CS Objectives Exam 2 PDF

Venipuncture and Peripheral Intravenous Catheter Insertion 1. Recognize the indications and contraindications for venipuncture and insertion of an IV catheter. a. Indications for Venipuncture i. indicated for the evaluation and management of many different disease pr...

Venipuncture and Peripheral Intravenous Catheter Insertion 1. Recognize the indications and contraindications for venipuncture and insertion of an IV catheter. a. Indications for Venipuncture i. indicated for the evaluation and management of many different disease processes ii. required to obtain a venous blood specimen for the purpose of laboratory tests when the quantity required for testing is larger than can be obtained by puncturing the skin with a lancing device. b. Contraindications for Venipuncture: i. Skin infection, skin rash, or a newly tattooed area ii. Extensive scarring from burns, surgery, injuries, repeated venipuncture, or trauma iii. Phlebitis or sclerosed veins iv. Lymphedema: The upper extremity on the ipsilateral side of a mastectomy should be avoided owing to the frequent presence of lymphedema occurring after dissection and removal of the lymphatic system. v. Hematoma vi. An intravenous infusion catheter distal to the proposed site of venipuncture vii. An arm with a cannula in place viii. An arm with a vascular anomaly, such as an arteriovenous fistula a. Indications for IV catheter insertion: i. Fluid administration is done by IV access in clinical settings in which it is deemed medically necessary, including illness, volume depletion or loss, burn, blood loss, electrolyte disturbance, heat stroke, shock, and trauma. ii. Medical emergency situations may require IV administration. iii. Administration of antibiotics, chemotherapeutics, or other medically necessary treatments may require IV access. iv. Administration of blood products requires IV access. v. Administration of diagnostic substances, such as dyes or contrast, may require IV access. vi. Administration of some nutritional components require IV access b. Contraindications for IV catheter insertion: i. Extremities with significant burns, edema, or injury should not be used, to avoid more mechanical trauma. ii. Extremities with cellulitis or significant infection should not be used, to avoid introducing bacteria into the blood circulation. iii. Insertion should not be performed distal to prior failed IV catheter insertion attempts. iv. Insertion should be avoided distal to any area of preexisting phlebitis. v. Insertion should be avoided in extremities with impaired circulation : mastectomy, axillary lymph node dissection, lymphedema, clot, peripheral vascular disease, venous insufficiency. vi. Extremities with indwelling fistulas should not be used. vii. Care should be taken when performing IV access in a patient with a known bleeding diathesis. viii. Consideration should be given to placing a peripherally inserted central catheter if the medication being infused is too caustic, hypertonic, a sclerosing agent, a vasopressive agents, or is to be given for longer than 6 days. ix. When appropriate therapy can be given by a less invasive route (orally) 2. Recognize common crystalloid solutions used in IV infusions and differentiate between isotonic, hypotonic, and hypertonic solutions. Isotonic Type Description Osmolality Use Miscellaneous Normal Saline (NS) 0.9 NaCl in water Isotonic (308 Increasing circulating - Replaces losses without crystalloid solution mOsm) plasma volume when red altering fluid concentration cells are adequate - Na+ replacement Lactated Ringers (LR) Normal saline + Isotonic (275 Replaces fluid and - Normal saline with K, Ca, electrolytes and buffer mOsm) buffers pH and lactate - Seen in surgery D5W Dextrose 5% in water Isotonic in the bag Raises total fluid volume - Provides 170-200 crystalloid solution but physiologically Helpful in rehydrating calories/1,000 cc for energy hypotonic (260) and excretory purposes - Physiologically hypotonic Normosol-R Normosol Isotonic (295 Replaces fluid and - Ph 7.4 has Na,K,Cl,Ca,Mg2+ mOsm) buffers pH - Common for OR & PACU Hypotonic Type Description Osmolality Use Miscellaneous ½ Normal Saline (½ 0.45 NaCl in water Hypotonic (154 Raises total fluid volume - Helpful for establishing NS) crystalloid solution mOsm) renal function - Can be used for daily maintenance but not used for NaCl replacement - Fluid replacement for those who don't need extra glucose → diabetics Hypertonic Type Description Osmolality Use Miscellaneous D5 NS Dextrose 5% in 0.9 saline Hypertonic(560 Replaces fluid sodium, - Watch for fluid volume mOsm) chloride, and calories overload D5 ½ NS Dextrose 5% in 0.45 Hypertonic (406 Useful for daily - Most common saline mOsm) maintenance of body postoperative fluid fluids, nutrition, and rehydration D5 LR Dextrose 5% in lactated Hypertonic (575 Same as LR plus provides - Watch for fluid volume ringer’s mOsm) about 180 calories per overload 1000 cc’s 3. Identify and describe common complications associated with phlebotomy, IV catheter insertion and IV fluid administration Complications Phlebotomy IV Catheter Insertion IV fluid Administration - Latex or adhesive allergy - Allergy to iodine, adhesive, latex - Allergy - Vasovagal syncope - Tissue infiltration/necrosis → failure to - Anaphylaxis - Cellulitis or phlebitis cannulate vein - Hypovolemia - Bruising/ hematoma - Thrombophlebitis (mechanical trauma to - Hypervolemia - Prolonged bleeding in pts with vein) coagulopathies - Local site infection (>72-96 hrs) - Rejection of sample by lab - Systemic (rare): - Sepsis - Catheter emboli, air emboli, pulmonary emboli 4. Describe the essential anatomy and physiology associated with phlebotomy and the insertion of an IV catheter. Venipuncture Veins serve as conduits for channeling deoxygenated blood back to the heart and, eventually, to the lungs. Muscles within the vein walls facilitate the movement of blood within the vein, and one-way valves in the vein prevent the backward flow of blood. The cubital fossa is a triangular area on the anterior aspect of the elbow; because of the prominence and accessibility of the superficial veins in the cubital fossa, it is the site most frequently utilized for venipuncture. In the fossa, the basilic and cephalic veins are most prominent. - The median cubital vein is the preferred site for venipuncture - Other Insertion Sites: metacarpal veins, cephalic veins, basilic veins, greater/lesser saphenous veins, medial/marginal veins - CMP or chemistries (red top) & invert 5 times before CBC (purple top) IV insertion The forearm is used, if possible, because it offers easy accessibility, avoids the wrist, and contributes to increased patient comfort The dorsum of the hand offers good IV access. Bifurcations and valves should be assessed before IV placement to help determine the best insertion site. - The metacarpal, basilic, and cephalic veins in the upper extremity are commonly used. - In the pediatric population, the foot and ankle have adequate circulation, it is an equally acceptable IV site. It offers easy IV access and is less visible to small children, which decreases anxiety. Commonly used lower extremity veins are the greater and lesser saphenous and medial marginal veins. - 5. Correctly select the materials necessary for insertion of an IV catheter and venipuncture. Venipuncture IV Catheter Gloves Cotton IV catheter (18-24 g) Antimicrobial agent to cleanse Tourniquet Max time is 2 min. balls/gauze/tape/bandage Biohazard Waste/Sharps the site (70% alcohol, iodine,or chlorhexidine gluconate) Alcohol Pads Vacutainer Blood collection Gloves, Tourniquet, Gauze Administration Set/ Tubing/ tubes/labels and IV fluid and pole Vacutainer Holder and Sharps Disposable Container Scissors, Eye protection Tegaderm non occlusive needles (21-23 g, butterfly) dressing 6. Identify the important aspects of patient care after establishing an IV line. Fluids administered at the rate of 100 ml/hr replaces oral intake - Increased fluid need with fever, burns, surgical drains, intubation, GI loss, tachypnea, diaphoresis and polyuria - Evaluate for volume overload: cough, shortness of breath, edema, tachypnea, crackles, jugular vein distention, elevated central venous pressure, elevated pulmonary wedge pressure - Evaluate for dehydration especially with hypotonic solutions:dizziness,headache, confusion, hypotension, tachycardia, decreased skin turgor, decreased urine output - Instruct the patient on signs of infection, including increased discomfort or pain, redness, or swelling. Have the patient notify the caregiver immediately if any of these occur. - The IV site should be changed every 96 hours to reduce the likelihood of infection. 7. Demonstrate basic skill in performing one venipuncture on a manikin. 8. Properly perform insertion of an intravenous catheters and establish an IV line on a manikin. 9. Apply the principles of standard precautions and biohazard material disposal. Surgical Knot Tying 1. Recognize and apply general principles of knot tying to include cutting and removal Indications for Knot Tying: - Anytime there is a suture , these are an alternative to instrument tissues Intracorporeal Hand Ties Extracorporeal hand or instrument ties - Deeper Tissues - Securing lines, drains, and tubes - Vessels - Suturing skin - Mesh - Slip Knot: only on one side of the body , can be unreliable - Square Knot: when you cross over the midline , desirable because they are strong - Surgeons Knot: two handed tie with a slip & square knot at the same time - Removal → → → → → → → → → → → → → → → → → → → → → - 0 is big, 10 is tiny cutting, reverse cutting, blunt, tapered needles are for different parts of the body Absorbable Non Absorbable “Breaks down over time” “Permanent“ Type: Braided suture Types: Monofilament/Polypropylene: - Feels and looks like a rope and it's the - Feels like a fishing line and is slippery to tie easiest to tie - Ex. Nylon or Prolene - Ex. Vicryl Used for dermal skin closure Used for sewing in mesh, vascular anastomoses, or can be used externally - 2. Determine which surgical knot is appropriate for closing an incision Cardiac/ Bladder require permanent sutures that won't degrade or unravel Square Knots Slip Knots Surgeon’s Knot More binding than a slip knot Throwing knots in the same direction Super strong - You have to cross the suture, or to avoid an air knot Used to close tissues under tension, your hands to orient the knot and - Second knot increases tension of or when handling slippery suture lay it flat the first knot, allows for knot to be aka prolene Higher chance for an air knot slid down into a cavity and tightened Double throw - No crossing hands or suture  3. Recognize and identify an image of a square knot and a slip knot 4. Recognize the complications of an improperly tied surgical knot - Usually only 4-5 throws - Too many can be too bulky - Too few can be weak and unraveled X Too Loose X Too Tight - Air knot - Strangulates tissue (ischemia) - Risk of dehiscence - Infection and dehiscence - Avoid excessive force - Fragile sutures and smaller caliber sutures can break - Delicate sutures can tear - Maintain a comfortable working distance - 4-6 inches & follow the knot down to the tissue 5. Demonstrate two-handed slip and square knots a. Both hands are active i. Thumb & forefinger are alternating leads 6. Demonstrate one-handed slip and square knots a. When you only have one tail free i. Needle attached ii. Wheel b. One hand is the post, the other hand is active and creates the knot i. Karate chop and claw → Tie using the short end of the suture pinching the thumb and index or middle finger → Guide the knot down just adjacent to the knot when tying into deeper structures 7. Recognize and demonstrate principles of cutting knots once created Radiology 1. Define radiology Radiology: - Medical specialty using medical imaging technology to diagnose and treat patients - Schooling: 1 yr intern, 4 yrs residency, 1-2 yrs fellowship 2. Develop an understanding of the nature, risks and benefits of a radiologic exam There are many imaging technologies available but they might not be available 24/7 May require advanced planning , NPO, premedications, holding blood thinners, sedation and anesthesia MRI → great for soft tissue CT & X-ray → great for bone, blood US → soft tissue, monitoring growth Fluoroscopy → great for procedures  3. Describe the different radiology exam modalities: XRAYs, US, CT, MRI, Nuclear medicine, Fluoroscopy, Interventional radiology (IR) Radiographs aka X-Rays Ultrasound Cost: Inexpensive, low $100s Cost: Moderately expensive, high $100s Risk: Mortality/Morbidity due to radiation exposure (minimal) Risk: Noninvasive with no radiation, Quality is operator dependent so may not get an answer Access: Plain films are widely available 24/7. Interpretation by radiologist may not always be available overnight or weekends Access: often available 24/7 in acute hospital settings and outpatient same day appts are feasible Considerations: pt mobility and cooperation can be a challenge Considerations: exams can be long, and can be limited to cooperation Weight Limit: No fixed weight limit but image quality declines with more weight Weight Limit: no formal weight limit but adipose limits visualization of deeper structures Prep: NONE Prep: pts should be NPO ( usually 4 hrs) for abdominal exams to decrease bowel gas. Ex. BG, liver, pancreas, biliary duct Computed Tomography (CT ) Magnetic Resonance Imaging (MRI) Cost: Expensive, high $100s - low $1000s Cost: Very expensive , low $1000s Risk: Risk: - Mortality/Morbidity due to radiation exposure (children, breast, - No radiation ovaries/testes) - Contrast has low risk - IV contrast exposure - Oral contrast poses no real risk , except in pts who may aspirate Access: Less easily available , not always 24/7. Complex exams may not be read overnight by radiology Access: Easily available 24/7 in most centers. Most centers have someone on call to provide at least a preliminary read at any hour Considerations: - Uncooperative, confused, claustrophobic pts may require Considerations: All use of IV contrast requires IV access capable of handling sedation or even anesthesia. high pressures ex. At least 18 g. Prior iodinated contrast allergy may require - Metallic implants require clearance or contraindicated planning to ensure adequate premedication Weight Limit: Typical weight limit 400-450 lbs. Open MRI for larger Weight Limit: Typical weight limit 400-450 lbs. Image quality declines with pts at some centers more weight Prep: Remove all metallic objects and scans take time Prep: NONE Nuclear Medicine Fluoroscopy Cost: Moderately expensive, high $100s Cost: Moderately expensive, low -high $100s Risk: Minimal mortality/morbidity from radiation and labeled Risk: Mortality/Morbidity due to radiation exposure (minimal). pharmaceuticals for most studies Aspiration of oral contrast material, theoretical risk of bowel injury Access: Less easily available, not always 24/7 Access: Less easily available, not always 24/7, Requires radiologist to be fully present to perform exam Considerations: Cooperative pts needed, exams often acquired over periods of time, ex. 20 min Considerations: Cooperative pts needed, exams involve numerous instructions Weight Limit: Weight limit 300-450 lbs based on modality Weight Limit: Weight limit 350 for standard fluoroscopy table Prep: NPO x 4 hrs for GB, GB EjF, Cardiac NM exams. Caffeine free diet for cardiac stress test Prep: NPO after midnight preferred  Interventional Radiology Cost: Expensive, variable ($ 100s to many, many $1000s) Risk: - Highest radiation risk in all of radiology - Ultra- minimally invasive, image-guided surgeries carry real risks - Ex. pain, bleeding, infection, damage to adjacent surgeries, medication/sedation reaction, cardiopulmonary compromise Access: - Requires consultation with interventional radiology service - 24/7 coverage for emergencies is typical but not guaranteed Considerations: - Iodinated contrast allergy → may require premedications - Blood thinners → antiplatelet or anticoagulants - Consent Weight Limits: standard newer angiography tables have weight limits of 450 pounds Prep: - Formal pre-op clinical evaluation - NPO after MN - Hold blood thinners for appropriate time - Appropriate pre medication for allergies & hydration 4. Identify common indications for IV contrast, the associated risks, and contraindications. IV Contrast Dye Types: CT Scans & IR procedures → “iodine” MRI Scans → “gadolinium” Indications Risks Contraindications Absolute Indications: 1. IV contrast allergy → will require - Pregnant Women but breastfeeding moms 1. Infection/Abscess/Inflammation future premedication CAN 2. Cancer Work-up or follow-up 2. Contrast-induced nephropathy - Pts at risk for aspiration → cannot receive 3. Vascular Pathology (CIN) → associated with iodinated Oral Gastrografin 4. Suspected Solid organ injury contrast and renal impairment - Pts with suspected bowel perforation → cannot receive Oral Barium contrast Other Indications: - - Suspected bowel infarct or ischemia - Metastasis evaluation - CT of neck and mediastinum - Post transplant patients - Soft tissue or bone mass/tumor 5. Describe the risks associated with radiation, IV contrast (allergy, reaction, nephropathy) Radiation Risk: - Slight increase in global cancer rate - Overblown by the media - Repeated CT scans hold a slightly higher risk IV Contrast Risk: - Allergy - Low incidence of iodine and gadolinium allergic reactions - Risk Factors: atopy, renal disease, elderly patients, any prior medication allergies  - Allergic Reactions: - Mild: urticaria, pruritus, sneezing, rhinorrhea - Moderate: erythema, edema, throat tightness, wheezing - Severe: facial edema, airway edema, hypotension, hypoxia - Requires premedication in the future - With either Medrol 12 or 2 hrs prior to exam or Benadryl 1 hr before exam Nephropathy - Contrast induced nephropathy: - Association between iodinated IV contrast administration and renal impairment - Pts with renal insufficiency who require intermittent or occasional dialysis have been noted to be at risk - Treat at GFR