Clinical Procedures & Specimen Collection

Clinical procedures are hands-on skills that medical assistants perform daily. The CMA exam tests your knowledge of injection techniques, phlebotomy, wound care, sterile technique, infection control, and specimen handling.

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Injection Administration

Types of Injections

IM Injection Sites

Injection Safety

• Always verify the seven rights before administration
• Never recap needles — activate the safety device immediately after injection
• Dispose of needles in a sharps container immediately
• Aspirate before injecting IM (to ensure not in a blood vessel) — though CDC/ACIP no longer requires aspiration for vaccine administration
• Document: medication name, dose, route, site, lot number, expiration date, and your initials

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Phlebotomy (Blood Collection)

Order of Draw (Tube Color)

The correct order of draw prevents cross-contamination of additives between tubes:

Memory aid: "You Love Really Great Green Lavender Gardens" (Yellow, Light blue, Red, Gold, Green, Lavender, Gray)

Phlebotomy Procedure

1. Verify patient identity (two identifiers)
2. Verify order and prepare supplies
3. Apply tourniquet 3-4 inches above the venipuncture site (max 1 minute)
4. Select vein by palpation (median cubital vein is preferred — large, well-anchored, less painful)
5. Cleanse site with 70% isopropyl alcohol in a circular motion from center outward; allow to air dry
6. Insert needle at 15-30 degree angle, bevel up
7. Fill tubes in correct order of draw
8. Remove tourniquet before removing needle
9. Apply gauze with pressure, then adhesive bandage
10. Label all tubes at the bedside with patient name, DOB, date/time of collection, and your initials

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Infection Control

Standard Precautions

Standard precautions apply to ALL patients and include:

• Hand hygiene — most important infection control measure
• PPE (gloves, gowns, masks, eye protection) based on anticipated exposure
• Sharps safety — use safety-engineered devices, never recap needles
• Respiratory hygiene/cough etiquette
• Safe injection practices — one needle, one syringe, one patient
• Environmental cleaning — regular disinfection of surfaces and equipment

Chain of Infection

The chain of infection has 6 links — breaking any link prevents transmission:

1. Infectious agent — the pathogen (bacteria, virus, fungus, parasite)
2. Reservoir — where the pathogen lives and multiplies (humans, animals, environment)
3. Portal of exit — how the pathogen leaves the reservoir (respiratory, GI, blood, skin)
4. Mode of transmission — how the pathogen travels (direct contact, droplet, airborne, vehicle, vector)
5. Portal of entry — how the pathogen enters the new host (mucous membranes, breaks in skin, respiratory tract)
6. Susceptible host — someone vulnerable to infection (immunocompromised, elderly, infants)

OSHA Bloodborne Pathogen Standard

OSHA requires employers to:

• Provide free hepatitis B vaccination to all at-risk employees
• Maintain an Exposure Control Plan (updated annually)
• Provide appropriate PPE at no cost to employees
• Provide sharps containers and safety-engineered devices
• Provide post-exposure evaluation and follow-up after needlestick injuries
• Train employees on bloodborne pathogen safety annually
• Maintain exposure incident records for 30 years

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Wound Care & Sterile Technique

Sterile Field Rules

• The 1-inch border around a sterile field is considered contaminated
• Never turn your back on a sterile field or reach across it
• Keep sterile items above waist level
• If sterility is questioned, it is contaminated — start over
• Use sterile transfer forceps to add items to the sterile field
• Open sterile packages: open the flap away from you first, then the sides, then the nearest flap

Wound Care Principles

• Clean wounds from the center outward (least contaminated to most contaminated)
• Use sterile technique for surgical wounds and any wound requiring sutures
• Change dressings per provider orders and PRN (as needed)
• Document wound appearance: size, color, drainage (amount, type, odor), surrounding skin condition

Signs of Wound Infection

• Increased redness and warmth
• Swelling and tenderness
• Purulent drainage (pus)
• Fever
• Red streaking away from the wound (lymphangitis)

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Urine Specimen Collection

Surgical Asepsis & Autoclave Operation

Levels of Infection Control

Autoclave (Steam Sterilization)

• Temperature: 250-254F (121-123C)
• Pressure: 15-20 pounds per square inch (psi)
• Time: 20-30 minutes (varies by load type and wrapping)
• Wrapped instruments: 30 minutes at 250F
• Unwrapped instruments: 20 minutes at 250F
• Liquids: 30 minutes at 250F (vent exhaust slowly to prevent boilover)

Autoclave Quality Assurance

• Chemical indicators (autoclave tape, strips): Change color when exposed to proper temperature — indicates exposure, NOT sterility
• Biological indicators (spore tests): Gold standard for verifying sterilization — uses Geobacillus stearothermophilus spores
• Run biological indicators weekly (or per manufacturer guidelines)
• Load monitoring: Document each autoclave cycle (date, time, temperature, items, operator initials)

Sterile Package Handling

• Check expiration date before using any sterile package
• Check for tears, moisture, or damage — if compromised, the package is no longer sterile
• Event-related sterility: Items remain sterile until the integrity of the packaging is compromised (replaced time-related sterility in most settings)
• Store sterile items in a clean, dry, dust-free area away from sinks and floors

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Medication Administration Documentation

After administering any medication, document:

• Date and time of administration
• Medication name (generic and/or brand)
• Dose administered
• Route of administration
• Site of injection (if applicable)
• Lot number and expiration date (especially for vaccines)
• Patient response or adverse reactions
• Initials and credentials of the person administering

Vaccine Administration

• Check the Vaccine Information Statement (VIS) — must be provided to the patient (or guardian) before administration
• Record in the patient's chart AND the immunization registry
• Store vaccines per manufacturer guidelines (refrigerator 35-46F or freezer 5F and below, depending on the vaccine)
• Monitor storage temperature with a data logger and document twice daily
• Never reuse needles or syringes — one needle, one syringe, one patient

Patient Positioning

Medical assistants must position patients correctly for various examinations and procedures:

Draping

• Always drape patients appropriately for modesty and warmth
• Only expose the area being examined
• Explain the procedure and positioning before asking the patient to disrobe
• Offer a gown and allow the patient to change privately
• Assist patients who have mobility limitations with positioning and draping

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Emergency Preparedness in the Medical Office

Common Office Emergencies

Crash Cart Contents

Medical offices should maintain emergency supplies including:

• AED (Automated External Defibrillator)
• Epinephrine (for anaphylaxis)
• Oxygen and delivery devices
• Oral glucose and glucagon
• Nitroglycerin (if stocked per physician order)
• Aspirin (for suspected MI)
• Blood pressure cuff, stethoscope, pulse oximeter
• Emergency medications should be checked monthly for expiration dates