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Clin Proc & SS
Clin Proc & SS
168
Other
Graduate
08/07/2010

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Cards

Term
What type of knot should be used to control hemostasis? What about high risk vessels?
Definition
Use a square knot or suture/double ligation for high risk vessels.
Term
Name and describe the 3 phases of recovery from major surgery.
Definition
Immediate/Postanesthetic phase
Intermediate phase - encompasses the hospitalization period.
Convalescent phase - transition from hospital discharge to full recovery.
Term
What are the 3 major causes of early complication and death following major surgery?
Definition
Acute pulmonary, cardiovascular and fluid derangements.
Term
In the postoperative orders how often and how long should a patient be turned that is unconscious and conscious? What are we trying to prevent?
Definition
Turn every 30 min until conscious and then every hour for the first 8-12 hours to minimize risk for atelectasis.
Term
What is the major cause of GI bleed in postoperative patients? What do you give to prevent it?
Definition
Stress ulcer, give a H2 blocker to prevent it.
Term
What are some causes of early (within 1-2 hours) and late (beyond 48 hours) respiratory failure after surgery?
Definition
Early = major chest/abdominal operation, pre-existing lung disease and too much anesthesia.
Late = cardiac failure, pulmonary edema, pulmonary embolism, or narcotic overdose.
Term
What is the most common postoperative pulmonary complication and how is it manifested?
Definition
Atelectasis, manifested as fever, tachypnea and tachycardia.
Term
What is the most common cardiac complication after operation under general anesthesia? Most common cause of cardiac death during the operation? Most common cardiac cause of death in those with a heart condition?
Definition
PVC's is most common complication.
MI is the most common cause of death during.
V Fib is the most common cause of death in those with heart conditions.
Term
What is the most common cause of PVCs after a surgical procedure?
Definition
Hypoxia
Term
Wound infections usually occur 5-10 days postoperative, what should you suspect if a would infection occurs in 12-24 hours?
Definition
Clostridium or streptococcal infection
Term
Describe the 3 types of operative wound classifications w/ examples (clean, clean contaminated and contaminated) by risk percentage of infection.
Definition
Clean - (hernia repair, soft tissue bx) incidence of wound infection is less than 2%.
Clean contaminated - (gastric or biliary surgery) potential exposure to bacteria, incidence is about 5%.
Contaminated - (colorectal or vaginal surgery) incidence is 7-10%.
Term
In which cases are prophylactic antibiotics used for clean operative wounds?
Definition
cardiovascular, neurosurgical or orthopedic cases
Term
Which class of antibiotic is typically used as a propylactic antibiotic for surgery?
Definition
3rd generation cephalosporin
Term
Which organ system is the most commonly affected to cause postoperative death? What is the most common cause in that organ system?
Definition
Respiratory, pneumonia is the most common cause.
Term
If atelectasis is left untreated and unresolved after 3-4 days, what can result?
Definition
pneumonia
Term
What is the most common cause of aspiration?
Definition
emergency intubation
Term
What is the most common cause of ARDS?
Definition
sepsis
Term
What is the treatment for a PE? What is it is a large PE with noted hypoxia and hypotension?
Definition
Treatment = immediate heparin followed by coumadin.
If severe, give thrombolytics.
Term
What is the most common cause of fat embolization? What is the most common cause of death due to fat embolization?
Definition
MCC is fracture of the shaft of long bones (particularly the femur) and the MCC of death is stroke.
Term
Describe the etiology of an air embolism, how it can be fatal, how much air in the circulation can be fatal, how to avoid this complication, how to manage a patient with this condition.
Definition
Etiology = it is typically iatrogenic through insertion of a central line.
It can be fatal bc air mixes with blood in the right heart causing frothy blood to block pulmonary blood flow.
200cc of air can be fatal.
Avoided by placing the patient in the Trendelenberg position (head below feet) when a central venous line is placed.
A patient with this condition should be placed right side up with their head lower than their feet, which will help dislodge the air from the right atrium.
Term
Name and describe the 5 W's of Postoperative fever.
Definition
Wind - (Atelectasis), first 1-2 days.
Water - (UTI), after 1 day.
Wound - (Wound infection), 5-10th day.
Walking - (DVT/PE), 1-7th day.
Wonder drugs - (Drugs), fever of unknown origin = consider drugs that they are taking.
Term
What does a HEPA filter NOT filter?
Definition
It does not filter viruses. (does remove bacteria and fungi)
Term
What does iodine kill out of: fungi, virus, gram positive and gram negative bacteria?
Definition
All of them
Term
What is the most common site for perforation for gloves?
Definition
Non dominant index finger
Term
What are some consideration that should be made to prevent puncture holes in gloves?
Definition
Change gloves before 2 hours, reinforce the non-dominant index finger and double glove.
Term
What is the most important feature of the surgical gown?
Definition
It is impermeable to moisture
Term
When should you use a single layer gown, reinforced (double/triple) layer gown and plastic reinforced gown?
Definition
Single = Under 2 hours duration and under 100mL blood loss.
Reinforced = 2-4 hours duration and 100-500mL blood loss.
Plastic = Over 4 hours duration and over 500mL blood loss.
Term
What are the sterile boundaries of the body when scrubbing into surgery?
Definition
Hands to elbows and waist to clavicle
Term
Name the 13 components of a clinical procedure note.
Definition
1. Demographic data (identification, etc).
2. Name of procedure.
3. Indications.
4. Contraindications.
5. Informed Consent.
6. Personnel (who performed procedure).
7. Anesthesia used.
8. Description of procedure performed.
9. Findings recorded.
10. Description of any new findings.
11. Complications, if any.
12. Instructions/Follow up plans.
13. Time the procedure was completed w/ patient condition.
Term
Describe the indicated therapy for a red, yellow or black wound.
Definition
Red = keep site moist, clean and protected.
Yellow = mechanical cleansing and excision to red wound and they will need antibiotics.
Black = surgical debridement and excision to red wound.
Term
What ABI results are indicative of mild/moderate PAD and severe PAD?
Definition
Mild/Moderate = .41-.90
Severe = .40 and less
Term
What are the best non-invasive tests for arterial and venous insufficiency?
Definition
Arterial = ABI.
Venous = venous Doppler.
Term
How should you initially treat venous insufficiency?
Definition
Diuretics and compression devices for the edema.
Term
Describe the 3 phases of wound healing (Reaction, Regeneration and Remodeling).
Definition
Reaction - (first 3 days), inflammation.
Regeneration - (3 days to 3 weeks), granulation, epithelialization and contraction of tissue occur.
Remodeling (3 weeks to 2 years), scar formation.
Term
Which wound color indicates that a wound is healing? Healing is disturbed? Healing is impaired?
Definition
Healing = red.
Disturbed = yellow (infection).
Impaired = black (necrosis).
Term
Describe the 4 stages of pressure ulcers.
Definition
Stage 1 - limited to epidermis (erosion or abrasion).
Stage 2 - limited to epidermis and upper dermis (blister).
Stage 3 - may extend down to underlying fascia but not into it.
Stage 4 - May extend down to muscle or bone.
Term
Describe the 5 stages of Wagner Grading System for diabetic foot ulcers.
Definition
Grade 1 = superficial ulcer.
Grade 2 = Involves ligament/tendon/joint capsule or fascia but NO abscess or osteomyelitis.
Grade 3 = Involves ligament/tendon/joint capsule or fascia WITH abscess or osteomyelitis.
Grade 4 = Gangrenous forefoot.
Grade 5 = Extensive gangrene to entire foot.
Term
What are the advantages of using a Vacuum Assisted Closure Device?
Definition
Decreases fluid and bacteria, increases capillary ingrowth and mechanically pulls edges of the wound together.
Term
What is the objective of mechanical wound dressings?
Definition
pressure reduction or edema management
Term
What is the objective of dynamic wound dressings?
Definition
Activation of the wound environment (granulation).
Term
What is the objective of topical wound dressings?
Definition
to promote oxygenation
Term
What is the objective of passive wound dressings?
Definition
To control moist wound environments
Term
What is the function of Platelet-Derived Growth Factors (pdGF)?
Definition
To form new blood vessels after injury
Term
What are the indications for Enzymatic debridement?
Definition
A wound requiring debridement of fibrinous exudate, necrotic material or slough.
Term
Which type of bone is stronger and is used to protect? Which type is more flexible?
Definition
Cortical = strong.
Tribecular = flexible.
Term
Discuss the pros and cons of plaster and fiberglass casts.
Definition
Plaster offers more moldability but it is heavy and requires many layers.
Fiberglass offers less moldability but is lightweight and requires few layers.
Term
What are the 3 contraindications to casting?
Definition
Massive swelling, infections and open wounds.
Term
What are the potential complications to casting?
Definition
Compartment syndrome, dermatitis, pressure sores, nerve injuries and DVT.
Term
Describe the relationship between suture number and size.
Definition
The greater the number the smaller the suture.
Term
What are the benefits of monofilament and multifilament (braided) sutures?
Definition
Monofilament = passes through tissue easier and resists harboring bacteria.
Multifilament = greater strength and they are pliable for easier handling and softer knots (good for eyes and corners of mouth).
Term
What is the difference between synthetic and organic sutures?
Definition
Synthetic is less reactive to the body and organic stimulates the inflammatory response.
Term
Name some examples of absorbable and non-absorbable synthetic sutures.
Definition
Absorbable = Vicryl or (-cryl's)

Non-absorbable =
Ethilon/Nurolon (nylon)
Prolene (polypropylene) Mersilene/Ethibond (polyester).
Term
Name some examples of absorbable and non-absorbable organic sutures.
Definition
Absorbable = Plain gut or chromic gut.
Non-absorbable = silk.
Term
Which suture is the gold standard to compare handling qualities?
Definition
Organic Non-absorbable (SILK)
Term
What are the indications for stainless steel staple or wire closure?
Definition
sternum, scalp, skull, or abdominal wall closure or bone fixation in orthopedics.
Term
Describe the filament type for Ethilon (nylon), Mersilene & Ethibond (polyester) and Prolene (polypropylene).
Definition
Ethilon = nonabsorbable monofilament.
Mersilene = nonabsobable monofilament and braided.
Ethibond = nonabsorbable braided.
Prolene = nonabsorbable monofilament.
Term
Describe the body and swag/eye of a suture needle.
Definition
Body = point of max curvature.
Swag/Eye = area of attachment for whatever it attached to needle.
Term
Describe the common Ethicon Needle codes for skin (FS, P, PS, PC, CPS).
Definition
FS: for skin
P: plastic
PS: plastic surgery
PC: precision cosmetic
CPS: conventional plastic surgery
Term
What size suture is used for the face and fingertips?
Definition
6-0
Term
When are sutures typically removed for the: eyelids, face, scalp, trunk, upper extremities and lower extremities?
Definition
Eyelids = 3 days
Face = 5 days
Scalp = 7-10 days
Trunk = 7-12 days
Upper Extremities = 7-14 days
Lower Extremities = 10-21 days
Term
What is undermining and what is the benefit of undermining a wound?
Definition
It is the technique of creating a plane of release beneath the skin edge of an open wound. It relieves tension and allows skin edges to be handled with greater ease.
Term
What are the complications of placing sutures too close together and too far apart?
Definition
Too close = vascular compromise to wound margins.
Too far = may not secure adequate closure.
Term
What is the average width that sutures are placed apart from each other and how far from the edge of the wound? How about on the face?
Definition
Average distance apart is 3-10mm and 3-4 mm from the edge of the wound.
On the face the average distance apart is 3-5 mm and 2-3mm from the edge of the wound.
Term
What are the advantages of a buried suture (subcuticular stitch)?
Definition
Eliminates dead space and reduces tension in the superficial closure.
Term
What is the advantage of Intradermal sutures?
Definition
If the approximation is good it can prevent the need for surface sutures.
Term
What is the advantage of a Running Locking Suture?
Definition
Maintains a more consistent tightness to the closure.
Term
Describe the Vertical Mattress Suture and what its tendency is.
Definition
It is far-far and then near-near. It has a tendency to be too tight.
Term
Describe the Horizontal Mattress Suture and its classic use.
Definition
Interrupted suture involving a perpendicular pass, parallel pass, and perpendicular pass to the wound before tying.
Its classic use is to secure a tight seal around a drain tube that exits the skin.
Term
How many "throws" should be used for multifilament and monofilament knot tying?
Definition
Multifilament = 3-4.
Monofilament = 4-5 or more if needed.
Term
How long should a typical "tail" of superficial sutures be to prevent chances for untying?
Definition
5-10mm
Term
What is the general rule for when not to use epinephrine as a local anesthetic?
Definition
Anywhere there is a single blood supply (fingers, toes, ears, nose, penis)
Term
What is the LACERATE mnemonic suturing and laceration repair?
Definition
Look
Anesthetize
Clean
Equipment setup before wound assessment
Repair
Assess results/Anticipate complications
Tetanus prophylaxis
Educate the patient about wound care
Term
When is regional anesthesia (ex = nerve blocks) usually indicated for wound treatment?
Definition
Procedures lasting longer than 30 minutes
Term
What is the maximum dose for lidocaine when used as a local anesthetic?
Definition
4mg/kg not to exceed 300mg
Term
What steps can you take to decrease pain when injecting lidocaine for local anesthesia?
Definition
Inject slowly, use small needle (27 gauge), add bicarbonate buffer to acidic lidocaine, and warm the lidocaine.
Term
What are the average needle gauges for blood withdrawals, IM injections, SubQ injections and Intradermal injections?
Definition
Blood draw = 18g
IM = 19-22g
SubQ = 25-27g
ID = 27g
Term
What body sites should never be used for injections in infants?
Definition
Deltoid or gluteal
Term
Rate the following routes in order of rate of absorption and duration of action(IM, IV and SQ).
Definition
Rate of absorption slowest to fastest is SQ, IM and then IV.
Duration of action shortest to longest is IV, IM and then SQ.
Term
What are the 3 principle sites for IM injections?
Definition
gluteal, deltoid or vastus lateralis
Term
What considerations should be made when doing a Deltoid IM injection?
Definition
Do not go below the humoral tuberosity bc of risk of hitting nerve, artery or vein.
Term
In what group is the vastus lateralis the perferred target for IM injections?
Definition
kids under 3 years old
Term
What is the major consideration when considering using the gluteal for an IM injection?
Definition
It cannot be used for immunizations
Term
Describe the 18 steps for how to give an IM injection.
Definition
1. Identify patient
2. Wash hands
3. Put on gloves
4. Select 2-5 mL syringe with 19-22 gauge needle
5. Using aseptic technique, withdraw medication from vial.
6. Prep injection site with alcohol
7. Press down and stretch skin at injection site with thumb and index finger of nondominant hand
8. Hold syringe like a dart at 90 degree angle to site
9. Insert needle straight into skin
10. Hold barrel with nondominant hand
11. Aspirate to check for blood
12. Slowly empty syringe
13. Remove needle quickly
14. Apply gentle pressure with cotton
15. Bandage
16. Discharge needle and syringe
17. Comfort patient
18. Record date, time, dose, purpose and site.
Term
What are the common sites for SQ injections?
Definition
upper arm, anterior thigh or lower abdomen
Term
What are the only 2 injectable medications that should not have aspiration before injection because they are so highly soluble?
Definition
Insulin and heparin
Term
Describe the 17 steps to giving a SQ injection.
Definition
1. Identify patient
2. Wash hands
3. Put on gloves
4. Select 2-3 mL syringe and 23-25 gauge needle
5. Prep injection site with alcohol
6. Using aseptic technique, withdraw medication from vial
7. With non-dominant hand, pinch SQ tissue between thumb and index finger
8. Insert needle with bevel up at 45 degree angle
9. Advance needle to about 3/4 length
10. Release skin
11. Aspirate to make sure not in vessel
12. Inject slowly
13. Withdraw needle quickly at same angle
14. Cover site with gauze and gently massage to distribute medication (except Heparin)
15. Bandage site
16. Depose of needle and syringe
17. Record type of injection, date, time and site.
Term
How should insulin be mixed before it is injected?
Definition
Gently between the palms of your hands
Term
What are the most common sites for intradermal injections?
Definition
ventral surface of the forearm (TB) or the back (skin allergen testing)
Term
What is the maximum volume that can be injected for IM, SQ and ID injections?
Definition
IM is 2cc (except gluteal is 3cc)
SQ is 2cc
ID is 0.1cc
Term
Describe the 14 steps to giving an Intradermal injection.
Definition
1. Identify patient
2. Wash hands
3. Put on gloves
4. Select correct syringe (1cc) and needle (27 gauge)
5. Prep injection site with alcohol
6. Using aseptic technique, fill syringe with desired amt of solution
7. With non-dominant hand, hold skin taut between thumb and index finger
8. Insert needle with bevel up at 10-15 degree angle
9. Advance needle into dermis to about 2/3 length
10. Inject slowly
11. Withdraw needle quickly at same angle
12. Cover site with cotton ball
13. Depose of needle and syringe
14. Record type of injection, date, time and site.
Term
How is seepage of medication after an IM injection prevented?
Definition
By drawing a 0.2cc air bubble into the syringe
Term
An ampule contains how many doses of a medication?
Definition
Generally 1 but it depends on the size of the ampule
Term
What are the 2 most common veins used for venipuncture?
Definition
median cubital and cephalic veins of the arm
Term
What are some areas to be avoided when doing a venous blood draw?
Definition
Scars, hematomas, ipsilateral arm of a previous mastectomy, or ipsilateral arm of a current IV.
Term
Describe the 12 steps to venipuncture.
Definition
1. Identify patient
2. Check requisition form for any special requirements
3. Select a site
4. Apply tourniquet 3-4 inches above selected site and have patient make a fist
5. Prep site with alcohol
6. Perform venipuncture by inserting needle at a 15-30 degree angle
7. Collect sample
8. Remove tourniquet before removal of needle
9. Remove needle and place gauze pad
10. Dispose of contaminated materials
11. Label collection tubes at patient bedside
12. Promptly send specimen with requisition to laboratory
Term
What are the best fingers to do a fingerstick on?
Definition
3rd or 4th fingers of the non-dominant hand because the 5th doesn't have enough soft tissue overlying the bone and the 2nd is usually callused
Term
How can prolonged tourniquet application (over 2 minutes) affect the venous blood sample?
Definition
Hemoconcentration of non-filterable elements causing an elevated total protein, AST, total lipids, cholesterol, iron, etc.
Term
What effect may exercise have on venous blood samples?
Definition
Elevated CK, AST, LDH and platelet count
Term
What affect might stress have on venous blood samples?
Definition
Elevated WBCs, cortisol, catecholamines and lactate if hyperventilation.
Term
Which artery is most commonly used for ABG's?
Definition
Radial artery
Term
What are the absolute and relative contraindications for ABG collection?
Definition
Absolute:
No pulse
Poor collateral circulation
Local infection
Aneurysm at puncture site
AV fistula above puncture site

Relative:
Chronic renal disease
Presence of arterial disease
Bleeding disorder
Term
Describe where the radial artery can be found in relation to other neighboring landmarks.
Definition
Lateral aspect of the volar forearm between the styloid process of the radius and the flexor carpi radialis tendon.
Term
Describe the 15 steps to collecting ABG's.
Definition
1. Perform the Allen test
2. If using a heparinized syringe, pull plunger all the way back and then expell all heparin
3. Palpate the point of maximal radial pulsation
4. Prep site with iodine or alcohol
5. Place 2nd and 3rd fingers of nondominant hand proximal to point of needle entry
6. With bevel up insert needle through skin at 45-60 degree angle slowly until blood is seen
7. Obtain at least 2mL of blood
8. Remove needle and apply pressure with gauze for at least 5 minutes
9. Insert needle tip into rubber stopper and remove needle from the syringe
10. Evacuate all air bubbles from syringe within 30 seconds by holding the needle side of the syringe upright/tapping and then evacuating the air
11. Cap the syringe once air is evacuated
12. Roll the syringe between fingers to ensure that the blood does not clot
13. Cap syringe and discard needle
14. Label sample and place it in ice
15. Deliver to lab
Term
What sites could be selected for ABG sampling if the radial artery is contraindicated?
Definition
Femoral artery or Brachial artery
Term
What are the possible indications for IV therapy?
Definition
Fluid/Electrolyte balance
Administer medication
Administer fluid to KVO
Administer blood/components
Anesthesia
Correct nutritional state
Diagnostic reagents
Monitor hemodynamic functions
Term
What are the contraindications for IV therapy?
Definition
Skin infection, any proximal thromboplebitis, or compromised veins (insufficiency).
Term
What are the typical gauges used for IV therapy?
Definition
14, 16 or 18
Term
How will hyper and hypo tonic solutions affect cell size?
Definition
Hypertonic will cause them to shrink.
Hypotonic will cause them to swell.
Term
Describe the differences between Crystalloids vs Colloids.
Definition
Crystalloids are isotonic and examples are LR and NS.
Colloids are hypertonic and are better at reducing edema but are much more expensive.
Term
What are the possible complications to IV therapy?
Definition
Brusing
Cellulitis
Phlebitis
Septicemia
Pulmonary Embolism
Air embolism
Infiltration out of the back of vein
Term
What is the patient education for the patient to notify a clinician after they have received IV therapy?
Definition
Notify the clinician if they notice any burning, stinging, redness, bleeding or swelling at the insertion site.
Term
What are the main indications for urinary bladder catheterization?
Definition
Obtain a sterile urine sample
Monitor urine output
Facilitate urinary drainage
Bypass obstructive processes
Term
What are the contraindications to Urinary bladder catheterization?
Definition
Previous urethral surgery
Urethral trauma
Inability to transverse the urethra to the bladder for any reason
Term
What is the main difference between a Robinson and Foley catheter?
Definition
Robinson is designed for one time use and Foley has an inflatable balloon and is meant to be left in.
Term
How long can plastic, latex and rubber urinary catheters be used?
Definition
Plastic = only one time in and out use.
Latex and Rubber = up to 2 weeks.
Term
Describe the 19 steps to Urinary Catheterization.
Definition
1. Ensure privacy
2. Wash genital area with warm soap and water
3. Position the patient (lithotomy for females and flat supine for males)
4. Position light
5. Wash hands
6. Open sterile pack
7. Add solution to cotton balls
8. Open catheter and place on sterile field
9. Open sterile gloves
10. Wash hands
11. Put on sterile gloves
12. Apply sterile drape to patient
13. Lubricate catheter tip
14. Cleanse urethral meatus
15. Pick up catheter with dominant hand 2 inches from the tip
16. Insert catheter until you see urine, then advance 2 more inches
17. Inflate balloon
18. Apply gentle traction to lodge the balloon
19. Secure the tubing to the patient
Term
What are the main indications for NG tube insertion?
Definition
Sample gastric contents
Remove gastric contents
Intestinal decompression
Nutritional support
Term
What are the contraindications to NG tube insertion?
Definition
Choanal atresia
Facial trauma
Gastrectomy
Recent UGI tract surgery
*Any condition that obstructs the pathway that the NG tube will follow
Term
Describe the 14 steps associated with an NG tube insertion.
Definition
1. Place patient at a 45 degree angle or greater
2. Wash hands
3. Put on gloves
4. Place a protective sheet over the patients chest/abdomen
5. Check for nasal patency and use the one that is most patent
6. Measure tube from tip of nose to ear lobe and then to the xiphoid process and mark the end
7. Lubricate the first few inches of the tube with lidocaine jelly
8. Flex the patient head to their chest
9. Insert the tube nearest the septal side of the nare to avoid the turbinates
10. Have the patient takes small sips of water through a straw as you advance
11. Insert until predetermined length
12. Check placement with CXR or inject 10cc of air into the tube and listen for the "gush of air"
13. Tape the tube in place using a tincture of benzoin
14. Record procedure and sign off in chart
Term
Describe the process of gastric lavage and indications.
Definition
NG tube is placed and the stomach is filled with water and then the water is sucked out.
Used to diagnose gastric bleeding or ingestion of toxic substances (activated charcoal is more common though)
Term
What are the contraindications to gastric lavage?
Definition
Insignificant overdose
Corrosive ingestion
Hydrocarbon ingestion
More than 1 hour post-ingestion
*All other NG tube contraindications
Term
What are the indications for arthrocentesis?
Definition
Undiagnosed arthritis with effusion
Suspected infection
Joint effusion after trauma
Therapeutic injections
Term
What are the contraindications for arthrocentesis?
Definition
Overlying infection
Overlying wound
Bacteremia
Neuropathic pain
Coagulopathies
Uncontrolled DM
Prosthetic joint
Inaccessible joints (Hip, SI, Pubic symphysis)
Lack of response to previous injections
Term
What should never be injected into a joint suspected of infection or hemarthrosis?
Definition
Steroids
Term
Describe the WBC count and % PMNs for Noninflammatory synovial fluid analysis (osteoarthritis, trauma).
Definition
WBC count under 2000 and less than 25% PMNs
Term
Describe the WBC count and % PMNs for Inflammatory (RA, Reiter's, viral/fungal/TB arthritis) synovial fluid analysis.
Definition
2,000-75,000 WBC's with more than 50% PMNs
Term
Describe the WBC count and % PMNs for Septic (bacterial) arthritis synovial fluid analysis.
Definition
WBC count over 60,000 with greater than 80% PMNs
Term
What is the maximum number of joint injections that you can receive per year?
Definition
3
Term
Describe the 10 steps to shoulder joint arthrocentesis.
Definition
1. Obtain Consent
2. Identify all bony landmarks and mark the injection site
3. Wash hands
4. Put on gloves
5. Prep the area
6. Insert needle perpendicular to the skin, medial to the humoral head and distal to the clavicle, inferior to the coracoid process
7. Advance the needle posteriorly, distal to the coracoid and directed to the medial side of the humeral head
8. Aspirate fluid
9. Withdraw the needle and bandage the entry wound
10. Submit the synovial fluid for analysis

*Knee is the same but you insert the needle 1-2 cm from the medial or lateral edge of the superior third of the patella and direct it towards the intracondylar notch
Term
What is involved in your patient education after a joint injection?
Definition
If pain returns after 2 hours it is due to the local anesthetic wearing off, use ice packs and avoid strenuous activity for 1-2 days. Seek advice if pain is getting worse after 2 days or if they develop systemic symptoms.
Normal local side effects include pain, flushing and swelling.
Term
Describe the process of finding where to give a Glenohumeral joint injection.
Definition
Have the patient sit with their arms by their sides and externally rotated. Find the sulcus between the humoral head and the acromion process. Palpate the posteriolateral corner of the acromion process and direct the needle anteriorly towards to coracoid process. Insert the needle to full length.
Term
Describe the process of finding where to give an AC joint injection.
Definition
Palpate the clavicle to its distal aspect, there is a slight depression where it meets the acromion process, insert the needle from the anterior and superior approach.
Term
Describe the process of finding where to give a Sub-acromial joint injection.
Definition
Insert just inferior to the posterolateral acromion process at the lateral shoulder directing the needle towards the opposite nipple, insert the needle to the full length.
Term
List the 14 steps to writing an Operative Note.
Definition
1. Preoperative diagnosis
2. Postoperative diagnosis
3. Procedure performed
4. Surgeon
5. Assistants
6. Anesthesia used
7. Findings
8. Specimens obtained
9. Drains placed
10. Closure type
11. Fluids given (type and amount)
12. Estimated blood loss
13. Complications
14. Sign all notes
Term
Describe the 5 steps to performing an I&D.
Definition
1. Administer local anesthesia
2. Incision
3. Wound dissection (use a hemostat wrapped in gauze to determine depth of abscess and collect sample)
4. Wound irrigation with NS
5. Packing and dressing
Term
What is involved with the post-splinting/casting instructions for the patient?
Definition
Keep it clean and dry
Keep extremity elevated for the first 2-3 days to decrease swelling
Return for evaluation for pressure ulcer or infection if they develop pain or burning sensation
Assess for neurovascular compromise
Term
Describe the 18 steps to starting an IV.
Definition
1. Identify patient
2. Connects tubing to IV bag and flushes the tubing
3. Apply tourniquet above the IV site
4. Have the patient open and close fist
5. Identify vein
6. Wash hands
7. Put on gloves
8. Prep the area
9. Hold catheter in dominant hand and apply traction with the other hand
10. Inserts IV at 15-30 degree with bevel up into vein
11. Stabilize the catheter with one hand and release the tourniquet with the other
12. Apply slight pressure above the IV site to remove stylet from the catheter
13. Attaches IV tubing and releases clamp
14. Verify flow of solution
15. Adjust flow rate if necessary
16. Apply antimicrobial ointment and secure IV
17. Dispose of sharps
18. Documentation
Term
What are the indications for chest tube placement?
Definition
Drainage of hemothorax or pneumothorax
Prophylaxis in patient with chest wall trauma during transport
Flail chest
Term
What are the contraindications to chest tube insertion?
Definition
Overlying infection or uncontrolled bleeding
Term
What is the average chest tube size for an adult? NG tube? Urinary catheter tube?
Definition
Chest tube = 28-32 Fr
NG tube = 10-18 Fr
Urinary cath = 14-18 Fr
Term
Describe the 15 steps to chest tube placement.
Definition
1. Obtain written consent
2. Select insertion site (midaxillary between the 4th and 5th ribs)
3. Put on mask, gown and gloves
4. Prep and drape area for insertion
5. Have patient put their arm over their head to open up ribs
6. Anesthetize area with 2% lidocaine local anesthetic
7. Remove catheter, dilator, introducer wire and introducer needle from bag
8. Thread inducer wire through needle into chest
9. Remove needle leaving the inducer
10. Thread dilator over the inducer wire and advance into chest
11. Dilate so that a catheter can be inserted and then remove the dilator
12. Insert catheter and remove wire
13. Tape or suture catheter in place
14. Attach catheter to suction unit
15. Obtain CXR to confirm placement
Term
Describe what is meant by the Admission Orders mnemonic ADC VANDALISM.
Definition
Admit
Diagnosis
Condition
Vital Signs
Allergies
Nursing
Diet
Activity
Labs
IV fluids
Special
Medications
Term
Describe the 14 step process of scrubbing into the OR.
Definition
1. Put on facemask, cap and shoecovers
2. Clean nails with nail file
3. Wash nails, hands and forearms
4. Scrub all 4 sides of each nail (30 scrubs) and finger (20 scrubs)
5. Scrub the 3 sections of the ventral and dorsal hand (20 scrubs)
6. Scrub all 4 sections of each forearm to just above the elbow (20 scrubs)
7. Rinse with water always flowing from the hand to the elbow
8. Keep hands and elbows elevated above the forearms as you walk in backwards into the OR
9. Dry hands off from hand to elbow with sterile towels included in the gown pack
10. Grasp inside of gown and lift away from the table
11. Unfold gown by placing arms into the sleeves
12. Unsterile assistant will tie the neck and inside waist tie
13. Sterile gloving technique (open and drop on sterile field, left hand puts the glove on the right hand and then gloved right hand puts the glove on the left hand)
14. Outside tie with assistance (hand white tab to assistant and they pull it back around to tie)
Term
Describe how you will format your surgical clinical case written exam for each patient.
Definition
Diagnosis
Assess the patient (Sx)
Treatment plan
Pick the procedure that needs to be done
Obtain Informed Consent (explain Indications, Contraindications, Risk and Benefits to the patient)
Write a Procedural Note (Demographics, Procedure, Indications, Contraindications, Informed Consent, Personnel involved, Description of the procedure, Findings, New/Unexpected findings, Complications, Follow up/Patient instructions, Time finished w/ patient condition noted)
Admit patient and write admission orders (ADC VANDALISM - Admit, Diagnosis, Condition, Vital Signs, Allergies, Nurse orders, Diet, Activity, Labs, IV fluids, Special, Meds)
Term
How much more fluid than is needed should be given during IV fluid replacement?
Definition
500cc more because they lose it through breathing etc
Term
What is problematic about a seroma?
Definition
It is a great nidus for infection
Term
What are the values that are indicative for respiratory failure?
Definition
Tachypnea over 25 bpm
Tidal volume under 4mL/kg
PO2 under 60mmHg
PCO2 over 45mmHg
and Low CO
Term
What should be checked if someone is having PVC's post-op?
Definition
Check oxygen levels first
Term
What are the causes of wound dehiscence? When is it most common postop? Where is a common place for it to occur?
Definition
MCC is technical problem in wound closure from excess wound tension, ischemia, improper suturing or knot tying. MC seen between the 5th and 8th postop day. Common on the abdomen
Term
What type of bacteria are primarily responsible for a wound infection that occurs more than 4 days post-op?
Definition
Enteric aerobes, anaerobes or staph
Term
What is the most common cause of postoperative abnormal coagulation parameters?
Definition
Hemodilution from the patient being given too much fluid
Term
What chemical is used in chemical sterilization and what surfaces is it good for?
Definition
Glutaraldehyde, it is good for rubber/plastic
Term
How do you prevent arterial ulcers?
Definition
Need to thin the blood so blood thinners (ASA, Plavix)
Term
What is the only enzymatic agent that is not compatible with topical antibiotics?
Definition
Silver dressings
Term
What is the use for Hydrogel, Calcium alginate and foam for use as packing?
Definition
Hydrogel for mildly exudating wounds.
Calcium alginate for wounds with large amounts of drainage.
Foam for highly exudative wounds requiring a non-stick surface.
Term
What kind of splint is used in a Colles fracture, scaphoid fracture, unstable ankle fracture and fracture to the 4th or 5th metacarpals or phalanx?
Definition
Colles fx: sugar tong splint
scaphoid fx: thumb spica splint
unstable ankle fx: lower leg sugar tong splint
4th or 5th metacarpal/phalanx: Ulnar Gutter splint
Term
Which suture has the most inflammation? Highest rate of inflammation?
Definition
Most = plain or chromic gut
Highest rate = silk
Term
Skin needs at least ___% tensile strength of original tensile strength to prevent dehiscence
Definition
30%
Term
What is the tensile strength of vicryl at 3 weeks?
Definition
50%
Term
What type of suture is used for intranasal and intraoral suturing?
Definition
5-0 chromic gut for intranasal
4-0 chromic gut for intraoral
Term
Where should you never apply buried sutures?
Definition
In the fingers
Term
Which 3 local anesthetics do patients most commonly have allergies to?
Definition
Procaine, Novacaine and Tetracaine
Term
Describe the order of blood draws into vacutainers.
Definition
first draw blood culture (yellow-black tube)
second draw non-additive (red tube) for serology (Ab or drugs)
third draw citrate (light blue tube) for coagulation (PT, aPTT)
fourth draw heparin (dark green tube) for chemistry (CMP)
EDTA (purple tube) for CBC
oxalate/fluoride (gray tube) for glucose
Term
Describe the ggt/cc for microdrips and macrodrips and what each is best suited for delivering/
Definition
Microdrip: 60 ggt/cc; good for meds or pediatric fluid delivery
Macrodrip: 10-15 ggt/cc; good for rapid or routine fluid delivery
Term
What is the complication that can arise if ABGs are not placed on ice in a timely manner?
Definition
Pseudohypoxemia
Term
Which nerve is most commonly injured from brachial artery blood sampling?
Definition
Median nerve
Term
What is the average length of the female and male urethra?
Definition
Female = 22cm
Male = 40 cm
Term
What is the name of the syringe used for NG tube used for gastric lavage?
Definition
Toomey irrigation syringe
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