter counting 10 high-power fields (hpf). Reported s # per h
pf White blood
cells Aver ge number visu lized fter counting 10 high-power fields. Reported s
# per hpf
Sperm tozo M y or m y not be reported ccording to l bor tory protocol C sts Av
er ge number
visu lized fter counting 10 low-power fields (lpf). Reported s # per lpf Cryst
ls Reporting
methods v ry; usu lly r re, few, moder te, or m ny per high-power field B cteri
R re, few,
moder te, or m ny per high-power field Ye st R re, few, moder te, or m ny per hi
gh-power field
1899_Ch22_439-455 22/12/11 11:41 AM P ge 452 Qu lity control refers more specifi
c lly to policies
nd procedures directly rel ting to the testing process. For urine microscopy, m
ost medic l
ssist nts will not di- rectly perform the microscopic qu lity control proce- du
res bec use they
re not qu lified to perform ex min - tion of urine sediment under the microscop
e. However, it is
import nt for medic l ssist nts to know th t they re still p rt of the qu lity
control process.
The medic l ssist nt needs to verify th t ll re gents (such s st ins) to be u
sed re not
expired. The instructions for use of commerci l systems must be followed c reful
ly to chieve
desired results. Appropri te m inten nce of the microscope is lso p rt of qu li
ty control,
bec use it is used directly in the testing process. Medic l ssist nts who h ve
been properly
tr ined to perform the urine microscopic ex min tion m y be re- sponsible for qu
lity control
procedures th t verify their bility to identify nd qu ntit te the formed elements in the
urine specimen correctly. These qu lity control procedures m y include ex min ti
on of commerci lly prep red specimens th t cont in known qu ntities of v rious formed ele
ments. The
l bor tory will lso p rticip te in proficiency testing procedures in which resu
lts from
st nd rdized specimens re com- p red to those of other l bor tories cross the
country to test

for competency. SUMMARY The microscopic ex min tion of urine specimens provides
v lu ble
inform tion to he lth-c re profes- sion ls. As the third p rt of complete urin
lysis, the
knowledge g ined from urine microscopy en- h nces the results obt ined from the
m croscopic nd
chemic l ex min tion of the specimen. The presence of formed elements in the uri
ne such s blood
cells, epitheli l cells, cryst ls, nd microor- g nisms provides v lu ble inform
tion to ssist
in di gnosis of urin ry tr ct infections, kidney dise se or tr um , or met bol
ic disorders. The
st nd rdiz - tion of the specimen processing nd microscopic ex min tion procedu
re llows for
more reli bility in the results. To perform urine microscopic ex mi- n tion, m
edic l ssist nts
would need ppropri te educ tion nd tr ining to meet the requirements for perfo
rm nce of CLIA
moder tely complex procedure. However, medic l ssist nts who h ve not received
this ddition l
tr ining m y still be responsible for prep ring
specimen nd focusing it under
the microscope
for re ding by qu lified individu l. TIME TO REVIEW 1. The presence of white b
lood cells
Outcome 22-1 in urine specimen is c lled: . Pyuri b. Hem turi c. Hemoglobin
uri d. Cysturi
2. List two types of formed elements th t Outcome 22-3 m y be identified in ur
ine microscopic
ex min tion. 3. Which of the following m y be Outcome 22-4 clinic lly signific n
t if reported s
p rt of urine microscopic ex min tion? . The presence of r re white blood c
ell b. M ny
b cteri c. The presence of r re hy line c st d. The presence of r re squ mo
us epitheli l
cell 4. Provide the n me of one commerci l Outcome 22-5 system used to prep re u
rine specimens
for microscopic ex min tions. 5. When focusing the urine sediment Outcome 22-6 u
nder the
microscope, which microscope objective is used initi lly to bring the speciment
into pproxim te
focus? . 10X b. 40X c. 100X d. None of the bove 6. True or F lse: The presence
of red Outcome
22-7 blood cells is reported s few, moder te, or m ny per lpf. 7. Which of the
following
represents Outcome 22-8 typic l t sk performed by medic l ssist nt in prep
ring for
urine
microscopic ex min tion? . Counting the number of white blood cells present in
10 fields using
the high-power objective b. Identifying the types of cryst ls present in the spe
cimen c.
Centrifuging the urine specimen d. Processing qu lity control specimens to verif
y competency with
the procedure 8. True or F lse: Medic l ssist nts re Outcome 22-9 not responsi
ble for ny
qu lity control procedures pert ining to the urine microscopic ex min tion. Ch p
ter 22
Microscopic Ex min tion of Urine 453 1899_Ch22_439-455 22/12/11 11:41 AM P ge 45
3 9. How much
supern t nt is usu lly left Outcome 22-10 in the tube with the sediment when pre
p ring the

sediment to be pl ced on slide for viewing? . 5 mL b. 3 mL c. 0 mL d. 1 mL or

less 454 Section
V Urin lysis C se Study 22-1: When is
specimen too cold? C ssie M son is me
dic l ssist nt
working in
physi- ci n office l bor tory t which urin lysis tests re per- fo
rmed. C ssie
completed ll the initi l urin lysis test procedures before le ving for lunch. T
his included not tion of the color nd ppe r nce of e ch specimen, s well s the chemic l dip
stick testing.
She cle ned her work re , put ll the specimens in the refriger tor, nd left t
he results for
the he lth-c re pr ctitioner to review before lunchtime. When she returned from
lunch n hour
l ter, there w s note from the pr ctitioner sking her to set up urine microsc
opic slides for
two of the urine specimens for the pr ctitioner to ex mine l ter th t fternoon
between
ppointments. About n hour l ter, C ssie removed the urine specimens from the r
efriger tor, centrifuged them, nd immedi tely set up the slides nd focused them on the microsc
ope. Immedi tely
there fter, the pr ctitioner c me into the l bor tory re nd looked t the sli
de of the first
specimen. After cursory gl nce, she sked C ssie whether this specimen h d bee
n refriger ted.
When C ssie cknowledged th t it h d, she told C ssie th t she needed to pour n
other specimen,
llow it to sit for t le st h lf n hour, then recentrifuge, nd set up the s
lide g in for
viewing. 1. Wh t did the pr ctitioner see in the specimen th t m de her sk bou
t the
refriger tion? 2. How will it help to h ve the specimen sit t room temper ture
for period of
time before setting up nother slide to be viewed? C se Study 22-2: Norm l resul
ts? A p tient
drops off urine specimen th t w s collected t home to the l bor tory. The tim
e of collection
noted on the requisition form w s sever l hours before the specimen w s delivere
d to the
l bor tory. The medic l ssist nt who is working in the l bor tory performed
c
hemic l n lysis
of the specimen, nd notes th t the pH of the specimen is 8, nd th t the nitrit
e result test
produces
positive result. 1. In this scen rio, wh t re the three det ils th t
provide
possible expl n tion for the test results obt ined? 2. Should this specimen be u
sed for
complete urin lysis? RESOURCES AND SUGGESTED READING University of Iow C rver C
ollege of
Medicine, pr ctice tests for the Urine Microscopic Ex min tion Present tion with
questions nd
nswers bout the urine microscopic ex min tion process http://www.medicine.
uiow .edu/cme/cli /modules. sp?testID=20 Origin nd composition of ren l c sts Exp
l ins the
origin nd composition of the v rious types of ren l c sts http://www. gor .cros
emont.qc.c /
urinesediments/doceng/doc_016.html 1899_Ch22_439-455 22/12/11 11:41 AM P ge 454
455 Section V
Urin lysis Wh t Does It All Me n? The typic l urin lysis test consists of three

compo- nents:
physic l ex min tion, chemic l ex min tion, nd microscopic ex min tion. In m ny
settings only
the physic l ex min tion nd chemic l ex min tion re routinely performed. A mic
roscopic
ex min tion is only performed when the physic l nd/or chemi- c l ex min tion re
sults suggest the
presence of formed elements. Some situ tions in which
micro- scopic ex min tio
n is typic lly
indic ted include the following: A s mple th t is cloudy or turbid A s mple th t
is red in
color A s mple th t h s l rge top l yer of white or yellow fo m A s mple th t
h s more th n
tr ce mounts of protein It is import nt to correl te the results obt ined in e
ch of the
urin lysis components performed. For ex- mple, one would expect to detect red b
lood cells on the
dipstick test of
s mple noted s being red dur- ing physic l ex min tion. C se
in Point Rec ll
Johnny, whom we met t the beginning of this section. He is n ctive 3-ye r-old
who loves to
pl y in the g r ge. He w s rushed to his doctors office fter drinking ntifreeze
. Ex min tion
of his urin lysis physic l ex min tion results reve ls th t both the color nd c
l rity of
Johnnys s mple re bnorm l. The f ct th t his urine is cloudy suggests th t form
ed elements re
present nd indic te th t microscopic ex min tion should be performed. The mos
t import nt
chemic l ex mi- n tion result in this c se is protein. Any mount more th n tr
ce is considered
bnorm l nd indic tes the need to perform microscopic ex min tion. These resu
lts re most
likely the result of Johnnys ingestion of ntifreeze, which is toxic to the kidne
ys. The kidneys
typic lly respond to such subst nces by ce sing to produce urine. This st gn te
st te pro- vides
perfect environment for the development of formed elements known s c sts. C s
ts re cig rsh ped structures th t cont in core m trix of protein known s T mm-Horsf ll
. Although this
is
different protein from th t which the corresponding dipstick test is design
ed to detect,
presence of bnorm l mounts of protein suggest th t c sts m y be present. The b
est next course
of ction in this c se is to perform
microscopic ex min - tion on Johnnys urine
looking for
formed elements, p rticul rly c sts. 1899_Ch22_439-455 22/12/11 11:41 AM P ge 45
5 456 On the
Horizon Adv nces in our underst nding of how the bodys im- mune system works h ve
exploded in
recent ye rs. From this work, import nt discoveries h ve emerged. One such ex mp
le is the f ct
th t we now know th t di betes mellitus is ssoci ted with the immune sys- tem!
No one would h ve
even suspected this just
few short ye rs go. As result of discoveries such
s this,
immunology h s truly become
l bor tory discipline within itself. Likewise, l b
or tory testing
in this re , lso known s immunology, h s improved nd ex- p nded. In f ct, th

ere is much
crossover of l bor tory disciplines ssoci ted with immunology tests. Some l bor
tories h ve
section dedic ted to performing immunology tests. In other settings, immunologic
test- ing is
performed throughout the l bor tory. Relev nce for the Medic l Assist nt (He lth
-C re Provider)
As with so m ny other spects of l bor tory testing, medic l ssist nts nd othe
r he lth-c re
support per- sonnel often p rticip te in immunologic testing by being involved i
n corresponding
s mple collection nd processing. Furthermore, medic l ssist nts of- ten perfor
m select
CLIA-w ived immunologic tests long with ppropri te qu lity control. Medic l s
sist nts re lso
responsible for completing the document tion ssoci ted with this testing. C se
in Point
Four-ye r-old P.J. presented to the pedi trici ns office where you work ccomp ni
ed by his very
worried f ther. In your initi l convers tion with P.J.s f ther you le rn th t lit
tle P.J. h d
been b ttling
fever nd sore thro t for more th n week nd w s not showing
ny signs of
improvement. Upon ex m- in tion of the p tient, the physici n noted th t the chi
ld h d numerous
yellow spots on the tonsill r re of his thro t. No wonder this little guy is so
uncomfort ble, you thought to yourself. The doctor ordered strep screen test n
d requested
th t you perform the test. You obt in the following results: R pid strip screenNe
g tive.
Questions for Consider tion: Wh t is the specimen type of choice for strep scree
n testing?
Wh t is the proper collection protocol for this specimen? Wh t is the strep scre
en test
designed to detect? Wh t ccounts for the neg tive strep screen results obt ined
? Wh t could
be done t this juncture to help deter- mine the microbiologic l gent responsib
le for PJs
infection? 1899_Ch23_456-472 22/12/11 12:28 PM P ge 456 457 Section VI Immunolog
y Ch pter 23:
Immunology provides the re der with
b sic underst nding of the im- mune system
. Immunologic
principles s they rel te to blood typing nd hemolytic dise se of the newborn
re covered. An
introduction nd overview of common immunology nd serology test methods re pre
sented. Ch pter
24: Immunologic-B sed R pid Testing includes
description of the common r pid t
ests th t re
routinely performed, including strep screen, infectious mononu- cleosis testing,
pregn ncy
testing, Helicob cter pylori testing, nd testing for influen- z s A nd B nd H
IV. The n ture of
e ch condition ssoci ted with these tests is ex mined. Appropri te follow-up te
sting is briefly
discussed when indic ted. Proper technique, norm l test reference r nge, qu lity
control, sources
of error nd interference, nd test interpret tion re described. 1899_Ch23_456472 22/12/11
12:28 PM P ge 457 1899_Ch23_456-472 22/12/11 12:28 PM P ge 458 Ch pter 23 Immuno
logy Const nce L.

Lieseke, CMA (AAMA), MLT, PBT(ASCP) 459 CHAPTER OUTLINE Immunity nd Immunology
The Immune
Process The First Line of Defense: Nonspecific Mech nic l nd Chemic l B rriers
The Second Line
of Defense: Intern l Nonspecific Response The Third Line of Defense: Acquired or
Ad ptive
Immunity How Immunity Is Acquired F ilure of Our Immune Systems Blood Types Eryt
hrobl stosis
Fet lis Immunology Testing Methods Common Serology Tests Performed in Reference
or Hospit l
L bor tories CLIAW ived Tests Commonly Performed in the Physici n Office L bor to
ry Summ ry Time
to Review C se Study Resources nd Suggested Re dings Le rning Outcomes After re
ding this
ch pter, the successful student will be ble to: 23-1 Define the key terms. 23-2
Expl in how
serology nd immunology re rel ted to immunity. 23-3 Describe the mech nic l b
rriers used by
the immune system. 23-4 Expl in how the intern l defenses t the site of n inv
sion by foreign
subst nces function. 23-5 Summ rize how cquired immunity is ctiv ted in the bo
dy. 23-6
Distinguish wh t h ppens when the immune process m lfunctions. 23-7 Ex mine how
v ccin tions
ctiv te the immune system. 23-8 Demonstr te underst nding of the b sic ABO nd
Rh blood typing
systems nd the role they pl y in hemolytic dise se of the newborn. 23-9 Describ
e v rious
immunology testing methods nd common serology tests performed in hospit l nd r
eference
l bor tories. 23-10 Expl in why some serology tests might be per- formed in phys
ici n offices
r ther th n in refer- ence l bor tories. 23-11 Expl in the clinic l signific nce
of the common
CLIA-w ived serology tests performed in physi- ci n offices. 1899_Ch23_456-472 2
2/12/11 12:28 PM
P ge 459 CAAHEP/ABHES STANDARDS CAAHEP St nd rds I.C.5. Describe the norm l func
tion of e ch body
system I.C.6: Identify common p thology rel ted to e ch body system III.C.10: Id
entify dise se
processes th t re indic tions for CLIA-w ived tests ABHES St nd rds Identify n
d pply the
knowledge of ll body systems; their structure nd functions; nd their common d
is- e ses,
symptoms, nd etiologies 460 Section VI Immunology KEY TERMS Agglutin tion Alle
rgy Antibody
Antibody-medi ted immunity Antigen Autoimmune dise se B cells Cell-medi ted immu
nity Chemot xis
Cili Complement ELISA or EIA testing Erythrobl stosis fet lis G mm globulins Gl
obulin Hemolytic
dise se of the newborn (HDN) Hist mine Immunity Immunoglobulins Immunology Infec
tion Infl mm tion
Interferons In vitro In vivo L ter l flow immuno ss y Lysozyme M croph ge Mucous
membr nes
N tur l killer (NK) cells Norm l flor P thogens Ph gocytes Ph gocytosis Pus Rho
G m RIA Serology
T cells V ccine IMMUNITY AND IMMUNOLOGY Our bodies re const ntly under tt ck b
y n rmy of
microorg nisms, toxins, llergens nd other subst nces th t re recognized s fo
reign or

nonself. Luckily, our defenses re usu lly ble to protect us from this ongoing t
t ck. The
recognition nd destruction of these foreign subst nces by our bodies re known
s immunity, nd
the study of this process is c lled immunology. Immunity includes numerous prote
ctive mech nisms
within our bodies. In order for these systems to function properly, we must be
ble to detect
wh t is self nd wh t is nonself. When
foreign (or nonself ) inv der is detected,
the
immune process is ctiv ted. A foreign sub- st nce c p ble of initi ting n immu
ne response is
c lled n ntigen. The ntigen m y be microorg nism (such s b cteri or virus
es), n llergen
(such s pollen or d nder), foreign body (such s
sliver), or even c n- ce
rous cell from
within the body. Antibodies re subst nces th t the body produces in response to
cert in
ntigens. The ntibody is designed to tt ch to, or bond with, the specific nti
gen t rgeted.
Antibodies re m de of type of protein c lled globulin, nd bec use they re p
rt of the immune
process, they re known s immunoglobulins. The job of im- munoglobulins is comp
lex, nd includes
tt chment to 1899_Ch23_456-472 22/12/11 12:28 PM P ge 460 nd destruction of th
e inv der, s
well s remembering the unique identity of the ntigen so th t if this inv der c
omes into the
body g in, the body is re dy to tt ck nd destroy much f ster th n it w s t t
he first
exposure. Antibodies seek out nd irreversibly bind to their specific ntigen, r
endering it
ineffective. A gre t de l of rese rch h s been performed on the immune responses
of our bodies.
We re now ble to test for specific ntibodies nd ntigens in the l bor tory,
us- ing blood nd
other body fluids. This re of the l bor - tory m y be known s the Immunology
Dep rtment, but
more commonly it is referred to s the Serology Dep rtment. Serology is the stud
y of ntigen nd
nti- body re ctions in serum, nd m y include methods such s r dio ctive l bor
tory testing,
gglutin tion re ctions, or simplistic tests such s those used to detect pregn
ncy. might ffect
the outcome of the encounter. On the other h nd, the b ttles won with minim l
number of c su lties were those th t employed multiple str tegies, or lines of defense. We w ge
simil r b ttle
in our bodies every d y. The sheer number of foreign subst nces we encounter is
overwhelming. We
need more th n one line of de- fense to defe t the inv ders with minim l h rm to
our- selves. A
he lthy immune system m kes use of three b sic defense mech nisms (Fig. 23-1). T
hese include
mech nic l nd chemic l b rriers, intern l defenses t the site of the inv sion,
nd cquired or
d ptive im- munity cre ted by the body in response to specific ntigen. The f
irst two lines of
defense re nonspecific, nd function in
simil r m nner with ny inv der they
encounter. These

nonspecific mech nisms re protecting us ll from birth or very soon fterw rd.
The third
defensive mech nism, however, is very spe- cific nd is something th t we develo
p throughout our
lives. The First Line of Defense: Nonspecific Mech nic l nd Chemic l B rriers T
he first line of
defense used by our immune system in- cludes mech nic l b rriers, chemic ls, org
nisms th t re
lw ys present in our bodies, nd protective reflexes. The go l of these mech ni
sms is to keep
the inv ders out of our bodies or prevent them from surviving long enough to c u
se ny further
h rm. Int ct skin nd the mucous membr nes of our bod- ies re extremely import
nt bec use they
form physic l or mech nic l b rrier to m ny p thogens nd other types of inv d
ers. Their
secretions lso pl y n import nt role, by djusting the pH to deter growth of m
ost p thogens,
nd by tr pping other inv ders in sticky environment where they c n be destroy
ed or
immobilized. The cili Ch pter 23 Immunology 461 Test Your Knowledge 23-1 How
re ntigens nd
ntibodies rel ted to immunity? (Outcome 23-2) Test Your Knowledge 23-2 Which de
p rtment in the
l bor tory provides testing methods to monitor the immune system? (Outcome 23-2)
THE IMMUNE
PROCESS If youve ever w tched movie bout the Revolution ry W r or Civil W r, i
t is difficult
to see the soldiers m rch forw rd on the b ttlefield in str ight lines g in nd
g in to meet
their enemies. Eventu lly, with gre t de l of effort nd subst nti l losses, t
his method of
comb t Antigens Pollen Foreign objects B cteri C ncerous cells Viruses First li
ne of defense
Mech nic l b rriers Chemic ls Norm l flor Protective reflexes Second line of de
fense
Infl mm tion White blood cells Fever Third line of defense T cells B cells Figur
e 23-1 Flow ch rt
showing the different kinds of immune responses nd their triggers. 1899_Ch23_45
6-472 22/12/11
12:28 PM P ge 461 lining the mucous membr nes const ntly work to sweep out ny t
r pped
subst nces. Reflexes, such s sneezing or coughing, then move these potenti l p
thogens out of
the body. The cidic environment in our stom ch nd the enzymes in s liv lso
ssist with this
first line of de- fense. E rw x protects our e rs, perspir tion helps to flush
w y unw nted
b cteri , nd n enzyme in te rs c lled lysozyme destroys m ny potenti l inv der
s. In ddition to
the protective mech nisms lre dy mentioned, our bodies re popul ted n tur lly
by nu- merous
types of b cteri . Although this might seem to be b d thing, it is ctu lly qu
ite benefici l to
our immune system. The presence of this norm l flor cre tes com- petitive env
ironment in which
most inv ding b cteri c nnot survive. We h ve norm l flor throughout our bodie
s, including in
nd on our skin, in our mouths, nd in our intestin l tr ct. is c lled infl mm t
ion, nd if it is

c used by p thogen, it m y be known s infection. Infl mm tion occurs s res

ult of injury to
or irrit tion of cell. When the cells become irrit ted or injured, they rele s
e hist mine. The
hist mine c uses the blood vessels in the re to dil te, or become l rger. The
blood flow
incre ses to the irrit ted re , nd this c uses the he t nd redness we see nd
feel. Hist mine
lso c uses the blood vessel w lls to become le ky, so more fluid le ks out of the
bloodstre m
into the surrounding injured re , c using swelling. P in is evident bec use the
surrounding
nerve receptors re stimul ted by ll the ctivity. As the blood supply is incre
sed, more
ph gocytes re brought to the re . While doing their job, these cells cre te
lot of debris.
The built-up de d ph gocytes, fluid, p thogens, nd injured blood cells th t cc
umul te re wh t
we recognize s pus. The next symptom we often note in p thogenic in- v sion i
s fever, which
occurs bec use the ph gocytes th t respond to the scene of the injury rele se
chemic l th t
sign ls the br in to incre se the bodys temper ture. The elev tion in temper ture
helps the
second line of defense by decre sing the bility of m ny p thogens to survive,
s well s
stimul ting even more ph gocytosis. As if ll the other ctivity werent enough, p
rotec- tive
proteins lso ssist t the scene of the inv sion. There re two groups of prote
ctive proteins,
known s interferons nd complement proteins. Interferons re secreted by cells
th t h ve been
infected by viruses, nd they help other cells resist the spre d nd replic - ti
on of the virus.
Complement proteins re ble to de- stroy b cteri by covering the surf ce of th
e b cteri l cells
nd punching holes in the cell membr ne, c us- ing the b cteri to die. The l st
component of the
second line of defense is the n tur l killer (NK) cells, which re speci l typ
e of lymphocyte
th t responds to the inv sion. NK cells c n tt ck nd destroy hum n cells th t
h ve been
infected by p thogens. In ddition, n tur l killer cells m y be benefici l by de
stroying cert in
c ncer cells before they c n spre d. The Third Line of Defense: Acquired or Ad p
tive Immunity
Acquired or d ptive immunity is defense mech nism th t requires the body to th
ink bout the
inv ders. It involves three ch r cteristics th t re not present in the first or
second line of
defense. Recognition of n ntigen s nonself must first occur, fter which the
ntigen (inv der) is identified very specific lly. Then the body 462 Section VI Immunology
Test Your
Knowledge 23-3 How does bre k in the skin trigger the first line of defense to
respond?
(Outcome 23-3) Test Your Knowledge 23-4 Are sneezes good thing? Why or why not
? (Outcome 23-3)
The Second Line of Defense: Intern l Nonspecific Response If foreign subst nce
m kes its w y

p st the first line of immune defenses, it will be confronted with w ve of new

defense
mech nisms within the body. These re ll p rt of the intern l nonspecific respo
nse, lso known
s the second line of defense. Included in this rsen l re ph gocytosis, infl m
m tion, fever,
nd n tur l killer cells. This second line of defense is lso known s n tu- r l
or inn te immune
response. When cells re injured, they rele se
chemic l into the bloodstre m t
h t sign ls the
second line of defense to ctiv te. This sign ling is c lled chemot xis, nd it
ttr cts cert in
types of white blood cells to the scene of the inv sion to ct s ph gocytes. Th
e white blood
cells (neutrophils nd monocytes) re speci lly progr mmed to ingest nd destroy
the inv ders.
This process is c lled ph gocytosis. When foreign subst nce h s entered the bo
dy, we often
observe the surrounding re become red, hot, nd swollen. The intern l process
th t c uses this
ppe r nce 1899_Ch23_456-472 22/12/11 12:28 PM P ge 462 forms
memory of th t
ntigen, so it
will be immedi- tely recognized in c se of subsequent exposure. Usu lly this en
tire process
requires 1 to 2 weeks fter the first exposure to
specific ntigen. T cells n
d B cells re
specific lly progr mmed lympho- cytes. They re both p rt of this third level of
the immune
process, but they e ch perform different functions when exposed to n ntigen. T
cells re
involved in cell-medi ted immunity, nd B cells re involved in ntibody-medi te
d immunity, lso
known s humor l immunity. Cell-medi ted immunity begins t the site of the inv
sion (Fig. 23-2).
The T cells become ctiv ted tow rd
specific ntigen when it is presented by
m
croph ge. (A
m croph ge is type of ph gocyte th t le ves the bloodstre m nd goes into the
tissues.) Once
ctiv ted, this T cell cre tes four identic l copies of itself, which ll h ve s
pecific
functions: Killer T cells re produced to kill the ntigens. Helper T cells re
designed to
stimul te other T cells nd help the B cells. Suppressor T cells ( lso known s
regul tory T
cells) re cre ted to inhibit the ctivity of the T nd B cells when enough h ve
been produced.
Memory T cells re responsible for remembering the ntigen for future encounters
, which llows
the cell- medi ted immunity to occur f ster with the next exposure. Most of the
lymphocytes in
our circul tion re T cells. Although no ntibodies re produced by the T cells,
they pl y n
import nt role in m ny cont ct sensitivity re ctions, s well s vir l infection
s, fung l
infections, nd destruction of m lign nt cells. Antibody-medi ted immunity uses
the lymphocytic B
cells (Fig. 23-3). As with the cell-medi ted immunity, the ntigen must first be
exposed, or
introduced, to the B cell by present tion from the m croph ge. The helper T cell
s rele se

chemic l to ssist with this recognition process. Once ctiv ted, the B cell pro
duces two
replic s of itself, which h ve their own duties: Pl sm cells re cre ted th t s
ecrete
ntibodies th t re specific for p rticul r ntigen. These ntibodies Ch pter
23 Immunology
463 Antigens pushed to membr ne surf ce of the m croph ge ( ntigen present tion)
Ingestion of
ntigen (p thogen) by m croph ge T cell T cell ctiv tion Kills ntigens (cell-t
o-cell comb t)
Stimul tes T nd B cells Killer T cell Suppressor T cell Helper T cell Productio
n of clone
Remembers the ntigen for future encounters Memory T cell Inhibits T nd B cells
Figure 23-2
Cell-medi ted immunity. This dr wing represents the T-cell ctiv tion nd the su
bsequent steps,
cre ting four subsets of T cells. 1899_Ch23_456-472 22/12/11 12:28 PM P ge 463 w
ork like
lock
nd key nd c nnot be interch nged with other ntigens. The ntibodies bind to t
he ntigens,
blocking their bility to ffect the cells of the body. Memory B cells form pic
ture of the
ntigen nd remember it for future encounters. HOW IMMUNITY IS ACQUIRED There r
e essenti lly
four w ys we c n cquire immunity: N tur l ctive immunity cquired from n infe
ction with
p thogen: This c uses the body to produce memory of the ntigen nd protects t
he body on 464
Section VI Immunology Antigens presented Ingestion of ntigen (p thogen) by m c
roph ge B cell
Helper T cell Memory B cells Pl sm cells (m ny) Activ tion of B cell nd helper
T cell Form tion
of clone Lymphokine Secrete ntibodies Remeber the ntigen for future encounte
rs Figure 23-3
Antibody-medi ted immunity. B-cell ctiv tion le ds to ntibody cre tion by pl s
m cells. Test
Your Knowledge 23-5 True or F lse: Antigen exposure lw ys triggers ll three li
nes of defense.
(Outcome 23-4) Test Your Knowledge 23-6 Which line of defense is unique tow rd s
pecific
ntigen? (Outcome 23-4) 1899_Ch23_456-472 22/12/11 12:28 PM P ge 464 subsequent
exposures. For
inst nce, n tur l ctive immunity is produced when person is infected with chi
cken pox. Once
the person recovers, he or she is now immune to this p thogen. This is long-te
rm type of
immunity. Artifici l ctive immunity cquired from v ccine: The typic l ntibo
dy response of
our body fter exposure to n ntigen is usu lly too slow to protect us from the
initi l
infection. However, with subsequent exposures, the protection is so f st th t we
never become
ill. V c- cines do this rtifici lly. They cont in n ntigen th t c uses the bo
dy to develop
ntibodies s if it were be- ing exposed for the first time. The v ccine m y be
killed or
we kened p thogen (known s ttenu ted) or it m y just be p rt of p thogen. V
ccines re v ilble for m ny dise ses, such s hep titis A nd B, me sles, nd mumps. The prote
ction is long

term with this type of immunity. N tur l p ssive immunity, such s the ntibodie
s mother
p sses on to n inf nt through the pl cent or through bre st milk: This is
te
mpor ry type of
immu- nity nd f des s the child grows. Artifici l p ssive immunity: This usu l
ly occurs with
the injection of g mm globulins ( rtifici l ntibod- ies). This immunity is shor
t cting, nd
protects the individu l in n emergency situ tion. For ex mple,
f mily member
h s been
di gnosed with hep titis A, but the rest of the f mily is unv ccin ted for th t
dis- e se. The
other f mily members re then injected with n rtifici l ntibody (g mm globulin)
so th t they
will be protected until the infected individu l recovers from the hep titis A in
fection. forms of
utoimmune dise ses, such s rheum toid rthritis. Also, s we ge, our immune s
ystems dont seem
to detect the m lign nt or d m ged cells in our bodies nd destroy them s they
should. This
llows the cells to reproduce nd c use c ncer t higher r te s we ge. In th
e c se of n
llergy, our immune system be- comes hypersensitive fter the initi l exposure t
o n nti- gen.
With subsequent exposures to th t ntigen, the immune response c uses infl mm ti
on nd org n dysfunction. Allergies m y r nge from those with nnoying symptoms (such s h y fev
er) to those th t
re truly life thre tening, such s re ctions to insect stings nd cert in medic
tions. T ble
23-1 provides ex mples of dise ses ssoci ted with the immune system. BLOOD TYPE
S Blood types
lso involve ntigens nd ntibodies, but in different w y. The ntigens th t
determine blood
types re on the surf ce of ll red blood cells. Blood typing lso involves n tu
r l nd cquired
ntibodies in the pl sm . There re sever l situ tions th t might w rr nt
test
for blood type,
including tr nsfusions, testing to prevent he- molytic dise se of the newborn,
nd for
investig tive or forensic re sons. There re hundreds of different nti- gens pr
esent on the red
blood cells of our bodies, ll c p ble of c using tr nsfusion complic tions. For
tu- n tely, most
serious complic tions from tr nsfusions re due to the ABO nd Rh blood groups,
so much of our
testing is focused on those groups. Ch pter 23 Immunology 465 Test Your Knowled
ge 23-7 Wh t does
it me n when we s y th t we re immune to
cert in dise se? (Outcome 23-5) Test Y
our Knowledge
23-8 How do v ccines fool our immune systems? Which line of defense do they t rget
? (Outcome
23-5) POINT OF INTEREST 23-1 V ccines V ccines re used to prevent dise se by in
troducing n
ntigen into the body to induce n immune re- sponse. After the v ccine is proce
ssed by the body,
n- tibodies re cre ted g inst th t specific ntigen. When the p tient is expo
sed g in to the
dise se- c using virus or b cteri , the body immedi tely pro- duces l rge mount
s of ntibody

th t prevent the dise se from developing. The v ccine ntigen m y be ttenu ted,
me ning th t the
ntigen it is killed or we kened. V ccines m y lso include p rts of b cteri or
virus p rticles
th t re c p ble of stimul ting n immune response but not c p ble of c using di
se se. In
ddition, n in ctiv ted toxin produced by the b cteri (c lled toxoid) m y be
used. The
tet nus nd diphtheri v ccin tions re toxoid v ccines. FAILURE OF OUR IMMUNE S
YSTEMS
Unfortun tely, our immune systems dont lw ys work s they should. Sometimes our
bodys bility
to recognize self nd nonself is not fully developed, or is somehow dysfunction
l. In this c se,
our body m y tt ck its own cells, c using d m ge. This is the theory behind m n
y
1899_Ch23_456-472 22/12/11 12:28 PM P ge 465 The ABO blood types include A, B, A
B, nd O, nd
they represent the ntigens present (or bsent) on the red blood cells of n ind
ividu l. If
people h ve
blood type of A, this me ns they h ve the A ntigens on their cell
s. If B ntigens
re present, they re blood type B, nd if both re present, the blood type is k
nown s AB. Type
O m y be thought of s type zero, s it me ns neither A or B ntigens re present
(Fig. 23-4).
The ABO blood typing system is unique, bec use in the pl sm of e ch person ther
e re n tur l
ntibodies to the nti- gens th t re not present on their red blood cells. This
me ns person
with type A blood type h s nti-B n tur lly in his or her pl sm , nd the pl s
m of person
with type B blood will cont in ntibodies to the A ntigen. An individu l who is
type AB h s
neither nti-A nor nti-B in the pl sm , nd type O individu ls n tur lly posses
s both nti-A nd
nti-B in their pl sm . These pl sm ntibodies re cre ted within the first few
months of life
s n immune response to diet ry ntigens nd exposure to v rious environment l
f ctors. When
p tients receive blood tr nsfusions, they gener- lly receive blood product kn
own s p cked red
blood cells r ther th n whole blood. To prep re p cked red blood cells, the unit
of donor blood
is centrifuged so th t the pl sm is sep r ted from the cells, nd most of the p
l sm nd the
white blood cells re sep r ted from the red blood cells. Remov l of the pl sm
voids n
overlo d of fluid for the p tients needing multiple units to incre se their red
blood cell nd
hemoglobin concentr tion. The bsence of white blood cells in the blood product
helps to reduce
the potenti l for n immune response. It is critic l to consider the n tur l nt
ibodies present
in the pl sm if tr nsfusion is needed. Ide lly,
person should only be tr ns
fused with his or
her own blood type. In n emergency situ tion, person m y be given
dif- fere
nt type, but
there re only few ltern tives th t re s fe. If type B person received typ
e A blood, the

n tu- r l nti-A ntibodies would c use the cells to clump ( gglutin te), nd ev
entu lly hemolyze
(rupture). The by-products of this re ction could lso clog the c pill ries in t
he kidneys nd
c use ren l f ilure. Blood type O is known s the univers l donor, bec use there
re no ABO
ntigens on the cells. When type O p cked red blood cells re tr nsfused to
p
tient with ny
other blood type, they re not rejected by the recipient nd the n tur l nti-A
nd nti-B th t
w s present in the pl sm of the donor re not present in the p cked cells to d
m ge the recipients blood cells. Type AB is known s the univers l recip- ient, bec use there r
e no ABO
ntibodies in the pl sm to d m ge ny blood type th t is tr nsfused to these re
- cipients. About
40% of the popul tion is type A, 11% is type B, 45% is type O, nd 4% is type AB
(T ble 23-2).
466 Section VI Immunology TABLE 23-1 Common immune system disorders Cl ssific t
ion Ex mples of
Specific Disorders Hypersensitivity An phyl ctic re ctions, derm titis ( llergy)
or eczem ,
rhinitis, sthm Autoimmune Systemic lupus erythem tosus, disorders type 1 di be
tes, Gr ves
dise se, celi c dise se, my s- theni gr vis, rheum toid rthritis, systemic scl
erosis
M lign ncies of Lymphocytic leukemi s, immune cells lymphom , multiple myelom C
ongenit l immune
Thymic hypopl si , disorders g mm globulinemi Second ry or AIDS, tr nspl nt n
ti-rejection
cquired medic tion use, systemic immunodeficiency infections, side effect of r
di tion
tre tment, overuse of ntibiotics A A A A A A A A A A A A A A A A A A A A A A A
A A A A A B B B B
B B B B B B B B B B B B B B B B B A A A A A A A A A A B A B B B B B B B B B B B
B B B B Anti B
Anti A AB None No ntibodies to A or B Anti A + Anti B Type A Blood type Antigen
s Antibodies in
pl sm Type B Type AB Type O Figure 23-4 V rious blood type ntigens nd ntibod
ies.
1899_Ch23_456-472 22/12/11 12:28 PM P ge 466 Another very import nt red blood ce
ll ntigen is the
Rh or D ntigen. It w s discovered in 1939 with work on rhesus monkeys, hence th
e design tion Rh.
Approxi- m tely 85% of the popul tion h s the D ntigen on their cells, nd they
re known s Rh
positive. Those who dont h ve the Rh (D) ntigen on their cells re known s Rh n
eg tive. Unlike
the ABO blood types, Rh-neg tive individu- ls do not h ve n tur lly occurring R
h ntibodies in
their pl sm . However, they c n be sensitized to this foreign Rh ntigen if expo
sed. This
exposure m y occur with
tr nsfusion error, or it m y occur with preg- n ncy n
d delivery. There
is usu lly no problem evi- dent with the first Rh exposure bec use the ntibody
production t kes
too much time. However, the nti- genic response is very swift nd strong with s
ubsequent
exposures to Rh-positive blood. ERYTHROBLASTOSIS FETALIS Erythrobl stosis fet li
s is severe

hemolytic nemi th t ffects Rh-positive newborns nd occ sion lly other newbor
ns with ABO
incomp tibility. This condi- tion m y lso be known s hemolytic dise se of the
newborn (HDN).
The Rh st tus of the blood cells is only n issue when the b by is Rh positive
nd the mother is
Rh neg tive. During
first pregn ncy, this incomp tibility does not usu lly c u
se h rm to the
b by, s the mothers response to the Rh ntigen does not h ppen quickly enough fo
r the
ntibodies to tt ck the b bys red blood cells. However, during the first pregn n
cy, nd
especi lly during delivery of the b by nd the pl cent , there is n exch nge of
fet l blood with
the mother, nd the mother will become sensi- tized, which me ns th t she will d
evelop ntibodies
to the Rh ntigens on the b bys red blood cells. If she becomes pregn nt g in wi
th n
Rh-positive b by, her ntibodies to the Rh ntigens will destroy the b bys red bl
ood cells nd
the b by m y be born with severe nemi , j undice, nd n enl rged spleen nd li
ver, which m y be
f t l for the newborn. An injection of RhoG m ( nti-Rh g mm globulin) during the
pregn ncy nd
shortly fter delivery should be given to ll Rh-neg tive mothers. This will kee
p the mother from
becoming sensitized to the Rh ntigen so she does not cre te the nti-Rh ntibod
ies. When she
becomes pregn nt g in with n Rh-positive b by, her body will re ct s if this
were her first
exposure, nd the Rh incomp tibility will not be
problem. Ch pter 23 Immunolo
gy 467 TABLE 23-2
Percent ge of v rious blood types in the U.S. popul tion Blood Type Percent ge o
f U.S. Popul tion
A 40% B 11% AB 4% O 45% POINT OF INTEREST 23-2 Kidney tr nspl nts for p tients w
ith incomp tible
blood types M ny potenti l kidney donors re rejected bec use their blood type i
s not comp tible
with th t of the p tients needing kidney. There is now process th t llows p
tients to
receive kidney from
donor with n incomp tible blood type. The n tur l ntib
odies present in
the pl sm of the recipient of
kidney with n incomp tible blood type usu lly
c use the kidney
to be destroyed. The process for ABO-incomp tible kidney tr nspl nt - tion inclu
des procedure
c lled pl sm pheresis. The p tient h s unit of blood removed from his or her b
ody, nd
portion of the liquid pl sm is then removed. After e ch of the pl sm pheresis p
roce- dures, the
p tient will receive repl cement ntibodies th t re necess ry to fight off othe
r infections. The
pro- cedure m y need to be repe ted numerous times, until the level of ABO ntib
ody detected in
the blood is low enough to be considered s fe for the tr nsfusion. Kidney tr nsp
l nt rejection
r tes for this proce- dure re not much different from the r te for p tients who
receive kidneys
of the s me ABO blood type. The p tient will h ve more pl sm pheresis nd rtifi
- ci l ntibody

tre tments fter the tr nspl nt, depend- ing on the individu l needs of the p ti
ent. In ddition,
the recipient m y lso require splenec- tomy, bec use the spleen is the org n
in which the ABO
ntibodies re produced. Test Your Knowledge 23-9 Wh t ntigens re present on t
he blood cells of
n individu l with
blood type of AB positive? (Outcome 23-8) 1899_Ch23_456-472
22/12/11 12:28
PM P ge 467 IMMUNOLOGY TESTING METHODS V rious immunology testing methods re v
il ble for use
in the medic l office s well s hospit l nd reference l b- or tories. They c n
be performed in
vivo (inside
living org nism) s in llergy or tuberculosis testing; n ntige
n is pl ced under
the skin, nd the p tient is monitored for
visible re ction. More often, they
re performed in
vitro (within l bor tory testing environment), where we commonly refer to them
s serology
tests. Serology tests must be specific to the ntigen or nti- body being tested
, nd they must
lso be sensitive enough to detect even sm ll mount of the subst nce in the s
pecimen. M ny
medic tions or other concurrent dise se st tes c n interfere with the specificit
y of cert in
test, nd sometimes c n c use f lse-positive or f lse-neg tive results. The sens
itivity of
testing method c n be ffected by high or low temper tures during shipping or st
or ge, nd lso
by minor errors th t occur during the testing procedures. P ck ge inserts should
be ex mined
c refully for specimen requirements, interfering subst nces, stor- ge nd h ndl
ing directions,
nd testing procedures before performing ny sort of serology testing. All immun
ology tests re
performed to determine the presence of
p rticul r ntibody or ntigen. The spe
ci- men tested
m y be blood, serum, urine, or l fluids, or other body tissues. V rious testing
methods re used,
in- cluding the following: Enzyme-linked immunosorbent ss y tests (ELISA or EIA
) tests usu lly
involve testing surf ce th t is co ted with n ntibody or ntigen bound to n
en- zyme. After
the specimen is dded, if the m tching ntibody or ntigen is present,
color c
h nge will occur
th t c n be re d either by the testing personnel directly or by using n instrum
ent to me sure
the mount of color ch nge. An d pt tion of the EIA principle, l ter l flow immuno ss y is
used in m ny CLIA-w ived tests. The specimen must be bsorbed nd must flow cross
the testing
surf ce to re ch the re imbedded with the ntigen or ntibody. If the test is
positive, the
ntigen/ ntibody complex will c use color ch nge to occur in the testing re
. These tests re
re d directly by the testing personnel, nd h ve built-in qu lity control re
s well.
R dioimmuno ss ys (RIAs) use r dio ctively l beled protein s the indic tor of
positive
result. The ntigen/ ntibody complex formed in specimen th t is positive will
combine with the

r dio ctive protein r ther th n n enzyme s in the EIA method. The fin l result
is obt ined from
the mount of r dio ctivity present in the s mple t the end of the testing proc
ess. These ss ys
re complic ted, nd re performed only by qu lified personnel in hospit l or re
ference
l bor tories. Agglutin tion is the form tion of l rge insoluble ggreg tes (clum
ps) of cells
th t form when n ntigen/ ntibody complex is present. Agglutin tion m y use red
blood cells nd
ntibodies, s in the c se of ABO nd Rh blood typing, or it m y use l tex be ds
, s do some of
the mononucleosis testing pro- cedures. This re ction is re d by the testing per
sonnel directly,
s the complex is visible to the n ked eye. COMMON SEROLOGY TESTS PERFORMED IN R
EFERENCE OR
HOSPITAL LABORATORIES Serology tests m y sh re common methodology, but the compl
exity of the
testing process c n v ry gre tly. The tests mentioned below re usu lly performe
d only in reference or hospit l settings, s they require ddition l tr ining nd/or credenti
ls for the
person performing the test. Testing for ABO/Rh m jor blood ntigen groups uses
gglutin tion
techniques. Screening is lso performed for other common red blood cell ntigens
, nd comp tibility tests re performed on the donor blood when
tr nsfusion workup is n
ecess ry. The
ntistreptolysin O (ASO) test is used to detect ntistreptolysin O ntibodies, w
hich re present
in p tient with prior recent infection by group A strepto- coccus. The identif
ic tion of those
with prior infec- tion is import nt, s group A streptococcus infection c n le d
to other
complic tions such s glomeru- lonephritis, rheum tic fever, nd b cteri l endoc
rdi- tis. The
ASO ntibody m y be present for sever l months fter the initi l infection. Cold
gglutinins
re ntibodies present with cert in types of infections, pneumoni s, c ncers, or
infl m- m tory
utoimmune disorders. These ntibodies c n c use the red blood cells of the body
to clump together when exposed to cold temper tures. This le ds to hemolytic nemi nd oth
er complic tions.
468 Section VI Immunology Test Your Knowledge 23-10 A fellow student just found
out th t she is
expecting b by. Her blood type is A, Rh neg tive. Will she be likely to receiv
e RhoG m
injection? Why? (Outcome 23-8) 1899_Ch23_456-472 22/12/11 12:28 PM P ge 468 The
C-re ctive
protein (CRP) test verifies the pres- ence of th t protein, which is present in
the blood with
cute systemic infl mm tion. It m y be used s p rt of the di gnosis for
speci
fic condition
rel ted to infl mm tion, or to monitor the effectiveness of tre tment. Hep titis
testing
determines which form of vir l hep - titis (A through E) n individu l h s, nd
it m y lso
provide more inform tion bout where n individu l is in the dise se process. Al
though

pregn ncy test c n be performed t home or in

physici n office l bor tory s
CLIA-w ived
test, it is sometimes necess ry to use the more sensi- tive methods th t re v
il ble in
l rger l bor tory. These methods c n sometimes detect pregn ncy sooner th n c n
the CLIA-w ived
tests, nd they c n lso qu ntit te the mount of hum n chorionic gon dotropin (
HCG) present in
the specimen. This qu ntit tive n lysis c n be vit l in the c se of suspected
ectopic
pregn ncy, or in the di gnosis nd tre tment of testicul r c ncer, in which the
hormone is lso
present in the bloodstre m in m le p tients. Rheum toid rthritis is crippling
nd
progressive u- toimmune dise se th t ffects the joints of the body. Those ffl
icted will h ve
the rheum toid f ctor present in their blood, which is unique ntibody used fo
r di gnosis.
The most common tests used to detect syphilis re the r pid pl sm re gin (RPR)
test nd the
venere l dis- e se rese rch l bor tory (VDRL) test. The tests detect the presenc
e of the
microorg nism Treponem p l- lidum, the c us tive gent of syphilis. CLIAWAIVED T
ESTS COMMONLY
PERFORMED IN THE PHYSICIAN OFFICE LABORATORY Tests performed in physici n offi
ce l bor tory re
very import nt for ppropri te di gnosis nd tre tment of v r- ious dise ses, s
the results re
v il ble quickly within the s me office where the p tient is being ex mined. Th
is section covers
these tests, s well s their testing proce- dures, in more det il (T ble 23-3).
Mononucleosis:
Mononucleosis is c used by the Epstein-B rr virus. The test performed for di gno
sis identifies
the presence of the heterophile ntibody produced with this infection,. Pregn nc
y: Pregn ncy
tests determine the presence or bsence of hum n chorionic gon dotropin (HCG) in
urine or serum.
CLIA-w ived tests re qu lit tive in n ture, with positive or neg tive result.
Helicob cter
pylori: H. pylori is the b cterium responsible for m ny g stric nd duoden l ulc
ers nd
g stritis. The test c n be performed on serum nd other body tissues. Ch pter 23
Immunology 469
Test Your Knowledge 23-11 Wh t do ll serology tests h ve in common? (Outcome 23
-9) Test Your
Knowledge 23-12 True or F lse: The s me dise se m y be detected by more th n one
serology test.
(Outcome 23-9) TABLE 23-3 Commonly performed CLIAw ived immunology tests Dise se/
Condition
C us tive Agent Test Performed Required Specimen Mononucleosis Epstein-B rr viru
s Mononucleosis
screen or Blood heterophile test Pregn ncy Hum n chorionic Pregn ncy (HCG) test
Serum or urine
gon dotropin (HCG) H. pylori Helicob cter pylori b cteri H. pylori test Blood o
r tissue s mple
HIV Hum n immunodeficiency virus HIV test Blood, or l fluids Flu Influenz virus
Influenz test
N s l or n soph rynge l sw bs Bl dder c ncer Bl dder tumor ssoci ted ntigen BTA
test Urine

Strep thro t Group A streptococcus b cteri Strep screen Thro t sw b 1899_Ch23_4

56-472 22/12/11
12:28 PM P ge 469 HIV: The hum n immunodeficiency virus screening test checks fo
r the presence
of the ntibodies produced with HIV infection. This is designed to be screenin
g test only, nd
more definitive testing would then be performed on positive s mples before the p
tient would be
deemed HIV positive. V rious body fluids c n be tested for the presence of HIV.
Influenz : The
influenz test is performed during the winter months to detect the presence of i
nfluenz A or B,
which c uses very serious respir tory infection. Bl dder tumor ssoci ted ntig
en: The
screening test for bl dder c ncer uses urine specimen. Group A streptococcus i
nfection: The
screening test for ctive infection with group A streptococcus uses thro t sw
b. The result is
v il ble in minutes fter collection, llowing for much f ster tre tment th n w
s previously
v il ble when only thro t culture w s used. TIME TO REVIEW 1. A subst nce rel
e sed in response
to Outcome 23-1 ntigenic exposure th t c uses blood vessels to dil te is (n):
. Lymphocyte b.
Hist mine c. Interferon d. Chemot xis 2. A(n) _____________________ is Outcome 2
3-1 nything th t
our body recognizes s nonself. 3. How re ntigens nd ntibodies Outcome 23-2
rel ted to
serology testing? 4. Wh t role does our stom ch pl y in Outcome 23-3 protecting
us from ntigens?
. Infl mm tion destroys the p thogens b. The pH of the stom ch cid helps to de
stroy
microorg nisms th t m y m ke their w y into our bodies c. Antibodies re produce
d here to destroy
the in- v ders; white blood cells engulf the ntigens d. The stom ch does not pl
y role in
immunity 5. Wh t is ph gocytosis? Outcome 23-1 . The process by which white blo
od cells engulf
nd destroy p thogens b. The process th t occurs when noncomp tible blood type
is given to
p tient c. A term used to describe the first line of immunity d. The production
of ntibodies 6.
True or F lse: Immunity provided by Outcome 23-5 the mother t birth is lifelong
for m ny
dise ses. 7. True or F lse: Acquired immunity Outcome 23-6 occurs only s cons
equence of
v ccin tions. 8. Wh t is used in v ccin tions to ctiv te Outcome 23-6 our immun
e systems? .
Immunoglobulin b. Killed ( ttenu ted) viruses or p rts of viruses c. Norm l flor
d. B cells 9.
Antibodies to blood type ntigens Outcome 23-8 A or B: . Occur fter exposure t
o nother blood
type b. Are n tur lly occurring nd do not require exposure to develop 470 Secti
on VI Immunology
Test Your Knowledge 23-13 Why might it be benefici l to perform simple serology
tests in the
physici n office inste d of reference or hospit l l bor tory? (Outcome 23-10)
Test Your
Knowledge 23-14 Wh t is the c us tive gent of mononucleosis? (Outcome 23-11) SU
MMARY Our immune

systems re complex nd protect us in v rious w ys. We h ve three b sic mech nis

ms th t inter ct
to provide this protection. They include v r- ious n tur l b rriers, cellul r n
d chemic l
responses to inv ders, nd ntibody form tion. We use v ccin - tions to protect
us by ctiv ting
our immune systems, nd we lso h ve n tur lly occurring ntibodies to ABO blood
types th t re
unlike our own. Blood type ntibodies m y be protective, but they c n lso c use
serious he lth
issues nd must be considered during pregn ncy to protect the unborn child. L bo
r tory testing
for immunity is known s serology. V rious tests re performed in the physici n
office
l bor tory, s well s in hospit l nd reference l bor tories. These tests m y b
e qu lit tive or
qu nti- t tive in n ture, nd re inv lu ble to id in ppropri- te di gnosis o
f numerous
dise se st tes. 1899_Ch23_456-472 22/12/11 12:28 PM P ge 470 c. Do not exist in
the bloodstre m
d. Are h rmless 10. True or F lse: Serology tests use Outcome 23-9 v riety of
testing methods.
11. Which of the following re cronyms Outcome 23-9 for tests used to detect sy
philis infection?
. VDRL nd RPR b. HCG nd IgG c. HET nd RPR d. CRP nd VDRL 12. Doctor Johnson
is bout to
prescribe Outcome 23-9
medic tion to tre t cne for C rly Luc s. This medic ti
on is not dvised
for those who re preg- n nt. Which CLIA-w ived test might the physici n order t
o be sure this
drug is s fe for C rly to t ke? . RPR b. H. pylori c. HCG d. Mononucleosis 13.
True or F lse:
All serology tests Outcome 23-11 performed in physici n office l bor tories requ
ire blood s mples
s the speciment type. RESOURCES AND SUGGESTED READINGS How Your Immune System Wo
rks Another
expl n tion for how the immune system works http://www.he lth.howstuffworks.com/
immunesystem16.htm Overcoming Sensitivity Limit tions of L ter l-Flow Immuno ss ys With
Novel
L beling Technique Inform tion bout v rious medic l devices nd testing methods
http://www.devicelink.com/ivdt/ rchive/ 06/05/010.html Quidel R pid Di gnostic Pr
oducts Links
to the Quidel point-of-c re test kits, including CLIAw ived tests
http://www.quidel.com/products/ product_list.php?c t=1&by=br nd&group=1 Tests W i
ved by the FDA
From J nu ry 2000 to Present List of ll CLIAw ived tests; upd ted regul rly http:
//www.
ccessd t .fd .gov/scripts/cdrh/cfdocs/cfCli /testsw ived.cfm Wh t Does It Me n t
o Be Rh
Neg tive? Further inform tion bout Rh-neg tive immunity issues nd the use of Rh
oG m. This site
h s inform tion for p - tients nd he lth-c re profession ls. http://www.rhog m.
com/
P tient/Wh tRhNeg tiveMe ns/P ges/def ult. spx Ch pter 23 Immunology 471 C se S
tudy 23-1: Could
this be right? Dr. Johnson h s just h nded his medic l ssist nt
req- uisition
form for blood
dr w for Mr. D niels, 22-ye r-old m le. The physici n h s ordered HCG test.
The medical

assistant is surprised, ecause she has only seen HCG tests ordered for females
in the past. She
is sure there is an error, and asks Mr. Daniels to wait a few minutes until she
can confirm the
order with the physician. 1. Is this test an appropriate one for a 22-year-old m
ale? If so, why
might the physician have ordered the test? 1899_Ch23_456-472 22/12/11 12:28 PM P
age 471
1899_Ch23_456-472 22/12/11 12:28 PM Page 472 Chapter 24 Immunological Based Rapi
d Testing
Constance L. Lieseke, CMA (AAMA), MLT, PBT(ASCP) 473 CHAPTER OUTLINE Immunology
Methods and
Procedures Rapid Testing Advantages of Rapid Testing Common Procedural Elements
of Rapid Testing
CLIAWaived Regulations and Their Application to Immunology -Based Rapid Testing C
ommon
CLIAWaived Rapid Tests and Their Clinical Significance Group A Streptococcal Scre
ening
Mononucleosis Testing Pregnancy Testing Helicoacter pylori Testing Influenzas A
and B HIV
Testing Summary Time to Review Case Study Resources and Suggested Readings 24-1
Define the key
terms. 24-2 Analyze the advantages of rapid immunology testing. 24-3 Restate the
common aspects
of various rapid test- ing procedures. 24-4 Descrie potential follow-up testing
procedures that
may e necessary ased on rapid testing results. 24-5 Differentiate the clinical
significance of
strep screens, mononucleosis testing, rapid urine preg- nancy tests, Helicoacte
r pylori testing,
BTA tests, influenzas A and B, and HIV testing. 24-7 Perform CLIA-waived rapid t
esting procedures
for a strep screen, a urine pregnancy test, and a test for mononucleosis. Learni
ng Outcomes After
reading this chapter, the successful student will e ale to: CAAHEP/ABHES STAND
ARDS CAAHEP
Standards I.P.I.15. Perform immunology testing III.P.III.2. Practice Standard Pr
ecautions
III.P.III.3. Select appropriate arrier/personal protective equipment (PPE) for
potentially
infectious situations III.P.III.8. Perform CLIA-waived microiology testing I.C.
I.6. Identify
common pathology related to each ody system III.C.III.10. Identify disease proc
esses that are
indications for CLIA-waived tests ABHES Standards Perform selected CLIA-waived t
ests that
assist with diagnosis and treatment, #6: Kit Testing, a. Pregnancy, . Quick Str
ep Dispose of
Biohazard Materials 1899_Ch24_473-490 22/12/11 12:40 PM Page 473 I ntroduced in
Chapter 23,
immunology is defined as the study of the components of the immune system and th
eir function.
This includes numerous areas of specialty, such as autoimmune disorders, infecti
ous disease,
lood anking, and even tissue typing and organ transplantation. Serology descri
es the area of
the laoratory where antigen-antiody reactions are studied. Serology implies th
at serum is used
for the testing method, ut immunology (or serology) testing performed today doe
s not just use

serum; urine, tissues, whole lood, and other ody fluids may also e used. Immu
nology or
immunoassay testing is per- formed to detect or identify antiodies or antigens
in a specimen.
The testing process may e qualitative, employing a positive or negative result,
or quantitative, employing a numerical result, including varied levels of test complexity.
Diseases such as
mononucle- osis, influenza, and hepatitis may e diagnosed using immunology test
s. antigen or
antiody for that specific disease or condi- tion. If the appropriate counterpar
t (antigen or
anti- ody) is present in the specimen, a reaction will occur. In CLIA-waived im
munology testing
methods, a color change is evident when this reaction takes place. The CLIA-waiv
ed kits use an
asorent memrane that is treated with a chemical additive. Once the specimen a
nd additional
reagents are added to the memrane, a color change will occur, indicating whethe
r the test is
positive or negative. Testing methods that include a color change may e called
chromatographic
or colori- metric assays. When choosing a certain test method, laoratories must
consider whether
the test method demonstrates specificity and sensitivity for the desired sustan
ce. The
specificity of a certain method descries the aility to detect only the sustan
ce that is eing
tested for in the specimen. Testing methods that are not very specific will have
an increased
amount of false-positive test re- sults ecause sustances other than the one de
sired will also
e detected y this method. The sensitivity of a testing method is related to th
e minimum
concentra- tion of the desired sustance that will e detected. Ideally, laorat
ory testing
methods will demonstrate a positive result when a very small amount of the sustance is present
in the specimen so that this presence is not overlooked. 474 Section VI Immunol
ogy Test Your
Knowledge 24-1 How are immunology and serology similar? (Outcome 24-1) IMMUNOLOG
Y METHODS AND
PROCEDURES The majority of the common immunology tests are per- formed to detect
the presence of
a specific antigen or antiody in the specimen. The patients specimen is mixed wi
th the
commercial solution that contains the Test Your Knowledge 24-2 If a test reacts
positively with
the presence of several different antigens, is this descried as a lack of speci
- ficity or a
lack of sensitivity? (Outcome 24-1) KEY TERMS Agglutination Chromatographic Colo
rimetric
Epstein-Barr virus (EBV) Helicoacter pylori (H. pylori) Heterophile antiody Hu
man chorionic
gonadotropin (HCG) Immunology Lateral flow immunoassay Mononucleosis Qualitative
Quantitative
Quantitative HCG Rapid flow immunoassay Sensitivity Serology Specificity Strepto
coccal
pharyngitis 1899_Ch24_473-490 22/12/11 12:40 PM Page 474 Chapter 24 Immunologic
al Based Rapid

Testing 475 RAPID TESTING Rapid testing descries immunology and other laorator
y tests that have
results availale in a very short time. Usually a rapid test can e completed an
d read within 30
minutes. For rapid immunology testing, the most common rapid testing methods use
d are rapid flow
immunoassay procedures and agglutination tests. Rapid flow immunoassay procedure
s are testing
methods in which the specimen and any additional reagents must e asored and fl
ow across the
testing surface efore they can interact with the antigen or antiody present to
display a
result. This type of testing may also e known as lateral flow immunoassay proce
dures. These
testing methods are usually chromatographic, which means that their results are
evident as a
color change on the surface of the testing area. When agglutination testing is p
erformed, the
sample and reagents are mixed on a flat surface designed to al- low full view of
the mixture. The
antiodies and antigens present in the specimen will aggregate (agglutinate) if
they oth are
present. Agglutination is visile as clumps on the testing surface. Common Proce
dural Elements of
Rapid Testing Rapid testing methods differ y manufacturer and y test. However,
there are
similarities that are present no matter what type of test or which manufacturer
is in- volved.
These include the following: Relatively few reagents Small sample volume Detaile
d package
inserts with images to use for result interpretation Qualitative results interpr
eted as
positive or negative Lateral flow immunoassay tests have internal valida- tion i
ndicators that
change color to indicate whether the device is working and the sample and reagen
ts were added
appropriately Testing methods that are timed for completion and usually take 10
minutes or less
to complete Advantages of Rapid Testing Many physician office laoratories perfo
rm rapid testing
so that the health-care provider can otain as much diagnostic information as po
ssile in a short
period of time. This can e especially advantageous when the testing is performe
d efore the
patient leaves the office. Testing in the physician office laoratory allows the
health-care
provider to prescrie medication or other treatment immediately without an addit
ional office
visit or phone call. Immediate results can save time and money for the patient,
and often lead to
etter compli- ance with follow-up care. Large laoratories may also choose to p
erform rapid
testing rather than automated analysis for certain assays. In some situations, t
hese rapid tests
are the most cost- effective way to perform a specific assay. For tests that are
not performed
often, rapid testing kits may also e used to minimize potential waste of outdat
ed reagents and
controls. The CLIA-waived tests may e performed y employees with minimal train
ing, allowing the

laoratory professionals to perform tests of higher complexity. Rapid testing al

lows for the
results to e availale sooner than they might e if the tests were atched (tes
ted together in
large groups) and only performed at certain intervals as they often are in refer
ence or hospital
laoratories. POINT OF INTEREST 24-1 Bladder tumorassociated antigen Bladder tumo
r antigens
(BTA) are produced y lad- der tumor cells and shed into the urine of those ind
i- viduals with
ladder cancer. There are two CLIA- waived rapid tests that are designed to dete
ct the presence
of this antigen in the urine. This test has not een approved as a screening tes
t for ladder
cancer ecause of its low specificity. The BTA test may e positive in the prese
nce of other
disorders of the renal system, such as renal stones, nephritis, renal cancer, ur
inary tract
infections, or recent trauma to the lad- der or urinary tract. The CLIA-waived
rapid screen- ing
test is used for monitoring residual or recurring ladder cancer after treatment
. Positive
results are often followed up with urine cytology, cystoscopy, and examination o
f iopsy samples.
Test Your Knowledge 24-3 Provide two similarities present in most rapid testing
procedures.
(Outcome 24-3) Test Your Knowledge 24-4 List two advantages of rapid testing pro
cedures. (Outcome
24-2) 1899_Ch24_473-490 22/12/11 12:40 PM Page 475 Kits that include all supplie
s needed for
the test, with the exception of personal protective equipment Positive and negat
ive controls
included with each kit CLIAWaived Regulations and Their Application to Immunology
-Based Rapid
Testing Many rapid tests are CLIA-waived procedures. The U.S. Food and Drug Admi
nistration (FDA)
has classi- fied these as simplistic assays with minimal steps and easy-to-inter
pret test
results. However, those rapid methods that require additional specimen preparati
on or multiple
steps in the testing process may e catego- rized as moderately complex y CLIA
standards. For
instance, agglutination tests are relatively simple to perform, ut reading the
results requires
sujective in- terpretation that places agglutination tests in the CLIA moderate
ly complex
category. Some rapid lateral flow immunoassay tests may e CLIA waived if whole
lood is used for
the testing process, ut regarded as moderately complex if plasma or serum is us
ed ecause of the
additional steps required to process the speci- men for the procedure. If the la
oratory where
the testing is performed is authorized to perform only CLIA-waived procedures, i
t is important to
verify whether the testing method is appropriate for the qualifications of the p
ersonnel
performing the test in the facility efore it is used. The vendor should e ale
to verify
whether the test is CLIA waived or of higher complexity, and often the CLIA-waiv
ed tests are la-

eled as such in old letters to avoid confusion. The instructions provided y t

he manufacturer
must e closely followed for all CLIA-waived testing proce- dures, as well as th
ose of moderate
complexity. These instructions will specify the temperature at which the testing
kit should e
stored; the conditions for appro- priate specimen collection, preparation, and s
torage; and the
frequency at which quality control samples should e tested, in addition to the
step-y-step
testing procedure instructions. The package insert will also provide necessary i
nformation to
interpret the test results correctly. COMMON CLIAWAIVED RAPID TESTS AND THEIR CLI
NICAL
SIGNIFICANCE Common immunology-ased CLIA-waived rapid tests include strep scree
ns, pregnancy
tests, tests for the infec- tious mononucleosis, and tests for Helicoacter pylo
ri. CLIA-waived
rapid tests for influenzas A and B and HIV are also availale. Group A Streptoco
ccal Screening
Group A streptococcal infection is a common cause of streptococcal pharyngitis,
more commonly
known as strep throat. Common symptoms of group A strep throat infection include
sore throat,
fever, white or yel- low deposits on the tonsillar area of the throat, swollen g
lands at the
front of the neck, and an asence of cough. It is important to identify patients
with
streptococcal in- fections and treat them appropriately with antiiotics so that
a more serious
secondary disease does not develop. If a patient with pharyngitis has a negative
group A strep
screen ut exhiits additional symptoms, the health-care provider may order a cu
lture specimen to
e set up to verify whether group A strep is present. Group A strep infection ma
y cause
inflammation of the joints, forma- tion of scar tissue on the heart as a complic
ation of endocarditis, or a dangerous kidney condition called glomerulonephritis. A group A
strep screen is
an uncomplicated test that can e completed in less than 10 minutes. A sterile t
hroat swa
(provided in the kit) is used to collect a specimen from the tonsillar area and
ack of the
throat. Following the instructions included in the package insert, single drops
of the kit
reagents are added to the swa, after which the reaction is timed for the approp
riate interval,
usually 5 minutes. The specimen/reagent mixture will travel across the reac- tio
n area of the
kit, and a positive result will e evident within the time frame indicated in th
e manufacturers
insert. The result must e read at the specified time after the addition of the
reagent to the
sample to e valid. Mononucleosis Testing Mononucleosis is an infectious disease
caused y the
Epstein-Barr virus, primarily infecting children and adolescents. It is spread t
hrough saliva,
and is also called the kissing disease. Infectious mononucleosis is 476 Section VI
Immunology

Test Your Knowledge 24-5 What is a possile complication of untreated streptococ

- cal infection?
(Outcome 24-5) 1899_Ch24_473-490 22/12/11 12:40 PM Page 476 Procedure 24-1: Perf
orm a CLIAWaived
Rapid Strep Screening Procedure Rapid strep screens are the most common CLIA- wa
ived test
performed in physician offices. They may also e performed in hospital or refere
nce laoratories.
In addition to patient samples, rapid strep screens may also e used y the micr
oiology
departments in some settings to verify the identity of the growth on a culture s
pecimen. TASK
Perform a rapid strep screen on an appropriate speci- men taken from the throat
of a patient.
CONDITIONS Hand sanitization equipment Gloves Rayon collection swa inoculated w
ith throat
specimen Laoratory coat CLIA-waived rapid strep kit External quality control ma
terials (if
required y manufacturers recommendations or laoratory policy) Timer or watch Co
ntrol log
sheet Test log sheet Manufacturers insert with reference material for reading res
ults
Biohazardous waste container CAAHEP/ABHES STANDARDS CAAHEP Standards I.P.I. Anat
omy and
Physiology, #15 Perform immunol- ogy testing III.P.III. Applied Microiology/In
fection Control,
#2 Practice Standard Precautions, #3 Select appropriate arrier/personal protect
ive equipment
(PPE) for potentially infectious situations, #8 Perform CLIA-waived microiology
testing ABHES
Standards Perform selected CLIA-waived tests that assist with diagnosis and trea
tment, #6: Kit
Testing, . Quick Strep Dispose of Biohazard Materials Procedure Rationale 1. Ve
rify the test
ordered on the requisition form and the identification information on the specim
en lael. 2.
Gather necessary supplies. Verify the expiration date on the kit and the require
d frequency for
the quality control materials. Refer to the manufacturers insert, if necessary, t
o verify the
quality control (QC) frequency recommended for the kit. 3. Wash hands (if they a
re visily
soiled) or apply hand sanitizer. Allow hands to dry completely. The test and ide
ntification on
the specimen lael should e verified every time to avoid erroneous results. Exp
ired kits may not
e used. The manufacturers in- sert will provide minimum frequency for external q
uality control
testing, as well as information aout any internal quality control testing. Each
laoratory may
estalish a unique schedule for QC testing; however, it may not e less frequent
than that recommended y the manufacturer. Clean hands stop the spread of infection. Hands sh
ould e
completely dry efore attempting to ap- ply gloves, or it will e difficult to p
ut the gloves on
the wet hands. Chapter 24 Immunological Based Rapid Testing 477 Continued 1899_
Ch24_473-490
22/12/11 12:40 PM Page 477 most common in those etween the ages of 15 and 25. F
atigue, weakness,

sore throat, headache, fever, and swollen lymph nodes are common symptoms of thi
s infection.
Sometimes the mononucleosis test may e ordered as a heterophile antiody test,
ecause of the
type of antiody produced y the ody when infected with the Epstein-Barr virus.
The
antigen-antiody tests used to diagnose infectious mononucleosis use erythro- cy
tes from sheep,
horse, or cattle cells to interact with the heterophile antiodies. The CLIA-wai
ved mononucleosis
tests demonstrate a positive result when the heterophile antiodies are present
rather than
reacting specifically with the Epstein- Barr virus. This means that false-positi
ve results are
not 478 Section VI Immunology Procedure Rationale 4. If necessary, perform exte
rnal quality
control testing on the test kit. Log the results. Verify whether the kit is perf
orming correctly
efore proceeding. 5. Perform the strep screen test as recommended y the manufa
cturer. 6. Read
the test result at the appropriate time. Test results are invalid after the time
has elapsed, so
they must e read immediately. Use the reference mate- rial included with the ma
nufacturers
insert to inter- pret the results correctly. Record the results on the test log
sheet and/or in a
computer-ased reporting system. 7. Dispose of the throat swa and all testing m
aterials in the
iohazard disposal container. 8. Remove gloves and wash hands. 9. Record the res
ults in the
patients chart, if availale. CLIA-waived kits usually come with external quality
control
testing materials. For those that do not in- clude these materials, they may e
purchased separately. Before patient testing may continue, it is important to verify that the
positive and
negative controls are testing in a valid range. If the controls are out of range
, no patient
testing can e per- formed until the prolem has een identified and solved. Tes
t procedures will
vary. Some kits use a test tue and dipstick, whereas others use a reagent well
that is part of a
test cassette. It is imperative that the instructions for the procedure are foll
owed carefully.
The numer of drops and the timing of the different procedures are very importan
t for accurate
results. The result must e read at the appropriate time for the test to e vali
d. Reading
results too soon or too long after the time interval has elapsed will result in
erroneous
results. The manufacturers inserts will provide a chart to e used for reference
when
interpreting the color development changes for the kit. All supplies should e d
isposed of
properly for infec- tion control reasons. Hands must always e washed after glov
es are removed.
All results need to e charted immediately for the health-care provider to take
appropriate
action. Procedure 24-1: Perform a CLIAWaived Rapid Strep Screening Procedurecontd D
ate

2/20/2014: Rapid strep screen performed. Results negative

2:00 p.m.
Connie Lieseke, CMA(AAMA) 1899_Ch24_473-490 22/12/11 12:40 PM Page 478 u
ncommon. Patients
with lupus or lymphoma may also have heterophile antiodies present in their spe
cimen, even
though they do not have infectious mononucleosis. The CLIA-waived tests may resu
lt in a
false-negative result for young children ecause they often do not create het- e
rophile
antiodies even when infected with the Epstein- Barr virus. Because the symptoms
of infectious
mononucleosis are very similar to those of streptococcal pharyngitis, the health
-care provider
may order a throat swa collection for a group A strep screen to e collected at
the same time
that the sample is otained for the mononucleosis test. Procedure 24-2 explains
the testing
process for a CLIA-waived mononucleosis test. Pregnancy Testing CLIA-waived test
s for pregnancy
are designed to react in the presence of human chorionic gonadotropin (HCG), a h
ormone that is
found in urine or lood during pregnancy. The developing placenta secretes HCG,
and most rapid
test kits can detect the presence in the urine or lood just a few days after co
nception.
CLIA-waived HCG tests provide a qualitative positive or negative result. Procedu
re 24-3 explains
how to perform a CLIA-waived pregnancy test in more detail. Chapter 24 Immunolo
gical Based Rapid
Testing 479 POINT OF INTEREST 24-2 RSV Respiratory syncytial virus (RSV) is a vi
rus that affects the respiratory system. In most cases, an infected individual will recover
from this virus
within 2 weeks of infection. However, some populations are severely ill with RSV
infection. Some
infants, young children, and older adults (over the age of 60) may e at risk fo
r serious
infection. In the United States, RSV is the most common cause of the inflammatio
n of the small
airways in the lung (also known as viral ronchiolitis) and pneumonia in infants
younger than 1
year of age. Recent studies have also linked an increase in cases of severe resp
iratory illness
in the older population to RSV infection. There are rapid tests availale for id
entification of
RSV infection in respiratory specimens. Viral cultures are also commonly perform
ed. RSV is
especially sensi- tive to changes in temperature in the laoratory, which means
that it may e
expressed as a false-negative result if the specimen is not handled correctly. O
lder children and
adults may need a lood test performed, as they historically have low viral leve
ls present in the
respira- tory specimens. Infectious mononucleosis is diagnosed using laoratory
data and clinical
symptoms of sore throat, fever, and swollen lymph glands. A positive laoratory
test indi- cates

the presence of heterophile antiodies, which are present with the Epstein-Barr
virus infection
in most patients with acute infectious mononucleosis. TASK Perform mononucleosis
testing using
the CLIA-waived OSOM mononucleosis testing kit, manufactured y Genzyme. CONDITI
ONS Hand
sanitization supplies Gloves Completed patient requisition form and patient char
t
Appropriate venipuncture supplies if a venous lood sample is to e used. EDTA o
r heparinized
lood samples are acceptale. Supplies included in the test kit Test stick Test
tue
Diluent Positive and negative control material Workstation Capillary tues and 
ul for
capillary lood samples Timer or watch Biohazardous disposal container Biohazard
ous sharps
container Procedure 24-2: CLIAWaived Mononucleosis Testing Using an OSOM Mononucl
eosis Testing
Kit Continued 1899_Ch24_473-490 22/12/11 12:40 PM Page 479 480 Section VI Immun
ology Note: This
test may e performed using a capillary lood sample or a sample otained throug
h venipunc- ture.
Be certain to have the necessary supplies availale for the method used for samp
le collection, as
well as a iohazardous sharps disposal container and gloves. Either EDTA or hepa
rin is an
appropriate additive for venous samples for the OSOM mononucleosis test. CAAHEP/
ABHES STANDARDS
CAAHEP Standards I.P.I. Anatomy and Physiology, #15 Perform immunol- ogy testing
III.P.III.
Applied Microiology/Infection Control, #2 Practice Standard Precautions, #3 Se
lect appropriate
arrier/personal protective equipment (PPE) for potentially infectious situation
s ABHES Standards
Perform selected CLIA-waived tests that assist with diagnosis and treatment, #4
Immunology, #6
Kit Testing Dispose of Biohazardous Materials Procedure 24-2: CLIAWaived Mononucl
eosis Testing
Using an OSOM Mononucleosis Testing Kitcontd 1. Verify test ordered on requisition
. Greet and
then identify patient. 2. Sanitize hands, allow them to dry, and apply gloves. 3
. Gather
necessary supplies. The requisition form should always e examined to e certain
which test is
ordered, and the patient iden- tity must always e verified efore proceeding. G
loves protect the
hands from exposure to potential loodorne pathogens. Gloves should always e a
pplied in the
presence of the patient. Supplies must e within reach efore staring the proces
s so that the
timing of the testing is accurate. Courtesy of Genzyme Corporation. Procedure Ra
tionale
1899_Ch24_473-490 22/12/11 12:40 PM Page 480 Chapter 24 Immunological Based Rap
id Testing 481 4.
Verify whether quality control (QC) testing needs to e performed on the kit. If
so, perform QC
test- ing and verify validity of results efore proceeding with patient testing.
5. Determine the
method to e used for specimen collection. Collect the sample using appropriate
techniques. a. If

a capillary sample is to e tested, use the cap- illary tue and ul supplied w
ith the test kit.
Follow appropriate procedures to fill the pro- vided capillary tue with lood.
. Blood otained
through venipuncture is acceptale, as long as it is collected into a tue conta
ining EDTA or
heparin. 6. Add the sample to the test tue. 7. Add one drop of diluent to the 
ottom of the test
tue. Mix the diluent with the sample y gently moving the tue from side to sid
e. 8. Remove a
test stick from the container, and imme- diately recap the container. 9. Place t
he asorent
(testing) end of the test strip into the sample/diluent mixture in the ottom of
the tue and
leave the strip in place. 10. Set a timer (or note the time on a watch) for 5 mi
nutes. The
frequency of the QC testing is ased on the man- ufacturers and individual laora
tory recommendations. Minimum recommendations from the Genzyme Corporation are that the posit
ive and negative
QC should e run with each new lot numer and each new untrained operator. If th
e quality control
results are not within the esta- lished range, patient testing cannot e perfor
med until the
prolem has een solved. Capillary or venous whole lood may e used for this te
sting procedure.
The capillary sample is the most common method of testing used in the physician
office
laoratory. Always follow appropriate venipuncture collection procedures. For ca
pillary samples,
use the ul provided to add the entire contents of the capillary tue to the te
st tue. If a
venous sample is to e tested, add one drop to the test tue, using the transfer
pipettes
included in the test kit. Samples must e at room temperature at the time of tes
ting. Slowly add
the diluent so that it goes to the ottom of the test tue. The test sticks must
not e exposed
to moisture. The container must not e left uncapped for an extended period of t
ime. One end of
the test strip is asorent, and the other end is designed to e handled during
the testing
procedure. The test result is to e read at 5 minutes. Positive re- sults may e
read earlier, as
long as the red control line is present. Procedure Rationale Continued 1899_Ch24
_473-490 22/12/11
12:40 PM Page 481 In some situations, the HCG level in the lood or urine is not
elevated enough
to e detected y the rapid test procedure. This may e the case very early in p
reg- nancy when
the placenta has not had an opportunity to secrete enough of the hormone for the
test to e
positive. When a woman has an ectopic pregnancy, the hormone levels may never e
elevated enough
to pro- duce a positive rapid test. In this situation, the health- care provider
may order a
quantitative HCG test, which provides a numer representing the level of hormone
present in the
lood. If the quantitative HCG result does not increase over time, the pregnancy
is usually not

viale. In a normal pregnancy, the HCG levels should continue to increase until
approximately 3
months of gestation, at which time they will start to decline through the rest o
f the pregnancy.
Helicoacter pylori Testing In 1982, it was discovered that most duodenal ulcers
and many gastric
ulcers were caused y a previously unknown acteria, Helicoacter pylori. Until
then, it was
elieved that ulcers were caused y stress, lifestyle, and food choices. Medicat
ions that reduced
the produc- tion of stomach acid were often used to heal these ulcers, 482 Secti
on VI Immunology
Procedure Rationale 11. At 5 minutes, oserve the test stick for the test result
s. a. If a lue
line and the red control line are pres- ent, the test result is interpreted as a
positive. . If
the red control line is present, ut no lue line is evident, the test is interp
reted as a negative result. c. If there is no red control line or if the ack- ground in the te
sting area is not
clear (white), the test is considered to e invalid, and must e repeated. 12. M
ake note of the
test result. 13. Discard the pipette or capillary tue, testing strip, and test
tue in the
iohazardous disposal container. 14. Sanitize the work area and put away supplie
s. 15. Remove
gloves and sanitize hands. 16. Document the test results in the patients chart. I
t is important
to pay close attention to the test stick to interpret the results appropriately.
The red control
line must always e visile for the test to e valid. Results are not to e repo
rted as invalid.
This is an in- dication that the test must e repeated with careful attention to
the procedure.
Quality control material should also e used to verify the performance of the te
st kit. It is not
appropriate to chart the result while still wear- ing gloves that may e potenti
ally
contaminated. Because lood was used in the testing procedure, all contaminated
material must e
disposed of as io- hazardous sustances. The testing kit may e stored at room
temperature.
Follow laoratory protocol for storage of any un- used specimens. Hands must alw
ays e sanitized
after removing gloves. All results must e documented in the patients chart. Proc
edure 24-2:
CLIAWaived Mononucleosis Testing Using an OSOM Mononucleosis Testing Kitcontd Date
04/18/2013:
Mono test performed from capillary puncture. Results negative
11:33 a.m.
Connie Lieseke, CMA (AAMA) 1899_Ch24_473-490 22/12/11 12:40 PM Page 482
Chapter 24
Immunological Based Rapid Testing 483 Human chorionic gonadotropin (HCG) is secr
eted y the
placenta shortly after implantation of a fertilized ovum. It may e detected in
the urine
specimen 7 to 10 days after conception, which may e as early as the first day o
f a missed

menstrual period. TASK Perform urine HCG testing using the Beckman Coul- ter Ico
n 25 testing kit,
and record the results appropri- ately. Complete all steps within 10 minutes. CO
NDITIONS Hand
sanitization supplies Gloves Completed patient requisition form and patient char
t Supplies
contained in test kit Test devices Disposale transfer pipettes Commercial quali
ty control
material Timer or watch Urine specimen collected in clean container Biohazardous
disposal
container Biohazardous sharps container 1. Verify test ordered on requisition. G
reet and then
identify patient if present for collection. 2. Sanitize hands, allow them to dry
, and apply
gloves. Note: The HCG test kit may e used for urine testing or serum testing. T
he test is only
CLIAwaived when performed using urine samples. CAAHEP/ABHES STANDARDS CAAHEP Stan
dards I.P.I.
Anatomy and Physiology, #15 Perform immunology testing III.P.III. Applied Micro
iology/Infection
Con- trol, #2 Practice Standard Precautions I#3 Select appropriate arrier/perso
nal protective
equipment (PPE) for potentially infectious situations ABHES Standards Perform se
lected
CLIA-waived tests that assist with diagnosis and treatment, #6 Kit Testing, a. P
regnancy
Dispose of Biohazardous Materials The requisition form should always e examined
to e certain
which test is ordered, and the patient identity must always e verified efore p
roceeding. Gloves
protect the hands from exposure to potential loodorne pathogens. Gloves should
always e
applied in the presence of the patient. Procedure 24-3: CLIAWaived Urine HCG Test
ing Using the
Beckman Coulter Icon 25 Testing Kit Procedure Rationale Continued ut recurrence
was common once
the treatment ended. In 1982, pathologist Roin Warren discovered that at least
50% of the
iopsies examined from ulcer patients exhiited small, curved acteria in the ar
ea of inflammation. Together with his partner, Barry Marshall, Warren provided evidence that t
hese ulcers were
caused y the acteria he had oserved and that the ulcers could e eradicated (
without
recurrence) with antiiotics and medication to reduce the acidity of the stomach
. The acteria
cause inflammation and weaken the stomach lining, allowing stomach acids and ac
teria to
penetrate the layers and cause a hole or ulcer. There are now numerous CLIA-waiv
ed rapid tests
availale to detect the presence of H. pylori. This ac- terium is unique, as it
has een
isolated only from humans. It is thought that the transmission usually 1899_Ch24
_473-490 22/12/11
12:40 PM Page 483 484 Section VI Immunology Procedure Rationale 3. Gather neces
sary supplies.
Supplies and samples must e at room temperature for valid test results. 4. Veri
fy whether
quality control (QC) testing needs to e performed. If so, perform QC testing an
d verify validity

of results efore proceeding with patient testing. 5. Examine the urine specimen
. If it appears
cloudy, centrifuge the specimen efore testing. 6. Remove the test device from t
he wrapper just
prior to use. 7. Place the test device on a flat stale surface. Place three dro
ps of urine in
the sample well (marked with an S) using the supplied transfer pipette. 8. Set t
he timer (or note
the time on a watch) to 3 minutes. Supplies must e within reach efore staring
the process so
that the timing of the testing is accurate. The frequency of the QC testing is 
ased on the manufacturers and individual laoratory recommenda- tions. The package insert for th
is testing
procedure does not specify a minimum frequency for quality control testing. Exce
ssive particulate
matter needs to e removed from the specimen through centrifugation to ensure va
lid test results.
The specimen should e collected in a clean container. The test device should no
t e exposed to
room air (and potential exposure to moisture) for an extended period efore use,
as this may lead
to an invalid test result. Avoid formation of air ules in the specimen during
application. The
sample results are not valid efore 3 minutes have elapsed. Procedure 24-3: CLIAW
aived Urine HCG
Testing Using the Beckman Coulter Icon 25 Testing Kitcontd Courtesy of Beckman Cou
lter.
1899_Ch24_473-490 22/12/11 12:40 PM Page 484 Procedure Rationale Date 04/23/2013
: Urine HCG test
performed. Results positive. Physician notified.
1:15 p.m.
Connie Lieseke, CMA (AAMA) 9. At 3 minutes, oserve the reaction area fo
r the presence of red
lines. a. A red line in the Control area in addition to the Test area is to e i
nterpreted as a
positive result. . A red line in the Control area without the pres- ence of a r
ed line in the
Test area is to e inter- preted as a negative result. c. If there is no red lin
e in the Control
area, the result is not valid, and the test must e repeated. 10. Make note of t
he test result.
11. Discard the testing device and transfer pipette into the iohazardous trash.
12. Put away the
test kit, and store the specimen according to laoratory protocol. 13. Sanitize
the work area.
14. Remove gloves and sanitize hands. 15. Document the test results in the patie
nts chart. The
test results need to e read precisely at 3 minutes. A delay in reading the resu
lts may allow for
slight color development to occur, which may e erroneously interpreted as a pos
itive result. To
e a valid test, there must always e a red line in the Control area at three mi
nutes. Look
carefully at the Test area efore reporting a result. Invalid tests are not to 
e reported as
such; this is an in- dication that the test must e repeated with partic- ular a
ttention to

procedural details. Quality control material should also e used to verify the p
erform- ance of
the test kit. It is not yet appropriate to chart the result, as the oper- ator i
s still wearing
gloves that may e potentially contaminated. The testing supplies were exposed t
o urine. The test
kit may e stored at room temperature. The work area must always e sanitized e
fore proceed- ing
to other tasks. Hands must always e sanitized after removing gloves. All result
s must e
documented in the patients chart. Courtesy of Beckman Coulter. Chapter 24 Immuno
logical Based
Rapid Testing 485 1899_Ch24_473-490 22/12/11 12:40 PM Page 485 occurs early in l
ife and that the
microorganism is pro - aly passed directly from one person to another. The mos
t common specimen
used for H. pylori testing is whole lood, ut there are also CLIA-waived kits a
vail- ale for
testing gastric iopsy specimens. Serum, plasma, and stool specimens may also e
tested.
Influenzas A and B The Centers for Disease Control and Prevention (CDC) estimate
s that every year
5% to 20% of the U.S. popu- lation comes down with the seasonal flu. More than 2
00,000 people are
hospitalized with complications of this infection, and it leads to at least 36,0
00 deaths each
year. Influenza flu viruses cause the flu. There are three types of human flu vi
ruses, ut only A
and B are of clinical significance. Symptoms of the flu include fever, ody ache
s, dry cough,
headache, and sore throat. The duration of the symptoms may vary, ut for many i
ndividuals the
recovery time is a week or more. Human influenza C causes mild upper respiratory
symptoms and is
not vaccinated against. Yearly vaccination is rec- ommended for the majority of
the population
against influenzas A and B. Laoratory testing for identification and treatment
of the flu virus
is not always necessary. Many times the health-care professional will diagnose t
he patient with
seasonal flu ased on a clinical examination, and prescrie rest and symptomatic
treatment.
However, in situations in which the patient has other complicating factors (such
as asthma, heart
disease, or low immunity) it may e necessary to verify whether the patient is i
n- fected with
influenza A or influenza B so that antiviral medications may e administered. La
oratory testing
may also e indicated if the patient is living in a con- trolled, confined envir
onment (such as a
long-term care facility) so that the spread of the virus can e controlled with
isolation of the
patient and administration of antiviral medication. Influenza cultures will prov
ide detailed,
specific in- formation aout the virus if it is present, ut a culture result wi
ll usually take 3
to 10 days to e finalized, during which time the patient may e spreading the v
irus to others.
Rapid CLIA-waived tests are a etter option for the initial influenza screening,
as the results

are usually availale within 15 minutes after collec- tion. Examples of CLIA-wai
ved tests include
Quick Vue and BinaxNOW. Many times the symptoms of the seasonal flu may mimic th
ose of acterial
infections. Identification of the flu virus through rapid testing methods will a
lso eliminate the
use of unneeded antiiotics when acter- ial infection is not present. All CLIAwaived testing
methods, as well as the rapid tests that have een cate- gorized as moderately c
omplex use
nasopharyngeal swas for influenzas A and B. Nasal swas, nasal rinses, or nasal
aspirates may
also e acceptale for some test- ing methods. Ideally, the specimen will e col
lected 3 to 4
days after infection is suspected. A viral culture may e indicated when an unex
pected negative
result is encountered, especially in situations in which the prevalence of the v
irus in the
community is high. Blood testing may also e performed, using a method called re
verse
transcription polymerase chain reaction. This method is very sensitive and speci
fic to the virus,
and may allow for differentiation of variant strains present in the population.
486 Section VI
Immunology Test Your Knowledge 24-6 True or False: The presence of Helicoacter
pylori in the
stomach is linked to an infection of the lungs with the same acteria. (Outcome
24-5) Test Your
Knowledge 24-7 When may a viral culture e indicated after a rapid influenza tes
t is performed?
(Outcome 24-4) HIV Testing Approximately one individual out of every five infect
ed with HIV is
unaware of his or her positive status, accord- ing to the CDC. It is also estima
ted that there
are ap- proximately 40,000 new individuals infected y HIV an- nually in the Uni
ted States.
Historically, many of the individuals tested did not return to the health-care p
rovider to
receive their HIV results, so they were not treated appropriately, and continued
to potentially
spread the disease. In 2004, the FDA approved several rapid testing kits to e u
sed for HIV
testing. This development was signif- icant ecause it facilitated access to ear
ly diagnosis and
treatment. The patient is now ale to visit a health-care provider for pretest c
ounseling and
have the test run while waiting for the results. Before leaving the office, the
patient will e
provided with a result (although pos- itive results are considered to e prelimi
nary). The patient is also given information aout appropriate inter- pretation of their HIV
status and
instructions efore 1899_Ch24_473-490 22/12/11 12:40 PM Page 486 they leave. Onl
y patients with a
preliminary positive HIV screening test are required to return for their con- fi
rmatory results.
There are currently four CLIA-waived test procedures availale for HIV testing:
1. OraQuick
ADVANCED HIV-1/2 Antiody Test, y Orasure Technologies 2. Uni-Gold Recomigen H
IV Test, y

Trinity BioTech 3. Clearview HIV 1/2 Stat-Pak, y Inverness Profes- sional Diagn
ostics 4.
Clearview Complete HIV 1/2, also y Inverness Pro- fessional Diagnostics All fou
r are CLIA waived
for whole lood testing from capillary or venous samples. Several may also e mo
derately complex
if serum or plasma is used for the test procedure. The OraQuick and Clearview me
thods are capale
of detecting two strains of HIV. HIV-1 is the most common strain worldwide, ut
an additional
strain (HIV-2) has een identified, especially in West Africa. It is important t
o rememer that
any presumptive positive HIV rapid test result must e confirmed with a western
lotting test or
a immunofluorescent assay efore the patient is considered HIV positive. The new
est CLIA-waived
testing procedure for HIV (OraQuick) uses a sample of oral mucosal transudate ra
ther than lood.
Oral mucosal transudate is the fluid from the gums and cheek tissue. This method
can ene- fit
those patients who are reluctant to have their lood drawn for the test. The sam
ple is otained
y handing the patient a special collection paddle and having him or her place it
for a few
seconds etween the cheek and gum, after which it is rued over the gum area in
the mouth. The
end of the paddle that contains the speci- men is then placed in a tue that con
tains the reagent
for the test. If HIV antiodies are present in the sample, the reaction indicato
r on the paddle
will demonstrate a pos- itive result after 20 minutes. If the CLIA-waived rapid
test is positive,
another oral fluid specimen or a lood specimen must e collected for the confir
matory test.
Negative test results are interpreted as a negative result for current HIV infec
tion. Although
some of the processes involved in the rapid HIV testing procedures may vary, ec
ause a positive
HIV test result is clinically significant, all rapid HIV testing procedures incl
ude specific
federal requirements: 1. All patients must receive an information sheet (in- clu
ded with the
testing kit) that explains HIV/AIDS, the testing process, and what the results m
ean, and provides
information aout the confirmation of pos- itive results. Patients also sign a c
onsent form
efore testing. 2. Quality control (QC) testing (positive and negative control s
amples) must e
performed as directed. This includes QC testing whenever a new operator uses the
test kit (prior
to testing patient samples), whenever a new lot goes into use, and whenever a ne
w shipment is
received (even if it is the same lot numer). Quality control testing must also
e per- formed if
the storage temperature drops elow 35F or rises aove 80F, or if the testing envi
ronment drops
elow 59F or rises aove 99F. Each laora- tory will also specify additional testi
ng intervals
for quality control. SUMMARY Immunologic-ased rapid testing methods are com- mo
nly used as

diagnostic tools for various diseases. The tests will identify the presence of a
ntigens or
antiodies present in whole lood or other ody flu- ids. Many of the rapid test
ing procedures
are CLIA- waived lateral flow immunoassays that indicate a positive result throu
gh a color change
on the result area of the kit. Some of the rapid tests are used for confirmative
diagnostic
information so that the patient can e treated appropriately as soon as possile
, whereas others
may e used as an initial screening test or to follow up after disease treatment
. Additional
testing procedures are sometimes warranted once the rapid testing procedures are
complete. The
manufacturers insert for the CLIA- waived rapid tests must always e followed clo
sely to avoid
erroneous results or invalid tests. TIME TO REVIEW 1. If a test result is report
ed as positive
Outcome 24-1 or negative, the test is __________________. a. Qualitative . Quan
titative Chapter
24 Immunological Based Rapid Testing 487 Test Your Knowledge 24-8 What is an ad
vantage of rapid
HIV testing? (Outcome 24-4) 1899_Ch24_473-490 22/12/11 12:40 PM Page 487 2. How
do rapid testing
methods save Outcome 24-2 money for patients? a. Fewer office visits . Inexpens
ive testing
methods c. Less expensive antiiotics d. a and  3. If a rapid test for HIV is p
ositive, Outcome
24-4 what is the required follow-up testing procedure? a. HIV culture . AIDS te
st c.
Immunofluorescent assay or western lot test d. Neutrophil lood count 4. True o
r False: A
negative urine Outcome 24-5 HCG test always means that the patient is not pregna
nt. 5. When
performing a group Outcome 24-6 A strep screen, where should the sample e colle
cted from the
patient? a. Tonsillar area and the ack of the throat . Tonsillar area and the
tongue c. Gum
line d. Nasopharynx 6. How is an infection of Outcome 24-5 Helicoacter pylori t
reated? a.
Surgical correction . Antiseptic suppositories c. Antiiotics and acid reducing
medications d.
None of the aove 7. Which of these may e an order Outcome 24-5 for a mononucle
osis test? a. BTA
. Influenza A c. Heterophile d. GAS 488 Section VI Immunology Case Study 24-1:
CLIA-waived
testing procedures James works as a float medical assistant at Briarcreek Medical
Center. Today
he has een assigned to work in the laoratory area at the usy ostetric/gyneco
logy office of
Dr. Stanton. The first patient of the day has a requisition with an FSH and a LH
ordered, which
oth require serum for processing. James draws two tiger top tues, thanks the p
atient, and
cleans up his work area. Right after the patient leaves, Dr. Stanton tells James
that he would
also like a STAT pregnancy test to e performed on this patient. 1. Is it possi
le for James to
perform a STAT HCG test on the specimen that he has in the laoratory? 2. What m
ay keep James

from performing the test? RESOURCES AND SUGGESTED READINGS Tests Granted Waived S
tatus under
CLIA https://www.cms. gov/CLIA/downloads/waivetl.pdf Helicoacter pylori Fact She
et for Health
Care Providers Information aout Helicoacter pylori infection and treat- ment
http://www.cdc.gov/ulcer/files/hpfacts.PDF Getting Tested San Francisco AIDS Found
ation, HIV
Testing http://www.sfaf.org/aids101/hiv_testing.html#urine Evaluation of Rapid Inf
luenza
Diagnostic Tests for Detection of Novel Influenza A (H1N1) VirusUnited States, 20
09 CDC
Moridity and Mortality Weekly Report, August 8, 2009 http://www.cdc.gov/mmwr/pr
eview/mmwrhtml/
mm5830a2.htm 1899_Ch24_473-490 22/12/11 12:40 PM Page 488 Section VI Immunology
What Does It All
Mean? As this section clearly points out, immunology is an important aspect of l
aoratory testing
that spans all of the other laoratory disciplines. Immunologic connec- tions ar
e often
associated with advances, new discov- eries, and findings in the field of medici
ne. Perhaps the
most important concept in immunology testing is antigen-antiody complexes, that
is, when
antiodies targeted against specific antigens find them and ind together. Visua
lization of these
complexes, as seen in the laoratory, is known as agglutination. Case in Point I
t was noted in
the case of little P.J. that his strep screen test was negative, meanng that no
agglutina- tion
was seen. Most strep screen tests are designed to detect group A streptococci an
tigens when present. A negative test indicates that the antigens eing sought were not present.
Because throat
infections of this type may e caused y other acterial or viral agents, the e
st step to take
at this juncture is to su- mit a new, fresh specimen to the laoratory for micr
o- ial culture.
Note that, in this case, if the strep screen was sumitted to a clinical laorat
ory, it would
likely e performed either in the microiology area, e- cause the test is looki
ng for a
microiological agent or in a section dedicated to immunologic testing. The loca
tion of such
tests eing performed depends on the organization of the laoratory. Rapid tests
such as the
strep screen have revolutionized laoratory testing in terms of time and resourc
es. In the case
of strep screen results, what used to take 48 hours or more to complete is now a
vailale in aout
10 min- utes. Furthermore, ecause some of the rapid tests have een deemed CLIA
-waived , trained
medical assistants and other primary health-care providers can perform these tes
ts in a physician
office setting. 489 1899_Ch24_473-490 22/12/11 12:40 PM Page 489 1899_Ch24_473-4
90 22/12/11 12:40
PM Page 490 491 Appendix A Reference Ranges Reference Ranges for Glucose Testing
Results Fasting
plasma glucose 70100 mg/dL 2-hr PP glucose Less than 140 mg/dL Glycosylated hemog
loin (HA1c)
Nondiaetic 5% Diaetes, well controlled 2.5%6% Diaetes, well controlled >8% Fro

m the American
Diaetes Association. Reference Ranges of Common Chemical Analytes (listed alpha
etically)
Alanine aminotransferase (ALT) 1035 U/L Alumin (Al) 3.55 g/dL Alkaline phosphata
se (ALP)
42136 U/L Amylase 3070 U/L Aspartate aminotransferase (AST) 035 U/L Biliruin, tota
l (TBili)
0.31 mg/dL Blood urea nitrogen (BUN) 1020 mg/dL Brain natriuretic peptide (BNP) 010
0 ng/L
Calcium (Ca) 8.210.5 mg/dL Caron dioxide (CO 2 ) 2230 mEq/L Chloride (Cl) 96106 mE
q/L
Cholesterol, total (Chol) Less than 200 mg/dL Creatine kinase (CK), aka 55170 U/L
Creatine
Phosphokinase (CPK) Creatinine (Creat) 0.61.2 mg/dL Erythropoietin 535 IU/L Ferrit
in, adult
10150 ng/mL High-density lipoprotein (HDL) Greater than 50 mg/dL Iron, serum adul
t 35165 mcg/dL
Lactate dehydrogenase 100190 U/L (LD, LDH) Reference Ranges of Common Chemical An
alytes (listed
alphaetically)contd Low-density lipoprotein (LDL) Less than 100 mg/dL Magnesium 1
.62.2 mg/dL
Myogloin Less than 90 g/L Potassium (K) 3.55.0 mEq/L Phosphorus, adult 2.54.5 mEq/
dL
Phosphorus, child 4.56.5 mg/dL Sodium (Na) 136145 mEq/L Thyroid-stimulating hormon
e (TSH)
0.44.2 U/mL Thyroxine (T4) 4.511.2 g/dL Triglyceride (Trig) Less than 150 mg/dL
Triiodothyronine (T3) 75220 ng/dL Reference Ranges for Urine Tests Appearance and
color Clear;
straw to yellow in color pH 4.68.0 Protein 28 mg/dL (negative to trace) Specific g
ravity
1.0051.030 Leukocyte esterase Negative Nitrite Negative Glucose Negative Ketones
Negative
Leukocytes Negative Blood Negative Uroilinogen 0.11.0 mg/dL White lood cells 34/
hpf White
lood cell casts Negative Red lood cells 12/hpf Red lood cell casts Negative Cr
ystals
Few/negative 1899_Appendix A_491-492 22/12/11 2:14 PM Page 491 492 Appendix A R
eference Ranges
Reference Ranges for Hematology Red lood cell, male 4.66.2
10 6 cells/L Red lood
cell,
female 4.25.9
10 6 cells/L Hemogloin, male 1318 g/dL Hemogloin, female 1216 g/dL
Hematocrit, male 45%52% Hematocrit, female 37%48% White lood cell count 4,300 10,8
00 cells/mm
3 Neutrophils 54%65% Lymphocytes 25%40% Monocytes 2%8% Eosinophils 1%4% Basophils 0%1
%
Platelets 150,000 450,000/mm 3 Reticulocyte count, adult 0.5%1.5% of all RBCs Reti
culocyte
count, child 0.5%2.0% of all RBCs Erythrocyte sedimentation rate Adults: males yo
unger <15 mm/hr
than 50 years Adults: males older <20 mm/hr than 50 years Adults: females younge
r <20 mm/hr than
50 years Adults: females older <30 mm/hr than 50 years Children: 6 months12 years
313 mm/hr
Reference Ranges for Coagulation Firinogen 150400 mg/dL D-dimers <250 ng/mL Prot
hromin time
1113 sec Activated partial thromoplastin 2531 sec time Bleeding time (Ivy method)
19 min
1899_Appendix A_491-492 22/12/11 2:14 PM Page 492 Chapter 1 1-1. Reference laor
atories have the
most tests availale. (Outcome 1-2) 1-2. The microiology department would test

the patient
specimen to identify the microorganisms present in the wound. (Outcome 1-3) 1-3.
. The test is
eing performed to see if the patient is developing diaetes so that the disease
can e treated
early, or prevented if possile. (Outcome 1-4) 1-4. False. Medical assistants m
ay work in
specimen pro- cessing or as laoratory assistants performing a vari- ety of duti
es in
microiology, histology, and the like. They may also work as phleotomists if th
at laora- tory
provides this service. Medical assistants may also perform CLIA-waived or modera
te-complexity
tests with appropriate training. (Outcome 1-5) 1-5. Yes, as long as the training
is appropriate
and they have een designated as CLIA-waived or moderate- complexity tests. (Out
come 1-5) 1-6.
There are various correct answers to this question. One reason is so that the re
sults can e
delivered or transmitted to the correct health-care provider upon completion. An
other reason may
involve reimurse- ment. Insurance companies require the name of the ordering pr
actitioner for
successful payment. (Outcome 1-6) 1-7. The ABN allows patients who have Medicare
as their primary
insurance to make an informed decision aout whether they want to have laorator
y tests performed
that may not e reimursed. The form of- fers an opportunity for the patient to
refuse the test,
or to accept the fee and have the test performed any- way. (Outcome 1-7) 1-8. To
verify specimen
requirements, tue stopper colors to e drawn, or any special handling procedure
s nec- essary for
the test ordered. (Outcome 1-8) 1-9. They oth contain important patient informa
tion, as well as
the name of the ordering practitioner. They are oth critical parts of the proce
ss, and oth must
e used for quality patient care. (Outcome 1-9) 1-10. The three phases of laora
tory testing
include the pre- analytical phase, the analytical phase, and the post- analytica
l phase. (Outcome
1-10) 1-11. The preanalytical phase. This error occurred prior to the performanc
e or reporting of
the test results, so it is included with the preanalytical phase of testing. (Ou
tcome 1-11)
Chapter 2 2-1. Yes, a physician assistant may serve as a laoratory director in
a physician
office laoratory. (Outcome 2-2) 2-2. Yes, this is a role often assumed y a med
ical technologist. (Outcome 2-3) 2-3. A phleotomist (in most states) is not required to hav
e specific
credentials gained y a national examination or formal education. A phleotomist
is required to
have a high school education (or the equivalent) and documented training in phle
otomy. (Outcome
2-4) 2-4. No, they are not limited to drawing lood. They can perform a variety
of duties, as
long as there is documented training for these expanded duties. (Outcome 2-5) 25. CLIA 88 was
designed to ensure reliale, accurate, and timely laoratory results. (Outcome 2

-6) 2-6. The

minimum level of education is as follows: a. High school graduate (or the equiva
lent) . Same,
ut additional documented training (on the jo is sufficient) c. At least an ass
ociate degree in
a laoratory-ased curriculum. (Outcome 2-7) 2-7. Assignment of complexity level
s takes into
account the difficulty of the actual test performance (how many steps involved,
etc.) as well as
the clinical significance of the test results. (If the test was reported incorre
ctly, what impact
would it have on the patient and his or her treatment?) (Outcome 2-7) 2-8. A cli
nical laoratory
scientist with four years of edu- cation could perform any level of testing as d
esig- nated y
CLIA. (Outcome 2-8) 493 Appendix B Test Your Knowledge Answers 1899_Appendix B_4
93-504 22/12/11
2:15 PM Page 493 494 Appendix B Test Your Knowledge Answers 2-9. The U.S. Food
and Drug
Administration assigns the categories to the laoratory tests. (Outcome 2-9) Cha
pter 3 3-1.
Viruses, fungi, and parasites are examples of other types of microorganisms. (Ou
tcome 3-2) 3-2.
No. (Outcome 3-3) 3-3. They appear different under the microscope. Staphy- lococ
ci appear in
clusters, and diplococci appear in pairs. (Outcome 3-4) 3-4. Bacilli appear as o
vals or
rod-shaped organisms. (Outcome 3-4) 3-5. Viruses have a different cellular makeu
p than acteria;
acteria have cell walls and memranes, and contain various structures that allo
w them to survive
and reproduce. Viruses have genetic mate- rial contained in a protein capsule, a
nd depend on the
cells of other living organisms to reproduce. Viruses are much smaller than act
eria. Antiiotics work to destroy acteria, ut not on viruses. (Outcome 3-5) 3-6. No, it is
just medically
aseptic, with most of the acte- ria destroyed, with a special emphasis on patho
gens. (Outcome
3-6) 3-7. By washing their hands. (Outcome 3-7) 3-8. She has roken the chain at
the point of a
susceptile host; she is no longer ale to e affected y hepatitis A. (Outcome
3-7) 3-9.
Everyone is considered infectious. (Outcome 3-8) 3-10. Hand washing. (Outcome 38) 3-11.
Alcohol-ased hand rus. (Outcome 3-9) 3-12. Before eating or drinking, after re
moving gloves,
etween patients, when visily contaminated. (Outcome 3-10) 3-13. So that the he
alth-care worker
doesnt contaminate his or her hands again y touching the dirty handles. (Outcome
3-10) 3-14.
She touched the phone with her gloved hand; her gloves may e contaminated with
pathogens and
should e removed efore she touches the phone or puts her hand near her face. (
Outcome 3-9)
3-15. A laoratory coat and gloves. (Outcome 3-9) 3-16. Employees. (Outcome 3-11
) 3-17. The
laoratory assistant may look at the lael on the container; it is required to c
ontain the
manufacturers information. (Outcome 3-13) 3-18. There are nine required component

s. (Outcome
3-12) 3-19. The NFPA laels provide information aout flamma- ility, reactivity
, health hazards,
and other specific hazards for the chemical. They are color coded and have numer
ic symols to
indicate the severity of the hazard. (Outcome 3-14) 3-20. The letters are assign
ed to the fire
extinguishers to indicate what type of fire they should e used to extinguish. (
Outcome 3-14)
3-21. Other potentially infectious materials include semen, vaginal secretions,
cererospinal
fluid, pericardial fluid, pleural fluid, etc. (Outcome 3-16) 3-22. False. It wa
s designed to
protect health-care employees. (Outcome 3-15) 3-23. Determination of the employe
e risk of
exposure, education, and implementation of appropriate use of personal protectiv
e equipment and
other means to reduce the potential exposure of the employees; hepatitis B vacci
nation;
postexposure evaluation pro- cedures; and ongoing communication of hazards. (Out
come 3-17) 3-24.
No; this is why it is so important to find out how to use the one that is in pla
ce at your
worksite. (Outcome 3-18) 3-25. No; much of the waste generated in a laoratory i
s routine office
waste, such as paper. (Outcome 3-19) 3-26. No. Hepatitis, or inflammation of the
liver, can e
caused y a variety of disease states. Viral hepatitis still has several forms;
hepatitis A in
particular is not a loodorne pathogen. (Outcome 3-20) 3-27. They are oth loo
dorne pathogens,
they are oth caused y viruses, and they oth have long- lasting effects on the
ody that may e
or are fatal. (Outcome 3-20) 3-28. She should immediately rinse them out with wa
ter. (Outcome
3-21) 3-29. True. (Outcome 3-21) Chapter 4 4-1. Both include documentation, ot
h affect the
quality of the test results, oth involve employees, oth involve written proced
ures, and oth
may involve external quality controls. (Outcome 4-2) 4-2. Incorrect laoratory r
esults may result
in improper treatment for the patient. Patients may not receive the necessary tr
eatment, or they
may e treated incor- rectly ased on the inaccurate results, leading to seri- o
us consequences.
(Outcome 4-3) 4-3. No, they do not. They may provide information aout whether t
he instrument is
operating correctly, ut they do not let you know whether a test is valid. (Outc
ome 4-4) 4-4. d,
a, and c. (Outcome 4-4) 4-5. Cindy is following the procedure as she was taught;
this means that
the manufacturers instructions may have changed since she was trained. Additional
explanations
1899_Appendix B_493-504 22/12/11 2:15 PM Page 494 495 Appendix B Test Your Know
ledge Answers may
include the use of lood for a kit for which urine is the required specimen, or
using an expired
kit or one that has een stored incorrectly. This scenario stresses the need to
follow the
package insert instruc- tions. (Outcome 4-6) 4-6. Without a date, there is reall

y no reason to
docu- ment the result, as it is not evident when the test was performed and whic
h patient results
were dependent on that result as verification that the test- ing device or instr
ument was working
correctly. (Outcome 4-7) 4-7. No, it is not used to document qualitative results
, only
quantitative. It would not e possile to use this sort of chart to document pos
itive and
negative answers, as it is designed to show an acceptale range of results for a
specific test.
(Outcome 4-7) 4-8. A caliration sample has a known value, not a known range of
acceptale
values. Once the caliration specimen is tested, the instrument is adjusted unti
l it reads
precisely the known value. A quality control specimen has a known range of value
s, and it is
designed to show that the machine is within calira- tion. (Outcome 4-8) 4-9. It
is not required
for all laoratories. Those that per- form only CLIA-waived tests are not requir
ed to per- form
proficiency testing, although some sort of outside verification of performance i
s recommended.
(Outcome 4-8) 4-10. The most important step that a medical assistant can take is
to follow the
manufacturers instructions specif- ically. (Outcome 4-8) Chapter 5 5-1. Enforceme
nt: Laws are
enforced y governmental agencies, and those who are noncompliant may e punishe
d financially or
even imprisoned. Ethics are not enforced or punished in the same way. Creation:
Laws are created
y government agencies; ethics are either created personally y the individual 
ased on morals
and values or they are created y a professional organization. (Outcome 5-2) 5-2
. . Implied
consent. (Outcome 5-3) 5-3. Yes, she has the right to get a copy of her medical
record, although
she might have to wait for it to e copied. No, it is not all right for her to t
ake the entire
original record from the office. (Outcome 5-4 and Outcome 5-5) 5-4. No; assault
means the threat
of injury, not the actual injury. (Outcome 5-1) 5-5. An intentional tort means t
hat a wrong was
commit- ted y one person against another person intention- ally, or on purpose.
An unintentional
tort is a case of accidental wrongdoing. (Outcome 5-6) 5-6. A medical assistant
is certainly
liale, and it is possile for him or her to e sued for malpractice. (Outcome 5
-7) 5-7. No, the
scope of practice may change state to state, depending on the laws for a particu
lar state.
(Outcome 5-8) 5-8. No, it also includes the portaility of health insurance, and
the method in
which health-care information is transmitted for reimursement, as well as stand
ardi- zation of
health-care information. (Outcome 5-9) 5-9. Several standards are presented in t
he AAMA code of
ethics, including respecting patients, keeping confi- dential information confid
ential unless it
is required y law, upholding high principles of the profession, eing a life-lo

ng learner, and
eing involved in the community. (Outcome 5-10) 5-10. This is most definitely an
example of risk
manage- ment, as appropriate documentation is very important to avoid potential
legal issues.
(Outcome 5-11) Chapter 6 6-1. d. Compound microscope. (Outcome 6-2) 6-2. The st
age is the
surface where the slide is placed for oservation/examination. (Outcome 6-3) 6-3
. The condenser
concentrates the light from the light source. (Outcome 6-3) 6-4. False; this ou
tcome should e
cleaned last. (Outcome 6-4) 6-5. c. Lens paper. (Outcome 6-4) 6-6. The coarse a
djustment kno
should e used first. (Outcome 6-5) 6-7. No, the stage should not e moved once
the specimen is
in focus with a lower magnification when changing from one outcome to another. (
Outcome 6-5) 6-8.
. Electron microscope. (Outcome 6-2) 6-9. Generally, medical assistants do not
perform microscopic examinations in which they are identifying differ- ent formed elements in
a specimen.
However, with ap- propriate training, a medical assistant may e ale to perform
a normal manual
differential count, and also to perform urine microscopic examinations. (Outcome
6-6) 6-10.
Answers may vary, ut they may include cleaning the centrifuge, using a tachomet
er to monitor the
rpms, checking the centrifuge for any cracks or discol- orations, and checking t
he electrical
system for wear. All these procedures would, of course, e docu- mented. (Outcom
e 6-7)
1899_Appendix B_493-504 22/12/11 2:15 PM Page 495 496 Appendix B Test Your Kno
wledge Answers
6-11. Whenever the centrifuge is used, a container of simi- lar size with the sa
me volume of
liquid must e placed across from the specimen efore turning on the centrifuge.
(Outcome 6-7)
6-12. Temperatures should e monitored at least daily. In situations in which th
e temperature
control is critical (as in lood ank facilities), the temperatures must e moni
tored
continuously. In these critical situations, an alarm system is also in place to
verify that the
temper- ature stays within the estalished range for that storage unit. (Outcome
6-8) 6-13.
Answers may vary, ut could include the following: On-site testing allows for a
definitive
diagnosis to e estalished as well as a plan of treatment while the patient is
still in the
office. CLIA-waived tests performed in the office may e less expensive. Patient
s are often
more compliant ecause the tests can e performed in the office during an office
visit. (Outcome
6-10) 6-14. This method of measurement uses an electrical cur- rent. When the sp
ecimen is passed
through an aper- ture that runs etween the two electrodes for the current, the
numer, size, and
other characteristics of the cells in the specimen can e measured. The amount o
f disruption (or
impedance) to the electrical current provides the information needed for the mea

surement.
(Outcome 6-11) 6-15. d. Whole lood. (Outcome 6-13) 6-16. Yes, the results are
visile on the
screen of the instru- ment, and often the instrument is capale of printing the
results at the
time of the test as well. (Outcome 6-13) 6-17. The Cholestech LDX is a common CL
IA-waived instrument used for cholesterol testing in the physician of- fice laoratory. (Outcome
6-14) 6-18. No,
it is not measured from intact red lood cells. The cells must e roken (or lys
ed) efore the
hemogloin test can e performed. (Outcome 6-15) 6-19. No, the glucometer is an
instrument used
to test glu- cose levels in the lood, which is a type of chemistry test, not a
hematology test.
(Outcome 6-14) 6-20. d. Meniscus. (Outcome 6-17) Chapter 7 7-1. Demographic inf
ormation,
documentation of test ordered, ICD-9 codes, last dose of medication if a drug le
vel is ordered,
type of fluid to e tested, wound source, date of testing, name of ordering phys
ician. (Outcome
7-2) 7-2. Both types of panels are designed to assist the health- care provider
with an easier
diagnosis y grouping tests that complement one another in a panel. (Outcome 7-3
) 7-3. This is
not an acceptale order, ecause standing orders cannot e extended for more tha
n a year.
(Outcome 7-4) 7-4. No repeat collections needed, quicker opportunity for diagnos
is, faster
treatment. (Outcome 7-5) 7-5. No, it should not ecause there is no way of verif
ying if it is the
armand that elongs to the patient who is in the ed. (Outcome 7-6) 7-6. The me
dical assistant
should ask him if he has had coffee in the past 12 hours efore she egins the 
lood draw.
(Outcome 7-8) 7-7. The reference ranges for most laoratory tests are dependent
on many factors,
including the collection method. Reference ranges for arterial lood are dif- fe
rent from those
of venous specimens, which are different from capillary specimens. In addition,
the reimursement
for the collection may e different for the various types of lood specimen coll
ections. (Outcome
7-10) 7-8. Initials or identification of the person who has col- lected the spec
imen, date and
time of collection, pa- tient name, and unique identifier (such as patient ID or
irth date).
(Outcome 7-12) 7-9. The specimen has a special lael placed over the top of the
container that is
tamper evident. Also, the chain of custody form provides documentation of all th
ose who had
access to the specimen. The specimen should e kept in a locked area with limite
d access when it
is not in the possession of a laoratory employee. (Outcome 7-13) Chapter 8 8-1.
The heart,
arteries, veins, and capillaries. (Outcome 8-1) 8-2. Arteries have a pulse, vein
s do not.
Arteries carry right red lood that has just een oxygenated, whereas the lood
in veins is
darker. Veins have valves to help the lood to move in one direction; arteries h

ave lood pulsing

through and do not need the valves. Upon palpation, they feel differ- entthe arte
ries are a it
stiffer; veins are spongier. (Outcome 8-3) 8-3. No. Capillaries are much smaller
; they are microscopic in size. (Outcome 8-4) 8-4. The antecuital area. (Outcome 8-5) 8-5. No.
They are also
performed on the heel when draw- ing an infant. (Outcome 8-6) 1899_Appendix B_49
3-504 22/12/11
2:15 PM Page 496 8-6. Not always; there are times when there is no other choice,
so certain
precautions have to e taken efore drawing the lood near a site at which an IV
is running.
(Outcome 8-7) 8-7. The edema can add additional fluid to the sample, causing err
oneous results.
There is an increased chance of infection, and the lood draw may e very diffic
ult. (Outcome
8-7) 8-8. Needle, tues, sharps iohazardous disposal con- tainer, gauze, alcoho
l pads, tue
holder or syringe, gloves. (Outcome 8-8) 8-9. No. The ones used for the evacuate
d tue system
have two ends that are sharp; syringe needles have only one end that is sharp, a
nd they screw
onto the syringe. Butterfly systems have needles that are much shorter and attac
h to a long piece
of tuing. (Outcome 8-8) 8-10. Because they have the air removed from the tue t
o create a vacuum
and allow the lood to enter without any additional pulling action. (Outcome 8-8)
8-11. The
stoppers are color coded to indicate the type (or asence of) additives. (Outcom
e 8-10) 8-12. To
avoid potential crossover contamination from one type of tue to another. This c
ontamination may
cause erroneous results. (Outcome 8-11) 8-13. Because the reference ranges are d
ifferent for each
type of lood specimen. The capillary specimens generally have more fluid contam
ination so the
results may e much different. (Outcome 8-13) 8-14. No, it is not. The capillary
samples dont
have the potential contamination issues from each tue that the venipuncture pro
cedures have, so
the order of draw is ased more on the tues that might clot accidentally if the
y are left
unattended too long. (Outcome 8-11) 8-15. Proper patient identification procedur
e is the most
important aspect. (Outcome 8-14) 8-16. The specimens must e drawn into a tue t
hat does not
contain anticoagulant. After the draw is complete, the sample must sit for at le
ast half an hour
undis- tured at room temperature to allow for a clot to form. After a clot has
formed, the
sample can e centrifuged for at least 10 minutes so that complete separation ca
n occur. Finally,
the serum may e sep- arated using various techniques. (Outcome 8-17) 8-17. Seru
m does not
contain clotting factors, as they are used up in the lood clot. Plasma does con
tain the clotting
factors. Serum is taken from a tue that does not contain anticoagulant. Plasma
is taken from a
tue that contains anticoagulant. (Outcome 8-18) 8-18. False. Tests that requir

e whole lood
must e thor- oughly mixed prior to testing. (Outcome 8-17) 8-19. d. All of the
aove. (Outcome
8-19) 8-20. False. The angle at which the needle is inserted for venipuncture p
lays a
significant role in the success of the procedure and avoidance of the negative o
utcome. (Outcome
8-20) Chapter 9 9-1. Diagnosis of urinary tract infections, chemical analy- sis.
(Outcome 9-2)
9-2. Laeling procedures, documentation of medication, documentation of collecti
on times for
specimen, com- munication to the patient for collection procedures. (Outcome 9-2
) 9-3. To avoid
external contaminants which may lead to a misdiagnosis and incorrect patient tre
atment. (Outcome
9-2) 9-4. The urine specimen container should e laeled efore it is given to t
he patient.
(Outcome 9-6) 9-5. A straight or intermittent catheterization procedure is used
to collect a
urine specimen for culture, if needed. (Outcome 9-3) 9-6. The patient should e
told not to
urinate directly into the container. (Outcome 9-7) 9-7. The first morning void s
pecimen is
collected immedi- ately after waking up. The 24-hour urine specimen is collected
over 24 hours.
(Outcome 9-3) 9-8. Because it is not possile to control the urination times of
an infant, the
device has to e ready to collect the specimen whenever it is generated. (Outcom
e 9-3) 9-9.
Because microscopic pathogens may e present, and OSHA recommends that gloves ar
e worn when- ever
there is a potential for exposure to ody fluids. (Outcome 9-4) 9-10. The acter
ial count.
(Outcome 9-5) Chapter 10 10-1. Pathogen. (Outcome 10-1) 10-2. Specimen source, p
atient name, name
or ID for col- lector, date, and time of collection. (Outcome 10-2) 10-3. Ideall
y, the sample
should e collected efore the antii- otic therapy has een initiated. (Outcome
10-2) 10-4. It
may differ in the form that it takes (liquid versus solid), the container it is
provided in, and
y how selective it may e for specific types of samples. (Outcome 10-3) 10-5. B
acterial samples
will grow more quickly than the other types listed. (Outcome 10-4) 10-6. No, thi
s will
contaminate the specimen with organ- isms that were not present in the area of s
pecimen
collection. (Outcome 10-2) 497 Appendix B Test Your Knowledge Answers 1899_Appe
ndix B_493-504
22/12/11 2:15 PM Page 497 498 Appendix B Test Your Knowledge Answers 10-7. The
y oth use swas
for their collection, and they are oth collected from the same area at the ack
of the throat.
Also, the PPE used for oth types of collection is the same. (Outcome 10-5) 10-8
. No, it is est
to collect two swas, as one is used for the strep screen and one is used for th
e culture. If one
swa is collected and the culture is set up efore the strep screen is performed
, there is a
chance that the strep screen could produce a false negative ecause of an insuff

icient sample
volume. If the strep screen is performed first, the culture cannot e set up fro
m the swa
afterward, as there are chemicals added to the swa that would affect the acter
ial growth.
(Outcome 10-5) 10-9. No, they are not. Ideally, for oth types of collec- tions,
the medical
assistant will touch areas that appear most inflamed, and if there are any white
pustules, those
will e areas to target as well. (Outcome 10-5) 10-10. Many of the pathogens pre
sent in the
sputum of infected patients are spread y droplets while the patient is coughing
or sneezing.
Collection of the sputum specimen in the waiting area could poten- tially expose
all those who
are present and even those who follow, as the droplets may land on surfaces that
they touch.
Sputum specimens should e collected in a private area; it is recommended that t
he patients
collect them in the privacy of their home. (Outcome 10-6) 10-11. a. Specimens t
aken from
indwelling catheters. (Outcome 10-7) 10-12. The ottles include different nutrit
ion sources and
additives. One ottle is designed to encourage the growth of aeroic microorgani
sms, whereas the
other is designed for anaeroic microorganism growth. (Outcome 10-8) 10-13. .
Two times
(Outcome 10-8) 10-14. The CSF tues must e marked according to their order of c
ollection. This
allows the laoratory to process them appropriately when performing chem- istry,
hematology, and
microiology testing proce- dures. (Outcome 10-9) 10-15. c. Swas (Outcome 10-1
0) 10-16. False.
It is definitely advisale to wash a wound efore collecting a culture specimen,
so that any
extraneous (transient) microorganisms are washed away from the area. (Outcome 10
-11) 10-17. It is
important ecause stool specimens include a great deal of normal flora. The medi
a used for this
type of specimen encourages the growth of the path- ogenic microorganisms that a
re present in the
GI tract, while discouraging the growth of the normal flora to avoid overgrowth.
This is more
important for stool specimens than it is for any other type of spec- imen ecaus
e the normal
flora occurs in such high numers. (Outcome 10-12) 10-18. It reduces the discomf
ort of using a
dry swa in the eye; these patients usually are already in pain from the eye inf
ection. (Outcome
10-13) 10-19. a. Otitis externa. This is often linked to swimming or introducti
on of liquid to
the ear canal, as can occur in athing or showering. (Outcome 10-14) 10-20. No,
fungal infections
can occur in any area of the ody. (Outcome 10-15) 10-21. KOH preps and wet moun
ts are similar in
that they are used for examination of microorganisms in their living state, with
out preservative
or staining. Ideally, the movement of the organisms can e evaluated, as well as
the morphology.
They are also similar in that oth methods may e used to examine samples taken

from the same

areas of the ody. KOH preps are different from wet mounts ecause the KOH prep
is designed
specifically to clear away all elements from the sample that are not fungal in n
ature; the wet
mount allows for examination of everything in the specimen. (Outcome 10-16) 10-2
2. a. The O&P
collection procedures include contain- ers with preservative solution, ut the s
tool culture
samples procedures do not. (Outcome 10-17) 10-23. To collect the sample for dete
ction of pinworms
or their ova, clear adhesive tape is pressed against the rectum to pull out the
worms or eggs.
The adhesive tape is then placed on the slide to e examined under the microscop
e. (Outcome
10-18) 10-24. The two different types of stains allow for acteria to e differe
ntiated with the
staining procedure. By using two different colors of stains, it is possile to i
dentify acteria
as gram positive (those that asor the purple stain in their cell walls) or gra
m negative (those
that asor the pink counterstain in their cell walls). If only one stain were u
sed, it would not
al- low a chance to examine the acteria that did not asor the initial stain,
as they would e
colorless. (Outcome 10-19) 10-25. d. All of the aove. (Outcome 10-20) 10-26. A
ntiiotic discs
are used to apply different types of antiiotics to the acteria so that the mic
roiologist can
determine which antiiotic may e most effective 1899_Appendix B_493-504 22/12/1
1 2:15 PM Page
498 to treat the infection. The antiiotics that do not allow the acteria to gr
ow close to their
orders are more effective in treating that specific acteria than are those ant
iiotics that
allow the growth to con- tinue right up to their orders. (Outcome 10-21) 10-27.
C&S means
culture and sensitivity. This is a pro- cedure in which the specimen is cultured a
nd the
infection-causing pathogen is identified Then an antiiotic sensitivity is perfo
rmed to determine
which medication is most effective for use. A C&S is not performed for viral or
fungal cultures,
as an- tiiotics are not used to treat these infections. (Outcome 10-22) Chapter
11 11-1.
Erythrocytes, leukocytes, and thromocytes (red cells, white cells, platelets) m
ake up the formed
elements in lood. (Outcome 11-3) 11-2. Hematopoiesis is the process of the prod
uction of lood
cells. (Outcome 11-2) 11-3. Pluripotent means having the aility to differentiate
into several
types of specialized cells. (Outcome 11-2) 11-4. No, the nucleus is expelled from
the red lood
cell efore it enters the general circulation. Mature red lood cells do not inc
lude a nucleus.
(Outcome 11-3) 11-5. There may e an increase in the numer of reticulo- cytes f
ollowing lood
loss. (Outcome 11-4) 11-6. The neutrophil is the white lood cell that first fig
hts acterial
infection; therefore, the numers increase as the cells are employed. (Outcome 1

1-5) 11-7. The

eosinophil count may increase in an allergic reaction. It is a granulocytic whit
e lood cell with
a iloed nucleus and right red-orange granules in the cytoplasm. (Outcome 11-5
) 11-8. The
lymphocyte has forms that make antiodies and are active in cell-mediated immuni
ty. (Outcome
11-5) 11-9. Platelets stick together to form the platelet plug to fill the reak
in the vessel,
release serotonin to help the vessel contract, and start the chemical reactions
of coagulation to
increase the staility of the platelet plug. (Outcome 11-7) 11-10. Three CLIA-wa
ived procedures
are hemogloin, hematocrit, and erythrocyte sedimentation rate testing. (Outcome
11-8) Chapter 12
12-1. The CBC (complete lood count) tests are the hemogloin, hematocrit, red 
lood cell count,
white lood cell count, and the differential. The erythrocyte indices and a plat
elet count are
often included. (Outcome 12-2) 12-2. The normal range is 4.2 to 6.2 million red
lood cells per
cuic millimeter of lood. (Outcome 12-3) 12-3. The white lood cell count is in
creased in
acterial infection and in leukemia. (Outcome 12-4) 12-4. The red lood cell ind
ices descrie the
size of red lood cells and the amount of hemogloin that they contain. (Outcome
12-6) 12-5. The
appearance of the white lood cell nuclei and the cytoplasm is used for differen
tiation. In
addition, the colors added y the polychromatic stain aid in the identification
process. The
nuclei, cytoplasm, and granules all asor different colors. (Outcome 12-7) 12-6
. From greatest
in numer to least, they are neutrophils, lymphocytes, monocytes, eosinophils, a
nd asophils.
(RememerNever let monkeys eat ananas.) (Outcome 12-7) 12-7. The normal red loo
d cell is
circular, with a pale center. (Outcome 12-9) 12-8. A pale red lood cell that ha
s a decreased
amount hemogloin is hypochromic. (Outcome 12-9) 12-9. Poikilocytosis is the wor
d used to
descrie a variety in the shapes of red lood cells on the lood smear. (Outcome
12-9) Chapter 13
13-1. Hemogloin is made up of one molecule of gloin and four molecules of heme
. (Outcome 13-2)
13-2. Oxygen delivery to the tissues of the ody. (Outcome 13-2) 13-3. Answers m
ay vary, ut
examples of anormal hemogloin strains are H S, H C, H D, H G, H J, and H
M. (Outcome
13-3) 13-4. No, the cells must e lysed first. (Outcome 13-4) 13-5. Errors may i
nclude
overfilling or underfilling the tue, sealing inadequately with the clay on the
end of the tue,
using an incorrect speed for the centrifuge, allowing the specimen to sit for to
o long efore
reading the result, contaminating with interstitial fluid, and using an incorrec
t reading
technique. (Outcome 13-5) 13-6. The hematocrit is the amount of space occupied 
y red lood cells
in a sample of whole lood. It is reported as a percentage. (Outcome 13-5) 13-7.

The centrifuge
is used to create the three layers in performing the hematocrit. (Outcome 13-5)
13-8. Anemia is
the disorder in which there is low oxygen- carrying capacity of lood. (Outcome
13-9) 499
Appendix B Test Your Knowledge Answers 1899_Appendix B_493-504 22/12/11 2:15 PM
Page 499 500
Appendix B Test Your Knowledge Answers 13-9. The physician could order a hemogl
oin and/ or
hematocrit. The red lood cell count and indices could also give additional info
rmation for
anemia. (Outcome 13-8) 13-10. Iron deficiency, pernicious, aplastic, and sickle
cell anemias are
examples. (Outcome 13-10) Chapter 14 14-1. The sedimentation rate is a laorator
y test where the
settling of red lood cells is oserved. (Outcome 14-1) 14-2. Rouleaux formation
is the stacking
of red lood cells on top of one another, as in a stack of coins. It occurs when
the red cells
are no longer repelled from one another. (Outcome 14-1) 14-3. Increased firinog
en and certain
gloulin levels in the plasma decrease the negative charge on the red lood cell
s, and they are
not as repelled from each other and will stack more easily into the rouleaux for
mation. (Outcome
14-2) 14-4. There is less surface area to the volume of the stacked cells so the
stack will
settle faster in the plasma than single red lood cells. (Outcome 14-3) 14-5. Fo
r those younger
than 50 years of age, the normal value for men is less than 15 and the normal va
lue for women is
less than 20 mm/hr. (Outcome 14-4) 14-6. The inflammatory process causes the shi
ft in proteins
that will lead to an increased ESR. (Outcome 14-5) 14-7. The Sediplast Westergre
n erythrocyte
sedimentation system and the Wintroe ESR system. (Outcome 14-6) 14-8. Any two o
f the following
procedure errors will affect the value of the ESR: using a clotted sample could
cause erroneous
results; using an EDTA tue that is not well mixed; using a sample that is at re
frigerated
temperature; leaving air spaces in the column that is filled with the aliquot of
lood; not
keeping the column vertical during the hour of the procedure; placing the column
in direct
sunlight or in an area where there is viration or movement. Also, reading the t
est at less than
60 minutes would cause an erro- neous result. (Outcome 14-7) Chapter 15 15-1. It
may e done to
screen for possile coagulation dis- orders or to monitor medication use. (Outco
me 15-2) 15-2.
No; there are other factors that are involved in addition to the platelets. (Out
come 15-3) 15-3.
The constriction of lood vessels in the immediate and surrounding area is the 
odys first
response to vessel injury. (Outcome 15-3) 15-4. This term refers to a series of
events that seal
off vessel injury and secondary coagulation steps that follow the formation of t
he initial
platelet plug. (Outcome 15-3) 15-5. A thromus is a lood clot that is stationar

y; an emolus is
a part of a lood clot or a whole lood clot that has left the point of formatio
n and has
traveled through the ody. (Outcome 15-4) 15-6. DIC and DVT are similar ecause
they oth involve
formation of lood clots. DVT is a deep vein throm- osis that is contained in a
particular
vessel, whereas DIC is intravascular coagulation that is spread throughout the 
ody. (Outcome
15-5) 15-7. Thromocytopenia is different ecause it is a disor- der specific to
the numer of
platelets; all the other disorders discussed are in reference to other aspects o
f the clotting
process. (Outcome 15-5) 15-8. No, the INR is used when monitoring a patient who
is taking
warfarin or Coumadin, not for initial screening. It may e reported as part of t
he initial
screening, ut the health-care provider will not use the INR to make a decision
on potential
coagulation defects without the prothromin time result as well. (Outcome 15-6)
15-9. c.
Heparin. (Outcome 15-8) 15-10. The patient may exhiit slow or inadequate lood
clotting with
lood vessel injury, resulting in exces- sive ruising and/or leeding. (Outcome
15-11) 15-11.
The answers may vary, ut should include the following: results are not reproduc
ile; aspirin has
a profound effect; other medications and health condi- tions may affect the resu
lt to a high
degree; and the leeding time result does not seem to correlate well to the true
risk of leeding
in surgical situations. (Outcome 15-10) 15-12. False. It is imperative that the
se tues are
filled to the point at which the vacuum is exhausted. (Outcome 15-13) Chapter 16
16-1.
Qualitative tests provide a result that indicates whether the specimen is positi
ve or negative
for a specific sustance. Quantitative tests provide an ac- tual numer that ind
icates the amount
of a sustance that is present in the specimen. (Outcome 16-1) 16-2. a. Serum.
(Outcome 16-2)
16-3. Glucose testing may e performed in a physician office laoratory to scree
n for the
presence of dia- etes mellitus or gestational diaetes, or to monitor 1899_Appe
ndix B_493-504
22/12/11 2:15 PM Page 500 the progress of a patient who is eing treated for the
se conditions.
(Outcome 16-4) 16-4. . LDL. (Outcome 16-5) 16-5. d. Cadmium. (Outcome 16-6) 1
6-6. Panels allow
the health-care provider to have access to a variety of test results, which can
often aid in a
differential diagnosis. If the provider orders only one test at a time, the pati
ent may need to
return to the office several times to have speci- mens collected, which would e
cumersome and
time consuming. Some panels also allow the health-care provider to eval- uate mo
re than one organ
system at once, which can help to estalish a diagnosis. Panels may e less expe
nsive in some
situations. (Outcome 16-8) 16-7. True. This is the most common reason that thes

e tests are
ordered. (Outcome 16-7) 16-8. When damage to the heart muscle occurs, the spe- c
ific cardiac
enzymes ecome elevated at different rates. To determine whether a myocardial in
farction
occurred, it is essential to collect a series of speci- mens to see if the enzym
es have ecome
elevated. (Outcome 16-10) 16-9. a, , and c. (Outcome 16-11) 16-10. a. Lipemia
. (Outcome 16-13)
Chapter 17 17-1. Glycogen is the storage form of glucose in the ody; it is prod
uced when there
is excess glucose present in the loodstream and stored in the liver and the adi
pose tissues.
(Outcome 17-1) 17-2. a. Formation of glycogen. (Outcome 17-3) 17-3. Answers may
vary and might
include the follow- ing: Type 1 and type 2 diaetes oth exhiit elevated levels
of lood
glucose. They oth may exhiit similar symptoms. Both type 1 and type 2 diaetes
are diagnosed
using lood glucose levels, in addition to physical examination and medical hist
ory. Both types
of diaetes are caused y pro- lems with insulin in the ody: a decrease in the
amount of
glucose, or cellular resistance to glucose. (Outcome 17-4) 17-4. Diaetic neurop
athy, damage to
the optic nerve, cardiovascular damage, irreversile kidney dam- age, poor heali
ng. (Outcome
17-6) 17-5. Gestational diaetes is more like type 2 diaetes ecause in oth th
ere is adequate
insulin present, ut the cells develop a resistance to the action of the insulin
. In type 1
diaetes, the patient does not have enough insulin produced. (Outcome 17-5) 17-6
. Untreated
gestational diaetes may lead to macro- somia (an excessively large fetus). (Out
come 17-7) 17-7.
c. A glucose level drawn at any time of the day without any previous preparation
. (Outcome 17-8)
17-8. True. A laoratory postprandial test involves the ingestion of a glucose
drink. A
postprandial lood glucose test done at home is performed a certain amount of ti
me after a meal.
(Outcome 17-9) 17-9. The lood is drawn a minimum of four times if the test is c
ompleted
entirely. This includes a fasting, 1-hour, 2-hour, and 3-hour draw. (Outcome 1710) 17-10. c. 3
months. (Outcome 17-11) 17-11. The plasma glucose will e higher than the whole
lood glucose.
(Outcome 17-12) 17-12. Medical assistants may assist with this process in many w
ays. These
include helping the patients understand how their plasma glucose and whole lood
levels will e
different from one another, showing the patients how to use their lood testing
equipment
properly, helping patients find an instrument that works well for them, explaini
ng how to
document lood glucose levels properly, and as- sisting with proper use and disp
osal of lancets.
MAs may also assist patients with reimursement for dia- etes testing supplies
y researching
the policies of their insurance. (Outcome 17-13) Chapter 18 18-1. Ingested chole

sterol comes from

animal products (like meat), dairy products, and processed foods. (Outcome 18-2)
18-2. LDL and
VLDL. (Outcome 18-3) 18-3. Yes, it is desirale to have high HDL levels and low
LDL levels,
respectively. (Outcome 18-4) 18-4. No, this result is not within the desirale r
ange. The
reference range (or desirale range) is less than 200 mg/dL. (Outcome 18-4) 18-5
. Elevated LDL
levels are considered a health risk ecause they directly contriute to plaque 
uildup y
depositing cholesterol on the lining of the lood vessels. (Outcome 18-5) 18-6.
a. Consumption
of excess calories. (Outcome 18-6) 18-7. . Excess fat particles. (Outcome 18-7
) 18-8. False.
Electrolytes exhiit a positive or negative charge when dissolved in water. (Out
come 18-1) 501
Appendix B Test Your Knowledge Answers 1899_Appendix B_493-504 22/12/11 2:15 PM
Page 501 502
Appendix B Test Your Knowledge Answers 18-9. The electrolyte most commonly asso
ciated with
arrhythmia is potassium. (Outcome 18-13) 18-10. c. Nitrogen. (Outcome 18-14) Ch
apter 19 19-1.
The physical examination of the urine specimen includes oservations of the urin
e that can e
seen with the naked eye; the microscopic procedures require the use of a microsc
ope for
magnification and are generally performed on urine sediment. (Outcome 19-7) 19-2
. The function of
the urinary system is the filtration of lood, excretion of waste, and the regul
ation of the
odys fluid and acid-ase alance. (Outcome 19-2) 19-3. c. Located on either sid
e of the
verteral column with one slightly lower than the other. (Outcome 19-3) 19-4. Be
cause urine is
formed in the nephron. (Outcome 19-3) 19-5. Reasorption and secretion. (Outcome
19-4) 19-6. No,
ureters are only involved in the transportation of urine, not in the actual form
ation of urine.
(Outcome 19-4) 19-7. False. Urinalysis testing is performed for a variety of re
asons, including
screening of asymptomatic individuals. (Outcome 19-6) 19-8. The physical examina
tion procedures
include oser- vation of color, clarity, and sometimes the odor of the urine. (O
utcome 19-7)
19-9. c. Chemical analysis. (Outcome 19-7) 19-10. d, a, and . (Outcome 19-9)
Chapter 20 20-1.
Urochrome is the pigment that gives urine its char- acteristic yellow color. (Ou
tcome 20-1) 20-2.
The right orange color present in the urine is not clinically significant; it i
s merely a result
of the medication she was given, proaly pyridium, which is prescried to those
with recurrent
urinary tract infections. (Outcome 20-2) 20-3. Using some sort of print or ojec
t ehind the
urine specimen allows the person performing the test to assess the transparency
of the urine with
more accu- racy; it gives a point of reference. (Outcome 20-3) 20-4. . Decreas
ed. (Outcome
20-4) 20-5. No, there are other causes for strong odors in addi- tion to a urina

ry tract
infection. (Outcome 20-4) 20-6. False. A high specific gravity means that the s
pecimen has a lot
of dissolved sustances; this does not necessarily mean that the urine is cloudy
. High levels of
large molecules such as glucose and protein do not make the urine cloudy. (Outco
me 20-5) 20-7.
No, this is not correct. Urine specific gravity must always e reported with thr
ee spaces to the
right of the decimal point, the first of which is a zero, for example, 1.025. (O
utcome 20-7)
20-8. Refractometers take only a drop of urine, they are relatively inexpensive,
and they may e
portale. (Outcome 20-6) 20-9. No, partly hazy is not a valid description of the
clarity of the
urine specimen. (Outcome 20-8) Chapter 21 21-1. False. The reference range for
many of the
analytes is actually a negative result; this means that they are not normally pr
esent in the
specimen. (Outcome 21-3) 21-2. Bile ostruction or liver dysfunction. (Outcome 2
1-2) 21-3. a.
Intact red lood cells. (Outcome 21-3) 21-4. No. If the diaetic has too much gl
ucose in the
loodstream at any given time, the urine may e positive for glucose. However, i
f the lood
glucose level is under control (through diet, exercise, med- ication, or insulin
use), then the
urine may e nega- tive for glucose. The values can fluctuate quite a it throug
hout the day.
(Outcome 21-2) 21-5. False. The leukocyte esterase result will not always e po
sitive when white
lood cells are present in the urine specimen, ecause not all white lood cells
contain this
enzyme. However, the only ones that do not secrete this enzyme are the lymphocyt
es, and they are
not usually the type of white lood cell pres- ent in an infection. (Outcome 213) 21-6. .
Fever. (Outcome 21-3) 21-7. The strips can e exposed to moisture y leaving the
lid off the
container they are kept in or removing the desiccant packaged with the strips. T
hey can also e
exposed to direct light, excessive heat, or volatile liq- uids. They can e used
past their
expiration date or when discolored. (Outcome 21-4) 21-8. . Allowing the reagen
t strip to remain
in the urine for 60 seconds efore removing the strip. (Outcome 21-4) 21-9. The
most common route
of exposure is through mu- cous memrane exposure y splashing or aerosol exposu
re. (Outcome
21-5) 21-10. True. Some only test for one or two analytes (e.g., glucose and ke
tones), and some
do or do not pro- vide an opportunity for specific gravity testing even if they
are the more
comprehensive strips. (Outcome 21-6) 1899_Appendix B_493-504 22/12/11 2:15 PM Pa
ge 502 21-11.
Less opportunity for operator error, less time inten- sive for the person perfor
ming the test,
and opportu- nities for multiple testing procedures to occur at once are all adv
antages of
automated urine chemistry testing. (Outcome 21-6) 21-12. Because the FOBT is a m

eans of detecting
early, asymptomatic colorectal cancer. (Outcome 21-9) 21-13. d. NSAIDs. (Outcom
e 21-10) Chapter
22 22-1. It may e added as a reflexive test when the chemi- cal tests are anor
mal. The urine
microscopic may also e performed when ordered y the practitioner; this may occ
ur if the
practitioner suspects the pres- ence of certain formed elements in the urine spe
ci- men, such as
crystals or casts. (Outcome 22-2) 22-2. No, the presence of squamous epithelial
cells is not
considered clinically significant. (Outcome 22-4) 22-3.  Yes, spermatozoa may
e present in the
urine of females if they have recently een involved in sexual intercourse. (Out
come 22-3) 22-4.
a. Viruses. (Outcome 22-4) 22-5. The KOVA system allows for a standardized amoun
t of sediment to
e visualized, and it also adds a stain to the sediment efore it is placed on t
he slide for
visualization. The stain will allow for more contrast with structures that appea
r similar, which
will aid with identification. (Outcome 22-5) 22-6. False. Many normal urine spe
cimens have very
few formed elements present in the urine sediment. (Outcome 22-4) 22-7. A medica
l assistant may
e responsile for providing instructions to the patient for specimen collection
; accepting and
logging in the specimen; pouring off some of the sample into a tue to e centri
fuged;
centrifuging the urine specimen; processing the centrifuged specimen to place th
e sediment on a
slide; adding stain to the sediment for visualization; focus- ing the microscope
for
visualization of the formed elements on the slide. (Outcome 22-8) Chapter 23 231. Antigens
stimulate an immune response in our odies, and antiodies may e produced in re
sponse to protect
us. (Outcome 23-2) 23-2. It is usually tested in the serology area of the laora
- tory. (Outcome
23-2) 23-3. The injured cells release a chemical that signals for the internal n
onspecific
responses to egin. These include histamine production and white lood cell migr
ation. (Outcome
23-3) 23-4. They are good for our immune system. They often occur in response to
a foreign oject
in our nasal passages, and they can expel this efore it causes a prolem for ou
r ody. (Outcome
23-3) 23-5. No. If the first or second line of defense destroys the foreign inva
der, the
susequent level is never involved in the process. (Outcome 23-4) 23-6. The thir
d line of defense
is the one that is very spe- cific toward each antigen. This includes antiody p
roduction.
(Outcome 23-4) 23-7. It means that we have een exposed (either naturally or art
ificially) to
that disease efore, and our ody has produced antiodies that will react immedi
ately to protect
us in susequent exposures. (Outcome 23-5) 23-8. Vaccines fool our immune system i
nto producing
antiodies to a specific antigen without ever ecom- ing ill with that disease.

They target the

third line of defense. (Outcome 23-5) 23-9. A antigens and B antigens. (Outcome
23-8) 23-10. Yes,
she will proaly e receiving a RhoGam injec- tion to keep her ody from formin
g anti-Rh that
might cause harm to this fetus or those in the future. (Outcome 23-8) 23-11. The
y involve
antigen/antiody reactions as part of the testing procedure. (Outcome 23-9) 23-1
2. Yes. An
example may e the tests for syphilis VDRL and RPR. (Outcome 23-9) 23-13. The re
sults are
availale quickly so that the physi- cian can take immediate action. They are al
so usually less
expensive than other methods may e for the patient. (Outcome 23-10) 23-14. The
Epstein Barr
virus. (Outcome 23-11) Chapter 24 24-1. Immunology is the study of the immune sy
stem, in- cluding
the antigens and antiodies involved in the process. Serology is the study speci
fically of the
anti- gens and antiodies; therefore, it is part of immunol- ogy. They are simil
ar ecause they
oth include the study of the reactions of antigens and antiodies. (Outcome 241) 24-2. The test
is demonstrating a lack of specificity. (Outcome 24-1) 24-3. Most are immunoassa
ys in which the
reagents and the sample are mixed and move across the testing surface to produce
a
chromatographic result indicat- ing a positive or a negative. They are also simi
lar 503 Appendix
B Test Your Knowledge Answers 1899_Appendix B_493-504 22/12/11 2:15 PM Page 503
504 Appendix B
Test Your Knowledge Answers ecause they usually take less than 15 minutes to o
tain a result.
(Outcome 24-3) 24-4. Answers may vary, ut should include the follow- ing: The r
apid tests allow
for faster treatment and etter patient compliance ecause the patients are in t
he facility when
the diagnosis is made and treatment is prescried; the tests are usually cost ef
fective,
especially so for tests that are seldom per- formed; the results are ready in a
short period of
time. (Outcome 24-2) 24-5. Complications include glomerulonephritis, inflamma- t
ion of the
joints, and endocarditis. (Outcome 24-5) 24-6. No, it is not present elsewhere.
(Outcome 24-5)
24-7. When there is an unexpected negative result with a high prevalence of infl
uenza in the
population. (Outcome 24-4) 24-8. The patient doesnt need to return for results, s
o it allows the
health-care provider to provide educa- tion and counseling to the patient at the
same time that
the test specimen is collected. This helps to control the spread of the disease
y those at high
risk who are unaware of their HIV-positive status. (Outcome 24-4) 1899_Appendix
B_493-504
22/12/11 2:15 PM Page 504 505 Appendix C Tue Guide for BD Vacutainer Venous Blo
od Collection BD
Vacutainer Venous Blood Collection Tue Guide For the full array of BD Vacutaine
r Blood
Collection Tues, visit www.d.com/vacutainer. Many are availale in a variety o

f sizes and draw

volumes (for pediatric applications). Refer to our wesite for full descriptions
. BD Vacutainer
Tues with BD Hemogard Closure BD Vacutainer Tues with Conventional Stopper Add
itive
Inversions at Blood Collection* Laoratory Use Gold Red/ Gray Clot activator and
gel for serum
separation 5 For serum determinations in chemistry. May e used for routine loo
d donor screening
and diagnostic testing of serum for infectious disease. ** Tue inversions ensur
e mixing of clot
activator with lood. Blood clotting time: 30 minutes. Light Green Green/ Gray L
ithium heparin
and gel for plasma separation 8 For plasma determinations in chemistry. Tue inv
ersions ensure
mixing of anticoagulant (heparin) with lood to prevent clotting. Red Red Silico
ne coated
(glass) Clot activator, Silicone coated (plastic) 0 5 For serum determinations i
n chemistry.
May e used for routine lood donor screening and diagnostic testing of serum fo
r infectious
disease. ** Tue inversions ensure mixing of clot activator with lood. Blood cl
otting time: 60
minutes. Orange Thromin-ased clot activator with gel for serum separation 5 to
6 For stat
serum determinations in chemistry. Tue inversions ensure mixing of clot activat
or with lood.
Blood clotting time: 5 minutes. Orange Thromin-ased clot activator 8 For stat
serum
determinations in chemistry. Tue inversions ensure mixing of clot activator wit
h lood. Blood
clotting time: 5 minutes. Royal Blue Clot activator (plastic serum) K 2 EDTA (pl
astic) 8 8
For trace-element, toxicology, and nutritional-chemistry determinations. Special
stopper
formulation provides low levels of trace elements (see package insert). Tue inv
ersions ensure
mixing of either clot activator or anticoagulant (EDTA) with lood. Green Green
Sodium heparin
Lithium heparin 8 8 For plasma determinations in chemistry. Tue inversions ensu
re mixing of
anticoagulant (heparin) with lood to prevent clotting. Gray Gray Potassium oxal
ate/ sodium
fluoride Sodium fluoride/Na 2 EDTA Sodium fluoride (serum tue) 8 8 8 For glucos
e
determinations. Oxalate and EDTA anticoagulants will give plasma samples. Sodium
fluoride is the
antiglycolytic agent. Tue inversions ensure proper mixing of additive with loo
d. Tan K 2 EDTA
(plastic) 8 For lead determinations. This tue is certified to contain less than
.01 g/mL(ppm)
lead. Tue inversions prevent clotting. 1899_Appendix C_505-506 22/12/11 2:16 PM
Page 505 506
Appendix C Tue Guide for BD Vacutainer Venous Blood Collection BD Diagnostics
Preanalytical
Systems 1 Becton Drive Franklin Lakes, NJ 07417 USA * Invert gently, do not shak
e ** The
performance characteristics of these tues have not een estalished for infecti
ous disease
testing in general; therefore, users must validate the use of these tues for th

eir specific
assay-instrument/reagent system cominations and specimen storage conditions. *
* * e h T
performance characteristics of these tues have not een estalished for immunoh
ematology testing
in general; therefore, users must validate the use of these tues for their spec
ific
assay-instrument/reagent system cominations and specimen storage conditions. BD
Gloal Technical
Services: 1.800.631.0174 BD Customer Service: 1.888.237.2762 www.d.com/vacutain
er BD, BD Logo
and all other trademarks are property of Becton, Dickinson and Company. 2010 BD
Printed in USA
07/10 VS5229-13 Note: BD Vacutainer Tues for pediatric and partial draw applic
ations can e
found on our wesite. Yellow Sodium polyanethol sulfonate (SPS) Acid citrate dex
trose
additives (ACD): Solution A - 22.0 g/L trisodium citrate, 8.0 g/L citric acid, 2
4.5 g/L dextrose
Solution B - 13.2 g/L trisodium citrate, 4.8 g/L citric acid, 14.7 g/L dextrose
8
8

8 SPS for lood culture specimen collections in microiology.

ACD for use in lood ank studies, HLA phenotyping, and DNA and paternit
y testing. Tue
inversions ensure mixing of anticoagulant with lood to prevent clotting. Lavend
er Lavender
Liquid K 3 EDTA (glass) Spray-coated K 2 EDTA (plastic) 8 8 K 2 EDTA and K 3 EDT
A for whole
lood hematology determinations. K 2 EDTA may e used for routine immunohematolo
gy testing, and
lood donor screening.*** Tue inversions ensure mixing of anticoagulant (EDTA)
with lood to
prevent clotting. White K 2 EDTA and gel for plasma separation 8 For use in mole
cular
diagnostic test methods (such as, ut not limited to, polymerase chain reaction
[PCR] and/or
ranched DNA [DNA] amplification techniques.) Tue inversions ensure mixing of
anticoagulant
(EDTA) with lood to prevent clotting. Pink Pink Spray-coated K 2 EDTA (plastic)
8 For whole
lood hematology determinations. May e used for routine immunohematology testin
g and lood donor
screening.*** Designed with special cross-match lael for patient information re
quired y the
AABB. Tue inversions prevent clotting. Light Blue Light Blue Buffered sodium ci
trate 0.105 M
(3.2%) glass 0.109 M (3.2%) plastic Citrate, theophylline, adenosine, dipyridamol
e (CTAD) 3-4
3-4 For coagulation determinations. CTAD for selected platelet function
assays and routine
coagulation determination. Tue inversions ensure mixing of anticoagulant (citra
te) to prevent

clotting. Clear Clear New Red/ Light Gray None (plastic) 0 For use as a discard
tue or
secondary specimen tue. BD Vacutainer Tues with BD Hemogard Closure BD Vacutai
ner Tues
with Conventional Stopper Additive Inversions at Blood Collection* Laoratory Us
e BD Vacutainer
Venous Blood Collection Tue Guide. Courtesy and 2010 Becton, Dickinson and Comp
any.
1899_Appendix C_505-506 22/12/11 2:16 PM Page 506 507 1 or 2 hours postprandial
(1 hr pp or 2 hr
pp) A speci- men drawn 1 or 2 hours after a meal. 24-hour urine collection A uri
ne specimen
collected over a 24-hour period to e used for chemical analysis. Accuracy A sta
tistical term
representing how close a laoratory result is to the true value. Acidosis An inc
rease in the
acidity of the lood and ody tissues (decrease in pH) ecause of a uildup of a
cids in the
lood. Activated partial thromoplastin time (aPTT or PTT) A test used to measur
e the time
required for a firin clot to form after the activation factor, calcium, and a p
hospho- lipid mix
have een added to the plasma. The results are recorded in seconds. Advance Bene
ficiary Notice of
Noncoverage (ABN) A form that must e filled out for Medicare patients when the
laoratory test
ordered is not likely to e reimursed. Aeroes Bacteria that require oxygen to
grow and
reproduce. Aeroic An organism that requires oxygen to survive and replicate. Af
ferent
arteriole The arteriole that transports lood toward the center of the glomerulu
s of the
kidney. Afirinogenemia A condition in which a patient lacks firinogen in the 
loodstream.
Agar A solid, jelly-like culture medium usually provided in Petri dishes or tue
s.
Agglutination The clumping of particles (living or nonliving) in fluid. This is
often a visile
reaction that may e viewed under the microscope. Aggregate To come together or
cluster in a
mass. Agranular A classification used to descrie white lood cells that do not
have granules
in their cytoplasm. AIDS Acquired immune deficiency syndrome. Alumin A plasma p
rotein that
functions as a carrier molecule for transporting various chemicals throughout th
e ody. Alumin
also functions to prevent plasma from leaking out of the capillaries. Patients w
ith poor glycemic
control may have alumin present in their urine, indicating damage to the kidney
s. Aliquot A
small portion of the whole specimen. Alkalosis An increase in lood alkalinity r
esulting from
an increased numer of alkaline sustances or a decrease in the numer of acidic
sustances. The
pH will e elevated from the normal range in a state of alkalosis. Allergy An im
mune response
to a foreign antigen that results in a hypersensitivity to that antigen. The imm
une response
includes inflammation and dysfunction of ody organs or systems. Amulatory Ale
to walk or

transport oneself; not confined to ed. Amulatory care Care provided to patient
s who are ale
to amulate (walk) into the premises. Generally refers to physician offices, urg
ent care
facilities, emer- gency rooms, and the like. Amorphous phosphates A granular dif
fuse
precipitate in alkaline urine that is made up of crystallized calcium and phosph
ate. Amorphous
urates A granular diffuse precipitate in acidic urine that is made up of crystal
lized uric
acid. Anaeroes Bacteria that do not need oxygen for growth and reproduction. An
aeroic An
organism that does not need oxygen to survive and replicate. The growth of this
type of organism
is often actually inhiited y the presence of oxygen in its environment. Analys
is Assists with
differential diagnosis of congestive heart failure or respiratory disease. Analy
te A chemical
sustance that is eing tested or analyzed. Anemia A reduction in the oxygen-car
rying capacity
of the lood. Anion An ion that carries a negative charge. Elec- trolytes are io
ns when
dissolved in water, and those with a negative charge (such as chloride and icar
onate) are
anions. Anisocytosis Condition in which there is inequality in the size of red 
lood cells.
Glossary 1899_Glossary_507-528 22/12/11 2:17 PM Page 507 Antecuital area The ar
ea of the arm
that is directly in front of the elow. This is the preferred area for venipunct
ure procedures.
Anterior Directional term meaning to the front. Antiiotic sensitivity testing Per
formed to
determine how effective antimicroial therapy is against a certain type of acte
ria. Antiody A
protein sustance developed in response to antigenic exposure. Antiody-mediated
immunity A
term used to descrie an immune response using antiodies; the third line of def
ense.
Anticoagulants Sustances added to keep lood from coagulating or clotting. Anti
gen A
sustance that the ody detects as foreign or nonself. This may initiate the formati
on of
antiodies. Antiphospholipid syndrome A disorder with increased systemic thromi
formation, in
which patients have high levels of antiodies against phospholipids in their sys
tem. Anuria The
asence of urine production. Aperture An opening or hole through which a con- tr
olled amount of
a sustance, liquid, or light is admitted. Aplastic anemia Anemia caused y defi
cient red cell
production in the one marrow. Apolipoproteins Proteins that comine with and tr
ans- port
cholesterol in the loodstream. Arm Part of a microscope that connects the ase
of the
microscope to the tue where the optical lenses are attached. Arteries Blood ves
sels that carry
lood away from the heart. Arterioles Small arteries that lead into a capillary
at its distal
end. Artifacts Contaminating sustances in the urine speci- men that have no cli
nical

significance. Asepsis A term that means that a surface is without pathogenic mic
roorganisms.
Aseptic Free of pathogens. Assault A term used to descrie a threat to inflict i
njury, with
the apparent means to accomplish the threat. Asymptomatic Without symptoms or o
vious outward
signs of disease. Atherosclerosis Sclerosis or hardening of the arteries ecause
of the uildup
of a waxy, sticky coating on the inside of the vessel walls. Atrial firillation
A disorder in
which there is ineffective ejection of lood into the atria. Those with atrial f
irillation have
a rapid and irregular hearteat. Autoantiodies An antiody that is produced y
the ody
against the cells of the same ody. Autoantiodies are thought to e the cause o
f the destruction
of the insulin-producing islets of Langerhans, leading to type 1 diaetes. Autoi
mmune disease A
disease in which the ody does not recognize the antigens on the surface of its
own cells; it
sees these cells as nonself. Autoimmune response The response the ody when it n
o longer
recognizes all the cells of the ody as self and egins to damage these cells. B c
ells A type
of lymphocyte that rememers an antigen after exposure to it. Bacilli Bacteria t
hat are oval or
rod shaped when viewed under the microscope. Bacteria Single-cell microorganisms
that possess a
cell wall in addition to the cell memrane that human cells possess. Balanced Th
e practice of
placing a tue of equal size and similar volume across from the specimen to e p
rocessed in the
centrifuge. This allows the centrifuge to operate with symmetry, and not e pulle
d to one side
or the other as it spins. Band cell An immature, unsegmented neutrophil. Base Th
e ottom of a
microscope that sits on the ench top. Basic metaolic panel (BMP) A group of ei
ght tests that
have een approved y the CMS for overall health screening and/or for monitoring
certain disease
states. Basilic vein A vein in the antecuital area that is on the inner side (m
edial) running
over the top of the rachial artery. This vein is the last choice of the major v
eins in this area
for venipuncture procedures. Basophil A granulocytic white lood cell essential
to the
nonspecific immune response in inflammation. Battery Touching another without hi
s or her
consent. Beaker A glass container that may e used in the lao- ratory to hold,
mix, or heat
chemicals. Beakers usually have a cylinder shape and a flat ottom. Bence Jones
protein An
immunogloulin (protein) that is present in the renal tuules and excreted in th
e urine of
patients having multiple myeloma. Bevel The slanted area of the needle that crea
tes a sharp
point at the tip. Biliruin A product produced from the degradation of hemogloi
n; it is yellow
or orange in color. Biloed Having two loes or sections. 508 Glossary 1899_Glos
sary_507-528

22/12/11 2:17 PM Page 508 Binocular A term used to descrie a microscope that ha
s two oculars
so that oth eyes can e used at once to view the specimen. Biohazard symol Sym
ol used to
mark ags or con- tainers that hold items that are iohazardous in nature. Bioha
zardous waste
Liquid or semiliquid lood or other potentially infectious materials. This inclu
des contaminated items that would release lood (or OPIM) in a liquid or semiliquid state i
f compressed. It
also includes items that are caked with dried lood (or OPIM) that are capale o
f releasing these
sustances while eing handled. This classification also includes pathological o
r microiological
waste that contains lood or other potentially infectious materials. (See also R
egulated waste.)
Bladder The urinary ladder is a muscular sac that holds urine until it is expelle
d from the
ody. Blast Immature stage in cellular development. Blood urea nitrogen (BUN) A
y-product of
protein metaolism that should e cleared from the lood y the kidneys. Elevate
d amounts in the
lood are indicative of renal dysfunction. Bloodorne pathogens (BBPs) Pathogeni
c microorganisms present in human lood that are transmitted y direct contact to lood or m
ucous memranes
of another person. Bloodorne Pathogens Standard (1910.1030) A regula- tion crea
ted y the
Occupational Safety and Health Administration to educate and protect health-care
workers from
occupational exposure to lood or other potentially infectious materials. Origin
ally created in
1988; there have een several addendums since that time. Body mass index (BMI) A
statistical
calculation compar- ing the weight and height of a person. This calculation is u
sed to estimate
whether a patient may e overweight or underweight according to his or her weigh
t. Bowmans
capsule A portion of the renal tuules that collects the initial urinary filtrat
e when it is
forced from the glomerulus. Brain natriuretic peptide (BNP) Enzyme secreted y t
he muscular
walls of the ventricles. Broth A liquid culture medium. Buffer Compound that rea
cts with
strong acids or ases to minimize pH changes in the ody. Butterfly system A sys
tem used for
venipuncture that includes a short needle attached to a length of tuing. The tu
ing is then
attached to a syringe or directly to an evacuated tue for lood withdrawal. C&S
Culture and
sensitivity; includes the growth and identification of the acterial microorgani
sms present in a
specimen as well as the determination of the antiiotics est suited for treatme
nt of the
infection. Caliration Standardization of an instrument y com- parison of the r
esults produced
against those of a known value, and appropriate adjustment of the instrument as
needed to achieve
optimal results. Caliration verification The verification of the success of a c
aliration

process y analyzing quality control samples. Calyx A cup-like drainage vessel t

hat collects
urine as it is formed in the renal pyramids and transports the urine to the rena
l pelvis to e
expelled from the kidneys. Candle jar A setup using a jar and a candle that enco
urages growth
of acteria that prefer less oxygen in their environment. A candle is placed in
the jar with the
culture plates and then lit. The jar is closed tightly, and the candle uses up t
he oxygen in the
jar, after which it goes out. Capillaries The smallest lood vessels. Capillarie
s are
microscopic in size and connect the arterial and venous systems. Capillary actio
n A surface
tension that attracts liquid to fill a capillary tue or elevates liquid when to
uched y a solid.
Capillary puncture A method of lood collection during which an incision is made
in through the
skin, which passes through the epidermis into the dermal layer. Capillary tues
Small, hollow
plastic or glass tues used to perform microhematocrit testing. Carohydrate An
organic
molecule that is used as an energy source y the ody. Carohydrates are roken
down during
digestion to provide glucose, which is easily used y the cells of the ody. Car
cinogenic
Anything capale of causing cancer. Cardiovascular Pertaining to the heart, arte
ries, veins,
and/or capillaries. Carriers Someone who is infected (or carrying) a pathogen in
the ody
without symptoms. Sometimes these individuals may have already undergone the com
plete disease
process ut keep the causative agent in the lood, and sometimes they have never
een
symptomatic. Casts Protein shells formed in the glomerular tuules. Casts may e f
illed with
white cells, red cells, granules, or other sustances. All ut hyaline casts may
e clinically
significant. Glossary 509 1899_Glossary_507-528 22/12/11 2:17 PM Page 509 Catio
ns An ion that
carries a positive charge. Electrolytes are ions when dissolved in water, and th
ose with a positive charge (such as potassium and sodium) are cations. CD4 cell A type of lymp
hocyte (a white
lood cell) that is attacked y HIV. Cell mediated A term used to descrie all t
he activities
of the T cells during the specific immune response to an antigen. Centers for Di
sease Control and
Prevention (CDC) The premier pulic health agency in the United States. The CDC
is part of the
Department of Health and Human Services, and it protects the pulic health throu
gh research and
implementation of recommendations for education, vaccination, infection control,
and proper
treatment of disease. Centers for Medicare & Medicaid Services (CMS) The organiz
ation
responsile for enforcement of the CLIA regulations. Its memers perform site vi
sits and collect
the fees associated with the registration process. Centrifugal force An outward
force caused y

the rota- tion of an oject. The centrifugal force causes the speci- men that is
eing
centrifuged to separate into layers ased on their relative weight or density. C
entrifuge An
instrument that spins specimens at a high speed to force the contents outward an
d separate the
components as needed. Cephalic vein A vein in the antecuital area that is on th
e outer
(lateral) side of this area when the arm is placed in the appropriate position f
or a
venipuncture. Cererospinal fluid (CSF) samples Used to help diag- nose various
diseases of the
central nervous system. Chain of Custody A form used to document all those who h
ave possession
of or process a legal specimen through all the steps of collection, testing, and
disposal.
Chemotaxis The process that signals more white lood cells to come to the scene
of an invasion
y a foreign sustance. Cholesterol A soft, waxy lipid that is found in various
parts of the
human ody, including the loodstream. Chromatographic Analysis of sustances on
the asis of
color changes that occur during the testing process. Cilia Slim, thread-like pro
jections on the
inner surface of mucous memranes that sweep away foreign ojects such as pollen
and dust.
Cirrhosis A chronic liver disease characterized y scarring and ineffective func
tion. Clarity
The clearness of appearance. A term used to descrie urine transparency. Clean-c
atch midstream
urine specimen A procedure to e followed for urine specimen collection in which
the potential
for contamination with microorganisms from outside the urinary tract is minimize
d. CLIA 88
Clinical Laoratory Improvement Amendment of 1988. CLIA-waived Laoratory tests
that have een
determined y the FDA to fit this category. These tests are very simple to perfo
rm, need very
little interpretation, and result in minimal clinical significance if they are p
erformed or
interpreted incorrectly. Clinical chemistry The quantitative or qualitative mea
- surement of
clinical compounds in the fluid portions of the ody. This includes analysis of
lood, urine,
CSF, and other fluid specimens from the ody. Clinical significance Meaningful r
esults or
actions affect- ing the clinical outcome or treatment of a patient. Clot activat
ors Sustances
(such as silicone) that acceler- ate or aid in the clotting process within an ev
acuated tue.
Clotting cascade The clotting process in which each step is dependent on the ste
p prior until
the clot has een formed. Clotting factor Enzymes and chemicals that interact in
the clotting
cascade to form a clot. Coarse adjustment kno The kno used on a micro- scope t
o ring an
oject into approximate focus. Cocci Round acteria, which can then e classifie
d fur- ther y
their appearance when examined microscopically. COLA An independent company that
accredits

laora- tories. Colonies Clusters of microorganisms visile on a culture. Colori

metric
Analysis of the amount of a sustance pres- ent in a sample, ased on the amount
of light
asored y the sustance. True colorimetric analysis often uses an instrument c
alled a
colorimeter to read the results. Colorimetric may sometimes e used synonymously
with
chromatographic. Competency assessment A process used to verify whether an emplo
yee is
performing a testing procedure properly. Competency testing See Competency asses
sment.
Complement A protein that assists in the second line of defense y destroying pa
thogens and
sending signals to stimulate phagocytosis and inflammation. Complete lood count
(CBC) A
hematology test that includes hemogloin concentration, hematocrit, red lood ce
ll count, red
lood cell indices, white lood cell count, leukocyte differential, and a platel
et count. 510
Glossary 1899_Glossary_507-528 22/12/11 2:17 PM Page 510 Complexity Level of int
ricacy,
difficulty, or complication. Compound microscope A microscope that has two means
of
magnification that are compounded or multiplied for a higher level of magnificatio
n.
Comprehensive metaolic panel (CMP) A group of 14 tests ordered together to prov
ide a
comprehensive analysis of overall patient health. This panel has een approved f
or reimursement
y the CMS. Condenser A lens on many microscopes that concen- trates the light a
s it comes
through an aperture. Conjugated iliruin Biliruin that has een changed y the
liver to e
water solule. Conjugated iliruin is also known as direct iliruin. Contagiou
s Anything that
is capale of eing transmitted from one person to another. Contaminated sharps
Sharps (needles
or other sharp ojects such as lancets or glassware) that have een contaminated
with lood or
other potentially infectious materials. Essentially, any contaminated oject tha
t can penetrate
the skin. Contraindications Any reason that a procedure would e inadvisale or
inappropriate.
Coumadin An anticoagulant medication used to prevent or treat lood clots. Couma
din is taken
orally, and mon- itored with the PT/INR test. Cover slip A thin piece of glass o
r plastic that
is placed on top of a liquid specimen when viewed under the microscope. Creatine
kinase (CK) A
y-product of muscle metaolism. May also e known as CPK. Creatinine A y-produ
ct of muscle
metaolism that is cleared from the lood y the kidneys. Elevated levels of cre
atinine in the
lood may e indicative of renal dysfunction. Credentialed Formal recognition of
competence
achieved y an examination. ASCP provides credentialing opportunities to laorat
ory
professionals. Critical results Results that are very far outside the expected r
eference range

for a specific test and indicate a critical or crisis condition for the patient.
These results
are considered to e something that must e acted on immediately y notifying th
e health-care
provider who ordered the test. The critical result ranges are estalished y the
practice (in the
case of a physician office laoratory) or the pathologist in a larger laoratory
. Crystals The
precipitation of dissolved sustances in the urine. Some of these may e clinica
lly significant.
Culture The growth of microorganisms in special medium that contains chemicals a
nd/or nutrition
to encourage and support their growth. Current procedural terminology (CPT) code
s These codes
are developed and monitored y the American Medical Association and are assigned
to individual
procedures to e used for reimursement. Cyanmethemogloin A colored compound us
ed to measure
hemogloin. Hemogloin is converted to this form so that the color change can e
measured and
quantitated. Cylinder A slim, round glass container used to measure liquids in t
he laoratory
setting. D-dimer A reakdown product when clots are dissolved in the loodstream
. D-dimers are
specifically formed when firin is roken down. It is is used as a diagnostic to
ol for different
types of thromosis. Deep vein thromosis (DVT) Blood clots formed in the deep v
eins of the
extremities, especially the legs. Diaetes A general term used to descrie a gro
up of diseases
that demonstrate excessive urination. This is most commonly used to descrie dia
etes mellitus,
which is diaetes with hyperglycemia. Diaetes insipidus Diaetes characterized
y excessive
urination resulting from the inaility of the kidneys to concentrate urine. Dia
etes mellitus
Diaetes that includes high levels of lood glucose. Diaetes mellitus is caused
either y a
failure of the pancreas to produce insulin (type 1 diaetes) or y the resistanc
e of the cells of
the ody to the presence of insulin (type 2 diaetes). Diaetic ketoacidosis A c
ondition in
which the lood pH is acidic, caused y an accumulation of ketones from an exten
ded state of high
lood glucose. Diaetic neuropathy Nerve damage caused y vascu- lar and metaol
ic changes in
those with diaetes mellitus. This may cause numness, tingling, or pain, especi
ally in the
extremities. The loss of sensation in the feet may lead to serious damage. Diape
desis The
movement of white lood cells out of small arterioles, venules, and capillaries
as part of the
inflammatory process. Differential A procedure wherey a lood sample is stained
and WBCs are
identified and counted y type. Diluent A liquid (such as water or saline) used
to dilute
another ingredient. Diplococci Round acteria that appear in pairs when viewed u
nder the
microscope. Glossary 511 1899_Glossary_507-528 22/12/11 2:17 PM Page 511 Disclo
sure Sharing of

the patients information. Disinfection The application of a sustance to material

s and
surfaces to destroy pathogens. Disk-diffusion method A procedure in which antio
dy- impregnated
disks are used to test for antiiotic sensitivity on an agar plate. Dissecting m
icroscope A
microscope used to achieve a low level of magnification of three-dimensional oj
ects, often those
that are untreated and/or unstained. Disseminated intravascular coagulation (DIC
) A disorder in
which the coagulation process is stimulated throughout the ody instead of in a
localized area.
Distal convoluted tuule A section of the renal tuule that is surrounded y cap
illaries in the
nephron. The distal convoluted tuule is a twisted tuule that is distal to the
Bowmans capsule.
Distal urethra The part of the urethra that is closest to the outside of the od
y, or furthest
from the ladder. Diurnal variation The change seen in a urinary or lood chemic
al at different
times during a 24-hour day. Documentation Recording of pertinent information. Th
is may e
documentation of patient results, quality control results, or maintenance proced
ures, in a chart
or on maintenance charts or logs. Duress The use of threats to accomplish a goal
.
Dysfirinogenemia Any anormality in the structure or function of the firinogen
present in the
loodstream. Ectoparasites Parasites evident on the outside of their host. Edema
A condition
in which ody tissues contain an excessive amount of fluid. An edema an e local
- ized or
systemic, and can result from many disease processes. Efferent arteriole The art
eriole that
transports lood away from the center of the glomerulus. The efferent ar- teriol
e is smaller in
diameter than the afferent arteriole. Efficacy The capacity for producing a desi
red result or
effect; a measurement of how effective a mechanism is toward reaching a desired
goal. Electrical
impedance A process for counting lood cells that depends on their resistance to
the flow of an
electrical current. Electrolyte A sustance that is capale of conducting electr
icity when
dissolved in water. In the human ody, common electrolytes include sodium, potas
sium, and
chloride. Electron microscope A specialized microscope that uses electrons to cr
eate a visual
image with great detail. Electronic quality control devices Devices that are use
d to verify the
accuracy of an instrument. These electronic devices should produce results that
are within a
narrow range every time they are tested on the instrument. Emancipated Not const
rained or
restricted; in the case of emancipated minors, this is a legal procedure that re
leases a child
from the control of the parents, and releases any responsiility that the parent
s may have for
the child. Emolus A mass of undissolved material traveling in the loodstream.
An emolus may

e a lood clot that has roken away from its point of origin, or other foreign
material such as
a cluster of acteria. Endogenous cholesterol Cholesterol that is created y the
liver for use
in the ody. Endoparasites Parasitic infection within the host. Endothelial cell
lining Flat
epithelial cells that line the interior of the lood vessels. Engineering contro
ls Devices that
are used to limit or eliminate the potential for exposure to loodorne pathogen
s in the
workplace. Enuresis Inaility to control the flow of urine. Enzyme-linked immuno
sorent assay
(ELISA) testing Also called EIA testing, ELISA testing is a common method of ide
ntifying the
presence or asence of antiodies and/or antigens in a serum or plasma specimen.
Eosinophil
Granulocytic white lood cells with a loed nucleus and cytoplasmic granules tha
t stain
red/orange with Wrights stain. Eosinophils contriute to the destruc- tion of par
asites and to
allergic reactions y releasing chemical mediators. Epidemiology The study of th
e spread of
disease. Epithelial cells Cells from the epithelial lining of the urinary tract.
These may e
squamous, renal tuular epithelial cells, or transitional epithelial cells. They
are classified
according to their point of origin. Epstein-Barr virus (EBV) The virus that caus
es infectious
mononucleosis. Erythrolastosis fetalis A severe hemolytic disease of the newor
n characterized
y anemia and jaundice. Erythrocyte Mature red lood cell. Erythrocyte sedimenta
tion rate (ESR)
A nonspecific laoratory test of the speed at which erythrocytes settle out of a
nticoagulated
lood. Erythroid Pertaining to erythrocytes. Erythropoiesis The process that res
ults in the
formation of red lood cells. 512 Glossary 1899_Glossary_507-528 22/12/11 2:17 P
M Page 512
Erythropoietin A protein made y the kidneys that stimulates the proliferation o
f red lood
cells. Ethics Moral standards and ehavioral codes that dictate the ehavior of
an individual.
Etiology The cause of a disease. Eustachian tue A flexile hollow tue that ext
ends from the
middle ear to the nasopharynx. Evacuated tue system A system used to draw lood
that involves
the use of a multipoint needle, a needle holder, and an evacuated tue. Exogenou
s cholesterol
Cholesterol that is introduced to the ody through ingestion of meat and dairy.
Exposure control
plan A plan that must e created y employers to educate and help protect employ
ees from
loodorne pathogen exposure. This plan includes education, vaccination, safety
procedures, and
follow-up in case of exposure. Expressed consent Consent for a ehavior that is
ex- pressed
fully and personally y the patient; it may e an oral or written expression. Ex
ternal quality
control specimens Quality control spec- imens that are purchased from an outside
source, or

those that are included in a test kit, ut are separate from the testing system.
These are
usually liquid controls. Extracellular Outside the cells. Used to descrie sustances outside
the cells of the ody, in the plasma or interstitial fluid. Extrinsic pathway Pa
rt of the
lood-clotting cascade that includes chemicals that are secreted into the loodstream in
response to vessel injury. Exudate A fluid that is released from the human ody.
Exudates are
classified according to the solid su- stances present in the drainage, or the l
evel of protein
present. Eyepiece The part of the microscope for viewing. Fasting A period of at
least 12
hours during which a patient forgoes food or drink (other than water). Generally
done in
preparation for a lood specimen to e drawn. Fasting lood sugar (FBS) The gluc
ose level
performed in a laoratory on a fasting lood specimen. Fasting plasma glucose (F
PG) The level
of glucose tested in the plasma (liquid portion of the lood) after a patient ha
s fasted for at
least 8 hours. Fasting urine specimen Urine collected during the sec- ond mornin
g void. This
urine will indicate the state of the ody after a prolonged fast. Fecal occult 
lood testing
(FOBT) Testing that identifies the presence of occult (hidden) lood in the stoo
l. This test
screens for the early stages of colorectal cancer, as well as additional sources
of leeding.
Fecal occult lood Blood, which cannot e seen, that is present in the feces of
an individual.
Fecal-oral route A method of transmitting infective microorganisms. The pathogen
is shed in the
feces of the infected individual and then transferred to the skin. It is then sp
read to food,
water, inanimate ojects, or other people. Firates A class of medication used t
o treat
elevated triglyceride levels. Firates may also decrease the LDL levels, ut to
a lesser extent.
Firin degradation products (FDPs) Sustances present in the loodstream when cl
ot dissolution
occurs in the ody. Firin degradation products include the y-products of firi
nogen as well as
firin that may e involved in the lood clots. Firinogen A protein that is cre
ated in the
liver and is present in lood plasma. Firinogen is converted into firin y the
action of
ionized calcium. Firinolysis The reakdown of firin in lood clots, allowing t
hem to
dissolve. Firinolysis occurs sponta- neously in the ody, and can also e accom
plished y use of
medications. Firinolytic drugs Also called clot usters. Filtration The process
of removing
large particles from a solution y allowing the liquid to pass through a semiper
meale memrane.
Fine-adjustment kno The focusing kno used on the microscope to provide fine, d
etailed focus
at higher levels of magnification. First morning void A urine specimen collected
right after

waking from sleep. This specimen usually is more concentrated, and is the recomm
ended collection
method for some tests. Flanges Flared edges at the ottom of the evacuated tue
holder that
allow for leverage when inserting or removing a tue. Flask A glass container us
ed to mix or
store chemicals. Flasks are generally smaller at the top than they are at the o
ttom. Fomites A
sustance or surface that adheres to and transmits infectious microorganisms. Fo
rmed elements
(lood) The cellular components of lood: erythrocytes, leukocytes, thromocytes
. Formed
elements (urine) Sustances in the urine speci- men that may e viewed microscop
ically, such as
cells, acteria, and fungal elements. Glossary 513 1899_Glossary_507-528 22/12/
11 2:17 PM Page
513 Fraud A dishonest or deceitful act that is performed with the intent to hide
the truth.
Fungal elements Fungus microorganisms present in the urine specimen. The most co
mmon are yeast.
Fungi A type of microorganism that causes disease in humans. This type of infect
ion is called a
mycotic infection. Examples of fungal infections in humans are yeast infections,
athletes foot,
and thrush. Gammagloulin (also known as immune gloulin) A fluid that contains
active
antiodies against a particular antigen that may e given to offer short-term, i
mmediate
protection to the recipient. Gauge A term used to descrie the diameter of the h
ollow interior
portion of a needle. Gauge numer is inversely related to the size of the needle
. Gestational
diaetes Hyperglycemia detected during pregnancy in women who did not have diae
tes efore
ecoming pregnant. Glass slides A piece of finely ground glass that is uniform i
n shape.
Specimens are applied to the glass slide to e viewed under the microscope. Some
speci- mens
require staining or some sort of treatment efore viewing, whereas others are vi
ewed as they
appear naturally. Gloulin One of the group of plasma proteins that con- trols c
olloidal
osmotic pressure (oncotic pressure) within the capillaries, participates in the
immune response,
and inds with sustances to transport them in lood. Glomerular filtration The
filtration
process that occurs in the glomerulus. Because the afferent arteriole is much la
rger in diameter
than the efferent arteriole, pressure uilds up in the glomerulus, forcing filtr
ate and small
molecules from the capillary ed while retaining large molecules in the loodstr
eam. Glomerulus
A group of twisted capillaries encircled y the Bowmans capsule in the nephron of
the kidney.
The hydrostatic pressure in the glomerulus forces out the initial filtrate from
the lood, which
eventually ecomes urine. Glucagon A hormone created y the islets of Langer- ha
ns in the
pancreas that offsets the effects of insulin on the cells of the ody. Glucose A
type of sugar

in the loodstream that results from digestion of carohydrates. Glucose is the

most commonly
used energy source in the ody. Glucose challenge A process in which a patient i
s given a
glucose drink that contains 50 g of glucose to ingest. The lood is drawn for a
glucose test 1
hour after the glucose drink has een ingested. Glucose tolerance test A test th
at screens for
diaetes (or occasionally hypoglycemia), which involves serial lood draws follo
wing ingestion of
a drink containing glucose. Sometimes known as an oral glucose tolerance test, o
r OGTT. Glucose
tolerance urine specimen A specimen collected as part of a glucose tolerance tes
t. These are
tested specifically for the presence of glucose and sometimes for ketones. Gluco
suria The
presence of glucose in the urine. Glycated hemogloin Hemogloin that is irrever
sily changed
with the addition of glucose to the molecule. This occurs when there have een e
levated lood
glucose levels for an extended period of time. Glycemic control A term used to d
escrie the
alance or control of lood glucose levels. Good glycemic control means that the
patient does not
have extremely high or low levels of lood glucose. Glycogen A storage form of g
lucose when
there are excessive amounts present in the loodstream. Glycogen is stored in th
e liver and some
of the cells of the ody, to e used for energy when glucose levels are low. Gly
cogenolysis The
reakdown of glycogen to allow for the release of glucose when needed. This ofte
n occurs during
periods of fasting, or when there is an elevated need for energy, such as during
exercise.
Glycolysis The first steps of the use of glucose y the cells of the ody; a ser
ies of
reactions that convert glucose to pyruvic acid and energy. Glycosuria The presen
ce of sugar in
the urine. This may e glucose, pentose, galactose, or fructose. Further testing
is necessary to
identify the type of sugar present in the specimen. Glycosylated hemogloin (Hg
A1c) Hemogloin
that has een changed y the addition of glucose molecules to the protein. The m
easurement of the
percentage of glycosylated hemogloin in the lood provides an indi- cation of t
he glucose levels
present in the loodstream over the past 3 months. A sutype of hemogloin (H A
) is glycated
when the lood glucose is elevated for an extended period of time, as in the cas
e of uncontrolled
diaetes mellitus. Graduated cylinder A cylinder that is marked in differ- ent q
uantities for
measuring liquids. Gram stain A staining method that allows the classifica- tion
of acteria
dependent on the color of the stain that they asor. Gram-positive acteria ret
ain the crystal
violet dye used in the process, and appear purple. Gram-negative acteria do not
keep the crystal
violet 514 Glossary 1899_Glossary_507-528 22/12/11 2:17 PM Page 514 dye in their
cell memranes,

and instead asor the color from the safranin counterstain. They appear pink wh
en viewed under
the microscope. Granular A classification used to descrie white lood cells tha
t contain
granules in their cytoplasm. Granulocyte White lood cells that have names endin
g in phil
(neutrophil, eosinophil, and asophil) and have distinct granules visile in the
ir cytoplasm.
Granulocyte-macrophage colony-stimulating factor (GM- CSF) A glycoprotein that s
timulates the
production and functional activity of neutrophils, monocytes, and macrophages. G
uaiac A type of
tree resin used for fecal occult lood testing. Guaiac interacts with the heme i
n the hemogloin molecule present in red lood cells. If there is lood present, the interact
ion makes the
guaiac paper turn lue when hydrogen peroxide developer solution is added. Hangi
ng drop slide A
slide with a depression in the center. This allows a drop of fluid containing th
e specimen to e
suspended from a cover slip over the depression for oservation microscopically.
Hazard
communication standard A document created to educate and protect employees from
the chemicals
in use at their workplace. H A The normal adult hemogloin, composed of two alp
ha and two eta
chains. H A1c; HgA1c See Glycosylated hemogloin (HgA1c). Health Information
Portaility and
Accountaility Act (HIPAA) A federal law that affects the security, stan- dardiz
ation, and
confidentiality of health-care information. It also affects the rights of those
who have
insurance coverage when they change jos. Health careassociated infection An infe
ction
contracted y an individual at a health-care facility. Refers specifi- cally to
an infection that
the individual did not come into contact with in any other way. Helicoacter pyl
ori (H. pylori)
A type of acterium that causes gastric and duodenal ulcers. Hematocrit (Hct) Th
e volume of
erythrocytes packed y centrifugation in a given volume of lood. Hematology The
study of lood
and lood-forming tissues. Hematoma A mass of lood caused y damage to a lood
vessel.
Hematopoiesis Production and development of lood cells, normally in the one ma
rrow. Hematuria
The presence of lood in a urine specimen. Hemoconcentration A condition resulti
ng from a
tourni- quet that is too tight or is left on too long, causing a relative increa
se in the cells
in the antecuital area and possily resulting in erroneous test results. Hemocy
tometer A
counting chamer for determining the numer of cells in a stated volume of lood
. Hemogloin
The protein in red lood cells that carries oxygen. Hemogloin (Hg) The iron-co
ntaining
pigment of red lood cells that carries oxygen from the lungs to the tissues. He
mogloin and
hematocrit (H&H) Hemogloin and hematocrit testing is often ordered together as
H&H. Hemogloin

electrophoresis The movement of hemoglo- in on a medium as a result of changes

in electrical
potential, used to determine type of hemogloin present. Hemogloinopathies Any
one of a group
of genetic diseases caused y or associated with the presence of one or several
forms of anormal
hemogloin in the lood. Hemogloinuria Hemogloin in the urine. Hemolysis The d
estruction
(lysis) of the red lood cell memrane with the release of the fluid contents. A
visi- le
reddish tint ecomes evident in the plasma if there is marked hemolysis in the s
pecimen.
Hemolytic disease of the neworn (HDN) A neonatal disease, usually the result of
an Rh
incompatiility in which the antiodies of the mother cross the placenta and atta
ck the
neonate. May cause neonatal anemia, jaundice, edema, and enlargement of the live
r and spleen.
Hemolytic uremic syndrome An anormal reaction to infection with the E. coli str
ain O157:H7.
The E. coli acteria secrete a toxin that causes an inflammatory process, result
ing in lood clot
formation in the capillary vessels of the ody. As the red lood cells of the o
dy pass through
these clogged capillaries, it causes them to ecome damaged, which consequently
causes damage to
the kidneys as they attempt to process these damaged cells. The patient must e
treated for the
anemia and renal failure immediately. Hemophilia Blood-clotting disorders in whi
ch the patients
have deficiencies of specific clotting factors. Hemostasis A stoppage of leedin
g or of
circulation. Heparin A naturally occurring anticoagulant in the human ody. Hepa
rin is also
provided as a fast-acting anticoagulant, administered via IV or sucutaneously.
Hepatic function
panel A group of tests that are ordered together to monitor liver function. Glos
sary 515
1899_Glossary_507-528 22/12/11 2:17 PM Page 515 Hepatitis Inflammation of the li
ver. Hepatitis
may e caused y a viral infection or other disease state that causes the liver
to e inflamed.
Hepatitis A virus (HAV) A type of virus that causes inflammation of the liver in
infected
patients. Hepatitis A is transferred via the fecal-oral route, and usually does
not cause
permanent liver damage. Vaccinations are availale for this disease. Hepatitis B
virus (HBV) A
type of virus that causes inflammation of the liver in infected patients. Hepati
tis B is
loodorne, and is transferred through sexual contact, contaminated needles, muc
ous memrane
exposure, or other direct lood-to-lood contact. Hepatitis B infection may lead
to permanent
liver damage. Hepatitis B is the most common loodorne pathogen to e transmitt
ed to health-care
workers. There are vaccinations availale for this disease. Hepatitis C virus (H
CV) A
loodorne virus that causes inflammation of the liver. Hepatitis C infection us
ually leads to

permanent liver damage, and is often asympto- matic until the liver damage has 
ecome quite
advanced. There is no vaccination availale for this disease. Hepatitis D A type
of virus that
causes liver inflammation. This is considered a genetic mutation or variant of t
he hepatitis B
virus, as it is present only in those who are already infected with hepatitis B.
There is no
vaccination for this disease. Heterophile antiody A nonspecific type of antiod
y that is
present in those with infectious mononucleosis. Heterophile antiodies are also
present in other
inflam- matory situations. Heterozygous A genetic term in which the two genes fo
r one
characteristic are not the same. High complexity Laoratory tests that have een
deter- mined
y the FDA to e complex enough so that the procedures can e performed only y
highly trained
laoratory professionals. High-density lipoprotein (HDL) A lipid sugroup; this
is known as the
good cholesterol ecause it helps to reduce the plaque uildup on the interior of
the lood
vessels. Hilum The indented (concave) portion of the kidney. Histamine A sustan
ce produced
y the ody in response to antigenic exposure that causes dilation of the lood
vessels,
increased secretion of acid in the stomach, smooth muscle constriction, mucus pr
oduction, tissue
swelling, and itching (during allergic reactions). Histogram A graph of the dist
riution of
cell sizes made during cell counting on an automated analyzer. Homeostasis The i
nternal alance
of the ody that is necessary for good health. Homeostasis includes minor adjust
ing to outside
stimuli. Homozygous A genetic term in which the two genes for one characteristic
are the same.
Hospital laoratories Laoratories that are usually housed within a hospital and
provide
services primarily to patients of that institution. Hospital laoratories may e
owned y the
hospital or contracted to provide their services. Human chorionic gonadotropin (
HCG) A hormone
that is secreted y the tropholasts of a fertilized ovum early in pregnancy. Th
is hormone
maintains the corpeus luteum so that it will secrete estrogen and progesterone.
The presence of
HCG in lood and urine is indicative of pregnancy. Human immunodeficiency virus
(HIV) This is a
retro- virus that invades the CD4 cells of humans and causes the failure of thei
r immune systems.
Infection leads to the eventual development of AIDS. It is a loodorne pathogen
, and may e
transmitted through sexual contact, mucous memrane exposure, or parenteral expo
sure.
Hyperchromic Pertaining to excess hemogloin concen- tration in the erythrocyte.
Hyperglycemia
Blood glucose levels elevated aove acceptale reference ranges. Hyperkalemia El
evated levels
of potassium in the lood plasma. Hyperlipidemia Excessive levels of lipid in th
e lood-

stream. Hypernatremia Elevated levels of sodium in the lood plasma. Hyperthyroi

dism A
condition in which the thyroid gland is overactive. Hypochromic A condition of t
he lood in
which the erythrocytes have a reduced hemogloin content and appear pale in colo
r.
Hypofirinogenemia Low levels of circulating firinogen in the loodstream. Hypo
glycemia
Decreased lood glucose levels elow acceptale reference ranges. Hypokalemia De
creased levels
of potassium in the lood plasma. Hyponatremia Decreased levels of sodium in the
lood plasma.
Hypothyroidism A condition in which the thyroid gland is underactive. 516 Glossa
ry
1899_Glossary_507-528 22/12/11 2:17 PM Page 516 Icteric A term used to descrie
the serum or
plasma of a patient with hepatic dysfunction. An icteric specimen has a yellowis
h green color.
iFOB An acronym used to descrie an immunochemical method of testing for fecal o
ccult lood. It
uses an antigen- antiody interaction with the gloin portion of the hemo- gloi
n molecule and is
an alternative testing procedure to the guaiac method for the presence of fecal
occult lood.
Immunity Protection from diseases. Immunogloulins Plasma proteins that play a r
ole in
protection from disease. These may occur on the surface of the lymphocytes, or m
ay e secreted in
response to antigenic exposure. Immunology The study of the components of the im
mune system and
their function. Impaired fasting glucose (IFG) A term used to descrie prediaet
ics who exhiit
elevated fasting plasma glucose levels. Impaired glucose tolerance (IGT) A term
used to
descrie prediaetics who exhiit elevated glucose levels after drinking a gluco
se solution.
Implied consent Consent for a procedure that is implied y the actions of the in
dividual.
International Classification of Diseases, 9th ed. (ICD-9) Codes assigned y the
CDC to symptoms
or disease states. These codes must e included for reimursement for laoratory
procedures. In
vitro Latin for in glass, referring to testing done outside of the ody. In vivo L
atin for
in the living ody, referring to some- thing occurring inside the ody, such as
antigen-antiody reactions within a living suject. Incuators A device y which
the
temperature, and sometimes humidity, of the environment can e controlled. Incu
ators are often
used to help acterial specimens grow for testing or to assist with the completi
on of a testing
procedure. Indwelling catheter A plastic tue that is allowed to remain in the u
rinary ladder
for a period of time to facilitate drainage of urine as it is formed. Infection
A disease state
caused y pathogenic microor- ganisms, including acteria, viruses, parasites, o
r fungi.
Infections may e localized or may spread throughout the ody. Symptoms often in
clude pain,
fever, redness and swelling, and loss of function. Infection control Policies an

d procedures to
help minimize the spread of infection and to analyze data in relation to infecti
on within a
health-care facility. Infectious A term used to descrie a suject who is capal
e of
transmitting disease to others. The transmission may occur directly or indirectl
y. Inflammation
A immunological defensive mechanism of the ody, including increased lood flow,
tissue swelling,
increased white lood cell presence, and release of chemical toxins. Informed co
nsent Approval
that is otained in writing after the patient has een informed aout the specif
ics of the
proposed procedure, the risks of the procedure, alternative treatments, and info
rmation aout
what may happen if the patient decides against the procedure. Inoculation Additi
on of a
specimen to a culture medium for growth. Insulin A hormone produced y the islet
s of Langerhans
of the pancreas. Insulin is necessary for the cells of the ody to asor glucos
e to e utilized
as energy. Insulin dependent Diaetes that requires injections of insulin to con
trol lood
glucose levels. Patients with type 1 diaetes are usually insulin dependent. Ins
ulin resistance
A condition in which cells have a diminished aility to interact appropriately w
ith insulin.
Intentional tort A wrongful act that is committed y one person against another
person
delierately. Interferons A group of proteins produced in the ody having antivi
ral properties.
Interleukin A hematopoietic growth factor affecting growth and differentiation o
f lymphocytes.
Intermittent (straight) catheter A catheter (hollow, plastic tue) placed direct
ly into the
ladder to facilitate drainage. The catheter is removed as soon as the ladder h
as drained.
Internal quality control Quality control that is uilt into the testing kit, pro
vided y the
manufacturer. International normalized ratio (INR) A mathematical calculation us
ed to
standardize treatment ased on pro- thromin time (PT) results. PT results may v
ary, depending on
lot numers of reagents and different instruments used for testing. The INR is a
calculation that
takes these vari- ales into account and provides a tool for monitoring those pa
tients on
anticoagulant therapy. Most patients on anticoagulant therapy should have an INR
etween 2.0 and
3.0. Interstitial Between the cells. Interstitial fluid The fluid etween cells.
Intracellular Within the cells. Intravascular lysis The destruction of red lood
cells within
the vessels of the ody. Glossary 517 1899_Glossary_507-528 22/12/11 2:17 PM Pa
ge 517 Intrinsic
factor A glycoprotein secreted y the parietal cells of the gastric mucosa, nece
ssary for the
asorption of vitamin B 12 . Intrinsic pathway Part of the lood-clotting cascad
e that uses
chemicals that are normally present in the loodstream. Ions An atom or group of
atoms that has

lost or gained electrons so that it possesses an electrical charge. Elec- trolyt

es are sustances
that ecome ions when dissolved in water. Iris diaphragm A device with a varial
e diameter that
controls the amount of light that is used to view a specimen through a microscop
e.
Iron-deficiency anemia Anemia resulting from a greater demand on stored iron tha
n can e
supplied. Ischemia An insufficient supply of lood to an organ or ody part. Thi
s term is often
used to descrie a lack of lood flow to areas of the heart when the patient has
atherosclerosis,
causing partial lockage of the vessels. Islets of Langerhans Specialized groups
of pancreatic
cells that produce insulin and glucagon. Insulin and glucagon are necessary for
controlling the
levels of lood glucose in the ody. Jaundice A yellow staining of ody tissues
and the fluids
of the ody as a result of excess iliruin in the loodstream in patients with
hepatic
dysfunction. Ketones A chemical that is elevated in the loodstream with increas
ed fat
metaolism. This is usually associated with dysfunctional carohydrate utilizati
on, as