PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE

SNEM – BSMT [A.Y. 2022-2023] I Instructor: Rochelle Ann M. Relucio, RMT, MSMT

LESSON 1: LABORATORY SAFETY AND HAZARD

LABORATORY SAFETY Note:
- Healthcare facilities / Institution have Infection Control
Safety begins with the recognition of hazards and is achieved
Program
through the following: - Different facilities, different protocols
➢ Application of common sense (think before you act) - These laboratories cannot operate without Infection
➢ Listen to the instructions Control Program
➢ A safety-focused attitude CDC → Universal Precautions (1985)
➢ Good personal behavior
o Blood and body fluid precautions should be consistently
➢ Good housekeeping in all laboratory work and
used for all patients
storage areas
Note:
➢ Continual practice of good laboratory technique
- All body fluids are treated as INFECTIOUS (even sweat
Two Primary Causes of Accidents
and urine)
o Unsafe activities
o Unsafe environmental conditions (i.e., broken pipes or BIOLOGICAL HAZARD
leaking gasses) 1. Infectious agents – source of biological hazard; consist
Safety Equipment of bacteria, fungi, parasites, and viruses. Microorganisms
o Safety showers and eye wash station (used in case of that cannot be seen by naked eye,
spillage) 2. Reservoir - is the location of potentially harmful
o Fire extinguisher microorganisms, such as a contaminated clinical
o Fume hood specimen or an infected patient. It is the place where the
o Biosafety cabinets infectious agent can live and possible multiply. Humans
o Personal Protective Equipment and animals make excellent reservoirs. (i.e., human; dito
NOTE: Laboratory cannot operate without safety equipment
sila nabubuhay, nags-stay for a while, for multiplication
TYPES OF SAFETY HAZARD and possible infection)
TYPE SOURCE POSSIBLE Fomites - these are equipment and other soiled
INJURY inanimate objects will serve as reservoirs, particularly if
Biological Infectious agents (infections) they contain blood, urine, or other body fluids. (i.e., chair,
Bacterial, fungal, doorknob, bed, etc.)
viral, or parasitic 3. Portal of Exit - infectious agent must have a way to exit
Sharps Needles, lancets, Cuts, punctures the reservoir to continue the chain of infection. This can
broken glass or blood-born
be through the mucous membranes of the nose, mouth,
pathogen
and eyes, and in blood or other body fluids.
exposure
4. Mean of Transmission – this include:
Chemical Preservatives and Exposure to toxic,
reagents carcinogenic (can a. Direct contact: the unprotected host touches the patient,
cause cancer), or specimen, or a contaminated object
caustic agents b. Airborne: inhalation of dried aerosol particles circulating on
Radioactive Equipment and Radiation air currents or attached to dust particles (i.e.,
radioisotopes exposure mycobacterium tuberculosis)
Electrical Ungrounded or Burns or shock c. Droplet: the host inhales material from the reservoir (i.e.,
wet equipment; respiratory droplets)
frayed cords d. Vehicle: ingestion of a contaminated substance
Fire / Explosive Bunsen burner, Burn, e. Vector: from an animal or insect bite (i.e., dengue; vector =
organic dismemberment mosquitoes)
chemicals Note:
Physical Wet floors, heavy Falls, sprains, or - Mean of transmission also depends on the
boxes, patients strains organism(s)
Note:
- Most of these hazards can be experienced inside the 5. Portal of Entry - can be the same as the portal of exit,
laboratory which includes the mucous membranes of the nose,
BIOLOGICAL HAZARD mouth, and eyes, breaks in the skin, and open wounds.
o Refers to biological substances that pose a threat to the (i.e., there are certain microorganisms that can be
health of living organisms, primarily that of humans. transmitted through ingestion; portal of entry = through
o These microorganisms are frequently present in the mouth)
specimens received in the clinical laboratory. 6. Susceptible Host - can be another patient during
Infection Control invasive procedures, visitors, and healthcare personnel
when exposed to infectious specimens or needlestick
o Healthcare facilities developed procedures to control
injuries
and monitor infections occurring within the facilities
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
STORAGE AND HANDLING OF CHEMICALS
o Flammable / Combustible Chemicals – classified
according to flash point → the temperature at which
sufficient vapor is given off to form an ignitable
mixture with air
o Corrosive Chemicals – injurious to the skin or eyes by
direct contact or to the tissue of the respiratory and
gastrointestinal tract if inhaled or ingested.
o Reactive Chemicals – spontaneously explode or
ignite or that evolve heat or flammable or explosive
gases.
o Chemical Labelling: Hazardous chemicals should be
labeled with a description of their particular hazard, such
as poisonous, corrosive, flammable, explosive,
teratogenic, or carcinogenic

Chain of Infection
o Proper hand hygiene, correct disposal of contaminated
materials, and wearing personal protective equipment
(PPE) are of major importance in the laboratory.
OSHA Blood-Borne Pathogens standard requires written MATERIAL SAFETY DATA SHEETS (MSDS) – each
“Exposure Control Plan” chemical used in the laboratory has MSDS wherein it
contains specific details of the chemicals.
Categories of Exposure:
1. Physical and chemical characteristics
a. Category I – daily exposure to blood and body fluids
2. Fire and explosion potential
b. Category II – regular exposure to blood and body fluids
3. Reactivity potential
c. Category III – no exposure to blood and body fluids
4. Health hazards and emergency first aid
NOTE: Employers must offer HBV vaccine to all personnel
procedures
(Category I and II)
5. Methods for safe handling and disposal
Note: 6. Primary routes of entry
- Specimens should be “capped” during centrifugation 7. Exposure limits and carcinogenic potential
- Any blood, body fluid, or other potentially infectious FIRE HAZARD
material spill must be cleaned up using o The Joint Commission on Accreditation of Healthcare
➢ Spill cleanup kit Organizations (JCAHO) requires that all health-care
➢ Common aqueous detergent
institutions post evacuation routes and detailed plans to
➢ 10% bleach using appropriate contact time
follow in the event of a fire.
CHEMICAL HAZARD o Laboratory personnel should be familiar with these
o Chemical spills and Exposure: When skin contact procedures. When a fire is discovered, all employees are
occurs, the best first aid is to flush the area with large expected to take the actions in the acronym
amounts of water for at least 15 minutes and then seek
medical attention. • Rescue
o Chemical Handling: Chemicals should never be mixed • Alarm
together unless specific instructions are followed, and • Contain
they must be added in the order specified. (This is • Extinguish / Evacuate
particularly important when combining acid and water). o The National Fire Protection Association (NFPA) has
o Chemical Hygiene Plan: OSHA also requires all facilities developed the Standard System for providing codes and
that use hazardous chemicals to have a written chemical standard information about the chemicals/solutions.
hygiene plan (CHP) available to employees. The purpose ➢ NFPA 704 – hazardous material symbol
of the plan is to detail the following: ➢ Usually found in a chemical bottle / label
➢ Appropriate work practices, Standard operation ▪ Blue – health hazard
procedures, PPE, Engineering controls, such as ▪ Red – fire hazard
fume hoods and flammable safety cabinets, ▪ Yellow – reactivity
Employee training equipment's and Medical ▪ White – specific hazard
consultation guidelines. ▪ Numbers – degrees (level)

2|Mangalindan, S.N.
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
ELECTRICAL HAZARD
o Equipment should not be operated with wet hands.
o Designated hospital personnel monitor electrical
equipment closely; however, laboratory personnel
should continually observe for any dangerous
conditions, such as frayed cords and overloaded circuits
o Equipment that has become wet should be unplugged
and allowed to dry completely before reusing.
Equipment also should be unplugged before cleaning.
o All electrical equipment must be grounded with three-
pronged plugs
SHARP HAZARD
o Pertains to needles, lancets, broken glassware/glass
slides
o All sharp objects must be disposed in puncture-resistant,
leak-proof container with the biohazard symbol
Note:
- Exposure to blood or other body fluids can cause
possible infection
- There are certain blood pathogens that can be
transmitted
PHYSICAL HAZARD
o Physical hazards are not unique to the laboratory, and
routine precautions observed outside the workplace
apply.
o General precautions to consider are:
➢ to avoid running in rooms and hallways,
➢ watch for wet floors,
➢ bend the knees when lifting heavy objects,
➢ keep long hair pulled back,
➢ avoid dangling jewelry,
➢ and maintain a clean, organized work area.
➢ closed-toed shoes that provide maximum support
are essential for safety and comfort.
MECHANICAL HAZARD
o Centrifuges → must be balanced to distribute the load
equally.
➢ Never open the lid until the rotor has come to a
complete stop (to avoid accident, spillage, etc.)
➢ Load must be equally distributed (to balance)
DISPOSAL OF HAZARDOUS MATERIALS
Biological / Biohazardous Waste
o All biological waste (EXCEPT URINE) should be placed in
appropriate containers labeled with biohazard symbol.
URINE: may be discarded by pouring it into the lab sink.
▪ The sink should be flashed also with water after the
urine has been discarded.
▪ Decontaminate the sink by 1:5 or 1:10 dilution of
sodium hypochlorite (bleach solution).
RADIOACTIVE HAZARD ▪ Disinfection of the sink should be performed daily.
o Equipment and radioisotopes Empty urine containers can be discarded as
o Radiation Safety nonbiologically hazardous waste.
➢ All areas where radioactive materials are used or stored o Incineration, inactivation, burial, chemical disinfection,
must be posted with caution signs, and traffic in these encapsulation in a solid matrix
areas should be restricted to essential personnel only.
Note:
➢ Exposure to radiation during pregnancy presents a
- Some microorganisms ay hindi agad namamatay, that
danger to the fetus, and personnel who are or who think
is why need muna gumamit ng autoclave before i-
they may be pregnant should avoid areas with this symbol.
discard.
➢ The symbol must be displayed on the doors of all
- Might cause infection if improper disposal is practiced
areas where radioactive material is present.

3|Mangalindan, S.N.
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
Segregation of Hospital Bio-Medical Waste

Chemical Waste
o Flush water-soluble substances down the drain with large
quantities of water
o Strong acids and bases should be neutralized before
disposal
o Foul smelling chemicals should never be disposed down
the drain
o Flammable solvents → collected in approved
containers
o Flammable material → specially designed incinerators
o Solid chemicals → landfill
Waste Disposal Technique
o Incineration
o Recycling
o Landfill burial
o Flushing down the drain

4|Mangalindan, S.N.
PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
SNEM – BSMT [A.Y. 2022-2023] I Instructor: Rochelle Ann M. Relucio, RMT, MSMT

LESSON 2: INTRODUCTION TO PHLEBOTOMY

HISTORY OF PHLEBOTOMY ADDITIONAL DUTIES
o “An incision into a vein” 1. Training other health-care
o Oldest medical procedures by early Egyptians personnel to perform
o “Bloodletting” is first used to cure diseases and phlebotomy
maintain the body in a state of well-being 2. Monitoring the quality of
o Hippocrates believed that disease was caused by an samples collected on the
excess of body fluids, including blood, bile, and phlegm, units
and that removal of the excess would cause the body to 3. Evaluation of protocols
return to or maintain a healthy state. associated with sample
o Bloodletting is now called “therapeutic phlebotomy” collection
o Greek “Phleb” (vein) and “tomia” (to cut) - Oldest 4. Performing and monitoring
medical procedure dating back to the early Egyptians point-of-care testing (POCT)
Note: 5. Performing electrocardiograms
- Blood: used for diagnosis and therapeutic purposed 6. Performing measurement of patient’s vital signs
(therapeutic – i.e., blood transfusion) 7. Collection of arterial blood samples
- Pope Innocent VII: the first person who got blood transfusion
8. Collection of samples from central venous access
but through ingestion
devices (CVADs)
TECHNIQUES FOR BLOODLETTING (earlier times) Note:
Includes: - POCT: bedside tests (i.e., blood typing, glucose monitoring,
a. Suction cup devices with lancets that pulled blood from etc.) – refers to any tests that can be done bedside.
the incision - RMTs are NOT ALLOWED to draw arterial blood unless with
proper training (usually done by respiratory therapists)
b. The application of blood-sucking worms called
“leeches” to an incision PROFESSIONAL & PERSONAL CHARACTERISTICS
c. Barber Surgery – blood from an incision produced by 1. Dependable, cooperative, committed
the barber’s razor was collected in a bleeding bowl 2. Compassionate, courteous, respectful
PHLEBOTOMY 3. Integrity, honesty, competence
4. Organized, responsible, flexible
o Primary role of phlebotomy is the collection of blood
5. Appearance (Clothing, Hygiene)
samples for laboratory analysis to diagnose and monitor
medical conditions. 6. Communication (avoid using jargons)
o Phlebotomist is cross-trained in venipuncture, capillary ➢ Verbal Skills
collection, patient care, receptionist duties, sample ➢ Nonverbal Skills
processing and computer work. ➢ Body Language
7. Respecting Cultural Diversity
DUTIES OF A PHLEBOTOMIST 8. Telephone skills
TRADITIONAL DUTIES ETHICAL AND LEGAL ISSUES
1. Correct identification and preparation of the patient o Principles of right and wrong, called the code of ethics,
before sample collection. provide the personal and professional rules of
2. Collection of the appropriate amount of blood by performance moral behaviour as set by members of a
venipuncture or dermal puncture for the specified profession. Medical ethics or bioethics focus on the
tests. patient to ensure that all members of a health-care team
3. Selection of the appropriate sample containers for the possess and exhibit the skill, knowledge, training,
specified tests. professionalism, and moral standards necessary to serve
4. Correct labelling of all samples with the required the patient.
information. (Labelling – full name, age, sex, date and
PATIENT’S RIGHT (DOH)
time of collection)
5. Appropriate transportation of samples back to the 1. Right to Appropriate Medical Care and Humane
laboratory in a timely manner. Treatment
6. Effective interaction with patients and hospital ➢ “Without any discrimination and within the limits of
personnel. the resources”
➢ “Human dignity, convictions, integrity, individual
7. Processing of samples for delivery to the appropriate
needs and culture shall be respected”
laboratory departments.
8. Performance of computer operations and record- ➢ “If any person cannot immediately be given
keeping pertaining to phlebotomy. treatment that is medically necessary he shall, either
9. Observation of all safety regulations, quality control be directed to wait for care, or be referred
checks, and preventive maintenance procedures. elsewhere, where the appropriate care can be
provided”
10. Attendance at continuing education programs
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
o Battery: actual harmful touching of a person without his
2. Right to Informed Consent
or her consent.
➢ Clear, truthful and substantial explanation, in a
o Defamation: spoken or written words that can injure a
manner and language understandable to the
person’s reputation.
patient, of all proposed procedures, whether
➢ e.g., releasing or are overheard saying any
diagnostic preventive, curative, rehabilitative, or
confidential information
therapeutic
o Libel: false defamatory writing that is published.
➢ Person who will perform the said procedure shall
o Slander: false and malicious spoken word.
provide his name and credentials to the patient
o Invasion of Privacy: is the violation of the patient’s right to
3. Right to Privacy and Confidentiality
be left alone and the right to be free from unwanted
➢ The patient has the right to demand that all
exposure to public view.
information, communication, and records
➢ e.g., unwanted releasing of confidential
pertaining to his care be treated as confidential
information is considered an invasion of privacy.
4. Right to Information
➢ e.g., entering a patient’s room without asking
➢ Right to be informed of the result of the evaluation
permission
of the nature and extent of his/her disease
5. Right to Choose Health Care Provider and Facility - Medical Malpractice: misconduct or lack of skill by a
➢ The patient is free to choose the health care health-care professional that results in injury to the
provider to serve him as well as the facility except patient.
when he is under the care of a service facility or - Negligence: as failure to give reasonable care by the
when public health and safety so demands or health-care provider, must be proven in a malpractice
when the patient expressly waives this right in suit
writing. In phlebotomy, be wary of the following that may cause the
➢ The patient has the right to discuss his condition patient to file a case of malpractice/negligence against you:
a. Nerve Injury
with a consultant specialist, at the patient's
b. Hemorrhage
request and expense
➢ From accidental arterial puncture
6. Right to Self-Determination
➢ From inadequate pressure to the vein
➢ The patient has the right to avail himself/herself of c. Drawing from inappropriate locations
any recommended diagnostic and treatment ➢ i.e., same side as mastectomy
procedures d. Injuries occurring when a patient faints
➢ Any person of legal age and of sound mind may e. Death of a Patient caused by misidentification of a
make an advance written directive for physicians to patient or sample
administer terminal care when he/she suffers
terminal illness
7. Right to Religious Belief
➢ The patients has the right to refuse medical
treatment or procedures which may be contrary to
his religious beliefs. Provided that such a right shall
not be imposed by parents upon their children
who have not reached the legal age in a life
threatening situation as determined by the
attending physician or the medical director of the
facility
8. Right to Medical Records
9. Right to Leave
10. Right to Refuse Participation in Medical Research
➢ Provided, that, an institutional review board or
ethical review board n accordance with the
guidelines set in the Declaration of Helsinki be
established for research involving human
experimentation.
TORT
o A wrongful act committed by one person against another
that causes harm to the person or his or her property.
INTENTIONAL TORT UNINTENTIONAL TORT
✓ Assault ✓ Negligence
✓ Battery ✓ Malpractice
✓ Defamation
o Assault: threat to touch another person without his or her
consent and with the intention of causing fear of harm.

2|Mangalindan, S.N.
PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
SNEM – BSMT [A.Y. 2022-2023] I Instructor: Rochelle Ann M. Relucio, RMT, MSMT

LESSON 3: VENIPUNCTURE EQUIPMENT

o Multisample needles
REQUISITION FORM
have the stopper
o CLSI Mandate: Verify
puncturing needle
Patient Information
covered by a rubber
from at least 2 sources
sheath that is pushed back
when a tube is attached
and returns to full needle
coverage when the tube is
removed. This prevents
leakage of blood when
tubes are being changed.
o All needles consist of a
bevel (angled point), shaft, lumen, and hub
NEEDLE DISPOSAL SYSTEM
Needles with safety
devices activated
must always be
placed in rigid,
puncture-resistant,
leak-proof
disposable “sharps”
containers labelled
BIOHAZARD that are
easily sealed and locked when full.
NEEDLE / TUBE HOLDER
o Made of rigid plastic and may
be designed to act as a safety
shield for the used needle.
EVACUATED TUBE SYSTEM (ETS) COLLECTION TUBES
o The evacuated o Tubes used for blood collection
tube system are called evacuated tubes
consists of a because they contain a
double-pointed premeasured amount of
needle to puncture vacuum.
the stopper of the o Evacuated tubes are available
collection tube, a in glass and plastic.
holder to hold the o Tubes may also contain
needle and blood anticoagulants and additives.
collection tube, The tubes are labeled with the
and color-coded type of anticoagulant or
evacuated tubes. additive, the draw volume, and
NEEDLES the expiration date.
o Venipuncture needles include multisample needles, o Tests requiring whole blood or
hypodermic needles, and winged blood collection plasma are collected in tubes
needles. containing an anticoagulant to
o Sterile, disposable, and are used only once. prevent clotting of the sample.
o Needle size varies by both length and gauge (diameter) Anticoagulants prevent clotting
➢ For routine venipuncture: 1-inch and 1.5-inch by binding calcium or inhibiting thrombin in the
lengths are used coagulation cascade.
➢ Needle gauge refers to the diameter of the needle ➢ Ethylenediaminetetraaceticacid (EDTA), citrates,
bore and oxalates are the most common anticoagulants
➢ Needles vary from large (16-gauge) needles used to that work by binding calcium.
collect units of blood for transfusion to much smaller ➢ Heparin prevents clotting by inhibiting the
(23-gauge) needles used for very small veins formation of thrombin necessary to convert
➢ The smaller the gauge number the bigger the fibrinogen to fibrin in the coagulation process.
diameter of the needle.
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
Evacuated Tubes: SERUM TUBES Black Top
1. GLASS TUBES • Black stopper tubes containing buffered sodium
• No clot activator citrate are used for Westergren sedimentation rates
• No anticoagulant / Erythrocyte Sedimentation Rate (ESR). They
• Clear differ from light blue top tubes in that they provide a
2. PLASTIC TUBES ratio of blood to liquid anticoagulant of 4 to 1.
• With clot activator and Specially designed tubes for Westergren
gel separator sedimentation rates are available.
• No anticoagulant Yellow Top
• Hazy • Sterile yellow stopper tubes containing the
Used for Routine Clinical Chemistry tests (electrolytes, anticoagulant sodium polyanethol sulfonate (SPS)
glucose, renal, liver and thyroid function, lipids, cardiac are used to collect samples to be cultured for the
markers), Immunochemistry (hormones, vitamins) and presence of microorganisms. SPS also prevents
Serology coagulation by binding calcium. SPS aids in the
Evacuated Tubes: PLASMA TUBES recovery of microorganisms by inhibiting the actions
1. EDTA of complement, phagocytes, and certain antibiotics.
• Lavender or Pink top • Yellow SPS used for bacteriology – for culturing the
• Dry di-potassium (K2) and microorganisms possible present on the patient’s
liquid tri-potassium (K3) sample
• Used for routine
Hematology tests, HBA1c,
Hemoglobin
electrophoresis, and
Reticulocyte counting
• Pink = for BLOOD BANK (crossmatching & ABO
blood typing)
2. Sodium Citrate
• Blue top
• 3 concentrations
▪ 0.105 mol/L or
3.13% (glass)
▪ 0.109 mol/L or 3.2%
(plastic)
▪ 0.129 mol/L or 3.8%
(plastic)
• 1:9 Citrate to Blood ratio
• For coagulation testing
ORDER OF TUBE STOPPER RATIONALE FOR
• Mix by inversion 3-4x only
DRAW COLOR COLLECTION
3. Heparin
ORDER
• Dark green (non-gel) and Blood cultures Yellow SPS Minimizes chance of
light green (gel) (sterile collections) Sterile media bottle microbial
• 2 anticoagulants contamination
▪ Sodium Heparin – for Coagulation tubes Light Blue The first additive tube
Special Chemistry in the order because
Tests (troponin assays), all other additives
Karyotyping, etc. affect coagulation
tests
except electrolytes
Glass nonadditive Red Prevents
▪ Lithium heparin – for routine Clinical Chemistry
tubes contamination by
tests and electrolytes additives in other
4. Fluoride tubes
• Gray top Plastic clot activator Red Filled after
• 2 forms tubes coagulation tests
▪ Sodium fluoride because silica
+ Potassium Serum separator Red & gray rubber particles activate
oxalate tubes (SSTs) Gold plastic clotting and affect
coagulation tests
▪ Sodium fluoride
(carry-over of silica
+ K2 EDTA into subsequent tubes
• Used for GLUCOSE testing can be overridden by
• Sample is stable for as long as 24 hours at room anticoagulant in them)
temperature Plasma separator Green & gray Heparin affects
tubes (PSTs) Light-green plastic coagulation tests and
interferes in collection
Heparin tube Green of serum specimens;
causes the least
interference in tests

2|Mangalindan, S.N.
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
other than coagulation
tests WINGED BLOOD COLLECTION SET / BUTTERFLY
EDTA tubes Lavender Responsible for more o Used for the infusion of IV fluids and for
Pink carry-over problems performing venipuncture from very small
Plasma preparation Pearl top that any other
tubes (PPTs) additive: elevates Na+ or very fragile veins often seen in children
Oxalate / Fluoride Gray and K+ levels, chelates and in the geriatric population.
tubes and decreases calcium o Usually 21 or 23 gauge with lengths of
and iron levels, 1/2 to 3/4 inch.
elevates PT and PTT
o Plastic attachments to the needle that resemble butterfly
results. Sodium
fluoride and wings are used for holding the needle during insertion.
potassium oxalate They also provide the ability to lower the needle
affect sodium and insertion angle when working with very small veins
potassium levels,
respectively, after
GLOVES
hematology tubes o Gloves are available in several varieties, including
because oxalate powdered and powder-free, and latex and nonlatex
damages cell (vinyl, nitrile, neoprene, and polyethylene)
membranes and
causes abnormal RBC o Gloves with powder are not recommended because the
morphology. Oxalate powder can contaminate patient samples and cause
interferes in enzyme falsely elevated calcium values. The glove powder can
reactions also cause a sensitization to latex.
The order of draw recommended by CLSI for both TOURNIQUET
evacuated system and when filling tubes in a syringe
• Blood cultures (yellow stopper tubes, culture o Used during venipuncture to make it easier to locate
bottles) patients’ veins.
• Light blue stopper tubes (sodium citrate) PUNCTURE SITE PROTECTION SUPPLIES
• Red/gray, gold stopper tubes (serum separator o 70% isopropyl alcohol - primary antiseptic used for
tubes), red stopper plastic tubes (clot activator), and cleansing the skin in routine phlebotomy
red stopper glass tubes o 2x2-inch gauze pads- used for applying pressure to the
• Green stopper tubes and light green (plasma puncture site after the needle has been removed.
separator tubes) (heparin)
o A bandage or adhesive tape/micropore is placed over
• Lavender stopper tubes (EDTA)
the puncture site when the bleeding has stopped.
• Gray stopper tubes (potassium oxalate/sodium
o It is not recommended to use cotton balls to apply
fluoride)
pressure because the cotton ball fibers can stick to the
• Yellow/gray or orange stopper tubes (thrombin
clot activator) venipuncture site and may cause bleeding to begin
again when the cotton is removed.
SYRINGE
ADDITIONAL SUPPLIES
ADVANTAGE:
➢ Phlebotomist is able to control o Clean glass slides may be needed to prepare blood
the suction pressure on the films for certain hematology tests.
vein by slowly withdrawing the o Pen/Marker for labelling tubes
syringe plunger
➢ Blood will appear in the hub of
the needle when the vein has
been successfully entered.
o Blood drawn in a syringe is
immediately transferred to appropriate evacuated tubes
to prevent the formation of clots.
o It is not acceptable to puncture the rubber stopper with
the syringe needle and allow the blood to be drawn into
the tube.
BLOOD TRANSFER DEVICE
o Provides a safe means for
blood transfer without using
the syringe needle or
removing the tube stopper
o It is an evacuated tube holder
with a rubber-sheathed needle inside.
o After blood collection, the syringe tip is inserted into the
hub of the device and evacuated tubes are filled by
pushing them onto the rubber-sheathed needle in the
holder as in an evacuated tube system

3|Mangalindan, S.N.
PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
SNEM – BSMT [A.Y. 2022-2023] I Instructor: Rochelle Ann M. Relucio, RMT, MSMT

LESSON 3.5: VENIPUNCTURE

WHAT IS YOUR GOAL? PATIENT IDENTIFICATION
- The goal of venipuncture is to collect blood from the patient o Identify the patient verbally by having him or her state
FOUNDATION IN VENIPUNCTURE both the first name and last name and compare the
o Safety (both patient and phlebotomist) information on the patient’s ID band with the requisition
o Patient comfort form.
o Quality o The most important procedure in phlebotomy is correct
Note: identification of the patient.
- Safety: phlebotomists should be safe from accidental needle Note:
prick - Unconscious / Coma patients: check their ID / hospital hand
- Patient comfort: the patient should be assured about the for their name
process (explain the process) so they will understand the - Multiple ways to check the identification of the patient
procedure PATIENT PREPARATION
- Quality: good blood quality and can be tested (i.e.,
homolyzed blood can’t be tested, you need to recollect POSITIONING THE PATIENT
blood from the patient) o Patient must be positioned conveniently and safely for
the procedure.
VENIPUNCTURE
o Always ask the patient if he or she is allergic to latex.
REQUISITION EQUIPMENT SELECTION
o All phlebotomy procedures begin with the receipt of a
o Phlebotomist should collect all necessary supplies and
test requisition form that is generated by or at the
place them close to the patient.
request of a health-provider.
WASH HANDS AND APPLY GLOVES
REQUIRED INFORMATION:
➢ Patient’s name and last name o OSHA regulations mandate that gloves be worn when
➢ Identification number performing a venipuncture procedure.
➢ Patient’s date of birth TOURNIQUET APPLICATION
➢ Patient’s location FUNCTION:
➢ Ordering healthcare provider/ physician o Impeding venous blood flow that causes blood to
➢ Test requested accumulate in the veins making them more easily located
➢ Date and time that is requested and provides a larger amount of blood for collection.
➢ Date and time of extraction NOTE:
➢ Status of sample o Maximum time for tourniquet application: 1 minute
Note: o Tourniquet be applied twice, first when vein selection is
- Tests are usually ordered by the doctors made, second when puncture is performed.
- Identification number – issued by the hospital / institution /
laboratory ; set of unique numbers that will identify you as
o According to the CLSI, when a tourniquet is used during
their patient (can be alpha-numeric set of values or numerical preliminary vein selection, it should be released and
values only) reapplied after 2 minutes.
- DoB: patient’s DoB will serves as identifier as well APPLICATION:
- Location: inpatient (ward or room number should be written) o Apply the tourniquet 3 to 4 inches above the antecubital
or outpatient
Are walk-in patient in the laboratory allowed to request their
fossa (beneath the bend of the elbow).
own tests? o When the tourniquet is in place, ask the patient to clench
- It depends but YES. Some patients want to know their HIV or make a fist.
status, thus, they request for tests (ordering physician is not o When a patient makes a fist, the veins in that arm
required). become more prominent, making them easier to locate
- Happens usually in free-standing laboratories
- Result of the tests should be given to the doctor and enter with a needle.
- Date and Time requested: the recent request should be o The use of disposable one-time use tourniquets is
processed advised, although not required, as part of good infection
- Date and Time of extraction: ruled out by the phlebotomists control practice to avoid health-care acquired infections
- Status of sample: ongoing / processing / for extraction / for
(HAIs) for patients.
releasing
Note:
- You cannot extract a blood without request slip
- Tourniquets are disposed right away when it was used to a
GREETING THE PATIENT patient with skin-contact disease
o Phlebotomist should greet the patient, introduce his SITE OF COLLECTION
name and explain the procedure o Preferred site for venipuncture: antecubital fossa (located
anterior and below the bend of the elbow)
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
SITE SELECTION IN ARM
1. Median Cubital Vein
SITE OF COLLECTION
• Located near the center; preferred vein for o Palpation is usually performed using the tip of the index
venipuncture because it is large and stationary finger of the nondominant hand to probe the antecubital
• It is often closer to the surface of the skin, more area with a pushing motion rather than a stroking
isolated from underlying structures, and the least motion.
painful to puncture as there are fewer nerve endings o Pressure applied by palpating locates deep veins;
in this area. distinguishes veins, which feel like:
2. Cephalic Vein ➢ spongy
• Lateral aspect; located on the thumb side of the arm ➢ bouncy
• Second choice ➢ resilient tube-like structures
• Hard to palpate but fairly well anchored and the
CLEANSING THE SITE
only vein can be felt in large patients
• Has more tendencies to move o 70% Isopropyl Alcohol
3. Basilic Vein o Cleansing is performed with a circular motion –
• Last option concentric circles (2-3 inches in diameter)
• Medial side; not well anchored & rolls easily, high o Allow to dry for 30-60 seconds (do not blow or fan)
risk of puncturing median cutaneous nerve or the o Povidone-iodine and tincture of iodine or chlorohexidine
brachial artery gluconate – most frequently used solution (for double /
• Should be used as the last choice because the triple cleansing ; usually in blood banking)
median nerve and brachial artery are in close Note:
proximity to it, increasing the risk of permanent 2 Methods of Cleansing
injury - Circular Motion: concentric from the inside to outside
- Back and Forth with friction (current recommendation by the
CLSI)
ASSEMBLY OF PUNCTURE EQUIPMENT
o Check equipment for defects
o Check needle and syringe if properly screwed
o Extra tubes should be near at hand
o Do not place collection tray on patient’s bed
PERFORMING VENIPUNCTURE
IMPORTANT: RE-APPLY TOURNIQUET FIRST
o Examine the needle – needle must be bevel up
o Anchoring the vein - Use the thumb of the
nondominant hand to anchor the selected vein while
inserting the needle. Place the thumb 1 or 2 inches
below and slightly to the left of the insertion site and the
four fingers on the back of the arm and pull the skin taut.
o Inserting the needle - When the vein is securely
anchored, align the needle with the vein and insert it,
bevel up, at an angle of 15 to 30 degrees depending on
SITE SELECTION IN HAND the depth of the vein. This should be done in a smooth
• Usually collected in dorsal movement so the patient feels the stick only briefly.
metacarpal veins / cephalic
vein located near the thumb
REMOVING OF THE NEEDLE – RELEASE TOURNIQUET
• May be used if antecubital BEFORE NEEDLE
fossa veins are unsuitable or o Failure to remove the tourniquet before removing the
unavailable needle may produce a bruise (hematoma).
• Extra care must be used to o Place folded gauze over the venipuncture site and
anchor these veins
• Use of winged (“butterfly”)
withdraw the needle in a smooth swift motion and
blood collection set may enhance success and make the activate the safety device if it is designed to function after
procedure less painful the needle is removed from the vein. Apply pressure to
SITE SELECTION IN FOOT the site as soon as the needle is withdrawn. Do not apply
• Collected in the dorsal area pressure while the needle is still in the vein.
• Make sure that you are puncturing the right vein (you
cannot do through-and-through because there are lots of
DISPOSAL OF NEEDLE
nerves/nerve endings and bones located at the foot) o Dispose of the contaminated needle and holder in an
• The last resort for blood collection is from the foot veins acceptable sharps container conveniently located near
after the arm veins have been determined unsuitable. the patient.
• As for dorsal veins, institutional policies may determine
which healthcare workers are authorized to access veins in
this area

2|Mangalindan, S.N.
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
LABELLING THE TUBES
o Information on the sample label must include the
following:
➢ Patient’s name and identification number
➢ Date and time of collection
➢ Phlebotomist’s initials
➢ Additional: Gender, Age, Birthday
o The tubes are labeled after they are drawn and mixed,
while the patient is still present, to reduce the risk of
specimen misidentification.
BANDAGING THE PATIENT’S ARM
o Bleeding at the venipuncture site should stop within 5
minutes. Before applying the adhesive bandage, the
phlebotomist should examine the patient’s arm to be
sure the bleeding has stopped.
DISPOSING THE USED SUPPLIES
o The phlebotomist disposes of all contaminated supplies
such as alcohol pads and gauze in a biohazard container
and needle caps and paper in the regular waste
container, removes gloves and disposes of them in the
biohazard container, and washes his or her hands.
Note:
- Yellow bag / container: infectious materials
- Black container: non-infectious material (i.e., balat ng
syringe)
LEAVING THE PATIENT
o Return the bed and bed rails to the original position if
they have been moved. Failure to replace bed rails that
results in patient injury can result in legal action.
o In the outpatient setting, patients can be excused when
the arm is bandaged and the tubes are labeled. If
patients have been fasting and no more procedures are
scheduled, they should be instructed to eat. Before
calling the next patient, the phlebotomist cleans up the
area. In both the inpatient and outpatient settings,
patients should be thanked for their cooperation.
POST VENIPUNCTURE
o The patient’s arm is examined to see if bleeding has
stopped. An adhesive bandage or tape is applied on the
site (following institutional policies)
o The patient is instructed to leave the bandage on for a
minimum of 15 minutes
o Outpatients should be advised not to carry a purse or
other heavy object or lift heavy objects with that arm for
1 hour.
o The patient should be thanked for his or her cooperation
– this helps leave the patient with a positive feeling.
o Contaminated materials should be disposed of in
approved biohazard containers following the institutional
policies before attending to the next patient

3|Mangalindan, S.N.
PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
SNEM – BSMT [A.Y. 2022-2023] I Instructor: Rochelle Ann M. Relucio, RMT, MSMT

LESSON 4: DERMAL PUNCTURE

DERMAL PUNCTURE PATIENT POSITION
o Dermal (capillary or skin) puncture is the method of o Must be seated or lying down with the hand supported
choice for collecting blood from infants and children on a firm surface, palm up, and fingers pointed
younger than 2 years downward for fingersticks (for good blood flow)
o Certain tests require capillary blood, such as newborn o For heelsticks, infants should be lying on the back with
screening tests and capillary blood gases. the heel in a downward position.
Dermal puncture may be required in many adult patients, SITE SELECTION
including:
o Primary dermal puncture sites:
• Burned or scarred patients
- heel (for infants)
• Patients receiving chemotherapy who require
- distal segments of the third and fourth fingers
frequent tests and whose veins must be reserved for
therapy (non-dominant hand)
• Patients with thrombotic tendencies o Performing dermal punctures on earlobes is not
• Geriatric or other patients with very fragile veins recommended.
• Patients with inaccessible veins o The choice of a puncture area is based on the age and
• Obese patients size of the patient.
• Apprehensive patients o Areas selected for dermal puncture should not be
• Patients requiring home glucose monitoring and callused, scarred, bruised, edematous, cold or cyanotic,
point-of-care tests or infected.
o Blood collected by dermal puncture comes from the o Do not collect blood from the fingers on the side of a
capillaries, arterioles, and venules (smallest of the blood mastectomy (removal of portion of the breast / breast)
vessels) without a health-care provider’s order.
Hemolysis may occur in dermal puncture for the HEEL PUNCTURE SITES
following reasons: • Infants younger than 1 year
• Excessive squeezing of the puncture site (“milking”) • Punctures should not be
• Newborns have increased numbers of red blood performed in other areas of
cells (RBCs) and increased RBC fragility the foot, and particularly not in
• Residual alcohol at the site the arch, where they may
• Vigorous mixing of the microcollection tubes after cause damage to nerves,
collection tendons, and cartilage.
• Acceptable areas for heel
DERMAL PUNCTURE EQUIPMENT puncture: medial and lateral
1. Dermal Puncture Devices areas of the plantar (bottom)
- Lancet surface of the heel.
2. Microsample Containers
- Capillary Tube
➢ referred as microhematocrit tubes.
➢ collect approximately 50 to 75 µL of blood FINGER PUNCTURE SITES
➢ tubes are designed to fit into a hematocrit • Are performed on
centrifuge and its corresponding adults and children
hematocrit reader over 1 year of age.
❖ Tubes are available • Sites of choice: fleshy
✓ plain – blue band areas located near the
✓ coated with ammonium center of the third and
heparin - red band fourth fingers on the
- Microcollection Tubes palmar side of the
➢ provide a larger collection volume and nondominant hand
present no danger from broken glass. • Tip and sides of the
3. Additional Dermal Puncture Supplies finger contain only
- Alcohol pads, gauze, sharps containers, and about half the tissue
glass slides mass of the central area, the possibility of bone
DERMAL PUNCTURE PROCEDURE injury is increased in these areas.
PATIENT IDENTIFICATION • Problems associated with use of the other fingers
include possible calluses on the thumb, increased
o Requisition form nerve endings in the index finger, and decreased
o Verbal Identification tissue in the fifth finger
o ID band
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
SUMMARY OF DERMAL PUNCTURE SITE SELECTION FINGER PUNCTURE SITES
• Use the medial and lateral areas of the plantar • The finger is held between the
surface of the heel nondominant thumb and index
• Use the central fleshy area of the third or fourth finger, with the palmar surface
finger facing up and the finger
• Do not use the back of the heel pointing downward to increase
• Do not use the arch of the foot blood flow.
• Do not puncture through old sites
• Do not use areas with visible damage
• Do not use fingers on newborn children younger PUNCTURE DEVICE POSITION
than 1 year 1. Choose a puncture device that corresponds to the size of the
• Do not use swollen sites patient.
• Do not use earlobes 2. Remove the trigger lock if necessary.
• Do not use fingers on the side of mastectomy 3. Place the puncture device firmly on the puncture site.
WARMING THE SITE 4. Do not indent the skin when placing the lancet on the puncture
site.
o Warming dilates the blood vessels and increases arterial 5. The blade of the puncture device should be aligned to cut
blood flow. across (perpendicular to) the grooves of the fingerprint or heel
o Moistening a towel with warm water (42°C) or activating print
a commercial heel warmer and covering the site for 3 to 6. Depress the lancet release mechanism and hold for a moment,
5 minutes effectively warms the site (purpose: for the then release.
blood vessels to dilate and have a good blood flow). 7. Pressure must be maintained because the elasticity of the skin
naturally inhibits penetration of the blade.
o Use caution in moistening the towel to ensure the water
8. Removal of the lancet before the puncture is complete will yield
temperature is not greater than 42°C to avoid burning
a low blood flow.
the patient. Site should not be warmed for longer than
SAMPLE COLLECTION
10 minutes or test results may be altered.
Note: o The first drop of blood must be wiped away with a clean
- Massaging the site may be an alternative if warmer is not gauze (because it contains tissue juices that may
available contaminate and may alter the results).
- Purpose: for good blood flow especially when the patients o When collecting microsamples, even a minute amount
are nervous
of contamination can severely affect the sample quality.
CLEANSING THE SITE o Blood should be freely flowing from the puncture site as
o Selected site is cleansed with 70% isopropyl alcohol, a result of firm pressure and should not be obtained by
using a circular motion. milking of the surrounding tissue, which will release
o The alcohol should be allowed to dry on the skin for tissue fluid.
maximum antiseptic action, and the residue may be o Alternately applying pressure to the area and releasing it
removed with gauze to prevent interference with certain will produce the most satisfactory blood flow.
tests. o Tightly squeezing the area with no relaxation cuts off
Failure to allow the alcohol to dry: blood flow to the puncture site.
• Causes a stinging sensation for the patient CAPILLARY TUBES AND MICROPIPETTES
• Contaminates the sample
o To prevent the introduction of air bubbles, capillary
• Hemolyzes RBCs
tubes and micropipettes are held horizontally while
• Prevents formation of a rounded blood drop
because blood will mix with the alcohol and run being filled (capillary tube should not touch the patient’s
down the finger finger).
PERFORMING THE PUNCTURE o Place the end of the tube into the drop of blood and
maintain the tube in a horizontal position to fill by
o The heel or finger should be well supported and held
capillary action during the entire collection.
firmly, without squeezing the puncture area.
o Removing the microhematocrit tube from the drop of
o Massaging the area before the puncture may increase
blood causes air bubbles in the sample.
blood flow to the area.
o The presence of air bubbles limits the amount of blood
HEEL PUNCTURE that can be collected per tube and will interfere with
• The heel is held
between the thumb
blood gas determinations.
and index finger of o When the tubes are filled, they are sealed with sealant
the nondominant clay or designated plastic caps.
hand, with the o Recommended tubes are plastic or coated with a
index finger held
puncture-resistant film.
over the heel and
the thumb below o When using a sealant tray, place the end that has not
the heel been contaminated with blood into the clay taking care
• The Clinical and to not break the tube.
Laboratory o Remove the tube with a slight twisting action to firmly
Standards Institute
plug the microhematocrit tube.
(CLSI) recommends that the incision depth should not
exceed 2.0 mm in a device used to perform heelsticks

2|Mangalindan, S.N.
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
MICROCOLLECTION TUBES
o Microcollection tubes are slanted down during the
collection, and blood is allowed to run through the
capillary collection scoop and down the side of the tube.
o The tip of the collection container is placed beneath the
puncture site and touches the underside of the drop.
o Gently tapping the bottom of the tube may be necessary
to force blood to the bottom.
o When a tube is filled, the color-coded top is attached.
o Tubes with anticoagulants should be inverted 5 to 10
times or per manufacturer’s instructions.
o If blood flow is slow, it may be necessary to mix the tube
while the collection is in progress.
o It is important to work quickly, because blood that takes
more than 2 minutes to collect may form microclots in an
anticoagulated microcollection container.
ORDER OF COLLECTION
o Blood gases
o Blood smear
o EDTA tubes
o Other anticoagulated microcollection tubes
o Serum microcollection tubes
BANDAGING THE PATIENT
o When sufficient blood has been collected, pressure is
applied to the puncture site with gauze.
o The finger or heel is elevated and pressure is applied
until the bleeding stops.
o Confirm that bleeding has stopped before removing the
pressure.
LABELLING THE SAMPLES
o Microsamples must be labeled with the same
information required for venipuncture samples.
COMPLETION OF PROCEDURE
o Disposing of all used materials in appropriate containers
o Removing gloves
o Washing hands
o Thanking the patient and/or the parents for their
cooperation.
o As with venipuncture, it is recommended that only two
punctures be attempted to collect blood.

3|Mangalindan, S.N.
PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
SNEM – BSMT [A.Y. 2022-2023] I Instructor: Rochelle Ann M. Relucio, RMT, MSMT

LESSON 5: NON-BLOOD SAMPLES (OTHER BODY FLUIDS)

Note:
NON-BLOOD SPECIMENS LABEL – full name, age, birthday, date and time of collection, SEX
o Phlebotomists may be involved in the collection and ▪ Sex - there are certain tests that differs (normal range of
handling of specimens other than blood or non-blood values) according to their sex
specimens such as urine, amniotic fluid, saliva, semen, ▪ Non-matching label should be rejected
REQ. FORM – without requisition form, no test / specimen
sputum, etc. They should be familiar with proper
collection
handling procedures to ensure the integrity of the ▪ Needed before processing the sample
specimens in order to produce accurate results. ▪ Serves as a record
URINE CONTAINER – screw top (to avoid leakage)
▪ Wide-mouth: for better collection (esp. female Px)
o Urine: consists of urea and other organic and inorganic ▪ Disposable
chemicals dissolved in water. ▪ 50 mL capacity (can be filled only until half ; depends on
➢ 95% water and 5% solutes certain labs)
o Urine volume depends on the amount of water that the ▪ 12 mL – needed volume of specimen (for urinalysis)
▪ 60 mL – needed volume for drug testing
kidneys excrete.
o Factors that influence urine volume includes: fluid intake, REASONS FOR REJECTING SPECIMEN
variations in the secretion of antidiuretic hormone, and o Specimens in unlabeled containers
need to excrete increased amount of dissolved solids o Nonmatching labels and requisition forms
(glucose and salts) o Specimens contaminated with feces or toilet paper
o Normal daily urine output: 1200-1500 mL o Containers with contaminated exteriors
o Range 600-2000 mL is considered normal o Specimens of insufficient quantity
Note: o Specimens that have been improperly transported
URINE - ½ liter per day (normal daily urine output) Note:
▪ Normal: 4-7x a day - Avoid contamination, if there’s contaminant, REJECT it (i.e.,
➢ Pregnant – urinate more often contaminated with feces – alters result due to presence of
▪ Compressed urinary bladder bacteria)
➢ Water intake - Rejection = Recollection
▪ Female: 2 liters per day - Samples should be well preserved (within 2 hours only)
▪ Male: 2.5 liters per day ▪ After 2 hours, samples may be altered (affects the
COMPONENT COMMENT clarity)
Urea Primary organic components
Product of protein and amino acid
SPECIMEN HANDLING
metabolism SPECIMEN INTEGRITY
Creatinine Product of creatine metabolism by muscles o Specimen should be delivered to the laboratory
Uric Acid Product of nucleic acid breakdown in food
and cells
promptly and tested within 2 hours
Chloride Primary inorganic component o A specimen that cannot be delivered and tested within 2
Found in combination with sodium (table hours should be refrigerated or have an appropriate
salt) and many other inorganic substances chemical preservative added
Sodium Primarily from salt, varies by intake
SPECIMEN PRESERVATION
Potassium Combined with chloride and other salts
Phosphate Combines with sodium to buffer the blood o The most routinely used method of preservation is
Ammonium Regulates blood and tissue fluid acidity refrigeration at 2 to 8 degrees Celsius
Calcium Combines with chloride, sulfate, and o When a specimen must be transported over a long
phosphate distance and refrigeration is impossible, chemical
SPECIMEN COLLECTION preservatives may be added
o Gloves should be worn at all times when in contact with PRESERVATIVES
the specimen (use gloves to avoid contact with urine) • Refrigeration
o All specimens must be labeled properly with the • Boric acid
patient’s name and identification number, the date and • Formalin (Formaldehyde)
time of collection, and additional information such as the • Sodium Fluoride
patient's age and location and the healthcare provider's PRESERVING – refrigeration (2-8 degrees Celsius) / adding chemical
name, as required by institutional protocol preservatives such as boric acid, formalin, sodium fluoride (done
within the lab only)
o Requisition form must be accompany specimens
delivered to the laboratory ANALYTE CHANGE CAUSE
o Clean, dry, leak-proof containers, screw top lids, wide Color Modified / Oxidation or
mouth, clear Darkened reduction of
➢ Disposable containers are recommended metabolites
➢ Recommended capacity of the container is 50mL, Clarity Decreased Bacterial growth
which allow 12 mL of specimen needed for and precipitation
microscopic analysis
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
of amorphous Urine is less contaminated from vaginal bacteria and
➢
material other cells
Odor Increased Bacterial ➢ Usually combined with First Morning
multiplication 6. Suprapubic Aspiration
causing ➢ Provides a sample for bacterial culture that is
breakdown of completely free of extraneous contamination
urea to ammonia ➢ The specimen can be also used for cytologic
pH Increased Breakdown of
examination
urea to ammonia
➢ Urine may be collected by external introduction of a
by urease-
needle through the abdomen intro the bladder
producing
bacteria/loss of (invasive procedure)
CO2 7. Three Glass Collection
Glucose Decreased Glycolysis and ➢ Detect the presence of prostatitis
bacterial use ➢ For male
Ketones Decreased Volatilization and TYPE OF SPECIMEN PURPOSE
bacterial Random Routine Screening
metabolism First Morning Routine Screening
Bilirubin Decreased Exposure to Pregnancy Tests
light/photo Orthostatic Protein
oxidation to 24-hour (or timed Quantitative Chemical Tests
biliverdin Catheterized Bacterial Culture
Urobilinogen Decreased Oxidation to Midstream Clean- Routine Screening
urobilin Catch Bacterial Culture
Nitrite Increased Multiplication of Suprapubic Aspiration Bladder urine for bacterial culture
nitrate-reducing Cytology
Three-Glass Collection Prostatic Infection
bacteria
Red and White Decreased Disintegration in URINALYSIS (EXAMINATION)
Blood Cells and dilute alkaline 1. Macroscopic / Physical – characteristic based on naked
Casts urine eye
Bacteria Increased Multiplication 2. Chemical Examination – to detect metabolites
Trichomonas Decreased Loss of motility, 3. Microscopic – analyzes metabolites / analytes under the
death microscope
TYPES OF SPECIMENS PHYSICAL EXAMINATION OF URINE
1. Random Specimen COLOR
➢ Most commonly received specimen o Color of urine varies from
➢ Useful for routine screening tests to detect obvious almost colorless to black
abnormalities o These variations may be
➢ No time / can be collected anytime due to normal metabolic
➢ There are some metabolites that are not present functions, physical
➢ Diluted sample activity, ingested
➢ Not 100% accurate materials or pathologic
2. First Morning Specimen conditions
➢ Ideal screening specimen (most concentrated) o Normal color: pale yellow, yellow, dark yellow, and
➢ Also essential for preventing false-negative amber
pregnancy tests and for and for evaluating o Yellow color of urine is caused by the presence of a
orthostatic proteinuria pigment called urochrome
➢ Usually for PT (especially if early pregnancy) o Care should be taken to examine the specimen under a
➢ Avoids false-negative test results good light source, looking down through the container
3. 24-hour Specimen (Timed Specimens) against a white background
➢ Carefully timed specimen must be used to produce ABNORMAL URINE COLOR:
accurate quantitative results • Dark Yellow / Amber – presence of the abnormal pigment
4. Catheterized Specimens bilirubin
➢ For bacterial culture • Yellow-orange – administration of phenazopyridine
(Pyridium) or azo-gantrisin compounds to persons with
➢ Specimen is collected under sterile conditions by urinary tract infections
passing a hollow tube (catheter) through the urethra • Red – presence of blood
into the bladder • Brown urine containing blood – glomerular bleeding
➢ Sample is obtained directly from the bladder • Brown or Black – melanin or homogentisic acid, levodopa,
➢ Less contaminated methyldopa, phenol derivatives, and metronidazole (Flagyl).
• Blue / Green – bacterial infections, including urinary tract
➢ For comatose patients / after surgery infection by Pseudomonas species and intestinal tract
5. Midstream Clean-Catch Specimen infections resulting in increased urinary indican
➢ Provides a safer, less traumatic method for obtaining
urine for bacterial culture and routine urinalysis

2|Mangalindan, S.N.
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
CLARITY CARE OF REAGENT STRIPS
o Refers to the transparency or turbidity of a urine 1. Store with desiccant in an opaque, tightly closed
specimen container
o Common terminology used to report clarity includes 2. Store below 30 degrees Celsius ; Do not freeze
clear, hazy, cloudy, turbid, and milky 3. Do not expose to volatile fumes
CLARITY TERM 4. Do not use past the expiration date
Clear No visible particulates, transparent 5. Do not use if chemical pads become discolored
Hazy Few particulates, print easily seen through urine 6. Remove strips immediately prior to use
Cloudy Many particulates, print blurred through urine
Note:
Turbid Print cannot be seen through urine
- Reagents strips must be checked with both positive and
Milky May precipitate or be clotted
negative controls a minimum of once every 24 hours

ODOR
o Freshly voided urine: faint aromatic odor
o Causes of unusual odors include bacterial infections,
which cause a strong unpleasant odor similar to
ammonia, and diabetic ketones, which produce a sweet
or fruity odor
ODOR CAUSE
Aromatic Normal
Foul / Bacterial decomposition, UTI
Ammoniacal
Fruity / Ketones (diabetes mellitus, starvation, vomiting)
Sweet
Maple Syrup Maple syrup urine disease
Mousy Phenylketonuria SEDIMENT PREPARATION OF URINE
Rancid Tyrosinemia 1. Specimen Preparation
Sweaty Feet Isovaleric acidemia • Should be examined while fresh or adequately
Cabbage Methionine malabsorption preserved
Bleach Contamination 2. Specimen Volume
COLOR AND CLARITY PROCEDURE • 10 and 15 mL is centrifuged in a conical tube
1. Use a well-mixed specimen 3. Centrifugation
2. View through a clear container • 5 minutes at a relative centrifugal force (RCF) of 400
3. View against a white background • All specimens must be centrifuged in capped tubes
4. Maintain adequate room lightning 4. Sediment Preparation
5. Evaluate a consistent volume of specimen • Sediment should remain in the tube after decantation
6. Determine color and clarity • Sediment must be thoroughly resuspended by gentle
agitation
CHEMICAL EXAMINATION OF URINE
SAMPLE RESULT
REAGENT STRIPS
o Consist of chemical-impregnated
absorbent pads attached to a
plastic strip
o Color-producing chemical
reaction takes place when the
absorbed pad comes in contact
with urine
o The reaction are interpreted by
comparing the color produced on
the pad with a chart supplied by the manufacturer
o Chemical analysis of urine including pH, protein,
glucose, ketones, blood, bilirubin, urobilinogen, nitrite,
leukocytes, and specific gravity

3|Mangalindan, S.N.
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
FECES CHEMICAL TESTING OF FECES
o Routine fecal examination includes macroscopic, microscopic, o OCCULT BLOOD
and chemical analyses for the early detection of gastrointestinal ➢ Annual testing for occult blood has a high positive
(GI) bleeding, liver and biliary duct disorders,
predictive value for detecting colorectal cancer in
maldigestion/malabsorption syndromes, pancreatic diseases,
inflammation,, and causes of diarrhea and steatorrhea
the early stages
o Normal fecal specimen contains: bacteria, cellulose, undigested o GUAIAC-BASED FECAL OCCULT BLOOD TESTS
foodstuffs, GI secretions, bile pigments, cells from the intestinal ➢ Most frequently used screening test for fecal blood
walls, electrolytes, and water ➢ Based on detecting the pseudoperoxidase activity of
o Approximately 100 to 200 g of feces is excreted in a 24-hour hemoglobin
period
QUANTITATIVE FECAL FAT TESTING
o Approximately 9000 mL of ingested fluid, saliva, gastric, lover,
pancreatic, and intestinal secretions enter the digestive tract
o Quantitative fecal analysis requires the collection of at
each day. Under normal conditions, only between 500 to 1500 least a 3-day specimen. The patient must maintain a
mL of this fluid reaches the large intestine, and only about 150 regulated intake of fat (100 g/d) before and during the
mL is excreted in the feces collection period.
Note: o The specimen is collected in a large, pre-weighed
- Bacteria: normal container. Before analysis, the specimen is weighed and
- Yeast & Parasite: not normal
homogenized. Refrigerating the specimen prevents any
SPECIMEN COLLECTION bacterial degradation.
o Normally collected in clean, dry, wide-mouthed ➢ Confirmatory test for steatorrhea
containers that should be sealed and sent to the o Steatorrhea (fecal fat) – absence of bile salts that assist
laboratory immediately after collection pancreatic lipase in the breakdown and subsequent
o Special containers with preservative are available for ova reabsorption of dietary fat (triglycerides) produces an
and parasite collection increase in stool fat.
o Preserved specimens can usually be kept at room Note:
temperature - Confirmatory test for steatorrhea
o Large gallon containers, similar to paint cans, are used - 3 days sample
- High fecal fat = steatorrhea
for 24-. 48-, 72-hour stool collections for fecal fat and
urobilinogen; these specimens must normally be
refrigerated throughout the collection period
o Feces should be pea-sized only
MACROSCOPIC SCREENING
COLOR AND APPEARANCE
o The first indication of GI disturbances can often be
changes in the brown color and formed consistency of
the normal stool
o Appearance:
➢ watery consistency – present in diarrhea
➢ small, hard stools – seen with constipation
➢ slender, ribbon-like stools – which suggest
obstruction of the normal passage of material
through the intestine (problem with GIT)
o Normal color – brown
o Normal consistency - formed
COLOR / POSSIBLE CAUSE
APPEARANCE
Black Upper GI bleeding
Iron therapy
Charcoal
Bismuth (antacids)
Red Lower GI bleeding
Beets and food coloring
Rifampin
Pale yellow, Bile-duct obstruction
white, gray Barium Sulfate
Green Biliverdin / Oral antibiotics
Green vegetables
Bulky / Frothy Bile-duct obstruction
Pancreatic disorders
Ribbon-like Intestinal constriction
Mucus or Blood- Colitis
streaked mucus Dysentery
Malignancy
Constipation

4|Mangalindan, S.N.
PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
SNEM – BSMT [A.Y. 2022-2023] I Instructor: Rochelle Ann M. Relucio, RMT, MSMT

LESSON 5.5: NON-BLOOD SAMPLES (OTHER BODY FLUIDS)

Tube 2 will be processed for culture and sensitivity to
▪
CEREBROSPINAL FLUID check if there is a presence of bacteria (secondly
o MAJOR fluid in the body collected because we are trying to avoid contaminants)
o Provides a physiologic system to supply nutrients to the ▪ Assuming that there are blood contaminants in the
nervous tissue, remove metabolic wastes, and produce a sample, Tube 3 is used for hematology to avoid
inaccurate results of cell counts due to blood
mechanical barrier to cushion the brain and spinal cord
contaminants in the first tap
against trauma ▪ Tube 4 will also be processed for microbiology section
o CSF is produced in the choroid plexuses of the two to undergo culture and sensitivity testing to identify
lumbar ventricles and the third and fourth ventricles. In bacteria present
adults, approximately 20mL of fluid is produced every Appearance – water-like
▪ Crystal clear – normal
hour. The fluid flows through the subarachnoid spaced ▪ Cloudy or Turbid – not normal (may indicate a problem)
located between arachnoid and pia mater. ▪ Bloody – may symbolize traumatic tap
o Body maintains a volume of 90 – 150 mL in adults and
SEMEN
10 – 60 mL in neonates
o Semen is composed of four fraction that are contributed
SPECIMEN COLLECTION by the testes, epididymis, seminal vesicles, prostate
o CSF is routinely collected by gland, and bulbourethral glands
lumbar puncture between the SEMEN COMPOSITION:
3rd, 4th, or 5th lumbar ➢ Spermatozoa – 5%
vertebra ➢ Seminal fluid – 60% - 70%
o Specimens are obtained by a ➢ Prostate fluid – 20% - 30%
physicians; most often ➢ Bulbourethral glands – 5%
through lumbar puncture STRUCTURE FUNCTION
(spinal tap) Seminiferous Tubules of Spermatogenesis
COLLECTION: Testes
Epididymis Sperm maturation
➢ Tube #1 – Chemistry and
Ductus Deferens Propel sperm to ejaculatory ducts
Immunology Seminal Vesicles Provide nutrients for sperm and fluid
➢ Tube #2 – Microbiology Prostate Gland Provides enzymes and proteins for
➢ Tube #3 – Hematology (cell counts) coagulation and liquefaction
➢ A fourth tube may be drawn for the microbiology lab Bulbourethral Glands Add alkaline mucus to neutralize
prostatic acid and vaginal acidity
Note:
Semen – does not only contain sperm, it includes other fluids to
protect the sperm because sperm is very sensitive and dies easily;
thus, it is coated with fluid rich in nutrients and protectants for it
not to be exposed in the acidic environment
▪ Testes – location where sperm is created
▪ Epididymis – sperm maturation
Note: Vasectomy – vas deferens is being cut (pathway of sperm
from the testes) ; fluids from seminal vesicles, prostate gland, and
APPEARANCE bulbourethral glands are still present. Engorgement will still
o Normal CSF: clear, crystal-clear, and colorless happen.
o The major terminology used to describe CSF SPERM MORPHOLOGY
appearance includes crystal-clear, cloudy or turbid, o Normal sperm has an oval-shaped
milky, xanthocromic, and hemolyzed / bloody. head approximately 5 µm long and
➢ Xanthochromia – used to describe CSF supernatant 3 µm wide, and a long flagellar tail
that is pink, orange, or yellow approximately 45 µm long
REASON FOR COLLECTION o It contains a head, neckpiece,
o To diagnose meningitis, subdural hemorrhage, and midpiece, and tail
other neurological disorders SPECIMEN COLLECTION
ROUTINE TESTS PERFORMED ON CSF o Collected and tested to evaluate
o Cell counts, chloride, glucose, and total protein fertility and post-vasectomy (to
Note: identify if there is no sperm present
CSF – surrounds our brain to provide cushion indicating that the vasectomy is
▪ Not only confined in our brain, it surrounds the entire successful)
CNS o FIRST portion of ejaculate missing:
▪ Represents the current state of our nervous system
➢ Sperm count DECREASED
Collection – must follow the order of draw
▪ Tube 1 contains most of the contaminants ➢ pH falsely INCREASED
➢ Specimen WILL NOT LIQUEFY
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
o LAST portion of ejaculate missing: REASON FOR COLLECTION
➢ Semen volume is DECREASED o To identify or differentiate arthritis, gout, and other
➢ Sperm count is falsely INCREASED inflammatory conditions
➢ pH falsely DECREASED
SPECIMEN COLLECTION
➢ Specimen WILL NOT CLOT
o Specimens are collected following a period of sexual o Synovial fluid is collected by needle aspiration called
abstinence of at least 2 days to not more than 7 days arthrocentesis
(even masturbation) o Normal synovial fluid does not clot (usually it is collected
o Warm sterile glass or plastic containers should be given in a syringe moisten with heparin)
o If the sample is collected at home, it must be kept warm o Turbidity is frequently associated with the presence of
and delivered to the laboratory within 1 hour WBC
o Specimens should be collected by masturbation; only o Normal viscous synovial fluid resembles egg white (but
non-lubricant containing rubber or polyurethane not clotted)
condoms should also be used to collect the specimen o COLLECTED IN TUBES:
o When accepting semen sample, it is essential that the ➢ EDTA or Heparin tube for cell counts, identification
phlebotomist record the time of sample collection, and of crystals, and smear preparation
the same receipt, on the requisition form because certain ➢ Sterile tube for culture and sensitivity
parameters of the semen analysis are based on ➢ Nonadditive tube for macroscopic appearance,
specimen life span and immunology tests and to observe clot formation
SYNOVIAL FLUID TEST REQUIRED TUBE TYPE
o Sample should be kept at 37 degrees Celsius
Gram stain and Culture Sterile heparinized or sodium
o A fresh semen specimen is clotted and should liquefy polyanethol sulfonate (SPS)
within 30 – 60 minutes after collection Cell Counts Heparin or liquid
o Normal semen volume ranges between 2 – 5 mL ethylenediaminetetraacetic acid (EDTA)
o pH: 7.2 – 8.0 Glucose Analysis Sodium fluoride
All other tests Nonanticoagulated
APPEARANCE
Volume < 3.5 mL
o Normal semen has a gray-white color, appears
Color Colorless to pale yellow
translucent, and has a characteristic musty odor Clarity Clear
(bleach-like odor) Viscosity Able to form string 4 – 6 cm long
o Semen analysis for fertility evaluation consists of both Leukocyte Count < 200 cells/µL
macroscopic and microscopic examination. Neutrophils <25 % of the differential
o Parameters reported include appearance, volume, Crystals None present
Glucose: plasma <10 mg/dL lower than the blood glucose
viscosity, pH, sperm concentration and count,
difference level
motility, and morphology Total protein < 3 g/dL
Volume 2 – 5 mL
Viscosity Pours in droplets
pH 7.2 – 8.0
Sperm concentration > 20 million/mL
Sperm count > 40 million/ejaculate
Motility > 50% within 1 hr
Quality > 2.0 (or a, b, c in next table)
Morphology > 14% normal forms (strict criteria)
> 30% normal forms (routine criteria)
Round cells < 1.0 million/mL
SEROUS FLUID
GRADE WHO CRITERIA SPERM MOTILITY ACTION
o It provides lubrication between the parietal and visceral
4.0 a Rapid, straight-line motility
3.0 b Slower speed, some lateral membranes
movement o Serous fluids are identified according to the body cavity
2.0 b Slow forward progression, of origin as follows:
noticeable lateral movement ➢ Pleural fluid: aspirated from the pleural space, or
1.0 c No forward progression cavity, surrounding the lungs
0 d No movement
➢ Peritoneal fluid: aspirated from the abdominal
SYNOVIAL FLUID cavity
o Joint fluid ➢ Pericardial fluid: aspirated from the pericardial
o Is a viscous liquid found in the cavities of the movable cavity surrounding the heart
joints (diarthroses) or synovial joints o Pale-yellow, watery, serum-like fluid found between
o Hyaluronic acid: contribute the noticeable viscosity to the double-layered membranes enclosing the pleural,
the synovial fluid pericardial, and peritoneal cavities
o Clear, pale-yellow, viscous fluid that lubricates and o Lubricates the membranes and allows them to slide past
decreases friction in movable joints one another with minimal friction (provides cushion).
o Serves as a cushion to avoid too much friction o Normally present in small amounts, but volumes increase
o Normally occurs in small amounts but increases when when inflammation or infection is present or when serum
inflammation is present (i.e., arthritis) protein levels decrease.

2|Mangalindan, S.N.
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
o Aspiration procedures are referred to as thoracentesis COLOR SIGNIFICANCE
(pleural), pericardiocentesis (pericardial), and Colorless Normal
paracentesis (peritoneal). Blood-streaked Traumatic tap, abdominal trauma, intra-
amniotic hemorrhage
o >100 mL is usually collected Yellow Hemolytic Disease of the Newborn
COLLECTED IN: (bilirubin)
➢ EDTA tube is used for cell counts and the Dark green Meconium
differential. Dark red-brown Fetal death
➢ Sterile heparinized or sodium polyanethol SPECIMEN HANDLING
sulfonate (SPS) evacuated tubes are used for o The specimen should be protected from light to
microbiology and cytology. prevent breakdown of bilirubin and delivered to the
➢ Chemistry tests can be run on clotted specimens in laboratory ASAP.
plain tubes or in heparin tubes o Specimens for chromosome analysis (cytology) must
AMMNIOTIC FLUID be kept at room temperature.
o Amniotic fluid is present in the amnion, a membranous o Specimens for some chemistry tests (gases) must be
sac that surrounds the fetus kept on ice.
o Provides a protective cushion for the fetus, allow fetal SPUTUM
movement, stabilize the temperature to protect the fetus o Mucus or phlegm that is ejected from the trachea,
from extreme temperature changes, and permit proper bronchi, and lungs through deep coughing
lung development. o For the diagnosis or monitoring of lower respiratory
o Amount of amniotic fluid increases in quantity tract infections such as tuberculosis (TB), caused by
throughout pregnancy, reaching a peak of approximately Mycobacterium tuberculosis.
800 to 1200 mL during the third trimester, and then ➢ Note: The microbe that causes TB is called an acid-
gradually decreases prior to delivery. fast bacillus (AFB), and the sputum test for TB is
o Can be analyzed to detect genetic disorders such as often called an AFB culture.
Down’s syndrome, identify hemolytic disease o Preferred specimen: First morning
resulting from blood incompatibility between the mother o At least 1 hour after meal
and fetus, and determine gestational age Note:
➢ most common reasons: to detect problems in fetal Sputum – sputum and saliva DIFFERS from each other
development and assess fetal lung maturity. ▪ Specimen collected from UPPER respiratory tract ; not
➢ preferably collected after 15 weeks of gestation saliva
▪ Presence of acid-fast bacilli may indicate that the patient
(pregnancy) and is obtained by a physician has TB
▪ May also be used for culture and sensitivity to make sure if
the patient really has TB
TISSUES
o Involves the different procedures that have been
adopted for the preparation of materials and tissues for
microscopic investigation, whether they are normal or
abnormal
o Includes examination of smears, preservation and
processing of tissue sections prior to actual evaluation
Note:
of tissue details
Amniotic – protection of the fetus from the environment
▪ checked through ultrasound (if amniotic fluid is sufficient) o A well processed tissue can help in the confirmation and
▪ insufficient amniotic fluid may indicate a problem proper evaluation of disease entity leading to a proper
▪ collection is ultrasound-guided mode of treatment
SPECIMEN COLLECTION METHODS OF TISSUE EXAMINATION
o Amniotic fluid is obtained by needle aspiration into the o Fresh Tissue Examination
amniotic sac, a procedure called amniocentesis o Preserved / Fixed Tissue Examination
o Maximum of 30 mL of amniotic fluid is collected in METHODS OF FRESH TISSUE EXAMINATION
sterile syringes. ➢ Teasing or Dissociation
o The first 2 or 3 mL collected can be contaminated by ➢ Squash Preparation (Crushing)
➢ Smear Preparation
maternal blood, tissue fluid, and cells and are discarded
➢ Frozen Section
o Normal amniotic fluid is colorless and may exhibit slight TEASING OR DISSOCIATION
to moderate turbidity from cellular debris, particularly ➢ A selected tissue specimen is immersed in a watch glass
in later stages of fetal development containing Normal Saline Solution (NSS), carefully
dissected or separated and examined
Note: ➢ Usually done by a pathologist
Amniotic – fluid is being drink and urinate by the fetus (cycle) SQUASH (CRUSHING) PREPARATION
▪ Bilirubin – being tested if the fetus has HDfN ; bilirubin is ➢ Small pieces of tissues are placed in a microscopic slide
light sensitive and forcibly compressed with another slide or coverslip

3|Mangalindan, S.N.
 PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2 LECTURE
SMEAR PREPARATION
1. Streaking
▪ used for preparing
mucoid secretions
vaginal secretions,
sputum and gastric
content (liquidly
sample)
▪ use a spatula, dissecting
needle or applicator stick and streak in a zigzag
fashion
2. Spreading
▪ used for thick mucoid
secretions (smears of
fresh sputum and
bronchial aspirates)
▪ spread from the middle
3. Pull-Apart
▪ for serous fluids, concentrated sputum, and enzymatic
lavage form the GIT, smears of urinary sediment,
vaginal pool and breast secretions

4. Touch or Impression Smear

▪ for preparation
of direct
impression from
the cut surface
of tissue like the
lymph nodes
and other
surgical or autopsy secretions.
FROZEN SECTION
➢ The frozen section procedure is a pathological laboratory
procedure to perform rapid microscopic analysis of a
specimen. The technical name for this procedure is Cryo
section.
➢ Does not undergo routine tissue processing
➢ Rapid tests ; results within an hour
FIXED TISSUE EXAMINATION
➢ Tissue Processing is designed to remove all extractable
water from the tissue, replacing it with a support medium
that provides sufficient rigidity to enable sectioning of the
tissue without parenchymal damage or distortion.
GROSS EXAMINATION OF SPECIMEN
➢ Surgical cut–up
➢ Specimen Dissection (done by pathologists)
➢ Grossing MedTech will assist pathologist in doing the
gross examination, he/she will write down descriptions of
the specimen received.
FIXED TISSUE HISTOPATHOLOGIC TECHNIQUES / STEPS
➢ Numbering
➢ Fixation
➢ Dehydration
➢ Clearing
➢ Impregnation
➢ Embedding
➢ Blocking
➢ Trimming
➢ Sectioning
➢ Staining
➢ Mounting
➢ Labelling

4|Mangalindan, S.N.