Clinical Skills Final Quiz 3.pdf

Central Lines Indications Inadequate or difficult peripheral venous access Administration of noxious medications: vasopressors, chemotherapy, parenteral nutrition Long-term IV therapy...

Central Lines Indications Inadequate or difficult peripheral venous access Administration of noxious medications: vasopressors, chemotherapy, parenteral nutrition Long-term IV therapy Hemodynamic monitoring: measurement of central venous pressure (CVP); cardiac output/index Hemodialysis; Plasmapheresis Venous Access for device placement: Transvenous cardiac pacing, IVC filter placement, Venous stenting Contraindications Avoid cannulation of venous sites with: Anatomic distortion Indwelling intravascular hardware (Stent, Pacemaker) Hemodialysis catheter Relative Contraindications: AV fistula (use opposite side) to avoid compromising blood flow to fistula à consult renal Coagulopathy (eg. INR 10) and/or thrombocytopenia (eg. if 8 Fr catheter) Gauge is used to describe needle size ↑ gauge = ↓ needle (eg. 24 gauge < 18 gauge needle) Non-tunneled Most commonly used for temporary access - Single, Double, Triple or Quadruple lumen; silicone or polyurethane Centrally Inserted Peripherally inserted central catheters (PICCs): outpatient IV abx administration (expected infusion 15-30 days) Venous Catheters Placed percutaneously w/ catheter exiting the skin in the vicinity of the venous cannulation site Jugular veins: most popular site for central venous access due to accessibility + overall low complication rates Jugular vs. Subclavian Access: Subclavian assoc. w/ a lower risk for infection BUT a higher rate of insertion failure Insertions Right: 15 cm jugular 16 cm subclavian Left: 18 cm jugular 17 cm subclavian Femoral Vein BEST* often in surgery inserted BELOW the inguinal ligament à biggest risk is retroperitoneal hematoma Placed often blindly due to palpable landmarks of the triangle: Adductor + sartorius muscle + inguinal ligament Vein is more medial (VAN mnemonic) PICC line Placed under EKG guidance by the PICC team D/c on longterm abx, under clothing and discrete, up to 1 year Tunneled Permacath, Hickman, Broviac, Quinton (different names every site) Catheters Catheter traverses a subcutaneous tunnel between the catheterized vein and the skin exit site Advantage: rates of infection are lower than those reported with the use of non-tunneled central venous catheters Typically reserved for long term access (>1 month) and dialysis Totally Catheter Names: Port-a-Cath, Infuse-a-Port, PowerPort Implantable Ports Implantable venous access devices Catheter is passed from vein beneath skin + attached to a subcutaneous infusion port placed into subQ pocket Port is accessed through the skin by needle puncture (port is a self-sealing membrane) Most often placed in the upper chest of adult patients (available in single & multiple lumens) Commonly used to administer chemotherapy; Typically reserved for long term access + intermittent infusion tx Advantages: Long-term use, cosmetically appealing (concealment), MRI compatible Disadvantage: need to puncture the skin; small catheter caliber limits infusion rate Factors for Duration of Venous Access Selection Short term: few days to no more than 1-2 wks (Non-tunneled Central Line) Mid-term: weeks to months (PICCs & Tunneled Central Line) Long term: months to years (Tunneled Catheters & Totally Implantable Ports) Type of Infusion: if irritant, consider a central venous device whose tip terminates in a region of greater blood flow Number of Lumens Patient Considerations: chest surgery or chronic kidney disease, prior complications from central line placement Provider-related issues: adequately experienced operator or vascular access teams reduce complications/safer Immediate Bleeding Arterial (ok if hit carotid à pressure) Arrhythmia (pull back) Complications Thoracic duct injury (L SC/IJ) Pneumothorax/hemothorax Air embolism à Trendelenburg *if tension pneumoà needle decompression! Delayed Infection (bacteremia à remove 24h) Venous thrombosis, pulmonary emboli Catheter migration Complications Catheter embolization Myocardial perforation Nerve injury Cannulated Leave it in – do not take it out! Will cause high risk of bleeding out + AV malformation + aneurysm + dissection… Artery à interventional radiology Right Lung Lower than the left lung à lower risk of pneumothorax if placing a subclavian Ultrasonography U/S imaging prior to the placement of central catheters helps to locate the vein and evaluate its patency It also identifies anatomic variations, and helps to reduce trauma Real-time U/S imaging during needle placement reduces time to venous cannulation & risk of complications Useful for patients w/ coagulopathy See: Waves on the beach (good) + Barcode (bad) + Ants marching / Lung point (collapsed side doesn’t move) Brachial Artery Good alternative if infectious state eg. COVID-19 Confirmation of Following Internal/External Jugular or Subclavian Venous Catheter (Not needed for femoral), confirmation via: Catheter Tip Chest X-ray (MC) Fluoroscopy Endocavitary Electrocardiography (EC-ECG) –typical P wave patterns Positioning (Cannot be used in patients with active arrhythmias)  Peripheral IV Insertion Indications Fluids: fluid + electrolyte balance Blood products Medications or chemotherapeutics Diagnostic substances, eg. dyes/contrast Nutrition (MC central lines > peripheral IV) Caution Any substance that is instilled directly into circulatory system à rapid effect due near-instant distribution à ensure absolute accuracy when instilling IV fluids and medications Contraindications Extremities w/ burns, edema, or injury to avoid more mechanical trauma Active skin infection (eg. cellulitis) Distal to any pre-existing phlebitis or prior failed IV catheter insertion attempt Extremities w/ impaired circulation (eg. LE in older adults, mastectomy) Surgical AV fistula for renal dialysis Complications w/ If no flash, catheter probably not in vein, and should not be threaded Technique If flash occurs but cannot thread catheter, a vessel valve may be occluding and you should not force threading, you should remove IV & apply pressure If catheter threaded but not freely flowing, likely kinked or has clotted, you should remove & apply pressure Local Infiltration (IV contrast) Minor bleeding Complications Thrombophlebitis Cellulitis Systemic Septicemia or bacteremia: Poor aseptic technique Complications Catheter placed in heavily colonized area (Rare) Catheter-fragment embolism: distal end of catheter sheared off by bevel Avoided by not reinserting the needle into the catheter Pulmonary embolism: clot formation at end of catheter dislodges + travels Air embolism: IV lines not properly flushed or air removed before connecting Essential Veins in arms are more accessible: Dorsal aspect of hand and forearm Anatomy & Median antecubital, metacarpal, basilic, & cephalic Physiology Avoid: Valves (palpable, knob-like lumps), Bifurcations, Tortuous veins When possible, use the non-dominant hand/arm Start distally, and When IV will be in for several days, try to avoid the ante cubital fossa (ACF) move up arm as Avoid lower extremities: Elderly, Vascular disease, Diabetes needed Exception: Pediatric population - Foot/ankle have adequate circulation ↓ concern for infection, less visible, ↓ anxiety Less likely IV device will be placed in the mouth for pediatrics Interferes less w/ parent-child bonding, feeding Patient Prep Identify the patient + obtain informed consent Discuss risk/benefit ratio, indications, procedure Identify allergies (iodine, latex, adhesives, lidocaine) Prep equipment/supplies (not in front of the patient) Offer saline or lidocaine injection for anesthesia (if appropriate) Equipment Appropriate-gauge IV catheter sizes Tourniquet PPE Correct IV fluid IV admin set (tubing, etc.) IV pole + infusion pump Antimicrobial agent to cleanse site Tegaderm/dressings 2 x 2 inch or 4 X 4 gauze Chux + Arm board Biohazard/needle container Antiseptic ointment IV Catheter Selection: Most needles are 2.5-4cm long (1 ¼ - 2”) Butterfly Needles Winged sides Used in smaller veins Needle stays in vein Over Needle Flexible plastic tube around an inflexible needle (needle tip acts only to puncture the vein, then removed) Sizing The smaller the “gauge” (#), the larger the bore of the needle/catheter Adult: Most gauges (G) 18-20 G (a smaller lumen can lyse RBCs) MC for maintenance IVF/Rx 20G 14-16G used for rapid fluid replacement Large bore (16-18G) for blood products Pediatric: Most gauges used in children are 22-24G (24G commonly used in a neonate/small infant) Insertion Apply tourniquet proximally (above elbow best): Do this on both arms; look for a distal, straight vein Procedure Palpate vein for stability + valves: Free of valves for length of IV catheter Confirm you have all needed equipment & IV fluid, Prep IV tubing (all air out of tubing) Apply tourniquet snuggly (Ideal: tighter than diastolic BP, less than systolic BP), apply gloves, eye protection Allow vein to distend, Palpate vein gently (do not slap + snap vein; can use gravity to help distend vein) Cleanse overlying skin w/ alcohol + aseptic cleanser >30”; allow skin to dry Apply traction on vein distal to point of entry (skin taut) w/ nondominant hand + tell patient they will feel “stick” Needle ~15-20° to vein, puncture w/ bevel of needle up in quick motion (Enter directly above or on side of vein) Note blood return in IV + advance the catheter a few mm; “flash” à lower the IV catheter to ~parallel to skin Slowly advance catheter while w/d needle until catheter hub is at skin Apply gentle pressure to vein just proximal to insertion site to secure + release the tourniquet Attach IV tubing, watch that fluid runs freely before you tape tubing securely & minimize tape-to-skin contact Unsuccessful Never reinsert the needle into the catheter à may sheer off tip à embolus Insertion Never reuse catheter once it has been removed à discard + use new one If the catheter site is painful or swollen when fluid is initiated à D/c fluid, remove catheter, try more proximal site Follow-up Care Observe IV site for: Signs of infection/infiltration Stopped IV flow Swelling (puffy) Redness Sudden ↑ in pain at site Should be assessed at least every shift by nursing personnel; IV site changes Q96h to ↓ infection likelihood IV Site Change 12-24 h after pre-hospital IV start 24h from ER start 72-96h for ANY peripheral IV IV Tubing Tubing comes in a variety of lengths; some has capability for extension tubing or connections Spike at the top is used to perforate the seal on the solution container Primary tubing always vented; Drip chamber should partially fill by squeezing/releasing empty reservoir Allow tubing fill, control with the regulator clamp; Select drip size that will best deliver the rate Midline Catheters Considered a LT peripheral catheter à end of the catheter is not in SVC NOT a central 6-8” catheter for intermediate duration (several weeks) of IV therapy; May remain indefinitely if no complications venous catheter Use stabilization devices for midlines; Catheter dressing should be labelled as midline – RNs may d/c IV Fluids + Electrolytes Fluid Total body water comprises 60% BW ♂, ~50% BW ♀ (Intracellular: 55-75% Extracellular: 25-45%) Compartments Plasma (intravascular): 10-20% of total fluid Interstitial (extravascular): 20-30% of total fluid (lymphatic fluid) Fluid movement b/w plasma + interstitial spaces determined by hydraulic + colloid pressure across capillary wall Colloids Mixture of water + protein that remain suspended in solution + do NOT become dissolved à a volume expander Whole blood, packed RBCs, Plasma (albumin, Fresh Frozen Plasma, Dextran, Hetastarch, Haemaccel, Gelofusine) Substances remain in intravascular space (molecules too large for capillaries); Replacement is 1:1 with fluid loss Indications for Volume expander (tx shock not caused by blood loss or cardiogenic shock) Colloids Treat interstitial, or third spacing, of fluid (pulls fluid back into vascular space) Crystalloids Mixture of water + uniformly dissolved crystals (solutes) eg. salts/electrolytes, glucose, saline, D5W, LR Small molecules that pass freely through cell membranes & vascular walls Indications for Fluid replacement + Maintain fluid balance Crystalloids Replacement is 3:1 for fluid loss (as opposed to 1:1 with colloids) Osmolality Solute concentration of plasma/fluid à Human Body Fluid Osmolality is maintained b/w 280–295 mOsm/kg Crystalloid fluids subdivided into hypertonic, hypotonic, isotonic solutions Isotonic Dissolved solutes, as normally found in human plasma Distribution of water and electrolytes will remain relatively unchanged Isotonic solution used for rapid replacement, fluid deficit, and to increase BP eg. bolus 0.9% Normal saline (NS), Lactated Ringers solution Hypotonic Mixture of water + solutes, w/ solutes in ↓ [c] than in intravascular fluid à Used primarily as maintenance fluid Diluted solution when compared to normal body fluid composition When infused IV, the solution will enter capillary membrane of blood cells à become larger as they fill w/ water eg. 0.45% Normal saline (NS) “half NS”, 0.2% NS 5% Dextrose in water (D5W), D5.45% NS, D5.2NS Hypertonic Mixture of water + solutes, w/ solutes in ↑ [c] than in intravascular fluid Rarely usedà Short increments to relieve edema, shrink tissues as H2O leaves follow NaCl cerebral edema, It will draw water from the cells and interstitial spaces into the vascular system severe Urine output will ↑ as regulatory mechanism compensating for added fluid volume (with normal cardiac function) hypo/ernatremia eg. 10% Dextrose in water (D10W), 3.0% saline Normal Saline 154 mEq/L of Sodium + 154 mEq of Chloride pH = 6.0 Osmolarity = ~308 Solution of choice when administering a blood product; Go-to until you determine which solution is best Lactated 130 mEq Sodium + 4mEq Potassium + 109 mEq Chloride + 28mEq Lactate pH = 5.1 Osmolarity = ~273 Ringers Mainstay for sepsis (K+ in LR is not enough to replace levels when low à MUST give additional PO/IV K+) D5W 278 mmoL/L of dextrose pH = 4.0 Osmolarity = ~272 Dextrose 5% Considered an isotonic solution in bag à once administered, glucose is metabolized + tonicity of infused solution ↓ in proportion to osmolarity/tonicity of electrolytes within water Adding Meds Confirm that added medications are compatible w/ the solution Medication, or any substance added to IV solutions should be clearly labeled on the bottle or bag! (red label used) Not all medications can be given as an “IV Push” à Use extreme caution when “pushing” IV meds Ssx of Fluid 10% ECF loss: findings may be overlooked Loss / Volume à 2% weight loss Thirst, mild ↓ of urinary output Urine dip: slight ↑ in sp gravity Depletion 20% ECF loss: findings always evident à 4% wt. loss Apathy, drowsiness ↓ skin turgor, dry mucus membranes Tachycardia, orthostatic hypotension Delayed capillary refill >3 sec Oliguria (output 1.030, ↑ BUN 30% ECF loss: findings are extreme (loss of 1-4 liters) à 6% weight loss Stupor, coma Skin cool/pale, ↓ turgor, sunken eyes Pulse rapid/weak/thready, hypotension Oliguria (output < 10ml/hr) Estimate Fluid 60% pt wt (kg) x (140 – pt serum Na) Deficit (L water) 140 Estimate Fluid For every 3 mg of sodium that is above normal (> 145) = ~ 1 L of water deficit Loss This method is used primarily when sodium is above normal range IV Fluid To calculate IV fluid maintenance rate in mL/24 hours (need patient’s weight) Maintenance 100 mL/kg for the 1st 10 kg = 1000 mL 50 mL/kg for the 2nd 10 kg = 500 mL 20 mL/kg beyond 20 kg Example: 70 kg patient fluid requirements: = 1000 mL + 500 mL (1500 mL) + 50 kg @ 20mL/kg (1000 mL) = 2500 mL/over 24 hours, or 110 mL/per hr. for maintenance IV fluids 4-2-1 Rule 1st 10kg = 4mL/kg/hr. 2nd 10kg = 2mL/kg/hr. > 20kg = 1mL/kg/hr. Example: 70 kg person = 40mL+20mL+50mL+ = 110 mL / hr (ok to round to 100 mL)  Electrolytes Review Sodium Na2+ Major extra cellular fluid cation Central role in maintaining circulatory vascular volume Hypernatremia Excessive water loss Limited water intake GI loss (Vomiting and/or watery diarrhea) Excessive intake of salt Excessive IV fluid Na (hypertonic/isotonic) Decreased sodium excretion Cushing syndrome Hyponatremia Diuretics (#1/Iatrogenic cause) Ketoacidosis Ingestion of large amounts of water Hypotonic fluid replacement w/ isotonic fluid loss (GI) Potassium K+ Major intracellular fluid cation Cardiac and skeletal muscle contractility Hypokalemia: muscles less excitable Hyperkalemia: cells more excitable pH on K+ Acidosis: causes shift of K+ out of cell into plasma, thus ↑ serum K+ level Alkalosis: causes shift of K+ into the cell, thus ↓ serum K+ level What’s the first step in treating this K+ problem? Treat the pH!!! Hyperkalemia Acute renal failure Diminished aldosterone secretion Metabolic acidosis Severe hemolysis Meds (ACE inhibitors; aldosterone-sparing meds) Hypokalemia Vomiting/Diarrhea (GI cause) Diuretics Primary aldosteronism / steroid use Black Licorice addiction (aldosterone-like action) IV Drip Macro drip: delivers 10-20 drops/ml (it will be marked on package) Micro drip: delivers 60 drops/ml (better control; easier to calculate rate) Abbreviations TKO: to keep open (~ 10 ml/hr drip rate) KVO: keep vein open (infusion rate < 500 ml in 24 hr) Consider Saline or Heparin lock when you do not need to give fluids IV Push Pushed directly into IV tubing > 2-5 minutes IV Piggyback/ Med mixed into smaller IV bag for dilution Rider Hung w/ secondary tubing to hook into primary tubing à infused slowly (~ 30-60 minutes) IV Bolus Large amount of fluid in short time (mainly replace fluids) à cautious to avoid rapid infusion à CHF  Venipuncture Indications Any time a sample of venous blood is needed in quantities larger than what can be obtained from a fingerstick Eg. Blood type/cross, electrolytes Contraindications Obvious areas of skin infection: cellulitis, rashes, or a new tattooed ( 2 min; 1st 5mL should be discarded Arm with an AV fistula Complications Cellulitis Phlebitis Thrombosis Hematoma at the site; hemorrhage (less common), arterial puncture Vasovagal syncope: pt should be sitting or supine; If h/o fainting à supine Common Sites Median cubital vein: usually the largest vein in the antecubital space Cephalic vein: easily palpated but poorly anchored Basilic vein: easily palpated, not well anchored, by median n. & brachial a. Vacutainers Vacutainer tubes are sealed with a partial vacuum à (-) pressure inside allows blood to be pulled in to fill tube Lavender top: contains ethylene diamine tetraacetic acid* prevents clotting Slowly invert ~8xto prevent clotting or platelet clumping à CBC w/diff, ESR, HgbA1c, Blood group typing Blue top: contains Na citrate; removes Ca to prevent clotting Must be filled completely and NOT contain air from collection system à PT/INR, aPTT/PTT (Coagulation) Gold top: contains gel that promotes blood clotting & serum separation à Chemistry (LFTs, electrolytes, etc), Serology, Serum testing *New Orange: does not need to be centrifuged, quicker Red top: no additive; can do what Gold/Orange does à Chemistry, Serology, Serum testing, Blood bank Black top: ESR tube - Measure distance in mm at which RBCs fall after 1 h à ESR (Erythrocyte sedimentation rate) Gray top: K oxalate + Na fluoride to prevent coagulation and glycolysis à glucose, lithium, alcohol levels Green Top: contains Na heparin à leukocyte function tests or chromosome analysis Needles ↑ gauge = ↓ needle (a 25-gauge needle is smaller than a 21-gauge needle) Venipuncture 1. Confirm what tests are being ordered & that you have all the correct supplies before proceeding Procedure 2. Wash hands + Introduce yourself to patient, explain procedure & obtain consent 3. Check patients wristband/ID + Position the patient in a seated or supine position 4. Evaluate the patients arm anatomy prior to placing the tourniquet on (look for any contraindications) 5. Apply the tourniquet proximal (3-4”) from anticipated puncture site (Never leave the tourniquet on > 2 min) 6. Begin by palpation to locate desired vein using palms of fingers 7. Put on gloves & make sure all equipment is close/within reach 8. Cleanse the desired area with alcohol and let dry 9. Anchor the vein by stretching the skin downward with opposite hand 10. Insert needle into straightest section of the vein, BEVEL FACE UP at 15-30°. Once skin is penetrated, lower needle until it is almost parallel with the skin (FLASH w/ only butterfly) 11. Fill Vacutainers to desired level (correct order next slide) 12. Release the tourniquet & Remove needle & cover with sterile gauze 13. Hold pressure for ~3-4 minutes or until bleeding stops (> 5 mins or more for patient on anticoagulation) Correct Order of Technique recommended when multiple tubes are to be drawn Blood Draw Avoid contamination of non-additive tubes by additive tubes Avoid cross-contamination between different types of additive tubes *Blood cultures should be 2 sets from 2 different sites Vacutainer Blood culture à Red à Gold à Blue à Lavender à Gray Syringe Blood culture à Blue à Lavender à Gray à Red à Gold Technique & Poor quality specimen à poor quality results à affect care of the patient Specimen Pitfalls of collection: Hemolysis* repeated fist clenching Integrity Hemoconcentration: leaving the tourniquet on too long Partially filled tubes or specimen contamination or mixup (label!) Special Never recap a needle + Never draw above an IV site Considerations If accidental arterial puncture à HOLD steady pressure > 10 minutes Only stick 1x w/ same needle (If no blood is obtained, reposition the needle before removing) After 2x unsuccessful attempts, stop and ask for help Helpful Tips For Promoting vasodilation: Keep extremity below level of heart for a few minutes Hard Sticks Apply warm towel to extremity; Carefully rub/tap veins à promote vasodilation Blood pressure cuff inflated to point b/n systolic + diastolic as a tourniquet Always make sure to allow alcohol to completely dry (Alcohol lyses RBCs + can cause stinging/discomfort)  Parenteral Medications & Injections – Kim Foito Goal Safely administer an injection while maintaining standard precautions + technique ID PPD and allergy serum for desensitization SQ insulin, Lovenox, heparin, live vaccines, morphine (lasts longer, not as abrupt onset) IM Abx (Rocephin, PCN-G), narcotics (morphine), antiemetics, vax (eg. flu, covid, tetanus), pain mgmt. (Decadron), NSAIDs (Toradol) Age SQ: omit abdomen in pediatrics until adolescence IM: omit deltoid until walking well x 6mo BMI SQ: in geriatrics w/ atrophy of subcutaneous tissue, consider abdomen 45° 1”, 90° 2” IM: consider SQ if obese Length Pediatric SQ 1” Depth SQ: depends on angle IM: if correct, can insert entire length Route Location Indication Needle Gauge Intradermal Dermis below epidermis Dx determinations 25-27 G Desensitization Immunization Subcutaneous Below dermal layer Low vol meds 25 G Vaccines Intramuscular Muscle High vol meds 21-25 G Vaccines 3 Checks Before prep: Compare the MAR to the order + compare MAR w/ the medication After prep: Compare the medication to the MAR 6 Rights Right Patient Right Medication Right Dose/Volume Right Route Right Time Right Documentation Patient Prep & Review reason for medication, Possible SE’s, contraindications, or concerns*** 3 checks + 6 rights Assessment Hand hygiene (NO GLOVES for MED PREP unless risk harm w/ manipulation); prepare med w/ aseptic technique 2 identifiers and allergy confirmation + Pt ID # à Explain procedure to patient before injection (+ drug education) Position patient for the route, prepare skin, administer with gloves Correctly and safely dispose of equipment + monitor the patient for any untoward effects Document and Reassess PRN Intradermal Blood supply to the area is ↓ Slowest route of absorption Injections Reserved for potent medications Assess for changes in skin color and integrity Bevel up, 5-15° Area lightly pigmented, free of lesions, hairless Max volume=0.1 mL; 1/8-5/8-Inch needle, 25-27G Bleb formation Subcutaneous à Loose connective tissue beneath the dermis Minimally vascular = slower absorption than IM route Pain due to pain receptors in tissue Area free of lesions, bony prominences, muscles, nerves 45-90° angle No abdominal administration in children Multiple injections OK in same extremity (2.5 cm/1 in. apart) Rate of absorption varies w/ site - 0.5-1.5mL (Adult); 0.5 mL or less (Pediatrics); 3/16 - 1” length; 25 gauge Eg: Heparin, enoxaparin, insulin Alter absorption w/ heat or site massage Irritating/viscous à induration, sloughing, abscess formation Irritating + vasoconstrictors à abscesses/necrosis If frequent injections, rotate sites to avoid lipohypertrophy BW determines needle length, angle, depth Intramuscular Fastest rate of absorption (Vascular) Require a longer/heavier needle to penetrate deep muscle BMI/adipose tissue influence needle size selection Volume (adult) 2-3 mL (ped/Geri) 0.5-1mL 90° angle Anatomical landmarking required Avoid infection, necrosis, bruising, or tenderness Approx axilla Promote relaxation w/ administration Consider z-track method to minimize skin irritation fold 1-1.5” 21 G (Adult); 5/8-1” 23 G (Pediatrics) Deltoid: 3 fingers from acromion Vastus lateralis: middle 3rd, palming greater trochanter + patella Ventrogluteal: iliac crest + ASIS fingers (R hip L hand), low risk Dorsogluteal: risk sciatic nerve – last resort Z-Track Helpful for larger volume - Push skin to one side Avoid Lipoatrophy / Lipohypertrophy Ampule Vial Single dose Single or multidose Glass w/ constricted neck to snap off Cap protects the seal until ready to use Colored ring=prescored May contain liquid or powder form Break away from self w/ alcohol prep/gauze Powdered=unstable in solution No air Specific solvent to reconstitute dry meds Filter needle – require needle change! Closed system=air installation required Change needle before administration Filter needle may/may not be required Minimize puncturing stopper Contamination Cleanse top of vial with alcohol and allow to dry Draw up medication quickly of Container Do not allow ampules to stand open Avoid reinserting needle into vial Contents Needle/ Clean table/counter before medication preparation Use packaging as a sterile field Content Avoid touching length of plunger/inner barrel Keep syringe tip covered w/ cap or capped needle before use Contamination Avoid letting needle touch a contaminated surface (outer edge, cap, clinician’s hand, counter, table surface etc.) Skin Wash with soap and water if visibly soiled Use friction when cleansing with an antiseptic wipe Contamination Swab from center of site + move outward (5 cm/2”) Dose Error Remove bubbles before changing needles or instilling medication Needle Sticks Plan safe handling + disposal of needles Use safety needles whenever possible Do not recap any needle after med administration Immediately dispose into puncture/leakproof sharps container Remove Keep the syringe tip in the medicine Tap syringe with finger to move air bubbles to the top Bubbles If a lot, push all the medicine back into the vial Remove the syringe from the vial and keep the needle clean Recapping Scoop technique to prevent rolling needle PRIOR to patient Rules After patient – apply the SAFETY Mild Reaction Moderate Reaction Severe Reaction Localized reaction More pronounced psychological s/sx Syncope Fear (psychological) Seizure with fever Anaphylaxis Fatigue Temporary musculoskeletal symptoms High fever Mild Respiratory s/sx Hematological changes Neurological changes Body aches Prolonged crying (peds 2h 30 mmHg Irreversible damage if pressures à diastolic BP New technology vs tradition testing Volkmann’s contracture Compartment Tx Consider splinting Proper application Post application assessment Patient education Bivalve Surgical release Removal Oscillating cast saw only cuts rigid material Can cause thermal injury but reassure your patient Consider using an assistive device Vertical, 90°; In + Out technique; Bivalve Keys If XR: IMMOBILIZE the extremity Proper technique, assessment, patient education, protect!  Urinary Bladder Catheterization Indications To obtain a sterile urine sample To monitor urinary output (most often in critically ill patients) To facilitate urinary drainage in patients unable to voluntarily do so To bypass obstructive processes in the urethra, prostate, or bladder neck caused by disease or trauma To hold urethral skin grafts in place after urethral stricture repair To act as a traction device for the purpose of controlling bleeding following prostate surgery Specialized 3-way catheters s/p bladder/prostate surgeries to allow for bladder irrigation (prevent clots/obstruction) 1x, Straight, To obtain sterile urine sample or to decompress a distended bladder caused by obstruction Robinson For intermittent catheterization in someone with a neurogenic bladder Indications To deliver topical antineoplastic medication to the bladder for bladder cancer patients To assess post-void residual volume Contraindications Blood at the urethral meatus in a patient who has sustained pelvic trauma Allergy to latex, rubber, tape adhesive, lubricants Complications Urethral dilation in long-term use (spasming à leakage à ↑ catheter size and dilation) Structural trauma from catheter insertion UTI, Inflammation of the urinary tract Difficulty performing the procedure (urethral stricture disease, bladder neck contracture, enlarged prostate) Creation of false passages Catheter U-turn at site of obstruction Improper securing/taping of the catheter Patient-caused trauma Physiological Urine is produced by the kidneys à ureters à bladder storage à urethra Theory Bladder catheterization involves passing a mechanical device into bladder through urethra Measurement from distal end of urethra to bladder is short in females (1.5-2”) longer in males (6-7”) Female course relatively unobstructed; male path has curves +a sharp bend through the prostate Prostatic hypertrophy can make the insertion more challenging Patient Set patient expectations and educate them on the procedure Preparation Patient comfort is important in order to keep a sterile field and an atraumatic catheterization Ask the patient to try their best to stay still Remind the patient of the sterile field and ask them not to contaminate it Patient will lie supine; Female patients will abduct legs Materials Sterile tray/working area Vessel for collecting urine Sterile gloves Sterile lubricant Antiseptic cleansing (Betadine) Sterile gauze for urethra/skin Sterile forceps Syringe w/ sterile water for catheter balloon (5-30mL) Sterile drapes to protect sterile field Urine collection tubing/bags/specimen collection containers Nonsterile drapes for patient modesty Catheter Catheterization Sterile lubricant Sterile drapes Sterile gloves Kits Sterile cotton swabs Povidone-iodine Forceps to grasp cotton swabs Container to catch urine Robinson or Foley (14, 16, 18 Fr.) Sterile spec container(UA/culture) Pre-filled 10-mL Luer-tipped syringe to inflate Foley balloon and pre-attached drainage bag Robinson aka straight catheter Soft, rubber, flexible tip One time use Coude Have a bend in the distal tip to allow the catheter to follow the anterior surface of the male urethra Helps with insertion in patients with false passages (usually located in the posterior ureteral surface) Foley Remain in place in the bladder w/ an inflatable balloon used to keep it in place; can be attached to a drainage bag Luer-Lok cap at distal end which is connected to balloon and allows for balloon to be inflated and deflated Often inflated w/ sterile water (NOT saline- could crystalize + result in the inability to deflate for removal) Typical 5mL balloons are inflated with 10mL of sterile water 30mL balloons used to ensure it does not leave the bladder + migrate to the prostatic fossa (w/ 50mL sterile water) Catheter Sizing Various sizes- reported in French (0.33mm = 1 Fr) 3-Fr = 1mm in diameter 30-Fr = 10mm in diameter Common sizing: Pediatric boy: 5-12Fr Adult man: 16-18 Fr Adult woman: 14-18 F (14-F for comfort) 20-30 Fr large: evacuate blood clots in post-op prostate patients or patients bleeding from kidneys or bladder Male Procedure Open catheter (if not in kit) + place it on the sterile drape (utilizing sterile technique) Ensure you have sterile lubricant; Once you are gloved, an assistant may be needed to help w/ lubricant Obtain supplies- Water-soluble lubricant can be substituted for sterile anesthetic jelly (lido) gather the Open betadine + pour onto cotton swabs; Inform the patient you will be holding penis + clean it w/ the betadine appropriate (and Swab head of penis by swabbing meatal opening first + wiping out to the glans sterile) sized In an uncircumcised male, the foreskin will need to be retracted before cleaning Robinson or Foley Once penis is clean, hold it at a 90° angle from abdomen + instill lubricant into urethra catheter + kit Occlude the urethra so the gel does not come back out; If using lidocaine wait 1 min for anesthesia takes effect Wash hands + Position urine container + Hold the catheter w/ dominant hand (3/4 of the way toward the catheter tip) have sterile gloves Inform the patient that you will now be inserting the catheter ready for the Gently begin inserting the catheter into the urethral meatus + continue insertion w/o stopping procedure + Open When the sphincter is in encountered, you will feel slight resistance the kit in a sterile Ask the patient to take a deep breath which can help them relax as you continue to insert the catheter manner Once the sphincter is passed, continue to pass the catheter until almost to the hub of the catheter Prep pt by draping Urine should begin to flow; Sometimes lubricant prevents immediate flow as it needs time to “melt” him in sterile Place end of catheter in urine container + empty the bladder; Obtain a specimen if needed drapes (from the Once bladder is empty, remove the catheter in one continuous motion + pinch it off to avoid leaking on your patient kit) to expose the Urine volume should be measured + recorded genital area If using a Foley, once urine obtained, use your pre-filled syringe to inflate the balloon to keep the catheter in place Make sure Foley is inserted almost to the hub Once the balloon is filled, pull Foley catheter until you meet resistance- now it is in the correct spot Ensure the drainage bag is in place + Tape Foley catheter to abdomen (penis pointing toward the umbilicus) Apply Bacitracin 1-3 times a day to the urethral meatus Female Procedure Open the catheter (if not in kit) + place it on the sterile drape (utilizing sterile technique) Ensure you have sterile lubricant; lubricate the catheter well- about 1/3 from catheter tip up Open betadine + pour onto cotton swabs; Inform the patient you will swab urethral opening by separating labia Swab the opening from anterior to posterior If using lidocaine wait 1 minute so the anesthesia takes effect Position urine container; Hold the catheter with your dominant hand and ensure there is lubricant on it Inform the patient that you will now be inserting the catheter; Gently insert until urine starts to flow or ~1/3 inserted Once bladder is empty + removed your specimen, block distal end + remove catheter in one continuous motion If using a Foley, inflate the balloon when urine begins to flow Once the balloon is blown up, pull the catheter until it stops ensuring proper position Attach the drainage bag + Tape the Foley catheter to inner thigh- w/ some slack so it is not pulling on bladder neck Follow-up Care Irritation or infection can occur A patient may experience a burning sensation the first few times they urinate after a catheter has been removed Instruct the patient to monitor for dysuria, frequency, hematuria, pyuria, fever, back pain