good day class I do apologize for not being in person today but I am out on leadership training so know that it is a benefit overall now they say is going to be a review that goes right along the side of your teal glean review book we are going to pretty much cover everything that is possible to come up on your national exam so please stay focused even though we go through this today please read through your book every night about a half an hour to an hour just to get ready the test is not that far away and at any point in time if you have any questions thoughts concerns I still will be working I'll be in and out of training until about 5:00 and then at 5:00 I will be double-checking all of my emails text messages voicemails so please do not hesitate to drop me a line thanks guys we'll help you enjoy now the first category is patient preparation now the one thing that Trump's patient identification is the requisition you must have the requisition before you can even approach the patient before you can even assemble your equipment right everything is written on that requisition from them meeting to fast from them meaning to have taking medications at a certain point in time to their name to their age everything now don't forget you need to fill out the requisition as well so you have to put in how many hours they fasted you have to sign and date when you drew you have to put in the time you have to do all of that stuff so once again don't forget to do that and my suggestion is after you invert your tubes label your tubes pack them up fill out your requisition then doctor your patient that way you're putting a lot of pressure on that puncture site now we always need to introduce ourselves and say what role we play at the organization and then confirm our patients now you know that we have to confirm our patient by to identify errs so we in impatient they must have a wristband and then we verbally have them identify themselves date of birth Social Security some kind of personal health information our personal information then if it's outpatient we need a physical ID and then of course a verbal as well and we'll do the to verbal confirmations now here's something we have really haven't talked a lot about while we're doing our introduction and confirming our patient we have to be evaluating the patient's level of understanding meaning that if I go in and I call mr. Jones and I say mr. Jones go ahead go to the room on the sector room on your left there and then the gentleman just keeps walking and I say you know okay sorry right through here go ahead sit down I ask him to state their name and they have a hard time right obviously something's wrong now we're not physicians so we're not going to diagnose dementia we're not going to diagnose if they're having a diabetic reaction but what we do know immediately if something is wrong and we do not want to draw that patient and tell a physician has looked them over so any type of losing consciousness or seemed like they're just spaced out you can't answer your normal easy questions we do not want to draw we want to have them checked out now we want to educate the patient on the procedure so essentially what's going to happen what to look for what to do and the kind of most common complications are any loss of consciousness any nausea or feeling sickness any continued pain at the draw site or any loss of sensation or numbness on the same side that has been drawn on if any of those things come up we want to tell the patient to contact us or their physician immediately and if somebody's never had their blood drawn before sit down with them take time to explain the entire procedure so not being is a surprise to them now we always want to evaluate the patient as an aging condition to determine the best site and method but it doesn't matter how old they are it doesn't matter anything that kind of goes along with that because we always want to look at the antecubital fossa first and if you don't remember the antecubital fossa is the bend of the elbow so inside the bend of the elbow we always want to look for the median cubital and then cephalic the silic and then we go to the dorsal hand beams but that's going to be the same no matter what if there's a 96 year old person who gets reeled in at a wheelchair you're still going to check their antecubital fossa first before you go anywhere else now you know as well as I do for palpation right we're looking for that direction and width and that is also going to determine the best method for our collection then we do want to make sure that they've met all requirements meaning that if they were to fast that they've met fasting and remember this has to be an open-ended question we can't read them we can't say anything other than when was the last time you ate or drank something if you say did you breakfast this morning well maybe they grabbed a banana on the way out and quite frankly they don't consider that breakfast so they're going to tell you no but they really did eat something in that of course is going to affect all of our labs now with complications you're going to know or need to know what causes them and what you do to help them so this first one excessive bleeding we know pretty much what causes excessive bleeding right the anticoagulated patient or the patient that's on blood thinners so that goes around heparin warfarin coumadin aspirin anything that's going to thin the blood that patient then has a tendency to have excessive bleeding what do you do for excessive bleeding pressure we want to apply pressure will do koban of course we can do our pressure bandage then we've been down the severe pain generally should not last more than a few minutes we know this right and one initial pinch and that's it it should be over so in the case that it does last very long we want to try ice first and then ice doesn't cool it down sorry that was a bad pun um if ice doesn't help then we do want them to be checked out by a physician now lack of sensation honestly the first thing I want you to think about if somebody says I just lost feeling in my hands is how long is that term it have been on right because not leave the tourniquet on for longer than 60 seconds but lack of sensation is insinuating that we nicked a nerve at any point in time somebody says this we do want to stop the drawing medially we want to get out and then of course apply pressure if it lasts more than a few hours we do want them to be checked out by a physician next type of bruising we consider excessive bruising being greater than the size of a god pad two by two and essentially we know how to reduce bruising right we put pressure somebody who's an anticoagulated patient has a greater chance of having excessive bruising and by any chance if you go through a vein which we all know happens sometimes and then you just pull back and boom you get blood re-establish your platform and finish your draw but we know then that they have a tendency to have more bruising because we pierce both sides of the vein so we definitely want to hold pressure for a little bit longer and put on our koban now inspection we haven't talked a lot about infection but the key signs and symptoms of infection is red swollen right generally if you're swollen it's going to cause some type of pain and depending on the pus is going to tell us how severe the infection is but anytime we have an infection of course we never want to draw through a bruise or through an infection or two and swollen extremities edema but we want to allow that site and any point in time if somebody gets infected a day or two after the draw we want them to come back and see us or contact our position and then patient feeling unwell that's a nother way of just saying nauseated so essentially if the patient feels nauseated that of course we want them to call us or contact their physician and may have signs or implications of greater things going on now we've gone over statin ASAP a few times but just to refuse review that means to drop everything and do it right then in there and ASAT means as soon as possible you want to collect it within that hour so essentially with the stat draw remember this control the patient-physician relationship this can trump everything because normally you do have to wait if you walk into a room in there consulting with a physician a nurse clergy member whatever the case might be we want to give them that respect and particularly with a physician or a nurse you have to it's hierarchy but if you have a stat sample ordered then you will excuse yourself so you have a stat of course the doctor and the nurse is going to understand and it trumps over that and you're capable of going ahead and drawing now here is our consent consents are very important you're going to really want to know these inside and out so let's start with the first one it's express consent this is when somebody expresses consent either through verbal or in writing so once again though how do you express yourself you either express yourself through verbal or through writing so it fits it's very appropriately named-- now informed consent means that the patient has provided plenty of information in their own native language given the opportunity to ask as many questions as their heart desires when it's very very crucial that they take that time and they receive plenty of information in regards to the procedure so once again named very appropriately implied consent actually is two different avenues that implied consent comes into play so the first one is when somebody comes to your Center hands you the requisition form sits in your phlebotomy chair sticks their arm out and you draw and they say they never consent well yeah it's implied consent they did everything as if they were going to have their blood drawn also if you go into somebody's room you confirm who they are introduce yourself and they just stick their arm out and turn their head that's also implying that they are allowing us to draw their blood now the other side of this is for emergencies so anytime we have an unconscious patient we are going to treat or help or provide care under implied consent because we imply they want our help and if you think about this right we're not just going to walk by somebody who's unconscious and going oh no I don't think they want me to help them no we're going to imply they want our help so just make sure any scenario if there's an unconscious person we are going to treat them through implied consent now we can set the minors of course 17 and younger must have a caregiver guardian that will sign for them unless they've been emancipated but please don't worry about that that's not going to come up on your national exam just know it's consent of minors and then refusal consent we've talked about this before we are not going to get emotionally involved we have no idea what our core patients have been up to that day or have gone through so if they are refusing that their blood drawn of course we want to take the proper steps educate them tell them what the basic tubes are that are ordered what they do still say no we go grab the nurse nurse comes out so there's nope you're not going to draw today that's okay go in with your refusal consent have them sign on the dotted line make sure it makes it into their chart and move on to your next patient my recommendation is these people are probably having a tough time so be cheery be nice thank them for their time and wish them the best of luck now we've talked about patient identification a couple occasions but just to review very very important right the only thing that comes before patient identification is the requisition form but when we go to identify somebody they're impatient they must have a wristband doesn't matter what oh they throw at you doesn't matter what's going on they must have a wristband if they're impatient and it must match their your requisition exactly there cannot be any variances within this now let's say they're out patient we know they have to provide an IV they can actually use a medical identification card as ID for outpatient then of course we want them to state their name and any personal health information or protected health information and it has to be something that they would only know date of birth social security zip code all of those type of things that are very personable and if the patient is unconscious we first of course have to go out there a span we're never going to draw if their wristbands not attached then secondly we need somebody that is identifiable so meaning the spouse the nurse the caregiver to verify who they are and then we're also going to verify that person with two identifiers so their first and last name their date of birth and we're going to write on the requisition that they were our second identifiers that identified that unconscious patient now there's something that's not listed here and that's called the sleeping patient yes we will never ever stick a patient who is asleep that is ridiculously rude and we would never ever do that so of course we're going to gently wake them tell them why we're there make them confirm who they are and then we're going to go ahead after they have consented and been identified now veins again so once again the bend of the elbow is called B and a cubital fossa and we're looking for three main veins what are these main things that we're looking for the first and foremost is the kneading cubital then secondly we go to the cephalic and lastly we are at the basilica and another side note remember cephalic is generally the best for obese patients the meeting queue a little bit deeper and no and hidden a lot with our obese patients so just remember cephalic can be the better vein a choice in that but no matter what we're always looking at the antecubital fossa first and then what are the fingers that we practice capillary puncture on and that's the greater and the ring remember if we do the pinkie it will have adipose and if we do our first finger it's callus not epithelial cells and no matter what we always wipe away the first drop because it is contaminated with interstitial fluid malla sized cells at the thelia cells and therefore we wipe away that first drop and then we never perform a finger stick on a cold cyanotic which means blue scarred swollen or Raschi finger obviously right the risk of infection goes up we know what cold cyanotic fingers they don't bleed very well anyways take the time to massage them I'll warm them up and then scarred and swollen of course is going to cause more pain and rash opens up for more infection okay once again an Aikido fossa is going to be our first choice and then we're going to run through our three main veins and then the dorsal is the for the back of the hand and we do use what's called the winged infusion set it's a butterfly essentially you will hear called butterfly out in the field just they call it a winged infusion set on your national exam all the same thing and I'm telling you right now I've never seen a phlebotomist look to another full bottom of sand so please hand me the weak infusion set they will always call it a butterfly as well now with this you can do the side of the wrist but a lot of facilities do not allow you to draw out of the wrist so make sure you stay within policies and procedures of wherever you're working but that one that runs right along the thumb that's a great cheater vein does cause a little bit more discomfort but you can generally have blood out of that one and remember with your dorsal veins anytime you leans Y together you have a valve and if you stick a needle through a valve it's going to send a signal to all your other valves to shut down so you may get the flash you may see blood inside of that butterfly but you're not going to get any blood out of those veins and then lastly we go to the ankle or foot we do need physician's approval for this and we never ever under any circumstances draw an ankle or foot of a diabetic patient it just increases the susceptibility of infection for them now there are other places that we draw and working with paramedics and EMTs they've taught me a lot of different tricks of different places to draw from but for your national exam these are going to be our primary focus places to draw now we've talked a lot about these throughout the class but this is a nice refresher to never ever perform a venipuncture and we never do it above an IV line for any reason we always go underneath and remember we had them stop the IV for just a couple minutes two to five minutes higher tourniquet and use a discard tube before we go ahead and we need to discard about five milliliters there and of course milliliters of different vein then what the IV is running in we never do an armed with a dialysis shot we just don't want to run the risk of popping it displacing anything like that and of course we're not going to draw through the dialysis shunt unless you are a dialysis technician and you will be trained specifically how to do that now we never do it on the same side as a mastectomy and remember if there's a double mastectomy we want to consult a physician and if one had been removed in 2005 and the other one 2012 we go the one that was removed first edema is a little work for swollen so we're going to avoid drawing out of swollen extremities for obvious reasons we're going to avoid drawing through scars stretch marks anything like that the veins don't bleed well and it hurts really bad for the patient's if we draw through a hematoma it will cosmos eyes samples it will bust those red blood cells releasing hemoglobin and therefore contaminate our specimen and then like I mentioned before we never ever draw on someone who is incoherent or confused it's bad practice and legality wise they if they're not in the right state of mind they can't consent to the procedure so we know the complications if you don't have consent then you just committed battery now these are new so sclerotic like sclerosis means hard so sclerotic veins are very hard and the best way I can explain these is if so if you take the pen the actual ink plastic ink part out of your pen that little small cylinder it's almost like somebody inserted that into somebody's vein so when you palpate it it's just like there's something underneath there like a piece of plastic inside of their vein and a lot of the times in your palpating sclerotic games it's hurts it's uncomfortable for the actual patient so of course we want to avoid this tortuous means twisted so these are really interesting generally when you're trying to figure out what direction it goes it disappears and then also I'm going to come back up and disappear come back up disappear well we know just a vision in your mind trying to stick a needle through a twisted vein it's going to go right through the vein you're not going to get any blood anyways from Bott ik infla bet ik I'm going to kind of twist together because what it's implying is that there's a clock there and of course if there's a clot we do not want to draw if a clot becomes dislodged it can hit the brain caused a stroke it can hit the heart cause of myocardial infarction it can go into the lungs and plug our pulmonary vein coming back in Casa Loma very embolism so very very bad but essentially the signs and symptoms of this is inflexible tender to the touch it can be swollen read the temperature will be different it could be either warm or cold and as soon as we identify this we do not want to draw we want to get the position to check it out because of the severity of having a blood clot and then you guys know this really fragile thin superficial veins we do not want to stick these veins so they're not going to bleed very well even if we do get some blood out of them it's not going to bleed on that much at all so but these are all veins that we can feel but we do not want to draw on antiseptics we've worked with several info septics here in the class and our number one antiseptic of choice is isopropyl alcohol so please don't let the test mess with you with 70% alcohol 90% alcohol isopropyl alcohol is our number one choice then we have what's called Clorox amine now there's two different types of Clorox inning there's clock singing squares and there's what's called clock Clorox in gluten aid swabs now Croxon agglutinates swabs do have alcohol in them so they are not appropriate to be using for blood alcohol test what the best thing to use is the benzalkonium chloride and when you get this question it's pretty obvious because we're never ever going to use hydrogen peroxide as an antiseptic pro-bono an iodine stain the skin leaves residue and causes an increase in potassium with our specimen and so therefore benzylic benzyl chloride becomes our best choice to do a blood alcohol test to do a clean catch midstream anything of that sort and this is just like where we tie our tourniquet we want to clean an area in three to four inches and concentric outward circles never crossing over the original points of cleansing sorry I got a little ahead of myself on that last one we didn't talk about blood cultures remembering what you do a blood culture you have to clean twice and the procedure changes a little bit when you're doing concentric circles you want to be very small and you want a most scrub as you're doing this in an hour motion and you want to scrub for a good 60 seconds as you do this and then you do want to clean twice so that we can create that sterile process not cross contaminating bringing outside microorganisms into our blood culture trough because remember blood cultures we generally do for somebody has a fever of unknown origin and we really need to find out what is causing their fevers and of course we're going to draw the aerobic and anaerobic tubes for that now patient compliance a lot of the times this is out of our hands right it's up to the patients to comply so the first one is a fasting sample and we know somebody has to fast for 8 to 12 hours and that means no liquids outside of water and no foods and then medication medication is kind of goes back and forth they can either have to take it before midnight or they have to take it a few hours beforehand whatever the case might be will be outlined on your requisition form and then basal state basal state is a combination of kind of all the above they have to be resting they have to be fasting and they cannot have exercise for roughly 12 hours so it kind of combines everything and for this we do have to ask all three of those questions so when was the last time you ate when was the last time you woke up how much rest did you receive last night and when was the last time you had any physical exercise now when we're talking about Pediatrics we will do a lot of capillary draws we will fill those micro containers a lot of times for children and remember when we're doing any type of capillary draw or filling the capillary micro containers the order of draw changes and it goes lavender green red but if we're going to do a draw on a child then we do need to use a smaller evacuated tube so that it doesn't immediately collapse their veins we are going to use a butterfly or winged infusion set makes a lot easier it's a lot smaller of a needle and essentially we want to ensure that anytime we're working with children we talk with the patient and the child we make sure they understand everything that's going on and we need to say calm confident and help them through that whole process now when we go to draw we hold the needle at fifteen to thirty degrees now this doesn't change for syringe either right that great a tube or syringe so fifteen to thirty the only time that changes is when we're talking about using a butterfly or winged infusion set and then it goes to five to fifteen now point-of-care testing a lot of people forget point of care testing this is when we're bad side we get immediate results such as a glucometer reagent dipstick testing pregnancy testing they're all point of care testing and remember when I did the original lecture on this I wanted you to link this to CLIA waived now we'll talk more about this as we go on but just to remind you CLIA is all about ensuring quality of testing hooya waived means easy tests require little judgment on little risk to our patients now we want to ensure safety throughout the collection process and we can do this through multitude of different ways the easiest way is through communication making sure that we are staying in communication with our patient we are assessing them constantly looking for our telltale signs of syncope different things so that we can ensure that we are doing the best thing for them of course that they start to have diaphoresis that they start to go pale then we can investigate further now anytime somebody loses consciousness we stop the procedure immediate release the tourniquet pull the needle out we want to figure out why they lost consciousness and I want to run scenario really fast you are drawing somebody loses consciousness one of the first things you should start to do is assess if they're breathing or not because if they're not breathing that changes the code that you have to call obviously we're going to call for help the moment they go unresponsive but we do want to assess the patient for what type of code we need to call now fragile and I want to say this differently fragile collapsing veins we always use a syringe slow rolling names we use a butterfly or winged infusion set now also remember when we have a infant newborn we're going to do a heel stick and this we're going to do a heel stick for anybody that's 12 months or younger and has not started walking if they started walking we do not want to do the heel stick it may impede on them learning how to walk and then of course we're going to evaluate our other options of capillary or using the winged infusion set but inside of this if you remember we're going to draw a line from the middle toe down to the heel and then from the ring in between the ring toe and the pinkie toe down to the heel that creates that B and we do want to stick on the outside or lateral side of the plantar surface now no matter what well for a full-term infant I should say we never ever want to use a Lancet that's greater than two millimeters I'm very important because if we go deeper we'll hit the bone causing osteomyelitis inflammation inside bone marrow and we know all your vessels run through the bone marrow and that is extremely bad now we're not going to go over the entire lecture again of how to recover veins how to help get veins but just remember anytime you use a warmer all you need is three to five minutes increases blood flow seven times in that little area and you generally can find your veins remember you can use a blood pressure cuff you can pump up to 80 millimeters of mercury sometimes we tying the tourniquet better helps and then of course what I really want to stress here is that we're just not going to give up when we go in we stick if there's no blood we want to pull back a little bit right we may have gone through it we may want to lean angle our bevel because we might have sucked up against the vessel wall we can even exchange our tubes because our two may have lost vacuum or something might be wrong with it but essentially before we just pull the needle out and stick them a second time we want to do everything that we can to recover that venipuncture and once again if they're not walking in the younger than 12 months we're always going to do a keel stick and like it's data before we still wipe away the first drop we do that for every single capillary puncture capillary finger dermal skin now with complications you need to be familiar with what causes them what to do once they've occurred and how to avoid them so essentially nerve damages when we Nick the nerve how do we avoid this we avoid drawing out of the basilic vein the basilic is generally covered with a lot of nerves and generally that's where we get the most injury and damage from now what's our signs and symptoms of nerve damage numbness loss of sensation and therefore we know that we've nicked and therefore hit a nerve and we want to stop our draw now kima Toma hematoma means bruised literally bleeding under the skin how to prevent this with pressure and also like we talked about earlier if you go through the vein they have a higher risk if they're on anticoagulants they're at a higher risk of bruising but flashier and we want to put a pressure for two minutes for venipuncture five minutes for a arterial puncture but pressure pressure pressure phlebitis is inflammation of the vein and unfortunately I think a few of you have felt this so the lightest does happen a lot of the times it's because we scrape the vein on the way in and it's caused it to swell does happen with certain disease states but when full by this occurs we do want to apply ice ice and pressure will help that out now rhombic just like thrombin thrombo is applying or implying that there is a clot and anytime there's a clot we do not draw we do not do anything we want them checked out we want them helped immediately because the complications are so severe now they also have physical reactions such as diaphoresis diaphoresis is the technical name for excessive sweating dizziness and nausea and I think everybody has experienced dizziness and nausea before so you understand what that is Prateek ii i now petechiae are small red dots that appear around your tourniquet now I want to stress this this is nothing you have done wrong Pitts TTI is due to a platelet malfunction so even if you stop your draw and you go to the other arm indefinitely those small little red dots are going to appear around that tourniquet again so what do we do to help somebody with petechiae we do complete our draw and when we apply extra pressure pressure after the draw because we just identified that a platelet problem or platelet malfunction so put more pressure on help that out quemo concentration chemo concentration is when we have left the tourniquet on for too long too long is any time outside of 60 seconds sometimes you may get a question that says one to two minutes it's sometimes you're going to have to choose the absolute best answer so when we have hemo concentration that occurs we do see an increase in potassium within our specimen so how do we avoid this obviously right we don't leave the tourniquet on for as long as for more than a minute and then collection and processing errors I do want to remind everybody that administration is 40 percent of errors for phlebotomist so taking your time labeling the tubes right in front of the patient before you leave the room making sure that you double-check your requisition making sure you spell everything correctly is absolutely key that attention to detail is going to make or break your success now let's go through some signs and symptoms of some of the most common things that take place now syncope hopefully everybody remembers means same team so essentially what happens is they become pale or like this says lack of blood supply to the brain they start having diaphoresis that excessive sweating they get these staring eyes where they just are basically like deer in headlights and then you can pretty much count that they're going to go out at that point when somebody does pass out we do want to put their head in between their legs we want to put a cold compress on the back of their neck now seizures remember we stopped the draw immediately oh and I apologize for syncope we're going to stop the drawing ideally as well but for seizures we stop the draw immediately we want help we do not beam for seizures that anything we move the furniture away from them so that they do not seize into it and cause extra damage to themselves even if they are bleeding we will treat bleeding after the seizure has stopped now shock shock is very similar to syncope except for they turn cold and clammy and therefore our response to this is to put a blanket over them and to raise their legs so they're going to have a lot of the same signs and symptoms but they're not going to lose consciousness hopefully and we can keep them in line now nausea everybody knows nausea and diaphoresis excessive squat sweating now hopefully everybody knows the order of draw by heart at this point yellow blue red green lavender gray and hopefully now when you see sodium citrate you think blue when you hit a fluoride oxley you think gray when you hear EDTA you think lavender hopefully these are all starting to just be synonymous with each other remember the serum - we really don't have an additive and let the clot activator and the clot activator is called thrombin I also remember with our blood cultures we are creating a sterile procedure so we do not cross contaminate and we're drawing the aerobic and anaerobic tubes and if it is a light yellow container then it does contain SPS which stops phagocytosis and slows white blood cells from getting to it now when you write your order of job yellow blue red green lavender gray remember you can draw a line right at lavender and do an arrow up to red and that will tell you the capillary order of draw it starts lavender green and red and why does this change because we have an increase in coagulation we have rapid coagulation when we puncture a capillary so very very important your national exam is going to flip the script on you on multiple occasions and it just has to make sure that you understand that this does change when we do capillary draws now we've talked a lot about this in class and you have that wonderful a grid that we build every time or graph that we build every time but just to hit the very big ones here sodium citrate is all about halation so anytime we're doing any test around clotting it's going to be linked with sodium citrate EDTA preserves the size of the shape size morphology of ourselves and therefore it's used for some ecology it's our best at preserving and for us to be able to test exactly how they're doing in their natural state so hematology EDTA heparin is our best for chemistry test half brain if you remember is natural inside of our body therefore if we want to see what's happening inside of our body right now heparin is our number one test and so for example if we're doing peak and trough we want to know how well medications are going inside of somebody's body heparin is our go-to choice and then last but not least potassium oxalate we know this preserves glucose therefore we can get the most accurate sugar test to help in aiding the diagnosis of diabetes mellitus here is your inversion rate on the best thing IV is remember me trying to give you some tips with this as four out of six or eight to ten times yellow green lavender gray eight to ten times serum is five times and I remember this because the s looks like a five and light blue is three to four times so however you want to remember this serum five and then blue is three to four everything is everything else was eight to ten now there are several ways that we verify the quality of equipment remember we do quality checks daily it's very very important as a phlebotomist that we do all of our check offs daily and to ensure that all of our equipment is working appropriately and that we are give the most accurate results to our providers so we verify the quality a couple different ways I essentially would never use anything that has an expiration date that's outdated if a label or seal has been broken we can't guarantee the sterility therefore we do not want to use it intact bevel some bevels are created with what's called bores on them so no matter what you do it's going to cut some form of pain to that patient and then safety devices if the safety devices were hanging off or not put on correctly do not draw with it just toss it it's not worth risking your safety or your patients safety now there's a couple other things that I want to talk about here with quality one is using external liquid controls anytime you use external liquid controls is for when we open a new box or we get a new lot number we do need to check and verify that the equipment is working properly and then we also want to verify that the covett strips of the glucometer match the glucometer every single time before we draw air before we test any patient blood smears now why do we create blood smears for white blood cell differentials this is so that we can smear the blood so thin that it's one cell thick and we can literally differentiate between all the different white blood cells and that tells us what type of infection that person is fighting so we do if we don't take this directly from a capillary we do draw this into an EDTA tube has to be prepared one hour after collection otherwise it's not accurate when we put the droplet of blood on the slide it wants to be a half an inch from the side in the center and remember there's a happy medium here a dime-sized droplet is way too big we don't want to use it but if we don't have enough blood then we're not going to smear out enough so kind of right in between there with one little droplet of blood or I shouldn't say one little normal sized droplet of blood and then we take our slider or smear and glass slide and we hold it at a 30-degree angle and we want to push into that droplet of blood and then in one movement pull off and that should create our tail a feathered edge where we get that oneself thick and we can complete our differential new bores we know newborns go through a screening they generally need to be screened 24 to 72 hours after birth and the number one thing that every single state has to test for is PKU phenylketonuria very very important and if we can catch this we can lessen the effects or even stop the effects of this now we are going to do use a screening card and we talked about the screening card it has the circle the absorbent circles we will essentially do a heel snake wipe away the first drop we want to milk a very large sized droplet of blood we want to take the screening card and bring it to the drop of the blood we never want to touch the actual heel we want the circles to absorb that blood without us doing anything at all we want it to happen naturally we never put two drops in the same circle and we never stack these screening cards we have to allow them to dry thoroughly it generally takes four hours we cannot hurry this process we can't waive it we can't blow on it we can't set it inside the Sun or otherwise it will be contaminated it has to be received within 14 days of collection we can never use expired forms and we do not want to over saturate or under saturate the circles now if you remember therapeutic phlebotomy is just a really fancy way of saying bloodletting and we do this for patients who are suffering from polycythemia vera and that's when they over produce too many blood cells and therefore we drain out some blood they're good for a few months they come back we repeat cycle ok donor blood I want to talk about donor blood for a quick minute here so essentially to donate blood you have to have waited eight weeks in between your last donation and you have to be 18 years of age you have to wait over a hundred and ten pounds and there is no age cap so essentially a 7 year old person who's in good health can still donate as well with this as a technician we must collect a medical complete medical history on every single patient before we can collect their blood obviously big things that have blood-borne pathogens they are disqualified from donating blood as well I do get the question a lot why is it that people are not allowed to donate after getting tattoos it's because of the fear of acquiring a blood-borne pathogen during that so there is a time period that people will make you wait but just remember it is very very critical crucial to remember that you must get a complete medical history before taking their blood now here's some words that I want to go over with you Avery sis means that we are going to separate one of the blood components as we draw blood so the most common apheresis is called plasmapheresis that's when you're removed plasma as we're drawing blood out of logos is when we take our own donation for our we give our own blood for ourselves so for example if we have an upcoming surgery and there's the possibility we're going to need a transfusion we can donate our own blood to ourselves after our surgery then they will transfuse our own blood back to us and then once again we've talked about I TRO genic anemia this is when we caused them to be anemic due to repeated blood draws so therefore we have to calculate the total blood volume and one of the easiest ways to do that we talked about this change to kilograms move it over twice that becomes your total blood volume and remember we can never ever draw more than 10% of the total blood volume on anybody okay so we've talked about this on several different occasions we want to label specimens before leaving the patients room right in front of them this will reduce the chances of errors remember CLIA is all about test quality of tests and CLIA waived is easy simple tests that require minimum judgment and interpretation and presents really no risk to the patient such as glucometer reagent dipstick all of those wonderful things now essentially we have a lot of different quality we talked about this right external liquid controls for new boxes lot numbers we want to check the strips to the glucometer every time we go to test a patient and then you can read through all these things these are nice things that will go along with ensuring that we are delivering the highest quality okay so special tests that require extra things so we have ammonia lactic acid in arterial blood gases that need to go on ice immediately and remember the ice family pulls out a green heparin now cold agglutinins remember we talked about this and this is a play on war our own words and cold agglutinins must be kept warm there's also another test called cryoglobulins cryo a lot of the times is implying cold but it's not and that one also needs to be kept warm so these are a couple of the only blood tests that need to get warm otherwise we are going to refrigerate store and preserve blood at five degrees Celsius or refrigeration hi you guys remember this Billy Rubin needs to be protected from the light because it is Dean liver function mostly jaundice and how do we cure jaundice with light so we need to draw us into an amber color tube or wrap it in tin foil then we have the post prandial post prandial means after eating generally is 2 hours after eating and then we have our peak and trough values peak and trough comes before and remember it's 15 minutes before the administration of medication then the medication is administered and depending on what type of medication and administration will depend on when the peak value needs to be drawn but then of course that needs to be drawn on time and given to the physician and the pharmacist to dial in the absolute therapeutic value now the wonderful world of non blood and I know a couple of you have expressed how you're not overly excited about this but understand how this plays into a big part of care so essentially we're going to start with stool remember the biggest thing about stool is you cannot mix urine with it it will kill the bacteria we're trying to test we generally test school for a cold blood and colorectal cancer those are kind of our primary things now you're in is a most common non blood sample that we are going to do you're going to you're going to collect your in almost as much as you do blood it is a lot now preservatives we can transfer the urine into the preservative tubes and remember the tubes look very similar to our evacuated tubes except they have pointed ends when we centrifuge them it creates the sediment and we can I essentially analyze the sediment but we use urine samples for all sorts of different things and let's just kind of go through this random we do randomly generally for drug testing clean catch midstream is our best for doing cultures because we clean we prevent cross-contamination we always want to refrigerate any page or any urine that we're not going to deliver directly to the office or to the lab and 24 hour specimen remember we do not take the very first void but we start with the second void of the day every single time they avoid we're going to add that to the container that container needs to be kept on ice and then we do it for 24 hours and then go ahead and pull that we're also looking for bacteria and then our first voided morning specimen is generally done for pregnancy testing now before we start talking any further I do want to highlight that all fluids should be collected into a sterile container I know right here it only highlights for semen but just please we do not want to cross contaminate we want to take a sterile non-contaminated container for all the fluids we're ever going to collect now with semen we cannot expose to light extreme temperatures we want to keep it as close to body temperature as possible which is 98.6 degrees or 37 degrees Celsius and it must reach the lab within 2 hours of collection to do any type of fertility testing but what we're going to tell our patients is to bring it back to us immediately because we don't want it sitting out we don't we don't want them to show up at 2 hours and 5 minutes and then be upset why we cannot test it so we tell them once they collect it keep it close and on their body so it's not exposed to light and that it's as close to body temperature as possible inside the pocket or something like that and bring it to us as soon as possible we do this a lot for post vasectomy testing to ensure that the vasectomy to take and the procedure went well sputum so we've talked about this before as well we do want the person to rinse their mouth out just with water nothing else we don't want to contaminate our specimen we don't want to anything like that so we just want them to rinse it out spit and then we need them to hock up or bring the mucus out of their lungs and that's what we need to test saliva is not going to do us any good we need that mucus we need that phlegm generally done for microbiology testing now and just a side note here for some water if you're ever going to collect a TB test via sputum first of all please we're in n95 respirator even though they haven't been diagnosed with TB if there's enough evidence that they want to do a sputum test for it protect yourself first and foremost secondly the container that actually you will put this in has poisonous preservatives so you need be careful so that you don't inhale this and your patient doesn't inhale this we have talked a lot about pre analytical or errors but I just want to remind you that it's broken into three stages pre-analytical analytical and post analytical and they can interchange exam for that as well pre exam exam post exam so inside your study guide there's literally two pages of pre-analytical errors so I don't really want to spend a lot of time on this we've talked a lot about this you can read through this but I do want you to make the distinguishment between pre-analytical and analytical remember analytical exam phase starts when the medical laboratory technologist begins to test the actual blood so even transportation is considered pre-analytical just when the MLT is actually running the exams does that become the examination or analytical phase now our wonderful chain of custody guidelines and remember chain of custody is implying this is going to go through the court of law is going to be ruled on judged on it's almost used as evidence in other words and chain of custody I think is such an appropriate way of saying this this is an extra form of documentation that accompanies the specimen and every single person who has ever touched or done anything with that specimen signs dates and documents what they did on the chain of custody therefore when it gets in front of the judge or when it's pulled for testing or excuse me when it's pulled for evidence that the judge can literally see every single second that the specimen has been alive who's done what with it and how it came to be and therefore there's no possible forms of contamination or foul play well I also want to remind you of the four tests that we are going to Center this round blood alcohol testing drug testing forensic poisoning and paternity DNA testing will all require that extra documentation that chain of custody to go along with it a reference laboratory is like quest lab course somewhere where we actually send the samples to be tested so of course we're gonna send these and biohazard bags because biohazard bags let the entire world know that there are potentially infectious material things fluids inside of them and it just warns everybody now we went over this the other day about how to package this but there's different different levels to how you package this of course it goes into evacuated to the evacuated tube then is placed inside of the biohazard bag with a copy of the requisition that's wrapped up tightly that's put inside the box with styrofoam with ice packs but we want a barrier because if we put the blood directly on the ice packs it will freeze the blood and of course ruin our samples so very very important that we package this all correctly and we ship it out and remember here in Houston you always want to ship with ice packs it's very very important it's duplicating refrigeration and preserving all of our samples now we talked about point-of-care testing before I literally done right there at the bedside we get our immediate results when a critical value is detected we need to report these results promptly to the ordering physician so let's go over that really fast if somebody has been fasting and they come in and we do a blood glucose test on them and they are still above 126 milligrams per deciliter we then know that there's an issue and we consider that a critical value now somebody does a post prandial test and they are still above 200 milligrams per deciliter then we are also going to consider that a critical value now in the case you call the physician's office and the physicians are unavailable you will leave the message with somebody that you can hold accountable so you're going to take down their name their date what you told them when you told them that so that you can hold them accountable to get that information to a physician as soon as possible and also why we're talking about this I just want to remind everybody we never ever release results or talk about results we always send the patient back to the ordering provider sorry jumped a little bit ahead there but essentially right if it's a critical value we need to call and make sure that that is reported immediately or as soon as we possibly can you can email or fax results through secure channels nowadays we use electronic medical records EMR systems where once it's input in the lab the physician already has access to it so it's pretty nice meaningful use incentive programs are still around but essentially Obama care changed everything in 2015 they did I don't want to use the term force but they did tell everybody that they had to start using EMR systems so that's become more universal at this point now our wonderful regulating bodies that ensure that we stay safe and our patients they say so the first one is OSHA and OSHA is more for us than workers right they want to ensure that we have everything that we need to keep ourselves safe and that we are not being exposed to more risk and hazards than needed and we do refer to OSHA as wanting to reduce incident exposures now the CDC is the Center for Disease Control they are really responsible for public education for ensuring that the spread of disease people are educated enough not to spread disease and to be aware of disease when it is around the MSDS has everything to do chemicals if we have a chemical spill if something gets somebody gets chemicals on them we are going to consult the MSDS the NIOSH really is focused on sharps so sharps must be leaked and puncture-proof they can't be overfilled then you'd be stored in appropriate height regiments and NIOSH is the one who's going to ensure that that happens like I said before sharps containers puncture-proof usually identifiably full so that we don't run the risk of going to drop a needle and getting an accident may poked display a biohazard symbol has to be very stable and essentially let's talk really fast what happens if you do get an accidental stick you need to flush it for 15 minutes bandage it record the patient's information if you can fill out an incident report to your supervisor now Jayco or Joint Commission there are big accrediting body they are the ones who have credit everybody to basically practice so they can come through we talked about this before race the race acronym know where your oat uh shutoff valves are at no all of that good stuff because the Jayco inspector can ask you that Jayco will find people who are not in order and not following things as well or putting patience and risk I'm so Jayco is our friend and we want to be very nice to Jay Cohen Spector's clsi these are guidelines for standards and operations remember sila sighs who gives us our order of draw who tells us what additive goes with which I'm very very important I'm just remember standards of operations they're the ones that I basically ensure that quality is being met HIPPA is all about privacy and confidentiality wants to keep private information private just to highlight this you guys we really shouldn't be talking about other patients at all we can talk with our nurse or provider when we are literally going through care plans but we really shouldn't be talking about patients in any other settings and pH is protected health information essentially what hippo wants to keep private now hopefully if you take nothing else from my class you take standard precautions very very seriously standard precautions states that if we're going to come into contact with any bodily fluid we must treat that bodily fluid as if it was potentially infectious we know all of the crazy statistics and we know how this goes now with that said the other side of this is since we are treating everybody as if they are infected or if their bodily fluids are infected then we do not treat certain patients any differently so if somebody states that they are HIV positive or hepatitis positive you cannot take any extra precautions other than raising your awareness but you don't want to put on a hazmat suit you don't want to treat this person any differently you should be treating every single patient as if they were infected anyways now let's run through this an immunocompromised patient means that they are have their immune system that has been broken down so burn victims cancer patients we put these people in protective isolation which means we are the primary source of infection and we need to keep protected from us when somebody is on contact precautions we need to wear gloves in a gown when somebody is on airborne or droplet precautions or has something like strep throat or the flu then we need to wear a face mask if somebody's on splash or spray precautions then we need to wear a face shield or goggles on top of our gloves and then if somebody's in TV isolation we need to wear an n95 respirator and remember no ciccone alaric wired inside the hospital generally mersa bre leadeth now c-diff remember is clustering difficile we just break it down to see tip your hand sanitizer does not take care see this so at any point in time if you get any visible bodily fluids on your gloves you need to stop and wash if you don't you can hit the hand sanitizer three times do for OSHA regulations but after three times you must stop and wash and also hand hygiene is the most effective way of preventing infection and then also outside of that wearing ppb's okay just a reminder to the class we will be doing CPR next Friday so it will be a little bit longer it does take a little while to go through that I do want to make sure that you're all properly chained and feel comfortable to jump in and save a life but the big key things here is if somebody is not breathing and does not have a pulse we absolutely need to start CPR anytime somebody does not have a pulse we won AED an automated external defibrillator and we want to hook them up as soon as possible I can really mean the difference between life and death now we'll go over a lot of the specifics with this how we keep a rate of a hundred to 120 beats per minute for single rescuer all across the board we're 32 two but when you get to child or anything you have to rescuers that switches to a ratio of 15 and 2 I will go over all of these specifics when we go through CPR but essentially I just wanted to highlight that somebody who is not breathing and does not have a pulse need CPR