Phlebotomy Class 1 (1/11/2025) PDF

Phlebotomy Class \#1 (1/11/2025) Veins: Antecubital 1. Median cubital 2. Cephalic (thumb) 3. Basilic 1. Cephalic (thumb) 2. Basilic (pinky) 3. Dorsal What are considered sharps? - IV needles - Hubs - Tubes - Lancets - Glass Slides - Capillary Tubes - Gauze if they...

Phlebotomy Class \#1 (1/11/2025) Veins: Antecubital 1. Median cubital 2. Cephalic (thumb) 3. Basilic 1. Cephalic (thumb) 2. Basilic (pinky) 3. Dorsal What are considered sharps? - IV needles - Hubs - Tubes - Lancets - Glass Slides - Capillary Tubes - Gauze if they are soaked What is Trash? - Gauze - Tape - Band-Aids Always identify what you are going to be doing with the patient **Focus on introductions** For bedside manner always start by introducing yourself as their phlebotomist and then ask for their name and dob and for them to spell their name. Always pay attention to my body language and verbal cues. Photo ID is for **OUTPATIENT** to identify then before touching them Need to see state issued id that contains the dob (will be used with the insurance card) Hospital band is for **INPATIENT** to identify before toughing them must be on the patient and is used in place od the id card Band allows us to see the name, dob, medications used, tests ordered, test results If there is a discrepancy you can not proceed with the draw Pay attention to the nonverbal ques the patients are giving you If patient wants needle taken out remove asap and do not wait Always pay attention to details when with the patients - Sendreceived proceed understood Portability **Communication=Consent** The joint commission (TJC): solely to look out for patients and to establish standards Clinical and Laboratory Standards Institute (CLSI): develops standards of care for patients and are made from representative from the field Always have a paper trail Have standard and up to date photocalls and hospital rules To edit patients paperwork you must be with them (do not leave the room with their chart or paperwork pulled up as that is a HIPPA violation) HIPAA: Health insurance portability and accountability act - Means I need to get written permission to disclose any information to the patient - Includes but is not limited to: - Treatments - Test results - Medications - Procedures - Appointment times - Appointment dates Incident reports will take actions to correct the issues **Test Question:** under the patient bill of rights the patient can always know what tests are being done and decline medical treatment. - Report to supervisor id they decline care - NEVER give the patient their results or explain what the tests check for Do not be lazy Battery is taking action if not implied or communicated Slander and liable= verbal and words Never tell the patients their results BUT you can tell them what is going to be done such as the tests that we will be taking from them Informed consent= expressed or implied (sticking arm out and saying here is implied) Types of consent: - Informed consent: compliant and voluntary permission - Expressed consent: verbal or in writing - Implied consent: without verbal or written consent - Parental/minors: parent or legal guardian must give consent Always have the caps or sheathed near The bands need to be on the patient not on the bed or attached to the bed If there is any discrepancy DO NOT poke. Always admit to a mistake PPE includes the gives being as the most basic Clean glasses as often as you can If outside scope of practice do not touch the patient and do not poke Pay attention to the room/smells when walking into exam room Pay attention to the patients allergies and if they are on blood thinners **30 second rub 30 second dry** Toutiquet shouldn't be on for more than 1 minute as it can causes skin irritation and issues if it needs to be on longer recommendation would be to use a blood pressure cuff Be straight with the body and the vein so you are not having to adjust your body mid poke Lower the gauge means bigger the needle Higher the gauge means smaller the needle Hemolyosys (red blood cells burst open) Causes pinkish and foamy blood Vibration means that the bevel of the needle is close to either the top or the bottom of the vein and is cutting the blood cells in half The Bevel always goes up ICD10 is a code that diagnoses disease The wings on the side of the butterfly needles are meant to help with the wiggling of the needle The Basilic vein is in front of an artery so need to be careful and aware when drawing it Anticubical fusa means ditch Inversion is considered a full cycle of flipping the tubes both back and forth Occupational Safety and health Administration (OSHA): federal agency Lab: - No eating drinking gum - Always wear proper ppe - Do not touch electrical equipment in the room while drawing blood - Leave the room as you came into it Compliant inspection: not following the rules or complaining. This is the most common type of inspection Fatality or accidents inspection: shocking or poking accident Programed inspections: random Will be done if a workplace is suspected to be hazardous Imminent danger inspection: when they receive a report that the place is in imminent danger in the workplace Least common type Homeostasis process This is when the blood vessels repair after injury The repairs come in three stages 1. Vascular phase: this is when there is an injury to a blood vessel and that causes it to tighten up (constrict) and slow down the blood flow 2. Platelet phase: harm to the endothelial (cell lining of vein or artery) makes platelets to stick (adhere) a. Aggregation happens and this is where the platelets stick to the injured site and form a temporary platelet type of plug b. A vascular and platelet phase can compromise the primary stages of homeostasis. c. BTT (bleeding test time) is used to show the primary stages of homeostasis and is normally done before surgery 3. Coagulation phase: this includes flowing of interactions between the coagulation factors that turn the platelet plug to a hole that is called a stable fibrin clot. d. (clot and scab) the cascade involves an inside and outside pathway system e. Both paths come together and become one i. Prothrombin time test (PT/INR): this is used to look at the outside (extrinsic) pathway. And can also look at the anticoags such as blood thinners (ex. Heparin) 1. INR (international normalized ratio): no matter where you are your ratios will always be calculated correctly to give accurate medication. ii. Partial Thromboplastin time (PTT): used to evaluate the inside (intrinsic) pathways f. PTT/PT must always be taken from the vein and never capillaries or IV. iii. Light blue top filled all the way 4. Fibrinolysis: this is the removal of the clot g. Plasmin which is an enzyme; begins to break down the fibrin clot h. Fibrin degradation product (FDP) monitors the rate of Fibrinolysis Homochron: a point of care testing working with PT/INR **Tubing:** - = **S**tart tube (discard tube, clear or red) - = **L**ight blue (sodium citrate) - **In between is the dark blue with red stripe (no additive)** - = **R**ed (clot activator only if plastic) - = **G**old/tiger/marble (silica/gel separator) - =Light green (lithium hepran/gel) - **=G**reen (dark) (sodium heparin) - = **P**ink (potassium EDTA) - **In between is dark blue and lavender (edta and heavy metals)** - = **L**avender (EDTA) - = **G**rey (sodium fluoride/potassium oxalate) Both the red and clear can be used as a discard tube Red top can run all serum tests w the tube and can run all serum preg tests with this and tiger Tubing Meaning: Ethylenediaminetetraacetic acid (EDTA) For the action of platelets: blue tube Counting platelets: purple tube - Blood culture (bcx): nutrient broth always comes in 2 bottles - Discard tube: will be clear or red and is used to clear the air out of the butterfly line/ prevent sample contamination - Light blue: sodium citrate/ can be used for anticoag studies (1:9 1 additive and 9 parts blood) - Inversion of 3-4 times - Dark blue with red stripe: has no additive/ used for heavy metals and toxicology reports - Red: w/ or w/out clot activator/ can also be used for studies such as hormone studies, therapeutic drug monitoring - White: no additive and can be used for rich fibrin - Gold/tiger/marble: SST/ Clot activator and thixotropic gel/ complete metabolic panel, basic metabolic - Light green: lithium heparin thixotropic gel (HCG, HGC qualitative and quantitative, electrolyte) - Dark green: sodium heparin additive/ ammonia but has to be placed on ice, lithium levels and flow cytometry - Pink: potassium EDTA/ can do type and screen ratios, cross matching and viral load monitoring \*must remember blood bank band and bank number\* - Dark blue with lavender: heavy metals - Lavender: edta additive and can complete blood count, sickle cell, anemia - Grey: sodium fluoride and can test for oral glucose, lactic acid Lab Departments for the tubing: - Hematology: Lavender, Urine, Light blue (this can also go to hemostasis if it's a larger lab) - Chemistry: red, gold/tiger/marble, mint, dark green, grey, dark blue - Microbiology: Blood cultures, samples such as stool and specimen, swabs - Blood bank: pink tubes Quiz: HI**P**AA= Health Insurance **Portability** and Accountability Act Providing Quality in healthcare= The Joint Commission Avoid doing any harm to patients is the first and foremost thing above all OSHA coming in randomly would be **The Programmed inspection** Syringe=slower Thinners=coflex Class \#2 1/19/2025 Plasma: liquid portion of the unclotted blood and still contains clotting factors Tubes: lavender, both green tubes, pink, royal blue with lav, light blue and grey Serum: liquid portion that coagulates Tubes: Clear, both types of red, royal blue with red For sterol bottles (broth bottles) you need to chloroprep both the arm and the bottle Butterflies One will be anerobic and one will be arobic Hemoglobin A1C will be on test **Capillary sticks** - Can be done when you cant find a vein - Warm the site For Infants 2.0mm and Preemies.85mm Vibration of the needle means it is hemolysis and are close to the wall of the vein Problem: Hematoma Solution: is it still growing if so that means you have gone through the vein Rolling vein solution is to anchor the vein Collapsing vein means you need to release and re do the puncture When the patient faints: They can have convulsions and tetne Don't tell them what happened ICD 10 Code: use to code the diagnosis Basic metabolic Panel: tests for the basic metabolisms, kidney function, electrolytes and fluid balance Complete Metabolic panel: test for the full panels not just partials like BMP Sharps log container must have: Type and brand of device involved in incident Department or work area where the exposure occurred Explanation of how the incident happened HBV: this is the most common nosocomial infection for employees working with blood Can stay on dried blood up to 7 days This is the primary concern for most employees **Always treat it as if you have been infected with a blood borne pathogen** Exposure control: Transmition based precautions second tier When patient might or does have a contagious disease Contact isolation: reduce risk of transmitions of microorganism both by direct and indirect contact Direct: skin to skin (always remove gloves first) Indirect: in patients environment ( clothing, lice, scabies) Airborne pathogens: in the air and can be inhailed or deposited onto the host **N95 Respirator** Ex: tb, measles, chickenpox Droplet: involves contact with mucose and or conjunctive membrane Can be from coughing sneezing or talking Ex: strep a, flue a, rubella If exposed 1. Wash exposed area with soap and water for 15 minutes 2. Report to supervisor 3. Go to MSD or SDS 4. Fill out exposure form a. Document the route of exposure and circumstances b. Unless prohibited identify and document source individual c. List the source for hbv and hiv d. Collect own bloos 5. All other finding will be confidential If blood is spilled put a 10% bleach and let sit for 10 minutes Other acceptable cleaning liquids would be Lysol or household bleach Dilution: Strong (1:10) Weak (1:100) Bodily fluids need to be cleaned with a 1:10 ratio For capillaries it can test for most things unless you need a lot of blood Always wipe away the first drop Always use the ring and middle finger Can use if you cant find vein, obease, thin skin Heel or plantar pokes need to be done on the outer portions of the feet There is a different order of draw for babies EHAS 1. EDTA tubes- purple and pink x10 2. Heparin- both the green tubes x10 3. Any other additive 4. Serum- red or tiger gold Inversions for infants serum no inversions, sst x5, glucose x10 CLSI estimates 46%- 68% to be phlebotomist error 5% of draws are inaccurate For hard veins Never exceed the 2 stick rule hemotoma is when the bevel of the needle isn't in the vein completely and leeks btwn the skin and the vein Petechiae: non raised red bumps on the skin and are from blood vessels popping Thrombosis: blood clotting, never use the same arm as a blood clot Phlebotomy class \#3 As phlebotomists we may have to educate the patient on what to and not to do for collecting samples We need to make sure the patient is following the guidelines before the draw aka fasting or not Fasting specimen: Basal state ( the first draw after a fast and will be done in SST tube) - Fasting is considered to refrain from strenuous activity for 8-12 hours before procedure - Water can be okay as long as it own affect the test - Sugar can affect the test so no sugary drinks - As opposed to fasting "postprandial" or after a meal - Always note if the patient didn't fast as it can affect the results and allows the lab to see Timed specimen: to monitor specific substances or conditions 1. Blood levels of substance exhibiting diurnal a. Hormone cortisol 2. Monitor patients condition b. Steady decline in hemoglobin levels 3. Determine levels of medications in bloodstream c. Therapeutic drug studies d. Digoxin for cardiovascular disease Therapeutic drug monitoring: looks at blood levels of certain medications to make sure patient is safe and maintaining plasma levels - Always drawing with the troughs and peaks - Troughs are drawn 15 min before scheduled pharmaceutical dose - Peaks are depending on the mediation - Always have times of last dose when blood collected for lab Transporting Aliquoting: dividing whole specimen into samples Warmed: tubes can be prewarmed with incubator or chem warmer prior to draw - 30 minutes at 98.6 f or 37 C - Some require it to be body temp until serum separates - Cold agglutinins are antibodies in response to a typical pnmonia - Pre warmed red tubes Chilled: crushed on ice water but the ice must be in a baggie and not touching the tube - Prevents separating - Ammonia (dark green) Light sensitive: wrap in aluminum foil which should be premolded to the tube - Should be transported in an amber or brown colored bag Tests that require chilling: - Ammonia - Lactic acid - ABG - Gastrin - Glucoligan - Parathyroid hormone - PTT/PT Tests that require warming: - Cryoglobulin - Cryofibrin - Cold aggulation Tests that require light: - Bilirubin - All vitamins - Urine porphy - Carotene - Red cells - Folate - Folate serum Tests that have to have no tourniquet: - Lactic acid Illicit drug use/ forensic specimen: urine collection Chain of custody: no mistakes should be made if there is nothing to record then write N/A This is to show who has the specimen on the travels Glucose Tolerance Test: diagnose gestational diabetes or in general diabetes - Some have windows such as OGTT which are 1hr, 2hr, 3hr 5hr - Glucoa comes in 50,75,100,250 gram drink - Blood draw must come first with a fast of 10-12 hours - Finish in 5 minutes and then take blood Diurnal: drawn blood starting at the beginning of the day PKU: infants in the first 72 hours of being born get this test to determine mental retardation and brain damage - Test requires a heel poke Arterial blood gas (ABG): levels of oxygen and carbon monoxide and blood pH levels - Sample ran with in 15 min of collection - Needle is inserted at a 90 degree angle from artery Arterial samples: - blood pH levels - co2 - o2 - bicarb - nothing can occur btwn the test and the collection it needs to immediately go to the lab. - Placed on ice POCT: patient using device onsite - Can be a waived test which means phlebotomists can preform - If not waived we cant preform APOCT: coagulation monitoring, ACT, prothrombin, platelet function, ABG, glucose, cholesteryl **Test Question:** Modern bloodletting: The average adult has btwn 5 and 7 liters of blood in their body 1%-5% of the patients blood can be drawn with in a 24 hour period Polycythemia vera: too many blood cells - Tests for hemocrit and if too high you need to complete a 500 ml blood draw - Therapeutic donation Hemochromatosis: too much iron and requires a draw of 450-500 ml of blood Swabs: Nasal Buccal: mouth swab and or under the tounge and chain of custody occurs because it is DNA Throat swab: has to go past gag reflex Stool: hat shaped plastic lids can be sued to collect from the specimen - Stool guaiac test of for occult blood studies - Fecal fat analysis: issues with fat malabsorption Sputum: collected in the mornings Seman: goes to lab w in 1 hr sill is still body temp Urine: most common sample other than blood Times urine: discard the first specimen and keep the sample sterol - 24 hour requires you to pour the urine into a larger vat of pee - Catheter can be another form of urine sampling - Components of the urine can be changed if kept at room temp Lab req forms require: - Icd10 m code - Physicians signature sometimes - Patients dob - Type of tests and physicians name Types of processing blood: centrifuging (separating cells from fluid) - Horizontal and fixed angle OSHA requires centrifuges to have the lids on when on and spinning Blood Shmering is always taken from a Lavender tube Labs: Hematology: studying the blood so the rb, wb and platelets Chemistry: biggest lab section - Electrophoresis: chemical component of blood - Urine and hemoglobin - Toxicology: plasma levels - Immunichem: hormones, enzymes and drugs Blood bank: transfusions and always pay attention to the patients information Immunology: evaluating patient immune response Microbiology: pathogenic microorganisms Uranalysis: metabolic diseases, drug abuse, disorders, infections Platelet rich plasma (PRP): always in the light blue tubes - Most common in physical therapy - Sodium citrate works with bonding the calcium - Uses horizontal centrifuge - Draw spin and collect the buffy middle layer Platelet rich fibrin (PRF): red glass or white tubes - Used in a lot of dental work - Draw the white tube first and do not open after - Draw red tube next and leave open for 5 min after spinning Draw out with a 2 in 18 gauge 20ml syringe PRF clots can be used to make sticky bone Place them into mixing bowl and add freeze dried bone to bowl and mix to get the sticky bone **The exam includes:** Order and Patient identification: (15) - Interpret requisition forms and tube selection - Verify patient information for a specific task - Identify types of consent Safety protocol: (24) - Apply procedural concepts regarding ppe regulations - Identify hand hygiene techniques - Apply procedural concepts regarding lab standards (OSHA and HIPPA) - Given a scenery, apply procedural concepts regarding risk management procedures - Apply procedural concepts related to maintaining clean work environment - Interpret federal state and local guidelines Communication: (7) - Apply procedural concepts relates to preforming and instruction - Communicate the procedure to the patient Phlebotomy procedure: (54) - Apply protocols required to assemble supplies and prepare the environment for the draw - Determine appropriate site selection on patients ranging from neonatal to adult to geriatric - Compare special specimen procurement methods - Identify skin antiseptics - Apply procedural concepts when preforming venipuncture using the correct order of draw - Identify disposal techniques for needles and sharps - Apply procedural concepts when preforming post puncture care - Identify the point of care testing (POCT) - Apply protocols to maintain integrity of the specimen during handling and transportation