Introduction to Sterile Technique, skin and joint Injections

Question 1

TREAT ALL HUMAN BLOOD

AND OPIM AS IF...

Answer 1

KNOWN TO BE INFECTIOUS WITH A BLOODBORNE DISEASE

Yep, all in capitals. She shouted it at us in lecture

Question 2

When do needle sticks typically occur?

Answer 2

40% during use,40% occur immediately after use or before disposal, 15% during disposal, 5% recapping

Question 3

Serious or fatal infections like _____ and _____ have been aquired from needlesticks.

Answer 3

Hep B/C and HIV

Question 4

What is the best approach to dealing with accidental needle sticks?

Answer 4

Prevention

Question 5

How do you protect yourself?

Answer 5

Wash hands

Wear gloves

Wear other PPE - masks, gowns, etc.

Question 6

What are two problems you must be aware of that patients commonly have with injections?

Answer 6

1. Fainting (pain, apprehension or needle phobia)
2. Allergic reaction (flushing, urticaria, itching, wheezing, SOB)

Question 7

What are four major contraindications to injections?

Answer 7

1. Known hypersensitivity to the drug or its excipients ( i.e. Flu vaccine contains egg)
2. Skin is inflamed, irritated, excoriated or infected.
3. Patient is pregnant or breastfeeding (drug may be contraindicated: Botox, Rubella, Hormones, opiates)
4. Stopper is latex and patient is allergic to latex (switch needle before administering the shot)

Question 8

What are the elements of the pre-procedure patient education?

(5)

Answer 8

Indications
Potential Risks
Complications and side effects
Alternatives
Potential Outcomes from the injection procedure

Question 9

What three things are involved in documenting patient’s consent to injection?

Answer 9

Sign a consent form
Third party should witness the patient’s signing
Consent is kept in the patient’s chart

Question 10

At what angle should you inject intradermally? What are the uses of these injections? What guage needles for this?

Answer 10

~15 degrees

Used primarily for diagnostic purposes (allergy, TB, Candida) or applying local anesthetics

Usually uses small syringes and small gauge needles

Question 11

What are 3 types of cutaneous injections?

Answer 11

Intradermal (ID)
Subcutaneous (SQ)
Intramuscular (IM)

Question 12

ID injections usually create a _____ on the skin. Common sites inlude: _______ and ______

Answer 12

Wheal

Arms and back

Question 13

At what angle should a subcutaneous injection be administered?

What would this be used for and what is the absorption speed?

Needle size?

Answer 13

45 degrees

Allows for slow sustained absorption of medications, such as insulin, and opiates

uses a variety of syringe and needle sizes, depending on the medication being used.

Question 14

Common sites of SQ injections>>

Answer 14

Abdomen

Lateral and posterior upper arm

Anterior Thighs

Ventrolateral gluteal region

(Anywhere with a nice juicy layer of subcutaneous fat)

Question 15

At what angle should intramuscular (IM) injections be given?

What must be done with this that is not necessary with other injections covered in this set.

Answer 15

90 degrees

Should aspirate first, then inject medication…
… No blood, continue with injection
… Blood present- withdraw slightly and redirect the needle, then inject; if needle comes out of skin, then start over.

Question 16

What are some examples of things that IM injections are commonly used for?

Answer 16

Includes vaccines such as Hep A/B, MMR,DPT Pentacel, tetanus, B12, epinephrine, opiates, promethazine.

Question 17

Common injection sites for IM?

Answer 17

Deltoid

Gluteus Medius

Vastus Lateralis

Rectus Femoris

Gluteus Maximus

Luke

Question 18

What are some complications of injections?

Quite a few, so discuss

Answer 18

ÒVasovagal syncope
ÒSkin infection
ÒToxic rxn. to local anesthetics
ÒHematoma formation
ÒNeuritis
ÒRebound pain
ÒUnintended intravascular delivery
ÒPneumothorax or Compartment syndrome

Question 19

What are the indications for joint injections?

Answer 19

DIAGNOSTIC

1. Acute or chronic symptoms present
2. Diagnosis is unclear or needs confirmation and
3. consideration of other diagnostic modalities has been made
4. Septic arthritis has been ruled out

THERAPEUTIC

1. Acute or chronic symptoms are present
2. After the diagnosis and therapeutic plan have been made
3. After consideration of obtaining radiographs

Question 20

What are joint injections used for?

Answer 20

ÒAspiration/Arthrocentesis of fluid from a grossly swollen joint for pain relief or assessment of the synovial fluid (i.e. dx of gout, arthritis and joint infections)
ÒDelivery of local anesthetics for pain relief
ÒDelivery of corticosteroids or visco-supplementation (hyaluronic acid) for suppression of inflammation and improved ROM

Question 21

Absolute contraindications of therapeutic joint injections?

Answer 21

Local cellulitis

Septic arthritis

Acute fracture

Bacteremia

Joint prosthesis

Achilles or patella tendinopathies

History of allergy or anaphylaxis to injectable pharmaceuticals or constituents

More than 3 previous corticosteroid injections within the past year in a single joint*.

Question 22

__________________: 27-30 gauge 1/2inch needles,

                   1-3 cc syringes

___________________: 22-25 gauge 1.5inch needles,

                 1-10cc† syringes

__________________: 18-20 gauge 1.5 inch needles, Sterile

                  3-60cc syringes, hemostat, culture tubes

Answer 22

Anesthesia

Injections

Aspiration

Question 23

What does epinephrine do with regard to lidocane?

Answer 23

Makes it stay put! Due to vasoconstriction cannot do on fingers, nose, hose (penis) toes, and earlobes. (the mnenonic kind of falls apart there at the end)

Question 24

How is lidocaine administered?

What is its duration?

What can it cause besides local anesthesia?

Answer 24

ÒLocal Cutaneous infiltration (lac repair, skin biopsy), field blocks
ÒQuick onset, short duration (30-60 minutes)
ÒCan cause vasodilatation: Use if vascular disease is present or pt. is immuno-compromised or in contaminated wounds

Question 25

What is the duration of bupivacaines? What is a problem with this? When might one use it though?

Answer 25

ÒLonger duration, but 4x toxicity than lidocaine; may cause cardiac arrythmia, contraindicated in pregnancy
ÒNerve blocks, when more time is needed

Question 26

Instructions for injecting anesthesia?

Answer 26

ÒUse the smallest needle possible (27-30gauge)

To minimize pain:

ÒWarm the anesthetic in your hands before injecting
ÒBuffer if lidocaine is used
ÒGently pinching or vibrating the skin
ÒInject rapidly thru skin into the Sub Q level
ÒInject the anesthetic slowly and steadily while withdrawing the needle

Question 27

What two major condition types are treated with corticosteroids? What are examples of each?

Answer 27

ÒArticular Conditions treated with steroids include: RA, OA, Gout and

Pseudogout, Ankylosing Spondylitis,

  Reiter’s Syndrome, Psoriasis

ÒNon Articular Conditions:

Fibrositis, Bursitis, Tenosynovitis,

 Tendonitis, Neuritis, Tender Points

Question 28

What are some bad consequences of corticosteroids?

Answer 28

CAN HAVE ADVERSE CONSEQUENCES: In decreasing order of frequency.

ÒMay accelerate normal, aging related articular cartilage atrophy or periarticular calcification (43%)
ÒMay weaken tendons or ligaments
ÒPost-injection (Steroid) Flare (4%)
ÒInfection or bleeding into a joint
Ò Tendon rupture
Ò Facial flushing, skin atrophy and/or

 depigmentation,

ÒHypersensitivity rxn., transient paresis

Question 29

What are the elements of a procedure note? This one is for you Michael Plump.

(11 things)

Answer 29

A clear but succinct description of procedure performed:

1. Patient ID: Name , sex and DOB
2. The names and titles of the providers performing the procedure (Physician and students)
3. Type of Procedure
4. Pertinent Pre (and Post) procedure diagnoses
5. Meds use, used before, during and after the procedure
6. Equipment used (Detailed list, include amounts and sizes)
7. Document that written informed consent was obtained and placed into chart
8. Procedure: Detailed description, step by step, start to finish; include anesthesia and cleansing, sterile technique)
9. Complications: if any occurred, include any blood loss) Document your post procedure instructions at the end of the note
10. Disposition of the patient: IS pt. stable, then what? Sent home, admitted into hospital, taken to surgery?? Also any directions given to the pt., such as wound care, signs of infections, etc.
11. Sign and Date the note

Question 30

Choose the type/angle/location of injection and the syringe size, needle size and length for each of the following:

1. 6 month old in office for a DPT vaccine (.5 cc)
2. Adult patient requiring a PPD (.1cc)
3. Adult patient requiring a flu shot (1cc)
4. Adult patient requiring 125mg (1 cc)of antibiotic Ceftriaxone, mixed with 1 cc of lidocaine)

Answer 30

1.

Question 31

For these, also decide on what meds to use.?

1. Patient has a 1 inch clean laceration on his arm. You plan to place 4 sutures.
2. Patient has a ¾ avulsion type laceration near the tip of his finger. He will need 4 sutures to hold in place.
3. Patient suffers from chronic pain and swelling of his right elbow. There is no effusion.
4. Patient comes in with an effusion of his right knee, you suspect Gout. What do you do?