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 this is going to be a review that goes right along the side of your teal green 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, and then at 5, I will be double-checking all of my emails, text messages, voicemails. So please do not hesitate to drop me a line. Thanks, guys, and I hope you enjoy. Now the first category is patient preparation.
Now the one thing that trumps 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 needing to fast, from them needing to have taken 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 two identifiers. So with an inpatient, they must have a wristband and then we verbally have them identify themselves, date of birth, social security, some kind of personal health information or 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 two verbal confirmations. Now here's something we 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 second 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 them 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 is something is wrong.
And we do not want to draw that patient until a physician has looked them over. So any type... of losing consciousness or seeming like they're just spaced out, 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 has never had their blood drawn before, sit down with them, take time to explain the entire procedure so nothing... 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 cilic and then we go to the dorsal hand veins.
But that's going to be the same no matter what. If there's a 96-year-old person who gets wheeled in 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 depth, 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 lead them, we can't say anything other than, when was the last time you ate or drank something? If you say, did you eat 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, and 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 we do for excessive bleeding? Pressure.
We want to apply pressure. We'll do co-band, of course. We can do our pressure bandage.
Then moving down to severe pain, generally should not last more than a few minutes. We know this, right? 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 if ice doesn't cool it down, sorry, that was a bad pun. 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 tourniquet been on right because cannot 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 draw immediately We want to get out And then of course apply a pressure if it lasts more than a few hours We do want them to be checked out by a physician Now excessive bruising, we consider excessive bruising being greater than the size of a gauze 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, you reestablish your platform and finish your draw. we know then that they have a tendency to have more bruising because we've pierced both sides of the vein. So we definitely want to hold pressure for a little bit longer and put on our coban.
Now infection, we haven't talked a lot about infection but the key signs and symptoms of infection is red, swollen, pussy, 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 through any 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 their physician. And then patient feeling unwell, that's another way of just saying nauseated. So essentially, if the patient feels nauseated, then 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 stat and ASAP a few times but just to review, stat means to drop everything and do it right then and there and ASAP means as soon as possible you want to collect it within that hour. So essentially with the stat draw remember this can trump the patient, physician, Relationship, this can trump everything because normally you do have to wait if you walk into a room and they're 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 consents. 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 is provided plenty of information in their own native language, given the opportunity to ask as many questions as their heart desires. But 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 consented. Well, that'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 be like, 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 consent of 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 We are not going to get emotionally involved. We have no idea what our poor patients have been up to that day or have gone through. So if they are refusing to have 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, says, nope, you're not gonna 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 on 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, if they're inpatient, they must have a wristband, doesn't matter what scenario they throw, throw at you doesn't matter what's going on they must have a wristband if they're inpatient and it must match their your requisition exactly there cannot be any variances within this now let's say they're outpatient we know they have to provide an id 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 off the wristband we're never going to draw if their wristband's not attached then secondly we need somebody that is identifiable so meaning the spouse the nurse the caregiver to verify who they are and 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 identifier that identified that unconscious patient. Now, there's something that's not listed here and that's called the sleeping patient. You guys, we will never ever stick a patient who's 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 the antecubital fossa and we are looking for three main veins.
What are these main veins that we're looking for? The first and foremost is the median cubital. Then secondly we go to the cephalic and lastly we are at the basilar.
And another side. Note, remember, cephalic is generally the best for obese patients. The median cubital is a little bit deeper and hidden a lot with our obese patients.
So just remember, cephalic can be the better vein of 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 pinky, it will have adipose. if we do our first finger, it's calloused and we'll have epithelia cells. And no matter what, we always wipe away the first drop because it is contaminated with interstitial fluid, hemolysis cells, epithelia 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 rashy finger. Obviously, right, the risk of infection goes up. We know with cold cyanotic fingers, they don't bleed very well anyways. Take the time to massage them, 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, antecubal 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 for the back of the hand. And we do use what's called the...
winged infusion set it's butterfly essentially you will hear it 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 phlebotomist and say please hand me the winged 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 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 get blood out of that one and remember with your dorsal veins anytime your veins 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 on the 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 have them stop the IV for just a couple minutes, two to five minutes, tie our tourniquet, and use a discard tube before we go ahead. And we need to discard about five milliliters there.
And of course, course we want to choose a different vein than what the IV is running in. We never do an arm with a dialysis shunt. We just don't want to run the risk of popping it, displacing it, 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 the physician. And if more...
one had been removed in 2005 and the other one 2012 we go to the one that was removed first edema is another word 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 patients if we draw through a hematoma or bruise it will cause hemolysis samples it will bust those red blood cells releasing hemoglobin and therefore contaminate our specimen and then like I mentioned before we never ever drawn someone who is incoherent or confused it's bad practice and legality wise, 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. 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's it's just like there's something underneath there like a piece of plastic inside of their vein and a lot of the times when you're palpating sclerotic veins it 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 all of a sudden it'll come back up and disappear come back up disappear well we know just envision 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.
Thrombotic and phlebetic, I'm going to kind of twist together because what it's implying is that there's a clot 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, cause a stroke, it can hit the heart, cause a myocardial infarction.
It can go into the lungs and plug our pulmonary vein coming back and cause a pulmonary embolism. So very, very bad. But essentially the signs and symptoms of this is inflexible, tender to the touch.
It can be swollen, red. The temperature will be different. It can be either warm or cold.
And as soon as we identify this, we do not want to draw. We want to get the physician 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 they're not going to bleed very well even if we do get some blood out of them it's not going to bleed 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 antiseptics 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 chloroxidine. Now, there's two different types of chloroxidine.
There's chloroxidine squares, and then there's what's called chloroxidine glutenate swabs. Now, chloroxidine glutenate swabs do have alcohol in them, so they are not appropriate to be using for blood alcohol tests. What the best thing to use is the benzoylchlorium chloride.
And when you get this question, it's pretty obvious because we're never, ever going to use hydrogen peroxide as an antiseptic. Provodone iodine stains the skin, leaves residue, and causes an increase in potassium with our specimen. And so therefore, benzoylchloride 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 in concentric outward circles, never crossing over the original point of cleansing. Sorry, I got a little ahead of myself on that last one. We didn't talk about blood cultures.
Remember when 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 do very small and you want to almost scrub as you're doing this in an outward 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 draw.
Because remember, blood cultures we generally do for somebody who 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, it 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 exercised 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 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 the times for children.
And remember, when we're doing any type of capillary draw or filling the cap... 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 any time 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 stay calm, confident, and help them through that whole process. Now, when we go to draw, we hold the needle at 15 to 30 degrees.
Now, this doesn't change for serenity. either right evacuated tube or syringe so 15 to 30 the only time that changes is when we're talking about using a butterfly or winged infusion set and then it goes to 5 to 15 now point-of-care testing a lot of people forget point-of-care testing this is when we're bedside we get immediate results such as a glucometer reagent dipstick testing pregnancy testing they're all point-of-care testing and remember when 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.
CLIA waived means easy test, 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 a multitude of different ways. The easiest way is through communication, making sure that we are staying in communication with our patients.
patient. We are assessing them constantly, looking for our tall tale signs of syncope, different things so that we can ensure that we are doing the best thing for them. Of course, if they start to have diaphoresis, if they start to go pale, then we can investigate further.
Now, anytime somebody loses consciousness, we stop the procedure immediately, release the tourniquet, pull the needle out. We want to figure out why they lost consciousness. And I want to run the scenario really fast.
You are drawing somebody who 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. Small rolling veins, 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've started walking, we do not want to do the heel stick. It may impede on them learning how to walk. And 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 pinky toe down to the heel and that creates that V and we do want to stick on the outside or lateral side of the plantar surface. Now no matter what, well for a full toe, term infant I should say we never ever want to use a lancet that's greater than two millimeters very important because if we go deeper we'll hit their bone causing osteomyelitis inflammation inside their 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 your veins remember you can use a blood pressure cuff you can pump up to 80 millimeters of mercury sometimes we're 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 re-angle our bevel because we might have sucked up against the vessel wall we can even exchange our tubes because our tube 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 vena puncture and then once again if they're not walking in the younger than 12 months we're always going to a heel stick and like it stated 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 damage is when we nicked a nerve how do we avoid this we avoid drying 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 a nerve or hit a nerve and we want to stop our draw immediately now hematoma hematoma means bruise literally bleeding under the skin how do we 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 pressure, and we want to put 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. Phlebitis 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 phlebitis occurs we do want to apply ice ice and pressure will help that out now thrombus just like thrombin thrombo is 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 petechiae now petechiae are small red dots that appear around your tourniquet now I want to stress this this This is nothing you have done wrong. Petechiae is due to a platelet malfunction. So even if you stop your draw and you go to the other arm, inevitably 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 then we apply extra pressure after the draw because we just identified they have a platelet problem or platelet malfunction. So put one.
more pressure on help that out. Hemoconcentration. Hemoconcentration 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 hemoconcentration 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. turn it 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% of errors for phlebotomists. 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. tale 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 fainting. 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 stop the draw immediately. Oh, and I apologize for syncope. We're going to stop the draw immediately as well.
But for seizures, we stop the draw immediately. We want help. We do nothing for seizures. If 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 have 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 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 hear fluoride oxalate you think gray. When you hear EDTA you think lavender. Hopefully these are all starting to just be synonymous with each other.
And remember, in a serum tube, we really don't have an additive unless it's a clot activator, and the clot activator is called thrombin. 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. cytosis and slows white blood cells from getting to it.
Now when you write your order of draw, 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 get rapid coagulation when we puncture a capillary. So very, very important. Your national exam is going to flip the script on you on multiple times. occasions and just test 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 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 coagulation 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 our cells and therefore it's used for hematology 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 tests heparin 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. The best thing, if you guys remember me trying to give you some tips with this, is four out of six are 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. or everything else is 8 to 10. 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 our check-offs daily to ensure that all of our equipment is working appropriately and that we are going to give the most accurate results to our providers so we verify the quality of a couple different ways. Essentially we never use anything that has an expiration date that's outdated. If a label or a 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 cause some form of pain to that patient. And then safety devices. If the safety device is hanging off or not put on. correctly do not draw with it just toss it it's not worth risking your safety or your patient's 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 covet strips of the glucometer match the glucometer every single time before we draw or 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...
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.
I shouldn't say one little, but a 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 or feathered edge where we get that one cell thick and we can complete our differential. Newborns, 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 use a screening card and we've talked about the screening card. It has the circles, the absorbent circles.
We will essentially do a heel stick, wipe away the first drop. We want to milk a very large size droplet of blood. We want to take the screening card. card and bring it to the droplet of 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 wave 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 oversaturate or undersaturate 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 overproduce too many blood cells in their Therefore, we drain out some blood. They're good for a few months. They come back.
We repeat the cycle. Okay, 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 weigh over a hundred and ten pounds and there is no age cap so essentially a 70 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 if they 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. Apheresis means that we are going to separate one of the blood components as we draw blood. So the most common apheresis is called plasma apheresis.
That's when we remove plasma as we're drawing blood. Autologos is when we take our own donations or we give our own blood for ourselves. So for example, if we have an upcoming...
surgery and there's a possibility we're going to need a transfusion we can donate our own blood to ourselves after surgery then they will transfuse our own blood back to us and then once again we've talked about i trojan economy a this is when we cause them to be anemic due to repeated blood draws arm so therefore we have to calculate the total blood volume And one of the easiest ways to do that, we've 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 patient's room right in front of them. This will reduce the chances of errors. Remember CLIA is all about tests, 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 and 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 words and cold agglutinins must be kept warm there's also another test called cryoglobulins cryo a lot of the times isn't 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 be kept warm.
Otherwise, we are going to refrigerate, store, and preserve blood at five degrees Celsius or refrigeration. Now you guys remember this, bilirubin needs to be protected from the light because it is testing liver function, mostly jaundice. And how do we cure jaundice?
With light. So we need to draw this into an amber colored tube or wrap it in tape. tinfoil. Then we have the postprandial. Postprandial means after eating.
Generally is two 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 under...
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. test stool for occult blood and colorectal cancer those are kind of our primary things now urine is our most common non blood sample that we are going to do you're gonna you're gonna collect urine almost as much as you do blood, it's 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 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 and we prevent cross-contamination. We always want to refrigerate any urine that we're not going to deliver directly to the office or to the lab.
And a 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 void, we're going to add that to the container. that container needs to be kept on ice and then we do that 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. 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 or extreme temperatures we want to keep it as close to body temperature as possible which is ninety eight point six degrees or 37 degrees Celsius and it must reach the lab within two 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 because we don't want it sitting out, we don't want them to show up at two hours and five 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... that the vasectomy did 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 do 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 just a side note here for some are if you're ever going to collect a tb test via sputum first of all please wear it in that 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 can container that actually you will put this in has poisonous preservatives so you need to be careful so that you don't inhale this and your patient doesn't inhale this. We have talked a lot about pre-analytical 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. It's going to be ruled on judge... on it's 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 for... forms of contamination or foul play.
Now I also want to remind you of the four tests that we are going to center this around. Blood alcohol testing, drug testing, forensic poisoning, and paternity DNA testing will all require that extra documentation, the chain of custody to go along with it. A reference laboratory is like Quest, LabCorp, some... where we actually send the samples to be tested. So of course we're going to send these in 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 levels to how you package this. Of course it goes into the evacuated tube. 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.
very very important its duplicating refrigeration and preserving all of our samples now we talked about point of care testing before 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's been fasting and they come in we do a blood glucose test on them and they are still above a hundred 126 milligrams per deciliter we then know that there's an issue and we consider that a critical value now if somebody does a postprandial 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 not available 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 the physician as soon as possible. And also, while 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 received. 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 Obamacare 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 stay safe. So the first one is OSHA and OSHA is more for us the 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 with 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 leak and puncture proof. They can't be overfilled. They need to be stored in appropriate height regimens.
And NIOSH is the one who's going to ensure that that happens. Like I said before, sharps containers, puncture proof, easily identifiably full so that we don't run the risk of going to drop a needle and getting accidentally 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 credit everybody to basically practice So they can come through. We talked about this before.
RACE, the RACE acronym, know where your O2 shutoff valves are at. Know all of that good stuff because a Jayco inspector can ask you that. Jayco will find people who are not in order and not following things well or putting patients in risk.
So Jayco is our friend and we want to be very nice to Jayco inspectors. CLSI, these are... guidelines for standards and operations remember CLSI is who gives us our order of draw who tells us what additive goes with which very very important just remember standards of operations they're the ones that basically ensure that quality is being met HIPAA 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 PHI is protected health information.
It's essentially what HIPAA 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 them protected from us. When somebody is on contact precautions, we need to wear gloves and 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 TB isolation, we need to wear an N95 respirator.
and remember nosocomial diseases are diseases that are acquired inside the hospital generally MRSA VRE C diff now C diff remember is clostridium difficile we just break it down to C diff and that your hand sanitizer does not take care of C diff 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 PPEs 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 want an AED, an automated external defibrillator. And we want to hook them up as soon as possible. It 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 100 to 120 beats per minute.
For single rescuer all across the board we do 30 to 2, but when you get to child or infant and you have two rescuers that switches to a ratio of 15 and 2, we'll 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 needs CPR.