Rest of Clinical Skills Material

used to evacuate gastric contents, may be used for feeding

Nasogastric

(nasoduodenal, nasojejunal) intended for feeding

Nasoenteric

usually placed endoscopically, nose to common bile duct

Nasobiliary tubes

placed endoscopically within the common bile duct for the purpose of drainage, allows for gravity drainage out skin

T-tubes

needle is threaded percutaneously into the gallbladder and used to decompress the organ, thus releasing pressure and relieving symptoms, gravity drainage

Placed by Interventional Radiology

Percutaneous Cholecystostomy

a minimally invasive, image-guided procedure (using X-ray or ultrasound) that places a thin tube (catheter) through the skin and into the liver to relieve bile duct blockages from liver to duodenum

Internal & External Drain

Placed by Interventional Radiology

Percutaneous Biliary Drain

can be placed by surgery, by endoscopy, by radiology

Gastrostomy

can be placed surgically or endoscopically, long term nutrition

Jejunostomy

•placed for pneumothorax, hemothorax, effusion.

•Often initially set to suction -20 mmHg

•May also have water seal to prevent air from entering pleural space

•Allows drainage of air / fluid

Chest tubes

short term tube for breathing

Endotracheal tubes

long term tube for breathing

Tracheostomy tubes

creation of an artificial opening into the kidney, drain urine directly from kidney, placed by IR

Nephrostomy

a procedure that places a thin, flexible tube through the skin (percutaneously) on the back, through the kidney, down the ureter, and into the bladder to drain urine, often bypassing blockage (stricture), placed by IR

can drain urine internally and externally (cap external portion/nephrostomy portion if patient is doing well)

Nephroureterostomy

how do you know if a patient has a nephrostomy or nephroureterostomy?

imaging

hollow bulb-like device used to collect drainage, pop open valve and squeeze then replace cap to generate vaccuum

need flushed frequently

Jackson Pratt (JP) Drain

aka Grenade Bulb Drain

a closed drainage system in which a soft drain is attached to a springlike suction device, hold more volume than JP, empty fluid and compress it down to initiate vacuum

Hemovac Drain

very large, placed to continuous suctions for when drainage is expected to be thick

Sump Suction Drains

this type of tube is not flushed or encouraged with vacuum

passive (used in very specific scenarios)

soft, flexible, latex or silicone tube used in surgery to passively remove fluids from a wound or surgical site

maintain a pathway for fluid flow

Passive tubes (Penrose)

orders for surgical drains

•Flushing

•Stripping the drain - when there is fibrous material in the drain

•Output

•Closed suction (correct method), wall suction, or to gravity (foley)

pinch proximal drain and pull down on drain to remove fibrous build up

stripping a drain

ways drains are sunctioned

closed suction

wall suction

gravity

when is a drain removed?

- decreased output over time

- confirmed volume depleted on imaging

orders for Immediate Post Op Care

vital signs, fluids, pain management, drain care, medications (including pain management), labs, imaging

for inpatients, post op check every ______ hours

4-6

Position in bed & mobilization post op

turning, upright position, stockings, allowing for drainage, knee & heel support for comfort

post op DVT prophylaxis

medication, stockings, movement

•Within _____ after surgical wound is closed by primary intention space fills with inflammatory exudate, epidermal cells begin to divide and migrate across wound surface, by ___ hours deeper structures are sealed off from external environment. Sterile dressing offer protection at this time.

hours; 48

wound care requires aseptic technique for a minimum of ___ hours

24

Remove dry dressings in _____ days, if wet remove _____

3-4, earlier

Vacuum dressings need to be replaced in ________hours, pain management at dressing changes

24-72 hours

Sutures and staples often remain in place for _____ days depending on location and healing

5-14

Adhesives will fall off in time, avoid ______.

lotion

Need to get Dermabond off?

Acetone, Vaseline, or triple antibiotic ointment will work

cause of surgical wound dehiscencec

Many causes including sutures being too tight, or infection

_______________ from wound is a sign of acute fascial dehiscence.

Spontaneous discharge of serous fluid

what to do if Dehiscence of abdominal fascia and evisceration

Cover organs with sterile towels soaked in saline solution, OR immediately

Parenteral opioids

morphine, meperidine, hydromorphone, etc

Nonopioid parenteral analgesics

NSAIDS

Oral analgesics

acetaminophen with codeine, hydrocodone with acetaminophen, oxycodone with acetaminophen

Release of catecholamines and other stress hormones by postoperative pain causes vasospasm and hypertension, which may in turn lead to complications such as

stroke, myocardial infarction, and bleeding

The patient may be reluctant to breathe deeply, promoting

atelectasis

ways to prevent post op atelectasis

•Smoking cessation 8 weeks preop

•Incentive spirometry, coughing

•Adequate pain management

•Early mobilization

T/F post op fever is always a sign of complication

False

High Temperature about _____ may initiate investigation

38.3° C

Postop pulmonary edema is caused by_______________

high hydrostatic pressures

In the absence of deranged cardiac function or fluid overload, the development of pulmonary edema should be regarded as evidence for ______.

sepsis

Early postoperative respiratory failure develops most commonly in patients with

major operations, severe trauma, and preexisting lung disease

Late postoperative respiratory failure (develops beyond 48 hours post op) is usually triggered by:

pulmonary embolism, abdominal distension, or opioid overdose

respiratory failure:

_____ bpm

tidal volume < _____

PCO2 > ________

PO2 < _______

____ cardiac output

25-30

4ml/kg

45mmHg

60mmHg

low

what may cause need for increased post-op fluids?

extra needs resulting from systemic factors (fever, burns, loss during surgery), loss from drains, tissue edema / ileus (third space losses).

maintenance fluids calculation

weight in kg x 30 in 24 hours period

rule of thumb: 2000 - 2500 ml of 5% dextrose in normal saline or lactated ringer solution daily

(no potassium in first 24 hours)

•After operations on the stomach and upper intestine, propulsive activity can be disorganized for ____ days.

3-4

Anemic patients with recurrent, IgA deficiency, severe allergic reactions benefit from _______ RBCs

washed

•Indicated for massive blood loss with pronounced hypovolemia

Whole blood 450-500 mL of donor blood, RBC, plasma, clotting factors, anticoagulant

Indicated for patients experiencing recurrent febrile nonhemolytic transfusion reactions to RBC or platelets or prophylactically in patients with long term transufion needs

Leukocyte-Reduced Red Blood Cells

•indicated for patients who are at risk for transfusion associated graft versus host disease.

Irradiated Red Blood Cells

Indicated for management of active bleeding in thrombocytopenic patients. Or for patients with platelet dysfunction

Platelets

Good for patients with deficiencies of multiple clotting factors. Albumin, and fibrinogen

FFP

ndicated for the correction of hypofibrinogenemia in dilutional coagulopathy and the hypofibrinogenemia/dysfibrinogenemias of liver disease and DIC.

Cryoprecipitate

are indicated in severely neutropenic patients with bacterial sepsis who have not responded to optimum antibiotic therapy after 48-72 hours

Granulocyte Transfusions

autosomal dominants Disruption of intracellular calcium metabolism

Tachycardia, cyanosis, muscle rigidity.

•Body temperature may rise 1-2 degrees every 5 minutes, may not present for up to 36 hours after exposure to triggering agent

malignant hyperthermia

cyanosis, symptoms of hypoxemia that does not improve with supplemental oxygen, discoloration of blood (dark red, chocolate, or brownish to blue) that does not resolve upon oxygenation

Methemoglobinemia

what is the treatment for malignant hyperthermia

dantrolene

causes of Methemoglobinemia

•An infant fed formula made with well water that was not tested for methemoglobin levels

•A member of the military who is administered malarial prophylaxis.

•An individual undergoing endoscopy or bronchoscopy who is treated with a topical anesthetic agent prior to the procedure

what is the treatment for methemoglobinemia?

methylene blue

what are the indications for doing a trauma-oriented eye exam?

- potential eye injury

- suspected scratch or abrasion

- suspected FB

- acute visual disturbance

what are the contraindications to performing a trauma-oriented eye exam?

- ruptured globe

- eyelid laceration (vertical)

if FB is not removed in timely manner, this complication may result

infection or ocular necrosis

when should you suspect ruptured globe?

high velocity injury

what should you do if you suspect a ruptured globe?

- NO topical agents on eye

- cover both eyes with Fox shield

- immediate referral to ophthalmologist

what should you do if someone comes in for a caustic splash exposure to the eye?

- begin flushing with lactated ringers (manually or Morgan lens) immediately and exam later

- check pH PRN until neutral

duration of flushing caustic splash exposure

mild irritant?

most other?

penetrating corrosive?

5 minutes

20 minutes

60 minutes

contact lens users are at high risk for ________ infections

pseudomonas

what are the complications to doing a trauma eye exam?

- increased pain

- N/V

- photophobia

what imaging is preferred for the eye?

plain films/CT

what is a topical anesthetic that can be used for the eye?

proparacaine 0.5%

what devices/tools can be used to remove a foreign body from the eye?

- eye or corneal spud

- 25 gauge needle

- flush

- moistened cotton swab

anesthesia is necessary!

the application of dye to the surface of the eye via eye drops or a strip applicator

with black or cobalt blue light, can help you see FB or abrasion

fluorescein staining

after applying fluorescein stain, its important to

inspect lower eyelid while patient looks up, upper eye lid by everting, and sweep the recesses of the upper conjunctival fornices

patient positioning during trumatic eye exam

patient presses head on forehead strap and chin rest, anchor clinician hand against pt face

from which direction does clinician approach patient eye?

from side and inferiorly (minimizes anxiety and blinking)

removal of rust ring

corneal bur

after removing FB

flush generously

check visual acuity

indicates corneal penetration injury with oozing aqueous humor

"dark waterfall"

seidel sign

T/F topical anesthetics are prescribed for pain relief after an eye injury

F; the anesthetic prolongs epithelial healing

Oral agents are a better choice (opiods/nsaids)

if removing FB with a needle, the bevel shuld face

up

functions as lubricant in eye

bacitracin, ciprofloxacin

ophthalmic antibiotic ointments

easier to apply than ointment, enhance patient compliance, sulfacetamide, ofloxacin

ophthalmic solutions

T/F opthalmic steorids are a good joice post eye FB removal

false; delays healing

A patient presents with an alkali chemical splash to the eye. What is the first priority in management?

A) Instill topical anesthetic before assessment

B) Flush the eye with lactated Ringer’s or normal saline

C) Perform a fluorescein stain to assess for corneal defects

D) Administer IV antibiotics

B

Which of the following findings suggests a penetrating corneal injury requiring immediate ophthalmology referral?

A) Fluorescein staining revealing a linear corneal abrasion

B) A positive Seidel sign

C) Conjunctival injection and tearing

D) Pain relieved by topical anesthetics

B

What is the purpose of using fluorescein dye during an eye trauma exam?

A) To check for corneal abrasions or epithelial defects

B) To test for increased intraocular pressure

C) To assess pupillary reactivity

D) To measure anterior chamber depth

A

An IV access into one of the major blood vessels.

central line

types of central lines

venous catheter in jugular, subclavian, femoral vein

peripheral inserted central catheter (PICC)

implanted ports (IR)

pulmonary artery catheter

plasmapheresis catheter

IVC filter

catheter whose tip is located in the SVC, RA, or IVC

central venous access

locations of CVA insertion

jugular, subclavian, femoral, brachial

PICC is most commonly inserted into

basilic vein

u/s guided

fever complications thatn central line

ideal for community-based parenteral anti-infective therapy

can remain in place for months

PICC line

placed by IR or surgery, common in chemo, place for long periods of time

implanted port