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PAM Semester 2 > APCS Final Exam > Flashcards

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

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2
Q

Why is the stockinette sometimes not used with cast or splint

A

It can cause constriction

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3
Q

3 usual types of splint

A

Gutter
Sugar tong
Posterior Mold

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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

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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)

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6
Q

Cast complications

A

Dermatitis

Compartment syndrome

Pressure sores
(bony prominence or finger indentations) (use palms)

Nerve injury

DVT

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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)

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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

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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)

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10
Q

Stockinette purpose

A

Provides barrier between skin and cast

Provides padding

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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

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12
Q

What to check before and after cast/splinting

A

Check pulses
and
neuro function before and after

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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

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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,

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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

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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

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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

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18
Q

Most common sequelae of diabetes

A

Foot ulcers

Infection

Amputation

(early recognition and aggressive management can delay morbidity)

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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

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20
Q

How often is a foot exam needed on diabetic patients

A

low risk = once a year

Higher risk (any risk factors (quarterly)

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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)

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22
Q

Type 1 diabetes

A

Auto immune beta cell destruction

Leading to absolute insulin dependence

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23
Q

Type 2 diabetes

A

Progressive insulin secretory deficit in a background of insulin resistance

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24
Q

Misc. Diabetes causes

A

Genetic defects

Diseases of exocrine pancreas

Drug or chemical induced

Gestational

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25
Q

Gestational diabetes

A

2nd or 3rd trimester

not previously diagnosed

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26
Q

Visual inspection of foot in diabetic exam

A

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)

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27
Q

Palpation of foot in diabetic exam

A

Temperature (cool, hot)

Pulses (2+, etc)

Perfusion (cap refill)

Edema (pitting)

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28
Q

Sensation testing of foot in diabetic exam

A 
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)

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29
Q

Patient education and advice

A

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

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30
Q

IV Contraindications

A

The obvious ones

Mastectomy
impaired circulation
lymphedema
Lymph node dissection
PVD
Venous insufficiency
clot
distal to phlebitis
when the med can be given orally
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31
Q

Local site infection or cellulitis is common in IV’s left in place for?

A

72-96 hours

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32
Q

Systemic complications of IV’s

A 
septicemia
bacteremia
embolization
Pulmonary emboli
Air emboli
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33
Q

Why is forearm best for IV’s

A

Avoids wrist and is more comfortable
less valves and bifurcations
easy access

Also the dorsal hand

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34
Q

Pediatric IV sites

A

Foot or ankle are acceptable

harder for them to see so they are less anxious

less saphenous
medial marginal vein

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35
Q

Typical IV Veins

A

Metacarpal
basilic
cephalic

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36
Q

Consent needed for IV insertion

A

Verbal consent is sufficient

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37
Q

Types of antimicrobial agents for IV prep

A

70% alcohol
Tincture of iodine
iodophor
chlorohexidine

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38
Q

Preferred catheter size under 1 yr

A

24 ga

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39
Q

Why can it be difficult to start in IV in an elderly person

A

The vein may be sclerotic and harder to puncture

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40
Q

When should IV site be changed

A

Every 96 hours

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41
Q

Purposes of joint aspiration (general)

A

Diagnostic
Therapeutic

Can be intraarticular or intrabursal
(process is the same)

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42
Q

How to know where to insert needle in joint aspiration

A

Anatomical landmarks

Ultrasound

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43
Q

Joint aspiration indications

A

Painful effusion
Rheumatic disorder
monoarticular inflammation

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44
Q

What are we looking for in fluid from joint aspiration

A 
Crystals
cell count
viscosity
bacterial culture
gram stain
PCR

(Always aspirate on insertion to avoid vessel)

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45
Q

When is joint aspiration contraindicated

A

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

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46
Q

What are herniations of the joint capsule

A

Bakers cysts

popliteal bursae

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47
Q

What approach is best for the olecranon bursa

A

lateral aspiration

prevent chronic sinus tract

48
Q

When can communication between olecranon bursa and elbow joint occur?

A

Rheumatoid arthritis

49
Q

Type of knee joint

A

diarthrodial joint

with a synovial lining

containing secretory cells

and a fine capillary system

from which synovial fluid is derived

50
Q

Synovial fluid

A

Plasma transudation and mucin production within the joint combine to give synovial fluid its viscous lubricating quality

51
Q

Traumatically induced bleeding within the synovial fluid

A

directly damages the synovial cartilage through the release of destructive proteolytic enzymes from blood cells

52
Q

When to aspirate a bloody synovial joint

A

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
Q

Why can inflammation make aspiration difficult?

A

Chronic inflammation can lead to proliferative changes on the synovial surface and can obstruct the needle

54
Q

Knee anatomy

A

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
Q

Joint aspiration prep

A

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
Q

Most common complications of bursal aspiration

A 
Infection
Pain
Chronic recurrence
Chronic drainage
Acute recurrent swelling
57
Q

Joint aspiration steps

A

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
Q

Joint aspiration after care

A

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
Q

Most common reason to perform LP

A

Check for CNS infection
Bacterial meningitis

Others:
Viral meningitis
Subarachnoid hemorrhage
Guillen barre
ALS,MS, Alzheimer's
60
Q

Things to check in a CSF sample for bacterial

A

elevated WBC count
elevated polymorphonuclear cell count
Low glucose
gram stain

61
Q

Things to check in a CSF sample for viral

A

mononuclear pleocytosis
Normal glucose
elevated protein
negative grams stain

62
Q

Things to check in a CSF sample for immunocompromised patient

A

CSF abnormalities (may indicate fungal)
CNS tuberculosis
neurosyphilis
Unusual viral infections

63
Q

What can be used to diagnose subarachnoid hemorrhage

A

LP
CSF (elevated erythrocytes)
Xanthochromic color

Can be differentiated from a traumatic LP
(initial will have RBC but fluid will turn clear

64
Q

LP results for Guillen Barre

A

Very high protein

>200

65
Q

Auto immune disorders LP can be used for

A

MS
ALS
Alzheimer’s

66
Q

Uses of an LP for therapeutic reasons

A

Relieve intraventricular pressure
(while waiting for shunt)

Administer intrathecal meds
(antibiotics, antivirals, antineoplastic)

67
Q

Contraindications to a lumber punture

A

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
Q

Complications of LP

A

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
Q

Spinal cord anatomy

A

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
Q

LP patient prep

A

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
Q

LP Patient Positioning

A

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
Q

LP Procedure steps

A

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
Q

If traumatic LP occurs

A

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
Q

Key to a good lumber puncture in children

A

Adequate restraint

sedation may be needed

Maintain body temp and airway

Easier in sitting position

Avoid over flexing neck which can obstruct airway

75
Q

LP aftercare

A

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
Q

Contraindications to obtaining blood cultures

A

Patients on Anti coags
(risk vs benefits)

Site of infection

If multiple cultures have failed, new ones will have low success rate

77
Q

Complications for Blood cultures

A

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
Q

Obtaining Blood cultures

A

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
Q

Blood culture prep

A

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
Q

Misc Blood culture info

A

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
Q

Bladder catheter indications

A 
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
Q

Bladder catheter types

A

Three way (irrigation)
Robinson (straight)
Coude (curved tip)
Foley (balloon inflated indwelling)

83
Q

Contraindications for bladder catheter

A

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
Q

Complications for bladder catheter

A 
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
Q

Bladder Catheter anatomy

A

Female urethra 1.5 - 2 in
Straight

Male urethra 6-7 in
less straight
Prostate can add curves and complications
(prostatic hypertrophy)

86
Q

Bladder cath sizes

A

Adults
14, 16, 18 fr

Peds boys
5-12 fr

20-30 fr can be used to evacuate blood clots

87
Q

Post bladder catheter

A

tape foley to stomach (males)
Inner thigh (females)
penis pointing towards umbilicus
apply bacitracin 1-3 times daily

88
Q

Best veins in order of preference

A

Median cubital vein
Cephalic vein
Basilic vein

89
Q

Things to help find vein

A

extremity below heart for few minutes
apply warm towel
Use BP cuff
Rub/tap vein

Tourniquet 3-4 inches above site

Make fist

90
Q

Max time for a tourniquet

A

2 minutes

91
Q

Draw from IV site

A

Stop line for 2 minutes
draw blood
discard first 5 ml

92
Q

Medical battery

A

Performs without consent
significantly different procedure than discussed
exceeds scope
someone else performs procedure

93
Q

Clinician negligence

A

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
Q

Four C’s of conset

A

Capacity
Competency
Clarity
Consent

95
Q

Acronym for consent

PARQ

A

Procedure (explanation)
Alternatives
Risks
Questions (patients)

96
Q

Minor emancipation

A

Military
Marriage
Living separately and managing own finances

97
Q

Two types of disclosure

A 
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
Q

3 main types of consent

A

Special
i.e. ICU

Implied
Emergency dept (life saving)
General
Blanket consent (hospital admission)
99
Q

Therapeutic privilege

A

Specific type of information withholding or non disclosure

if the disclosure would interfere with treatment
careful documentation

100
Q

Code of ethics

A

American academy of Physician Assistants

101
Q

Witness to consent

A

A witness should be used

Requirement varies due to state)

Try not to use someone form your office

102
Q

Healthcare associated infections

A

The most common healthcare related adverse event

103
Q

Standard precautions

A

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
Q

BSI

A 
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
Q

Universal precautions

A

Blood borne transmission

included in standard precautions

106
Q

N95 mask

A

Fit tested annually

107
Q

Male genital and rectal exam

A

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
Q

Male genital and rectal exam observation

A

Bulges, scars in inguinal region consistent with current or past hernias

Penile or scrotal abnormalities

Skin abnormalities on penis, scrotum or surrounding area

109
Q

Male genital and rectal exam steps

A 
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
Q

Compartment Syndrome

A

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
Q

Foot deformities (abnormalities)

A 
Ulcers
Tinea pedis
fallen arches
infections
(send them to podiatry)
112
Q

Bursal aspiration aftercare

A

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
Q

What happens if you meet resistance on LP

A

If you still meet resistance, remove the needle, recheck landmarks, and consider repositioning the patient with increase spinal flexion

114
Q

LP dry tap

A

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
Q

LP needle break

A

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
Q

False positive blood cultures

A

4000-8000 in extra cost 1-5 days extra stay in hospital

PAM Semester 2 (22 decks)

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