APCS Final Exam Flashcards
Splint vs Cast
A cast encases the circumference of the limb
A splint encases only part of the circumference of limb
Splint is better for allowing for soft tissue swelling during acute injury phase
Splint usually replaced with a cast after swelling of acute injury phase in fractures
Why is the stockinette sometimes not used with cast or splint
It can cause constriction
3 usual types of splint
Gutter
Sugar tong
Posterior Mold
Plaster vs fiberglass casts
Plaster is heavier and not as durable
Plaster is easier to mold
Plaster absorbs moisture from wound drainage
Plaster will soften and breakdown if it gets wet
Plaster Takes 6-8 hours to cure
Plaster is Exothermic causes heat as it sets
Fiberglass cures in 1-2 hours
Fiberglass must be kept in sealed package
Fiberglass is nearly impossible to get off clothes and skin
Cast contraindications
Acute injury Swelling 3-4 days
if it covers soft tissue infection
If it covers an open wound
(use a splint)
Cast complications
Dermatitis
Compartment syndrome
Pressure sores
(bony prominence or finger indentations) (use palms)
Nerve injury
DVT
What joints should a splint or cast immobilize
One joint proximal
One joint Distal
(rule not written in stone)
(see wrist splint that does not encompass the elbow)
Arm splint/cast application angles
Elbow flexed @ 90 degrees
forearm neutral pronation/supination
Thumb pointing up
Wrist at slight extension
Fingers curled like holding a can
Leg Splint/cast application angles
Patient lying prone
Knee flexed at 90 degrees
Ankle at 90 degrees of flexion
don’t let ankle drift to plantar flexion (impairs walking)
(can cause contraction of Achilles)
Stockinette purpose
Provides barrier between skin and cast
Provides padding
Casting process
Place extremity in proper position
Pick correct size stockinette
Cut stockinette to correct length (4in on each end)
pick correct size padding, roll on padding
extra padding over bony prominences
Don apron and gloves
immerse cast in water (til sloppy wet)
Roll on cast material overlapping 50% each time
What to check before and after cast/splinting
Check pulses
and
neuro function before and after
After casting/splinting
Check
Pulses
Neuro
Look for sharp edges
Make sure it doesn’t interfere with ROM
Make sure patient is comfortable with cast
Provide patient with Crutches, walker, sling, shoe etc if necessary
After cast/splint instructions
Don’t insert anything into it
keep dry, use plastic bag
return after 3-7 days for assessment
(splint should be replaced with cast at this time)
Notify if any numbness, tingling, lesions, discolorations, or increased pain,
Cast removal
Use oscillating saw
Demonstrate on own skin that saw will not cut skin
Avoid cutting over bony prominences
If blade becomes too hot, wait for it to cool down
Cut down both sides of cast
Cast window
A window may be cut into a cast to assess and care for wounds or remove an object
1/2 to 1 inch
Cast wedging
if a deformity is noted after cast has been applied
Remove cast and start again
or
Cut cast and attempt to bend it to proper form
cast wedging
Most common sequelae of diabetes
Foot ulcers
Infection
Amputation
(early recognition and aggressive management can delay morbidity)
Risk factors for diabetic foot damage
Neuropathy
Increased pressure on foot
Deformities of foot and nails
History of ulcers or amputation
Acute or chronic infection of foot or nails
Poor foot hygiene
How often is a foot exam needed on diabetic patients
low risk = once a year
Higher risk (any risk factors (quarterly)
Criteria for diabetes
A1C = 5.7 - 6.4
Fasting glucose = 100-125 (8 hours)
2 hr. post load glucose = 140-199
(Confirmed by repeat test on different day)
Symptoms of hyper/hypo glycemic crisis (random BGL of >200)
Type 1 diabetes
Auto immune beta cell destruction
Leading to absolute insulin dependence
Type 2 diabetes
Progressive insulin secretory deficit in a background of insulin resistance
Misc. Diabetes causes
Genetic defects
Diseases of exocrine pancreas
Drug or chemical induced
Gestational
Gestational diabetes
2nd or 3rd trimester
not previously diagnosed
Visual inspection of foot in diabetic exam
Color
Callus
Fissures
Ulcers
Maceration (swelling/skin breakdown)
Lack of hair
Toe nails (fungal, thick, flaky)
Appearance (bunions, hammertoes, deformities etc)
Shoe wear (pressure, friction, fit etc)
Socks (holes, clean, fit etc)
Palpation of foot in diabetic exam
Temperature (cool, hot)
Pulses (2+, etc)
Perfusion (cap refill)
Edema (pitting)
Sensation testing of foot in diabetic exam
Semmes Weinstein monofilament Tuning fork (256hz preferred, 126hz optional)
Checking for neuropathy
Press tuning fork against bony prominence on big toe
ask for when they feel it start and stop
press monofilament against specified places on foot until it bends, see if sensation is present or absent
(all plantar surfaces)
great toe, 4th toe, 3 places on pad (inner, middle, outer)
Patient education and advice
Inspect feet daily (mirror for bottom of feet)
Wash feet daily (check temp first with back of hand)
Use lubricating ointment on feet
(no lotion between toes)
Keep nails trimmed (straight across)
twice a month
Women to remove polish before visit
Always wear socks and shoes
Make sure they fit well
Don’t walk barefoot (not even at beach)
Check BGL regularly
IV Contraindications
The obvious ones
Mastectomy impaired circulation lymphedema Lymph node dissection PVD Venous insufficiency clot distal to phlebitis when the med can be given orally
Local site infection or cellulitis is common in IV’s left in place for?
72-96 hours
Systemic complications of IV’s
septicemia bacteremia embolization Pulmonary emboli Air emboli
Why is forearm best for IV’s
Avoids wrist and is more comfortable
less valves and bifurcations
easy access
Also the dorsal hand
Pediatric IV sites
Foot or ankle are acceptable
harder for them to see so they are less anxious
less saphenous
medial marginal vein
Typical IV Veins
Metacarpal
basilic
cephalic
Consent needed for IV insertion
Verbal consent is sufficient
Types of antimicrobial agents for IV prep
70% alcohol
Tincture of iodine
iodophor
chlorohexidine
Preferred catheter size under 1 yr
24 ga
Why can it be difficult to start in IV in an elderly person
The vein may be sclerotic and harder to puncture
When should IV site be changed
Every 96 hours
Purposes of joint aspiration (general)
Diagnostic
Therapeutic
Can be intraarticular or intrabursal
(process is the same)
How to know where to insert needle in joint aspiration
Anatomical landmarks
Ultrasound
Joint aspiration indications
Painful effusion
Rheumatic disorder
monoarticular inflammation
What are we looking for in fluid from joint aspiration
Crystals cell count viscosity bacterial culture gram stain PCR
(Always aspirate on insertion to avoid vessel)
When is joint aspiration contraindicated
when you would seed bacteria into joint
(infected skin, burn etc)
risk outweighs benefit
after joint arthroplasty (only by orthopedist)
Hemophilia
anticoagulation and an INR over 2.5
What are herniations of the joint capsule
Bakers cysts
popliteal bursae
What approach is best for the olecranon bursa
lateral aspiration
prevent chronic sinus tract
When can communication between olecranon bursa and elbow joint occur?
Rheumatoid arthritis
Type of knee joint
diarthrodial joint
with a synovial lining
containing secretory cells
and a fine capillary system
from which synovial fluid is derived
Synovial fluid
Plasma transudation and mucin production within the joint combine to give synovial fluid its viscous lubricating quality
Traumatically induced bleeding within the synovial fluid
directly damages the synovial cartilage through the release of destructive proteolytic enzymes from blood cells
When to aspirate a bloody synovial joint
first couple of days after swelling occurs
Clotting makes aspiration nearly impossible between 3-7 days after injury
Aspiration is again possible after 7 days
Damage to cartilaginous regions is likely to occur by this time
Why can inflammation make aspiration difficult?
Chronic inflammation can lead to proliferative changes on the synovial surface and can obstruct the needle
Knee anatomy
knee is formed between the femur and the tibia
Synovium covers the the femur in a saddle configuration and down to the tibia
A synovial draping also covers the proximal fibula
Joint aspiration prep
Informed written consent
tell patient instability may occur after fluid is drained
may need additional treatments (meds, immobilization, therapy, hospitalization)
Patient to be supine if possible
knee flexed (30-70 degrees)
Most common complications of bursal aspiration
Infection Pain Chronic recurrence Chronic drainage Acute recurrent swelling
Joint aspiration steps
Position patient
10 minute scrub with iodine(2in above 3 below knee)
Drape, prep sterile field, sterile gloves
Identify Joint spaces lateral to patella
use 3-5ml 1% lidocaine 25ga needle
insert needle along lateral margin
45 degrees of sagittal plane & 30 degrees off frontal
Insert needle, aspirate to makes sure it’s not in vessel
Inject as you withdraw along track
Use 18ga 20-30ml syringe
aspirate fluid while advancing needle
when syringe is full, hold needle with hemostats
replace syringe and repeat
milk for additional fluid
Meds can be added after aspiration if needed
remove needle apply pressure
Joint aspiration after care
Avoid joint use for 1 day (2 days for bursa)
may need to immobilize (may be unstable)
call office if sudden fluid return, heat, fever, chills, severe pain
(bursa, don’t rest on elbow)
may need plaster splint
If bursitis recurs 3 times, may need surgery
Most common reason to perform LP
Check for CNS infection
Bacterial meningitis
Others: Viral meningitis Subarachnoid hemorrhage Guillen barre ALS,MS, Alzheimer's
Things to check in a CSF sample for bacterial
elevated WBC count
elevated polymorphonuclear cell count
Low glucose
gram stain
Things to check in a CSF sample for viral
mononuclear pleocytosis
Normal glucose
elevated protein
negative grams stain
Things to check in a CSF sample for immunocompromised patient
CSF abnormalities (may indicate fungal)
CNS tuberculosis
neurosyphilis
Unusual viral infections
What can be used to diagnose subarachnoid hemorrhage
LP
CSF (elevated erythrocytes)
Xanthochromic color
Can be differentiated from a traumatic LP
(initial will have RBC but fluid will turn clear
LP results for Guillen Barre
Very high protein
>200
Auto immune disorders LP can be used for
MS
ALS
Alzheimer’s
Uses of an LP for therapeutic reasons
Relieve intraventricular pressure
(while waiting for shunt)
Administer intrathecal meds
(antibiotics, antivirals, antineoplastic)
Contraindications to a lumber punture
Increased ICP (brainstem herniation)
Coagulopathies
Thrombocytopenia
(hemophilia, leukemia, liver disease, anti-coag meds)
(Weigh benefit vs risk)
Infection at site of puncture
Surface abnormalities
(hair tufts, nevi, sinuses, bony abnormalities)
Critical illness or medical instability may be a reason
Complications of LP
Post Dural headache
(most common)
(bilateral, occipital, throbbing, pressure
Gets worse when upright, moving, coughing etc
History or migraines at higher risk
less common in children<3%
discomfort at site infection nerve damage Bleeding Intraspinal epidermoid tumor (rare) Disk herniation, fluid collection, cauda equina syndrome
Spinal cord anatomy
Spinal cord ends at L1-L2 in most adults but can extend lower
L4-L5 or L3-L4 interspace is best for LP
In infants spinal cord ends at L3
(never use L3-L4)
LP patient prep
Alleviate anxiety through explanation and education
Standard precautions
Informed consent
Explain steps and complications (low risk)
use “atraumatic LP needles that separate rather than lacerate dural fibers (reduce headache by 60%)
May use anxiolytics if needed
If outpatient, 1-2 hours observation post procedure
LP Patient Positioning
Position patient Lateral recumbent or sitting upright
(lateral recumbent must be used to measure opening pressure)
Fetal position
Upright sitting
hunched over a pillow or table
head flexed to chest
LP Procedure steps
Position patient
Identify L4 Space (line between iliac crests)
Mark site with pen
Sterile gloves, sterile field
Set up 4 collection tubes
Preassemble manometer and 3 way stopcock
Check needle
Clean site with cleansing solution (circular pattern)
Repeat 3 times (from iliac crests to buttocks to L3)
Drape
anesthetize with 1-2ml of 1% lidocaine
Position bevel of needle parallel to longitudinal dural fibers
Insert needle aimed at umbilicus
Popping should occur as it passes through ligamentum flavum
remove stylet and CSF should flow
Attach manometer measure opening pressure
allow 30-60 seconds for pressure to stabilize
Turn stopcock and collect fluid in 4 tubes
1 ml in each tube in numerical order
replace stylet, remove needle, apply pressure
If traumatic LP occurs
Rotate needle 45 degrees away from bleed
or
Allow bleeding to seal itself with stylet in place
or
Repeat attempt at next higher spot if possible
Key to a good lumber puncture in children
Adequate restraint
sedation may be needed
Maintain body temp and airway
Easier in sitting position
Avoid over flexing neck which can obstruct airway
LP aftercare
Ensure site has sealed itself
bandage may be removed 12-24 hours
keep clean and dry, check for leakage
Recommend treatments for headache
(oral meds, IV caffeine then epidural blood patch)
Patient to remain in decubitus position for 1-2 hours
Headache relief is usually rapid
Contraindications to obtaining blood cultures
Patients on Anti coags
(risk vs benefits)
Site of infection
If multiple cultures have failed, new ones will have low success rate
Complications for Blood cultures
Use of antibiotics can enhance bacterial resistance, increase antibiotic related complications and raise health care costs
Contamination from skin flora
Should be considered if multiple bacteria are found
growth is found in only some samples and not others
Obtaining Blood cultures
At least 2 cultures preferably 3, all from different sites
Use iodine, chlorohexidine, 70% alcohol
21 ga needle
2 culture bottles per site (Anaerobic/aerobic)
Blood culture prep
Clean site with 70% alcohol circular 2-3 times
Next
Apply chlorohexidine in same way 2-3 times
Allow to air dry
Sterile gloves
Reswab with 70% alcohol before stick
(lower contamination rates with chlorohexidine or iodine tincture than with povidone iodine)
Anaerobic then aerobic
Misc Blood culture info
Min collection 10 ml for adults 1-5 ml for children
Cultures should be drawn before antibiotics are given
Avoid indwelling catheters for cultures
Bladder catheter indications
Sterile urine sample monitor output drainage for incapacitated patients bypass obstruction hold urethral skin grafts in place traction for bleeding after prostate surgery irrigation
Straight Cath Bladder decompression Intermittent catheter Topical antineoplastic meds into bladder assess postvoid residue
Bladder catheter types
Three way (irrigation)
Robinson (straight)
Coude (curved tip)
Foley (balloon inflated indwelling)
Contraindications for bladder catheter
Only contraindication is
Blood at the urethral meatus in a patient with pelvic trauma
Can indicate a transected urethra
Allergies to material is also a contraindication
Complications for bladder catheter
Urethral dilation from long term cath Structural damage from trauma of cath UTI Inflammation Difficulty in enlarged prostate or stricture patient Catheter can double back Improper taping/securing Patient caused trauma
Bladder Catheter anatomy
Female urethra 1.5 - 2 in
Straight
Male urethra 6-7 in
less straight
Prostate can add curves and complications
(prostatic hypertrophy)
Bladder cath sizes
Adults
14, 16, 18 fr
Peds boys
5-12 fr
20-30 fr can be used to evacuate blood clots
Post bladder catheter
tape foley to stomach (males)
Inner thigh (females)
penis pointing towards umbilicus
apply bacitracin 1-3 times daily
Best veins in order of preference
Median cubital vein
Cephalic vein
Basilic vein
Things to help find vein
extremity below heart for few minutes
apply warm towel
Use BP cuff
Rub/tap vein
Tourniquet 3-4 inches above site
Make fist
Max time for a tourniquet
2 minutes
Draw from IV site
Stop line for 2 minutes
draw blood
discard first 5 ml
Medical battery
Performs without consent
significantly different procedure than discussed
exceeds scope
someone else performs procedure
Clinician negligence
Related to battery
4 elements needed
duty to meet standard of care
Failure to perform that duty
Casual connection between clinicians failure and the patients injury
Injury for which monetary compensation can provide adequate relief
Four C’s of conset
Capacity
Competency
Clarity
Consent
Acronym for consent
PARQ
Procedure (explanation)
Alternatives
Risks
Questions (patients)
Minor emancipation
Military
Marriage
Living separately and managing own finances
Two types of disclosure
Professional stander (prudent physician) (What a similarly train physician would find significant)
Patient centric model
(What a reasonable patient would consider significant)
Differs from state to state
3 main types of consent
Special
i.e. ICU
Implied Emergency dept (life saving)
General Blanket consent (hospital admission)
Therapeutic privilege
Specific type of information withholding or non disclosure
if the disclosure would interfere with treatment
careful documentation
Code of ethics
American academy of Physician Assistants
Witness to consent
A witness should be used
Requirement varies due to state)
Try not to use someone form your office
Healthcare associated infections
The most common healthcare related adverse event
Standard precautions
CDC recommend s standard precautions for all patient care
Hand hygiene
PPE (as appropriate)
isolation (if needed)
Includes universal precautions
BSI against all types of tranmission
BSI
New gloves when in contact with new patient Change gloves after moist contact Gown Proof of immunization Masks Goggles, glasses, hair, shoe covers Careful sharps handling
Universal precautions
Blood borne transmission
included in standard precautions
N95 mask
Fit tested annually
Male genital and rectal exam
Generally last part of physical exam
Explain what and why
Patient should be standing while you are seated
(if unable to stand, lie on exam table)
Male genital and rectal exam observation
Bulges, scars in inguinal region consistent with current or past hernias
Penile or scrotal abnormalities
Skin abnormalities on penis, scrotum or surrounding area
Male genital and rectal exam steps
Glans penis Retract foreskin if applicable replace foreskin when done (Paraphymosis) urethra shaft base of penis
Testicles
spermatic cord
evaluate for inguinal hernias
Rectal/prostate exam
External
prostate
Stool sample
Compartment Syndrome
5 P’s
Pallor, pulselessness, paresthesia, paralysis,
Pain out of proportion
Volkmann ischemic contracture
Normal soft tissue compartment pressure is 5-10
Over 30 or near diastolic pressure
irreversible damage can occur
Bivalve cast
May need to remove padding and stocking
Use padding to keep to halves apart
Foot deformities (abnormalities)
Ulcers Tinea pedis fallen arches infections (send them to podiatry)
Bursal aspiration aftercare
Don’t use joint for 2 days
recurrence is more likely
avoid resting on elbow (arm rests)
(can use elbow protector or plaster splint)
Surgery may be needed for chronic bursitis
What happens if you meet resistance on LP
If you still meet resistance, remove the needle, recheck landmarks, and consider repositioning the patient with increase spinal flexion
LP dry tap
The most common reason for this is that the epidural space was not pierced,
and repositioning of the needle is indicated.
Other things to consider are dehydration, blockage to fluid circulation, and congenital anomalies
LP needle break
If needle break is near surface
leave stylet in place
make small incision and remove piece with hemostat
if this can’t be done, call neurosurgery
False positive blood cultures
4000-8000 in extra cost 1-5 days extra stay in hospital
