8-28 CV Procedures - King

Question 1

What are the indications for venipuncture?

Answer 1

–Health screening

–Pre-operative evaluation

–Diagnostic aid

Question 2

What are the relative contraindications for venipuncture?

Answer 2

–Patient inability to sit still (young child)

–Skin conditions interfering with access (scleroderma, cellulitis)

Question 3

What are the complications with venipuncture?

Answer 3

–Bleeding (bruising, hematoma)

–Infection

–Arterial/nerve injury

Question 4

What are the supplies needed for venipuncture?

Answer 4

• Tourniquet
• Gloves
• Alcohol swabs
• Appropriate needle device

–Vacutainer, Butterfly, Syringe

• Blood specimen tubes

–Specific to the tests you want

• Gauze pads or cotton balls
• Bandage
• ID Labels

Question 5

What is the most common method for venipuncture?

Answer 5

•Vacutainer and needle holder

–Most common method

–allows for draw of multiple tubes

Question 6

What kinds of needles are frequently used for venipuncture? Why?

Answer 6

•10cc Syringe & 21-22 gauge 1” needle

–Easier to see flashback of blood

–Smaller bores needles cause RBC hemolysis which may be mistaken for anemia or hyperkalemia

•Butterfly needles

–Smaller and less painful

–Easy to hold

–Tubing is attached to vacutainer or syringe

Question 7

What should you do to prepare to do a venipuncture?

Answer 7

• Assemble all supplies first
• Position patient

–Straighten patient’s arm with their elbow resting on a flat surface

•Apply tourniquet

–Above the antecubital fossa

–In a snug slip knot

•Distend veins by having patient open and close fist several times

Question 8

How do you select a site for venipuncture?

Answer 8

• Choose a vein that is distended most commonly the median cubital
• Glove up
• Clean with the alcohol swab in concentric circles starting from the center and working out
• Don’t repalpate the clean area; you will contaminate it

Question 9

What is the venipuncture procedure?

Answer 9

• Use non-dominant hand to apply traction below the vessel to anchor it, keep it from moving and tense the skin making needle insertion easier
• Use dominant hand to insert the needle at a 15-30 degree angle until you see a flashback of blood into the needle hub

–Flashback not visible with evacuated tubes until they are inserted into the tube holder

•If no flashback, partially withdraw the needle and reposition and advance again.

–If you accidentally withdraw the needle from the skin you must start over with a clean needle

• Release the tourniquet before removing needle
• Apply pressure with cotton ball after removing needle

Question 10

What are the indications for IV catheterization?

Answer 10

–Administration of fluids and medications

Question 11

What are the relative contraindications for IV catheters?

Answer 11

•Relative contraindications

–Patient inability to sit still

–Skin conditions interfering with access

Question 12

What are the complications associated with IV catheters?

Answer 12

•Complications

–Bleeding (bruising, hematoma)

–Infiltration of fluid into subcutaneous tissue

–Infection

–Thrombosis

Question 13

What supplies do you need for an IV?

Answer 13

• Gloves – non-sterile
• Alcohol or Betadine
• Tourniquet
• IV catheter
• IV tubing
• Extension or saline lock
• Skin tape or OpSite
• Gauze pads
• IV solution

Question 14

How do you prep for an IV catheter?

Answer 14

• Assemble all supplies first
• Connect the IV tubing to the solution bag and allow the fluid to run through the tubing eliminating all the air (priming the tubing), then clamp the line closed.
• Tear several pieces of tape, 4-6 inches in length and place them nearby.

Question 15

How do you select an IV site?

Answer 15

•Select a vein on the non-dominant forearm that is fixed

–Basilic or cephalic veins on the dorsal forearm are preferred

–Metacarpal veins on the dorsum of the hand are the easiest to visualize, but are more likely to occlude and are prone to infiltration

Question 16

What should you avoid when selecting an IV site?

Answer 16

•Avoid

–Areas of flexion and bony prominences

•The antecubital fossa veins should be reserved for emergency use only

–Near multiple valves/branches

–Pre-existing catheter sites

–Ipsilateral mastectomy and/or lymph-node dissection

–Ipsilateral arteriovenous (AV) fistula or graft

Question 17

How can you use topical anesthetic to start an IV?

Answer 17

• Use if necessary but remember it often causes more pain to administer than starting the iv.
• Topical

–Lidocaine based cream or ointment applied to the insertion site 30-60 minutes prior

•Injectable

–Lidocaine solution (1% or 2%) injected locally 5-10 minutes prior to form a small wheal

Question 18

What is the procedure for an IV catheterization?

Answer 18

• Put on gloves.
• Tie a tourniquet using a “slip-knot” proximal to the venipuncture site.
• Clean the site with an alcohol or Betadine in a circular motion and allow to dry.
• Hold the catheter between your thumb and middle finger with your index finger on the top.
• Hold the catheter at a 30o angle with needle bevel facing upward and enter the skin .
• Continue to advance the needle until you feel a “pop” into the vein and see the “flashback of blood” within the needle’s transparent hub.
• Lower the angle of the needle and advance it about 3-5mm
• Slowly slide the catheter sheath of the needle into the vein by gentle twisting back and forth, while continuing to hold the needle hub at it’s present position. Do not advance the needle, just the IV catheter, until there is only 1- 3mm of the catheter remaining visible.
• Withdraw the needle completely from the catheter and occlude the blood flow from the catheter by pressing on the vein proximal to the catheter tip within the vein. Gauze placed under the catheter hub catches any leaks.
• Remove the tourniquet.
• While still holding the catheter still attach the free end of the primed IV tubing to the catheter hub.
• Open the clamps of the IV tubing to start the flow from the IV bag to ensure patency
• Use a small gauze pad or alcohol pad to wipe away the excess blood from the surface of the skin.
• Use the pre-torn pieces of tape or an OpSite to secure the catheter hub and tubing to the patient’s skin.

Question 19

If:

• The patient complains of pain or burning
• The skin appears to be swelling
• There is not good flow in the drip chamber

What’s happening?

Answer 19

•The IV fluid may be flowing into the surrounding tissue instead of the vein. Remove the catheter and start over at a different site.

Question 20

What are the indications for a central venous catheter?

Answer 20

–Inability to maintain peripheral venous access

–Need for access to central circulation, i.e. pacemaker or pulmonary artery catheter

–Infusion of hypertonic or substances that cause sclerosis of peripheral veins, i.e. TPN or chemotherapeutic drugs

–Hemodialysis

Question 21

What are the contraindications for a central venous catheter?

Answer 21

–Contralateral pneumonectomy

–Bleeding diathesis

–Operator inexperience

–Infection at insertion site

–Recent placement of pacemaker

Question 22

What are the possible contraindications with a central venous catheter?

Answer 22

–Arterial puncture

–Pneumothorax

–Thrombosis

–Infection

-Cardiac dysrhythmia

Question 23

What is the EKG a representation of?

Answer 23

• The electrocardiogram (EKG) is a representation of the electrical events of the cardiac cycle.
• Each event has a distinctive waveform, the study of which can lead to greater insight into a patient’s cardiac physiology and/or pathology

Question 24

What are the indications for an EKG?

Answer 24

•Indications

–Chest pain of suspected cardiac origin

–Suspected arrhythmia

–Screening for cardiac conditions (high risk)

–Pre-operative evaluation

Question 25

What are the contraindications for an EKG? Complications?

Answer 25

•Contraindications

–Patient inability to sit still

–Skin conditions interfering with lead placement

–Need for Basic Life Support

•Complications

–Skin reaction to adhesive

–Incorrect interpretation of results

Question 26

What are some findings you can find on EKG?

Answer 26

• Arrhythmias
• Myocardial ischemia and infarction
• Pericarditis
• Chamber hypertrophy
• Electrolyte disturbances
• Drug toxicity

Question 27

How is an EKG set up? Where are the leads and what do they represent?

Answer 27

•The standard EKG has 12 leads:

–3 Standard Limb Leads

–3 Augmented Limb Leads

–6 Pre cordial Leads

•Leads are electrodes which measure the difference in electrical potential between either:

–Two different points on the body, i.e. limb leads

–One point on the body and a reference point, usually the heart, i.e. precordial or augmented leads

Question 28

How should you prep the patient for an EKG?

Answer 28

•Lie patient flat with arms to sides

–If can’t lie flat make note on ECG what angle patient is resting at. (affects axis)

• Legs should be flat and shoulder with apart
• Wipe the areas for electrode placement with an alcohol pad to remove oil and dirt and shave any hair that may get in the way

Question 29

How are the leads placed for limb leads for an EKG?

Answer 29

•Place the limb electrodes on the Right arm (white), Left arm (black) and the left leg (red) [and right leg if available (green)]

–Way to remember: White = Right and Smoke over Fire

–These can be anywhere on the extremity but should be symmetrical

Question 30

How do you place the chest leads for an EKG?

Answer 30

•Place the chest electrodes in the following order

–V1 (red)- 4th intercostal space at the right sternal border

–V2 (yellow)- 4th intercostal space at the left sternal border (tricuspid)

–V4 (blue)- 5th intercostal space at the midclavicular line (mitral)

–V3 (green)- Halfway between V2 and V4

–V5 (tan)- Anterior axillary line at the same level as V4

–V6 (violet)- Midaxillary line at the same level as V4 and V5

Question 31

What should you interpret with each EKG?

Answer 31

• Rate
• Rhythm
• Axis
• Analysis of each wave

–P

–QRS

–T

•Analysis of each segment

–PR

–ST