PMRS121 Week 1-4 Notes PDF

PMRS121 Week 1 to 4 Notes Infection Control and Sterile Technique Types of infection: Nosocomial infection: o Infections patients acquire while admitted to health-care facility and generally develops 48 hours or later after admission...

PMRS121 Week 1 to 4 Notes Infection Control and Sterile Technique Types of infection: Nosocomial infection: o Infections patients acquire while admitted to health-care facility and generally develops 48 hours or later after admission o Examples include → UTIs, bacteremia, GI and skin infections Iatrogenic infection: o Infection acquired during medical or surgical procedure, whether the patient was hospitalized or not o Example include → an iatrogenic infection can occur after a healthcare provider didn’t wash their hands after touching the previous patient Elements needed to transmit infection: 1. An infectious agent and a reservoir of available organisms 2. An environment in which the pathogenic microbes can live and multiply 3. A portal of exit from the reservoir 4. A means of transmission 5. A portal of entry into a new host Types of infection isolations: Airborne infection isolation: o Airborne infection is the transmission that occurs when microbes are spread on evaporated droplets that remain suspended in air or are carried on dust particles in air and may be inhaled by persons in that room or air space o Diseases spread by airborne route: ▪ Sudden acute respiratory syndrome (SARS), smallpox, tuberculosis, varicella (aka chicken pox), and rubeola Droplet precautions: o Droplet infection is the transmission by droplets contaminated with pathogenic microorganisms that are placed in air from a person infected with a droplet-borne infection o May happen when a patient sneezes, cough, talks, or deposits infection from their eyes, nose or mouth in other ways and these droplets are inhaled or internalized in other ways to an uninfected person o Diseases spread by droplet route: ▪ Influenza, rubella, mumps, pertussis (whooping cough), most pneumonias, diphtheria, pharyngitis, scarlet fever, and meningococcal meningitis Contact precautions: o Two types of contact spread of infection → direct and indirect contact o Direct contact ▪ Occurs when a susceptible person actually touches an infected or a colonized person’s body surface in an area where infectious microbes are present  ▪ Colonization → the presence of microorganisms on the skin or body surface of a person who has no symptoms of the disease o Indirect contact ▪ Occurs when a susceptible person touches or comes into contact with an object that has been contaminated with infectious microorganisms Fomites = contaminated objects o Diseases spread by contact route: ▪ Diseases transmitted by contact: Drug-resistant wound infections: Gastroenteritis caused by C. difficile, E. coli, Rotavirus, Shigella and other GI infectious disease Hepatitis A, Herpes simplex, Herpes zoster, Impetigo, Scabies, Drug-resistant gastrointestinal, Respiratory, and Skin diseases (e.g., MRSA, VRE, VRSA, and ESBL) Ebola Infection Control: Goal: o To protect patients and staff from infectious diseases by incorporating practices of infection control and aseptic technique into clinical practice Importance of infection control o 30% to 50% of infections from exposure to healthcare facilities are preventable ▪ E.g., proper handwashing ▪ HAI (Hospital acquired infection Types of infection control: Routine practices o Infection prevention and control practices that should be used during routine care of all patients to prevent the transmission of microorganisms o Performed for all patients o Standard (universal precautions) o Examples of routine practices: ▪ One patient one bed ▪ RISK assessment (PCRA) ▪ PPE ▪ Hand hygiene ▪ Control of the environment Placement, cleaning, engineering controls ▪ Administrative control Additional precautions o Used in addition to routine practices when a patient has symptoms or is suspected of being colonized with certain microorganisms/diseases o Examples include Routine practices + ▪ Specialized accommodation and signage Patients contracted with same microorganisms placed together  Precautions ▪ PPE ▪ Dedicated equipment and additional cleaning measures Negative pressure rooms Regular cleaning ▪ Limited transport ▪ Communication o UHN additional precautions signage: ▪ Airborne precautions: Hand hygiene N95 mask Negative pressure room, keep door closed Signage used for patients that have measles, varicella, tuberculosis ▪ Contact precautions: Hand hygiene Gown Gloves Signage used for patients that have c-diff., MRSA, VRE ▪ Droplet precautions: Hand hygiene Gown Gloves Surgical mask Eye protection Signage used for patients that have influenza virus, Neisseria meningitidis, Bordetella pertussis (whooping cough) Point of care risk assessment (PCRA): A type of routine practice which should be conducted before every patient interaction by a healthcare worker to assess the likelihood of exposing themselves and/or others to infectious agents Types of questions: o Is there hazard present in the situation? o What is the health status of the client, patient or resident? o What type of task am I doing? o Where am I doing my task? o What action do I need to take? Management of Exposure/Contamination: Accidental exposure to blood or other body fluids Pre-exposure vaccinations o Only good for Hepatitis B Post-exposure prophylaxis (PEP)  o Done within 2 hours of exposure → emergency o Reduce the risk of transmission of blood-borne pathogens o Will draw blood from patient to confirm presence of microscopic disease o Apply first-aid o Seek medical attention and report incident o PEP, if applicable First-Aid management for exposure to bloodborne pathogens o Wash area immediately ▪ Flush with water, soap, saline ▪ Don’t use alcohol-based products → will cause irritation o Situations when needed: ▪ After percutaneous exposure ▪ After a splash of blood or bodily fluids onto unbroken skin ▪ After exposure of the eye ▪ After exposure of the mouth Handwashing techniques: Steps: o 1. Wet hands with warm water o 2. Apply soap o 3. Lather soap and rub hands palm to palm o 4. Rub in between and around fingers o 5. Rub back of each hand with palm of other hand o 6. Rub fingertips of each hand in opposite palm o 7. Rub each thumb clasped in opposite hand o 8. Rinse thoroughly under running water o 9. Steps 1 to 8, lather hands for 15 seconds o 10. Pat hands dry with paper towel o 11. Turn off water using paper towel o 12. Your hands are now safe 4 moments of hand hygiene: o 1. Before initial patient/patient environment contact o 2. Before aseptic procedure o 3. After bodily fluid exposure risk o 4. After patient/patient environment contact 2 dominant methods of removing microorganisms on the hand include: o Alcohol-based hand rub (hand sanitizers) o Hand washing with soap and water ▪ Best when hands are visibly soiled PPE: Donning full PPE: o Putting on PPE o Steps: ▪ 1. Perform hand hygiene ▪ 2. Gather all necessary PPE ▪ 3. Put on shoe covers ▪ 4. Put on gown ▪ 5. Put on mask ▪ 6. Put on goggles or face shield ▪ 7. Put on head cover ▪ 8. Perform hand hygiene ▪ 9. Put on gloves over cuff Doffing full PPE: o Taking off PPE o Steps: ▪ 1. Remove shoe covers with gloves still on ▪ 2. Remove gown and gloves and roll inside-out or remove gloves then remove gown ▪ 3. Perform hand hygiene ▪ 4. Remove head cover from behind head ▪ 5. Remove face shield or goggles ▪ 6. Remove mask from behind head ▪ 7. Perform hand hygiene Sterile Technique: Sterile technique: o Set of specific practices and procedures performed to make equipment and areas free from all microorganisms and to maintain that sterility Asepsis: o Absence of infectious material or infection Medical asepsis: o Any practice that helps reduce number and spread of microorganisms Surgical asepsis: o Absence of all microorganisms within any type of invasive procedure o Good and bad microorganisms are all removed o When is surgical aseptic (sterile) technique required? ▪ Any medical procedure that involves penetration of the body tissues Rules for sterile technique o When in doubt consider it to be unsterile o In surgery → everything below waist level is considered non-sterile Sterile sites of the body: Sterile sites of the body are sites that aren’t exposed to the environment → enclosed system  Sites that are prone to infection Examples: o Blood o Cerebrospinal fluid (CSF) o Pleural fluid o Peritoneal fluid o Pericardial fluid o Bone o Joint fluid o Internal body sites ▪ E.g., lymph nodes, brain, heart, liver, spleen, etc. Communication SBAR and Written documentation Communication Techniques: 3 way repeat back o To clarify understanding when information is transferred o Sender provides communication → Receiver acknowledges receipt by a repeat-back → Sender acknowledges the accuracy of repeat back → Write it down (don’t rely on memory whenever one receives critical information) and read it back Clarifying questions o To ensure you have all the information and understand what is communicated o Ask 1-2 clarifying questions ▪ In all high-risk situations ▪ When information is incomplete ▪ When information isn’t clear Phonetic and numeric clarifications o To clarify key words and numbers when communicating important information o To clarify key words → say the letter followed by a word that begins with the letter o To clarify numbers → say the number and then the digits SBAR o To transfer key information or request assistance effectively and efficiently Verbal communication: SBAR (Situation Background Assessment Recommendation) o Situation ▪ The bottom line ▪ Problem, concern o Background ▪ What is known o Assessment ▪ What is happening now? ▪ View of situation and urgency o Recommendation  ▪ What is next? ▪ Suggestion and recommendation of next step Written documentation: Record the date (and time as required) Patients concern/issue/complaint Specify treatment reaction and extent Recommendations made Patients progress and effectiveness of care plan Signature, print name, and print designation o Designation → e.g., student Summarize the encounter o What was the nature of the encounter? o What information did you provide? o What concerns did the patient express? o How did you address them? o How will you track your patient’s progress? Documentation format: o Legible (print, don’t write) o Permanent (permanent pen only) ▪ Preferably black or blue o Written objectively in third-person (preferred) o Accurate/specific o Concise o Appropriate/relevant o Accepted terminology and abbreviations  Intravenous Preparation Drug Administration Considerations: All drugs are potentially harmful Never give a drug without an order Understand the intended action, contraindications, side effects, and potential adverse reactions of any drug that you administer Must always adhere to the “5 Rights of drug administration” 5 Rights of Drug Administration: PDART P: Patient o Make sure it’s the right patient o Ask the patient for 2-3 ID information ▪ Patient’s full name, date of birth, and address D: Drug o Make sure the correct drug is given o Check drug 3 times ▪ When getting the drug, before pouring drug, and before administering drug o Things to check for on the drug: ▪ Correct drug name ▪ Expiry date ▪ Label ▪ Concentration A: Amount o Right amount/dose R: Route o Right route of drug administration o Examples of drug route administration: ▪ Oral ▪ Intravenous (IV) T: Time o Right time o The time drug is to be administered or is administered Minimum Documentation of Drug administration: Name of drug Dosage Route Time Reaction (if applicable) Signature and title o E.g., Helen Chen (Radiation Therapy student) Routes of Drug Administration: Enteral route: o Drug is administrated/absorbed through the gastrointestinal (GI) tract o Subtypes include: ▪ Oral By mouth ▪ Sublingual Placing a drug under tongue until it dissolves and is absorbed into the bloodstream directly ▪ Buccal Between the gums and cheeks until it dissolves and enters directly into bloodstream ▪ Rectal Drug administered through the rectum If patient is nauseated and unable to retain oral drugs ▪ Gastric Direct injection into the stomach/bowel either orally or via tube E.g., through existing tube Parenteral route: o Drug is administered outside of the GI tract and delivering drugs directly into systemic circulation or tissues ▪ Directly entry into blood/tissue o Subtypes include: ▪ Intradermal Injected directly beneath skin’s surface into dermis 0.5 mL or less Injected at 5–15-degree angle 25- to 27-guage needle, ½ inch in length E.g., TB test ▪ Subcutaneous Under the skin, into the layer of fat, between skin and muscle o Injected into the tissue beneath the dermis No more than 1 mL Injected at a 45-degree angle 23- to 25-guage needle, ½ inch in length E.g., insulin ▪ Intramuscular Drug is injected into the muscle Prompt absorption 1-5 mL maximum E.g., vaccines ▪ Intravenous Drug is injected directly into vein  Immediate effect o Patient can’t be left unintended Large volumes possible (e.g., 120 mL) Can be administered quickly (bolus) or over a period of time (infusion) ▪ Intra-arterial Into artery Rarely used for medication ▪ Epidural Into spinal cord in the epidural space ▪ Intrathecal Into the spinal cord into the intrathecal space (e.g., cerebrospinal fluid) Topical route: o Applied directly to skin or mucous membranes o Administered directly on to eyes, ears, nose, throat, respiratory mucosa, vagina, and rectum o E.g., Eye drop, cream Intravenous Line Considerations: Need for intravenous (IV) line: o Maintain access to venous circulation ▪ To keep vein open (TKVO) ▪ Use of 0.9% saline o May be used to administer infused drugs, replacement fluids, blood or electrolytes o Insertion site and type will depend on the need for the IV line ▪ IV lines work on gravity ▪ May be administered using electronic pump Infusion by gravity o Administering IV fluids or medications via gravity infusion ▪ The flow rate is controlled manually by adjusting IV tubing and relying on gravity o Provided by physician/order o Components of a gravity IV infusion: ▪ IV bag/bottle Contains the fluid or medication ▪ IV tubing: Spike: Inserted into the IV bag Drip chamber: Allows visualization of flow (count drops per minute) Roller clamp: Adjusts flow rate Filter (optional): Prevents particles from entering the bloodstream ▪ Needle/Catheter: Inserted into the patient’s vein o Calculated flow rates o TKVO: Safe flow rate = 15-20 gtts/min ▪ gtts/min = drops per minute  MRT scope of Practice regarding IV lines: o MRT’s role include: ▪ Monitoring or regulating the flow through the line ▪ Preventing dislodgement (to remain intact) of line ▪ Preventing introduction of air or contaminants into system ▪ Identifying and reporting any problems with the line Common IV Complications: o Leaking IV ▪ Partially dislodged o Fully dislodged IV o Check for coldness and swelling o IV outside vein and still being administered o If IV bag is placed below insertion site → will lead to blood flowing out into IV tubing Electronic Infusion Pumps: Medical devices designed to deliver fluids (e.g., medications, nutrients, blood) into a patient’s bloodstream with precise control overflow rate and volume Used for: o Total parenteral nutrition (TPN) ▪ E.g., used when patient is unable to eat orally o Continuous medication administration ▪ E.g., IV antibiotics o Patient-controlled pain medication If patient has the electronic infusion pumps when doing treatment: o Call in advance and inform the nurse if procedure will be lengthy o Whenever possible, plug in the pump rather than relying on battery power o If an IV set does run out or if the alarm sounds despite precautions → call the patient’s nurse immediately Insulin pumps o Used for treating patients with Type 1 diabetes o The patient is an expert in use and care of the pump o Insulin pump care ▪ Can’t be exposed to radiation or strong magnetic fields → will interfere with motor ▪ Store pump away in a safe place for the patient during tests o Patient care consideration with insulin pump ▪ Length of time for procedure ▪ Contact patient’s diabetes educator for advice as needed Equipment for IV Drug Administration: Preparation and delivery of IV drugs:  o Familiarize yourself with medications used in each department and which ones can be prepared by each speciality o Differences in loading and handling medications ▪ Exposure to light ▪ Able to inject air into vial ▪ Use of glass vs plastic syringes ▪ Disposal Methods of Delivery/Administration: o Pre-existing IV lines o Power/automatic injector ▪ Mainly used for administering contrast o Hand injection Key components of Needles: o Hub ▪ The plastic or metal base that connects the needle to a syringe or IV tubing ▪ Often colour-coded to indicate needle gauge (thickness) o Shaft (aka Cannula) ▪ The long, hollow metal tube that penetrates the skin ▪ Guage = diameter of the shaft Bigger the number, thinner it’s diameter o Bevel ▪ The slanted/angulated, sharpened tip at the end of shaft o Lumen ▪ The hollow interior of the shaft through which fluids (e.g., medication, blood) flow ▪ Lumen is the space inside the shaft and runs the length of the shaft o Point ▪ The sharpened end of the needle, including the bevel o Protective cap ▪ A plastic or silicone cover that shields the needle before and after use ▪ Function: maintains sterility and prevents accidental needle sticks Angiocatheters: o Medical devices used to access veins for administering fluids, medications, blood products or contrast agents o Key components of angiocatheters: ▪ Catheter (Cannula) Flexible plastic tube that stays in the vein Available in various gauges (diameters) and lengths ▪ Needle Sharp, hollow metal stylet inside the catheter used to puncture the vein ▪ Flashback chamber A transparent chamber that fills with blood (“flashback”) to confirm proper vein entry  ▪ Catheter hub Connects to IV tubing or a syringe ▪ Wings/Stabilizers (in winged angiocatheters) Plastic flaps for easier handling and securing the device ▪ Safety mechanism Retractable needle or protective cover to prevent needlestick injuries o The size of the lumen chosen depends on viscosity (thickness) and rate of administration of the fluid to be injected ▪ The smaller the lumen → larger the gauge of the needle ▪ 24G needle is smaller than 18G o Length and size depend on → condition of patient and type of injection Syringes: o Medical devices used to inject fluids into or withdraw fluids form body o Range from 1 to 60mL o Syringes are calibrated in milliliters and minims ▪ 1mL = 15 or 16 minims o Key components: ▪ Barrel Cylindrical body marked with volume measurements (mL or cc) ▪ Plunger Movable piston inside the barrel that creates suction or pressure ▪ Needle hub Connects the needle to the syringe ▪ Tip End of the barrel where the needle attaches ▪ Flange Wings on the barrel for grip and control during use o Syringe shields ▪ Used in nuclear medicine for radiation protection with radiopharmaceuticals housed in the syringe ▪ Disposal of syringes → in protective radioactive sharps container (different from regular sharps container) o Preloaded syringes ▪ Syringe prefilled with medication ▪ Single dose ▪ Auto-injectors E.g., epi-pen Educated patients may self-administer Proper disposal: o Sharps ▪ One time use ▪ Sharps container  o Biohazard ▪ Contaminated with bodily fluid (e.g., blood) Ampules: o Single-use, glass-sealed, ideal for unstable or emergency drugs o Labelled with: ▪ Name of drug ▪ Dosage per mL ▪ Route of administration o Can’t inject air into it → just draw out o Usually use the purple-coloured syringe for ampules as it contains filter in case of glass Vials: o A glass or plastic container with a rubber stopper circled by a metal band (holds band in place) o Flexible, reusable, and better for multi-dose therapies o Can be single or multi dose ▪ Multidose → it is considered contaminated after it has been used for 24 hours and must be discarded o Has to inject air into vials before drawing it out Considerations before using any drugs: Check: o Name/Label o Expiration o Concentration o Colour o Leaks Incident reporting: Near-misses and injuries o Near-misses → didn’t get injured, but almost injured  Patient History and Consent Patient interview process: NOD o Introduce oneself to patient using NOD o NOD: Name, Occupation, Duty Verify patient information o 2-3 IDs Ask about contraindications first o Contraindications → A specific condition, circumstance, or factor that makes a particular treatment inadvisable or unsafe for a patient o Questions that can be asked: ▪ If they have it before? ▪ Any complications when they took it? Review patient’s risk factors o Severity of symptoms o Medications used Explain procedure o E.g., CT scan with contrast Discuss expected side effects Ask if they have any questions/concerns Then lastly obtain patient’s consent to start procedure (again) Patient History: Most focused on: o Allergies o Asthma o Renal disease o Diabetes (Type III) o Heart disease o Pregnancy o BUN and Creatinine levels Multiple myeloma Sickle cell anemia Hypertension Thyroid disease Pheochromocytoma Lactation Medications Risk factors: Diabetics on metformin Renal disease/dysfunction Asthmatics/history of allergies  Cardiac disease Sickle-cell anemia Multiple myeloma Hypertension Pheochromocytoma Liver disease Previous contrast reaction Age o 65-year-old and older have higher risk Metformin: An oral anti-hyperglycemic agent used primarily to treat patients with non-insulin dependent diabetes mellitus Metformin is excreted unchanged by the kidneys, probably by both glomerular filtration and tubular excretion The renal route eliminates about 90% of the absorbed drug within first 24 hours Metformin seems to cause increased lactic acid production by intestines o Excessive lactic acid production → can significantly impact kidney function ▪ When lactic acid is high → the kidneys may struggle to compensate leading to metabolic acidosis and potential kidney damage o Any factors that decrease metformin excretion or increase blood lactate levels are important risk factors for lactic acidosis (build-up of lactate in the blood) o Renal insufficiency is a major consideration for radiologists Is a risk factor a contraindication?: Most contrast injections can still be performed after the risk assessment Some modifications can be taken: o If patient has previous known reaction = in high risk → requires pre-medication o Patient on Metformin (Glucophage) → discontinue 48 hours after CM (contrast media) injection if eGRF 120 µmol/L (1.5 mg/dL) o BUN = >8.2 mmol/L (30 mg/dL) Renal function estimation: o Risk best measured and based on estimated eGFR rather than absolute SCr levels ▪ eGFR = more reflective on kidney function o Radionuclide techniques more accurate, but very time consuming CM and Lactation: o Less than 1% of injected dose is excreted in breast milk with less than 1% of ingested dose being absorbed by infant’s GIT ▪ 1% of the 1% o Recommended from ACR = breastfeeding is safe after CM injection o Patient should make informed decision on continuing or abstaining breastfeeding Consent form requirement: Dependent on clinical site policy  o Responsibility rests with physician ordering the procedure Must explain the procedure to patient and get informed consent (verbal or signed) to start the exam Must be able to explain the risks/benefits and alternative options of contrast media  Venipuncture Venipuncture: Involves the introduction of a sterile needle, catheter or cannula into the vascular system o For IV access Peripheral IV cannulation: The procedure of puncturing a patient’s skin to allow insertion of a temporary plastic tube (cannula or catheter) into a vein Can be short or long term Common purpose: o Providing parenteral nutrition o Transfuse blood products o Provide avenue for dialysis o Avenue for hemodynamic o Avenue for diagnostic testing o Administer fluids and medications Long term IV therapy: Special training required to access these lines MRT responsibilities: Must work within the limits of own competence Have appropriate theory and skill preparation Keeping knowledge and skills up to date Seek consent Keep clear and accurate records As an MRT → will need access to the vascular system to deliver drugs, contrast media, and/or radiopharmaceuticals Appropriate vein selection: Anatomy of blood vessels o Vein ▪ Thinner wall ▪ Wide lumen ▪ Easily compressed/flatten ▪ Location: Superficial and palpable, can also be deep No palpable pulsation ▪ Blood characteristics: Dark blood with slow return when cannulated ▪ Valves: Present to prevent blood flow in the reverse direction ▪ Blood flow: Blood is carried toward the heart ▪ Supply: Numerous o Artery ▪ Thicker wall  ▪ Blood is pulsed ▪ Location: Located deep, can also be close to the surface Pulsation palpable ▪ Blood characteristics: Bright red blood and blood flow pulsates ▪ Valves: Absent ▪ Blood flow: Blood flows away from the heart ▪ Supply: Usually supplies one area of the body Order of Vein choice: 1. Median cuboidal mainly used o Least likely to bruise and is least painful of the 3 antecubital veins to cannulate 2. Cephalic (towards the thumb) o Runs upward along the radial border of forearm o Usually the second choice of antecubital veins 3. Basilic (towards the pinky) o Originates in the ulnar portion of the dorsal venous network and ascends the ulnar surface of the forearm o Below the arm, it curves toward the inside of the forearm to meet the median cubital vein o Very prominent in males Vein selection checklist: o Well-anchored o Bouncy or resilient o Large enough to support good blood flow o Straight path o Area proximal to original site of previous IV attempts ▪ Proximal area → an area closer to the shoulder ▪ But if there is damage where IV was → want to avoid it and prevent any complications Vein areas to avoid selection: o Small veins of the hand ▪ Not able to withstand pressure ▪ A lot of pain o Areas of inflammation/disease/bruising o Arm veins on the same side of a radical mastectomy o Arms with an AV (arteriovenous) shunt or fistula ▪ AV fistula: A surgically created anastomosis between an artery and a vein Easily recognizable by a surgical scar over a dilated, pulsatile vessel Never put a tourniquet on this arm or attempt venipuncture on the arm with AV fistula o Areas with extensive scars (from burns/injury/surgery) Other areas to avoid: o Selecting an artery o Inner aspect of the wrist o Tortuous veins  o Sclerosed veins ▪ Hardened or scarred from previous use o Rolling veins o Overused veins o Same side as recent surgery (mastectomy) o Inflamed or infected vein Venipuncture Procedure considerations: Venipuncture supplies needed: o Angiocatheter o Normal saline (0.9%) o Saline lock o Tourniquet o Alcohol wipes o Tape o Non-sterile Gauze o Gloves o Sharps container o Biohazard bin  Selecting equipment: o Bolus ▪ Small amounts of fluids ▪ CM 60-150 mL ▪ Given over 1 or 2 mins o Infusion ▪ Larger amount of fluids ▪ Over a long period of time o Guage of needle ▪ Bigger the gauge = smaller the lumen of the gauge ▪ Usually use the blue coloured gauge (22G) Tourniquet: o 8-10cm proximal to injection site o Ends of tourniquet not over puncture site o Should be tight, but shouldn’t restrict arterial flow IV Insertion Steps: 1. Assemble and prepare all the supplies that are needed 2. Prepare equipment, perform hand hygiene o Organize equipment and open packaging o Attach saline lock to 0.9% NaCl syringe and flush any air (push liquid out and shake it to get bubble out) o Prepare tape 3. Check for requisition, doctor’s order 4. Introduce yourself (NOD) 5. Identify patient (2-3 IDs) 6. Explain procedure to patient step by step 7. Establish rapport, probe for preference and history of venipuncture 8. Get consent for the administration of CM 9. Position patient (can be supine or sitting) 10. Perform hand hygiene and don gloves. Apply tourniquet and select appropriate vessel o Don’t leave tourniquet on for more than 1 minute 11. Prepare site o Firm strokes in concentric circles with alcohol swab from centre of site to outside, 1” radius o Allow aur to dry o Don’t touch site 12. Perform venipuncture o Inspect angiocatheter (360 degrees turn) o Tell patient to make a fist o Stabilize the vein o Approach at 10-30 degree angle o Assess for flashback in flash chamber o Lower needle one vein is felt almost parallel to arm and advance entire unit slightly o Partially withdraw needle to check for blood and advance catheter o Release tourniquet  o Gentle pressure proximal to catheter tip1 o Press button to retract needle o Tell patient to release fist o Quickly connect primed saline lock and syringe o Pull back syringe to ensure there is blood in drawback and push the 0.9% saline into vein 13. Secure the IV o Apply tape to IV site 14. Clean up and connect o Dispose of used equipment in appropriate bins o If required → connect IV drip to peripheral IV o Ensure appropriate flow rate 15. Discontinue the IV o Prepare supplies and perform hand hygiene and don gloves o Gently remove tape o Fold 2x2 gauze and apply over insertion site o Remove IV and apply pressure o Apply tape o Tell patient to hold pressure until hemostasis achieved (15-20 mins) IV Insertion Considerations: Before using angiocatheter, the cannula should be spun 360 degrees and visually inspected prior to insertion o To ensure that the needle isn’t stuck, and catheter isn’t damaged Bevel of the needle should be facing upwards After needle insertion → look for flashback (blood return) in the flash chamber to confirm the needle is in the vein o If no flashback is seen → can make minor adjustments and reposition while still in the arm if the stylet hasn’t been pulled back or removed the unit from the skin o Don’t dig o Can retry 2 times After removal of tourniquet → digital pressure should be applied proximal to where the tip of catheter resides in vein Documentation: Date and time of procedure Type/length/gauge of catheter Number of attempts Location of each attempt Patient’s response Drug information (what was infused?) Your name and designation Removal of IV: Wash hands Put on gloves Remove the tape/dressing gently Cover the area with gauze (sterilized) Remove the cannula while applying pressure with gauze Verify hemostasis Apply a tape and gauze or clean bandage Infection Control: 2 areas of concern: o Needle stick injuries → protect oneself o Nosocomial infections → protect patient ▪ Infection related to IV device can lead to bloodstream infections  Venipuncture Complications and Considerations Venipuncture procedural complications: Situations where flashback isn’t seen o Needle partially inserted ▪ Often how hematoma are formed o Bevel on lower/posterior vein wall o Vein rolls and needle slips to side of vein o Collapsed vein ▪ Often due to overuse ▪ Needle too big ▪ Would have a lot of resistance during venipuncture o Bevel on upper vein wall o Needle inserted too far ▪ No flashback, but may seen a bit from initial passing of lumen ▪ May result in hematoma Patient arm bruised after venipuncture o Due to hematoma (blood leaked into surrounding tissue) o Improper venipuncture technique ▪ Needle partially inserted ▪ Both vein walls (ant and post) being punctured = transfixation ▪ Digging with needle ▪ Not releasing tourniquet before removing needle o Homeostasis not achieved ▪ Apply pressure for minimum of 2 minutes (ensure patient not taking blood thinners Compartment syndrome o Complex of symptoms caused by increasing pressure of soft tissue within a confined space o Clinical presentation ▪ Mild to moderate redness ▪ Swelling ▪ Skin blistering ▪ Limited finger range of motion ▪ Pain and tenderness Venipuncture considerations: When a vein can’t be found: o Switch to the other arm o Pre-warm site (using a warm cloth, blanket, or saline bag) o Use double tourniquet o Encourage patient to drink water, if possible o Drop arm below heart → use gravity to encourage blood flow filling  Contrast Media: Contrast media: Substances used to fill hollow organs or blood vessels to highlight their internal structure or distinguish them from neighbouring anatomical features Main contrast agents: o Barium and iodine-containing agents often used in radiography o Radiopaque contrast media (ROCM) or simply CM Principle: o Higher atomic numbered tissues absorb more x-rays o E.g., bone vs soft tissues CM classified into 2 main groups: o Negative agents ▪ Radiolucent Appears black on radiographic image ▪ Used in GI procedures ▪ Contrast agents decrease organ density to produce contrast ▪ 2 types → carbon dioxide and air o Positive agents ▪ Radiopaque Appear white on the radiographic image AKA ROCM ▪ 2 types → barium and iodine ▪ Administered in 2 ways → enteral and parenteral Reactions to contrast media: 70% occur within 5 min of injection 16% between 5-15 min post injection 14% will occur after 15 min post injection Nearly all life-threatening reactions occur immediately or within 20 min post CM injection MRT response to CM reactions: Varies from: o Observing patient o Taking vital signs o Notifying radiation oncologist/radiologist/nuclear medicine physician/nurse o Preparing/administering supportive therapy and/or meds if authorized o Calling a “code” o Performing CPR CM expected side effects: Warm, flushing sensation Metallic taste Feeling like you have peed yourself Risk factors for adverse reactions to IV CM primary considerations: Risk factors exist that increase the risk/likelihood of a contrast reaction Allergy o Patients that have a prior allergic-reaction or unknown-type reaction to CM have about 5-fold increased risk of developing a future allergic-like reaction if exposed to same class of CM again o A prior allergic-like or unknown type reaction to the same class of CM is considered the greatest risk factor for predicting future adverse events o A prior reaction to a certain class of CM doesn’t predict a future reaction to another class of CM Asthma o A history of asthma increases the likelihood of an allergic-like contrast reaction o Due to the modest increased risk, restricting contrast medium use or premedicating solely on the basis of a history of asthma is not recommended Renal insufficiency o In patients with AKI, the administration of iodinated contrast medium should only be undertaken with appropriate caution, and only if the benefit to the patient outweighs the risk Cardiac status o Patients with severe cardiac disease may be at increased risk of a non-allergic cardiac event if an allergic-like or non-allergic contrast reaction occurs Diabetes: o The most significant adverse effect of metformin therapy is the potential for the development of metformin associated lactic acidosis in the susceptible patient (p. 51) o Two categories of patients on Metformin: ▪ Category 1: In patients with no evidence of AKI and with eGFR ≥30 mL / min/1.73m2, there is no need to discontinue metformin (p. 52) ▪ Category 2: In patients taking metformin who are known to have acute kidney injury or severe chronic kidney disease (eGFR