APCS Final Exam Flashcards
1
Q
Splint vs Cast
A
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
2
Q
Why is the stockinette sometimes not used with cast or splint
A
It can cause constriction
3
Q
3 usual types of splint
A
Gutter
Sugar tong
Posterior Mold
4
Q
Plaster vs fiberglass casts
A
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
5
Q
Cast contraindications
A
Acute injury Swelling 3-4 days
if it covers soft tissue infection
If it covers an open wound
(use a splint)
6
Q
Cast complications
A
Dermatitis
Compartment syndrome
Pressure sores
(bony prominence or finger indentations) (use palms)
Nerve injury
DVT
7
Q
What joints should a splint or cast immobilize
A
One joint proximal
One joint Distal
(rule not written in stone)
(see wrist splint that does not encompass the elbow)
8
Q
Arm splint/cast application angles
A
Elbow flexed @ 90 degrees
forearm neutral pronation/supination
Thumb pointing up
Wrist at slight extension
Fingers curled like holding a can
9
Q
Leg Splint/cast application angles
A
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)
10
Q
Stockinette purpose
A
Provides barrier between skin and cast
Provides padding
11
Q
Casting process
A
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
12
Q
What to check before and after cast/splinting
A
Check pulses
and
neuro function before and after
13
Q
After casting/splinting
A
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
14
Q
After cast/splint instructions
A
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,
15
Q
Cast removal
A
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
16
Q
Cast window
A
A window may be cut into a cast to assess and care for wounds or remove an object
1/2 to 1 inch
17
Q
Cast wedging
A
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
18
Q
Most common sequelae of diabetes
A
Foot ulcers
Infection
Amputation
(early recognition and aggressive management can delay morbidity)
19
Q
Risk factors for diabetic foot damage
A
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
20
Q
How often is a foot exam needed on diabetic patients
A
low risk = once a year
Higher risk (any risk factors (quarterly)
21
Q
Criteria for diabetes
A
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)
22
Q
Type 1 diabetes
A
Auto immune beta cell destruction
Leading to absolute insulin dependence
23
Q
Type 2 diabetes
A
Progressive insulin secretory deficit in a background of insulin resistance
24
Q
Misc. Diabetes causes
A
Genetic defects
Diseases of exocrine pancreas
Drug or chemical induced
Gestational
25
Gestational diabetes
2nd or 3rd trimester
not previously diagnosed
26
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)
27
Palpation of foot in diabetic exam
Temperature (cool, hot)
Pulses (2+, etc)
Perfusion (cap refill)
Edema (pitting)
28
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)
29
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
30
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
```
31
Local site infection or cellulitis is common in IV's left in place for?
72-96 hours
32
Systemic complications of IV's
```
septicemia
bacteremia
embolization
Pulmonary emboli
Air emboli
```
33
Why is forearm best for IV's
Avoids wrist and is more comfortable
less valves and bifurcations
easy access
Also the dorsal hand
34
Pediatric IV sites
Foot or ankle are acceptable
harder for them to see so they are less anxious
less saphenous
medial marginal vein
35
Typical IV Veins
Metacarpal
basilic
cephalic
36
Consent needed for IV insertion
Verbal consent is sufficient
37
Types of antimicrobial agents for IV prep
70% alcohol
Tincture of iodine
iodophor
chlorohexidine
38
Preferred catheter size under 1 yr
24 ga
39
Why can it be difficult to start in IV in an elderly person
The vein may be sclerotic and harder to puncture
40
When should IV site be changed
Every 96 hours
41
Purposes of joint aspiration (general)
Diagnostic
Therapeutic
Can be intraarticular or intrabursal
(process is the same)
42
How to know where to insert needle in joint aspiration
Anatomical landmarks
Ultrasound
43
Joint aspiration indications
Painful effusion
Rheumatic disorder
monoarticular inflammation
44
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)
45
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
46
What are herniations of the joint capsule
Bakers cysts
| popliteal bursae
47
What approach is best for the olecranon bursa
lateral aspiration
prevent chronic sinus tract
48
When can communication between olecranon bursa and elbow joint occur?
Rheumatoid arthritis
49
Type of knee joint
diarthrodial joint
with a synovial lining
containing secretory cells
and a fine capillary system
from which synovial fluid is derived
50
Synovial fluid
Plasma transudation and mucin production within the joint combine to give synovial fluid its viscous lubricating quality
51
Traumatically induced bleeding within the synovial fluid
directly damages the synovial cartilage through the release of destructive proteolytic enzymes from blood cells
52
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
53
Why can inflammation make aspiration difficult?
Chronic inflammation can lead to proliferative changes on the synovial surface and can obstruct the needle
54
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
55
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)
56
Most common complications of bursal aspiration
```
Infection
Pain
Chronic recurrence
Chronic drainage
Acute recurrent swelling
```
57
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
58
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
59
Most common reason to perform LP
Check for CNS infection
Bacterial meningitis
```
Others:
Viral meningitis
Subarachnoid hemorrhage
Guillen barre
ALS,MS, Alzheimer's
```
60
Things to check in a CSF sample for bacterial
elevated WBC count
elevated polymorphonuclear cell count
Low glucose
gram stain
61
Things to check in a CSF sample for viral
mononuclear pleocytosis
Normal glucose
elevated protein
negative grams stain
62
Things to check in a CSF sample for immunocompromised patient
CSF abnormalities (may indicate fungal)
CNS tuberculosis
neurosyphilis
Unusual viral infections
63
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
64
LP results for Guillen Barre
Very high protein
| >200
65
Auto immune disorders LP can be used for
MS
ALS
Alzheimer's
66
Uses of an LP for therapeutic reasons
Relieve intraventricular pressure
(while waiting for shunt)
Administer intrathecal meds
(antibiotics, antivirals, antineoplastic)
67
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
68
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
```
69
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)
70
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
71
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
72
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
73
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
74
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
75
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
76
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
77
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
78
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)
79
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
80
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
81
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
```
82
Bladder catheter types
Three way (irrigation)
Robinson (straight)
Coude (curved tip)
Foley (balloon inflated indwelling)
83
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
84
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
```
85
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)
86
Bladder cath sizes
Adults
14, 16, 18 fr
Peds boys
5-12 fr
20-30 fr can be used to evacuate blood clots
87
Post bladder catheter
tape foley to stomach (males)
Inner thigh (females)
penis pointing towards umbilicus
apply bacitracin 1-3 times daily
88
Best veins in order of preference
Median cubital vein
Cephalic vein
Basilic vein
89
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
90
Max time for a tourniquet
2 minutes
91
Draw from IV site
Stop line for 2 minutes
draw blood
discard first 5 ml
92
Medical battery
Performs without consent
significantly different procedure than discussed
exceeds scope
someone else performs procedure
93
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
94
Four C's of conset
Capacity
Competency
Clarity
Consent
95
Acronym for consent
| PARQ
Procedure (explanation)
Alternatives
Risks
Questions (patients)
96
Minor emancipation
Military
Marriage
Living separately and managing own finances
97
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
98
3 main types of consent
Special
i.e. ICU
```
Implied
Emergency dept (life saving)
```
```
General
Blanket consent (hospital admission)
```
99
Therapeutic privilege
Specific type of information withholding or non disclosure
| if the disclosure would interfere with treatment
careful documentation
100
Code of ethics
American academy of Physician Assistants
101
Witness to consent
A witness should be used
Requirement varies due to state)
Try not to use someone form your office
102
Healthcare associated infections
The most common healthcare related adverse event
103
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
104
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
```
105
Universal precautions
Blood borne transmission
| included in standard precautions
106
N95 mask
Fit tested annually
107
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)
108
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
109
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
110
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
111
Foot deformities (abnormalities)
```
Ulcers
Tinea pedis
fallen arches
infections
(send them to podiatry)
```
112
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
113
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
114
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
115
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
116
False positive blood cultures
4000-8000 in extra cost 1-5 days extra stay in hospital
