Deck 1 Flashcards
Contraindications for Plebotomy
Cellulitis Trauma Burns Radical Mastectomy on that side AV Fistula Hematoma That arm already has an IV
Phlebotomy vs Venipuncture
Plebotomy is the process of making an incision in a vein with a needle. The procedure itself is known as Venipuncture.
Complications of Venipuncture
Cellulits Plebitis Thrombosis Laceration of nearby Artery Hemorrhage or Hematoma Syncope (at the sight/thought of blood)
Phlebitis
Infection of a vein
Blue Cap Contains/Used For/Fill Vial?
Blue Cap:
Contains Citrate
Used for Coag Studies: PT/PTT/INR/D-Dimer/Fibrinogen
FILL the vial
Blue CAP
COAGULATION STUDIES! Fill The Vial
Red Cap Contains/Used For/Fill Vial?
SST: Serum Separator Vial
Bacteriology/Viral Testing
BMP, CMP Fill the Vial
For: Vitamin D, Insulin, C-Peptide, Se, Zn, Androgens
Gold Top
SST: Serum Separator Vial
FOR: IRON STUDIES!! Aldosterone, B12, Ferritin, Folate, Downs Syndrome Screening, Blood Chemistries not requiring other tubes ( Zn and Se go in a Red Top…)
Green Cap (Heparins)
Hemoglobins: Carboxy Hb, Meth Hb, Cytogenics
Purple Top (EDTA)
Full Blood Count (CBC)
A1c
Malaria + Sickle Cell
Electrophoresis
These tests require a purple cap tube and each one requires its own vial and blood needs to be sent to the lab asap:
Tacrolimus ESR Lead Testing Chromosomes Renin and a bunch more.
Tacrolimus
Immunosuppressant.
Blood levels are used to guide minimum dose needed to suppress immune function so as to minimize side effects.
Pink Cap
Cross Match
This Tube must have FOUR patient IDENTIFIERS and be SIGED
Grey Cap
Blood Glucose
Lactate
Ethanol
Blood stops flowing during venipuncture
Vein Collapsed.
Withdraw catheter and get another vein
Can you perform venipuncture on an artery?
Never
You can get arterial gases and arterial testing but these require different equipment.
Catheterization Indications
Output measurement (always with IV therapy)
To obtain a sterile urine sample (instead of a clean catch - this would not necessarily be a Foley, could use a strait cath for this)
Imaging of the urinary tract (running in dye/isotopes to be followed by Xray/CT)
Bladder Irrigation (w/saline or meds ex: Amphotericin B irrigation for fungal UTI)
Intermittent decompression of Neurogenic Bladder (again, unless bed-ridden, this will be a strait cath, possibly even self inserted)
Tidiness in managing bed ridden patients (I should think this somewhat controversial as it is not an insignificant infection risk with pseudomonas and
Common Nosicomial Catheterization Caused UTI pathogens
Usually it’s E.Coli or Enterobacteria - as anywhere but
Nosicomial Bugs are notoriously resistant to antibiotics and several can form biofilms on the tubing and in the bag. Also, many nosocomial UTIs occur when urine is alkinized from drugs or dietary changes.
Proteus Mirabilis Candida Albicans (esp ICU pts)
Pros + Cons of Plaster Splints
*Easier to mold than fiberglass, but messier
Mess cleans up with water though, not
solvent
*Plaster curing is an exothermic process and\
could potentially cause Pt a burn if COLD
water were not used to hydrate plaster
*Plaster is heavier than fiberglass and will soft-
en if it gets wet but
*Plaster will ‘wick’ underlying moisture off a
wound, which keeps things nice and
dry beneath, whereas fiberglass will
incubate bugs in moisture.
So…. Mix plaster with COLD water and keep i DRY!
Merits of Fiberglass
Its light weight, hard and the cast itself is waterproof, though the pad beneath is not so moisture will get trapped between skin and cast, no real way around that.
It cures quickly, as soon as it’s exposed to air, so you have to work fast
Its a resin + you need to wear gloves while applying and protect pts skin from the uncured fiberglass
Indications for Casting + Splinting
To immobilize simple NON-DISPLACED fractures, soft tissue ligament sprains, dislocations + strains
Straighten congenital abnormalities like club foot
Manage ankle ulcers + charcot foot
Casting Contraindications + Complications
Don’t cast early, let swelling ebb then cast 4+ days out.
Don’t cast over infection or wounds - you might get away with a casting window but think that through carefully
No Matter what you do, Cast Dermatitis may result from no air flow. Blow COOL AIR under the cast with a hair dryer. NO BABY PWD or itching beneath the cast with a knitting needle - you might scratch and cause infection!
Prevent compartment syndrome by
1) not casting until swelling is done
2) Bi-Valving the cast to allow for expansion
DVT from lack of movement - get Pt up and around and contracting that calf muscle inside his cast to prevent clot formation.
Pressure Sores + Nerve Damage: You must PAD bony prominences well and ensure that you mold the cast with your palms + not your finger-tips as tips make indentations that might press down on the skin and/or nerves
head of fibula - perineal nerve is a common site of nerve pressure damage.
Hematoma Block?
When fracture ends are displaced blood vessels are broken and bleeding between the broken bones occurs - this is the hematoma
To anesthetize that area (usually the wrist: radius or ulna) 7-8 ccs of LIDOCAINE is injected directly into the hematoma from various directions.
Then the fracture is reduced: pulled out and repositioned. This would obviously be very painful without the anesthesia.
Sugar Tong Splint For? Describe:
For DISPLACED Colles Wrist Fracture : Distal Radius fracture with posterior radial displacement. Also called Dinner Fork Fracture.
Also for fractures of the ulnar and or radial shafts
Splint extends from just proximal of the Metacarpal joints on the dorsal hand, around the medial aspect of the elbow and back to the
palm opposite the metacarpals.
Fingers need to be able to bend at the metacarpals. Thumb has FULL range of motion
Thumb Spica Splint For? Describe:
Thumb spika is for Scaphoid Fractures (Usually a Fall on Extended Hand) or for Game-Keeper’s Thumb (thumb pulled backwards stretching all its ligaments).
It immobilizes the thumb but leaves the pinky side of the hand and all 4 fingers with full range of motion
Alumi-form Splints For? Describe:
Alumiforms are for fractures of the metacarpals or first finger bones (proximal phalanges)
They are bendable aluminum on one side adhered to a pad that faces the digit.
STAX Splints For? Describe
Are for Mallet Finger (dorsal finger extensor ligament stretched/ruptured so ventral flexor ligament pulls tip of finger down @ DIP). The ligament may even avulse a bit of bone off the distal end of the intermediate philange)
They support the DIP from beneath, stretching the ventral ligament and allowing immobilization of the dorsal ligament in a fully extended position for healing.
These really have to stay in place a long time. Don’t take it off at all. They’re plastic so just leave them on through all activities for a FULL * WEEKS thereafter reducing splinted time gradually.
Grey Top
Blood Glucose
Ethanol
Lactate
(Hb A1C goes in the Purple EDTA tube with the CBC)
VENIPUNCTURE PROCEDURE
o WASH HANDS
o IDENTIFY yourself to Pt and confirm Pt is here for blood draw. Inquire about vasovagal syncope and LATEX ALLERGY.
o TOURNIQUET: Three Fingers about the cubital Fossa, tied so you can untie it with one hand in a single motion while needle is in the pt’s vein. Tie the tourniquet and “feel” for a vein, looking for “bounce”. Note where you see bounce and then
o ALCOHOL PADS: clean that area with the alcohol pad. Mark the direction of the vein with one side of the alcohol pad. Let alcohol dry on the skin while you finish preparations. LET tourniquet go.
o BUTTERFLY NEEDLE: + HUB Attatch HUB to tubing on the butterfly needle if not pre-attached.
o BLOOD COLLECTION VIAL: Attach Blood Vial loosely inside HUB – Don’t break seal just set it there such that it will be easy to manipulate with one hand.
o GLOVES: NOW GLOVE UP and
o RE-TYE The Tourniquet
o Grasp the Butterfly Needle by its wings and follow your alcohol pad side into the vein, as close to the skin a possible, a 10-20 degree angle.
o ADVANCE NEEDLE until you see flash in the butterfly chamber then
o PRESS BLOOD COLLECTION VIAL ONTO THE HUB initiating suction and Fill the vial.
o RELEASE TOURNIQUET when last vial is ½ full, remove last vial (full) from the HUB
o COVER INSERTION with a sterile gauze, folded and withdraw the needle, simultaneously activating safety feature.
o BANDAGE gauze and have pt bend elbow to stem bleeding
o TELL PT TO hold pressure and elevate until coagulated
o Discard needle and HUB into sharps/Biohazard
INDICATION FOR VENIPUNCTURE
Venous Blood Sampling
Naso-Gastric Tube Indications
-Oral Nutrition in pts w/functional GI
-Oral Meds
-Gastric Lavage/Removal of Contents
-Blood
-Toxins
-Air (relieve pressure on obstructed bowel)
-To Relieve Vomiting
-To Warm/Cool Pt with Gastric Saline Lavage
-Stomach Decompression during Surgury to
prevent aspiration of contents
NGT Contraindications
Facial/Skull Fracture Esophageal Stricture or Atresia Caustic toxin ingestion/burn Comatose w/an Airway Penetrating Cervical Wounds Recent Oropharyngeal Surgery Hx of Gastrectomy or Bariatric Surgery
NGT Complications
Nose Bleed/Epistaxis
Placement into Trachea/lung
Intracranial Damage (if inserted into pt w/skull
fracture)
Long Term Complications include:
-Sinusitis
-Esophageal/Gastric Erosion from contact
NGT INSERTION PROCEDURE
1) Obtain Consent after advising of risks + benefits
2) Gather Supplies:
a. NG Tube (14-16F for normal Adult)
b. Lidocaine Lube + Swabs (2)
c. Evacuation syringe
d. Emesis Basin
e. Chuck Pad
f. Vasoconstrictive Nasal Spray
g. Tape
h. Gloves, Mask/Shield, Gown
i. Stethoscope
3) Wash Hands
4) Open Tube + Measure from tip of nose to Xyphoid Process, mark w/tape
5) Tear Off another piece of tape and attach somewhere within reach, bisect tape like pair of pants. This is for holding the tube to the nose, later
6) Attach Syringe to distal end of NG Tube
7) Don Gloves, Mask, Gown and drape Pt with the Chuck
8) Open Lidocaine Lube, insert 2 swabs + swab each nostril with one swab, allowing time for lidocaine to take effect. Discard Swabs
9) Ask Pt to blow out each nostril separately and choose nostril that is more patent for NGT placement
10) Insert 2” of NGT into lidocaine lube
11) Sit Pt up Straight
12) Have glass of water with straw ready
13) Advance NG Tube into Nare at 90 degree angle 5-6” until visible in pharynx
14) Have pt take up water and tilt chin to chest
15) Have pt swallow sips of water as you advance the tube
16) If pt coughs -stop, take more sips and advance when you can. If coughing doesn’t stop, you are in the trachea – remove + start over with a new tube.
17) Once you have advanced to the tape mark, hold tube to nose with one hand and tape it to the nose with the other.
18) Assess Pt condition and comfort
19) Evacuate stomach contents into tube and take note of color/consistency. If no contents, express air from syringe into tube while listening over stomach with stethoscope for gurgling. If none, you may be in the lung. There ought to be coughing though.
20) Remove Syringe + Close Tube
21) Secure tube to Pt’s gown to prevent pulling and attach the business end to wall suction
22) Order an X Ray and write orders
23) Don’t turn on suction until you confirm placement in the stomach with the X-ray.
Components of NGT Procedure Note
Note why NGT is ordered/indicated
Consent obtained after risks/benefits described + Allergy inquiry
BSI
Size + Length of Tube used
Nare Placement
Describe Pt tolerance of tube advancement
Color/Quality of aspirated stomach contents in syringe
Describe checking for correct placement
Describe Pts Rxn to procedure post procedure
Injection Massage?
DO massage Sub Q and IM
Do Not massage Intradermal (PPD)
NG Tube Warnings
Don’t Irrigate Tube
Start Suction
Put Meds/Food down tube
UNTIL you confirm placement with an XRAY
NG Tube size for children
3-8 French
Adult Esophagus Legth +Diameter?
20cm long
3cm in diameter
NGT with and AIRWAY in place?
You can do it - place airway first. May need to deflate ET Tube cuff to get NG tube into the esophagus though.
Describe indications for performing urinary bladder catheterization.
Acute or chronic urinary retention Urethral or prostatic obstruction Monitoring urine output Collection of sterile urine specimen To act as a traction device for the purpose of hemostasis after prostate surgery
Describe contraindications for performing urinary bladder catheterization.
- Trauma with suspected urethral injury
- Blood @ meatus in pelvic trauma pt
- Penile, scrotal, or perineal hematoma
- Acute prostatitis or urethritis
