Procedures Proficiency Exam

What is venipuncture?

the puncture of a vein for withdrawal of blood or injection of a solution

What is the parenteral route?

drug administration by route other than the GI tract, typically intravenous, intradermal, intramuscular, subcutaneous

What precautions are used in venipunture?

strict aseptic technique with standard precautions (because we are penetrating the protective layer of the skin, and all patients are considered potentially infectious)

Explain standard precautions

• adhere to aseptic technique

• one needle, one syringe, one patient

• dispose after use

• use single dose vials when possible

What are the most common types of needle used for parenteral drugs?

• plastic/angiocath

• steel shaft/butterfly

How should the bevel be before inserting into the vein?

facing up

Label the parts of the needle

1. bevel

2. shaft

3. gauge number

4. hub

What are some things that determine which needle you use?

• what you need it for

  • blood draw

  • procedure

  • medication

• which veins are available

• how long the IV will be in

How are needles sized?

• gauge (G): the thickness or diameter of the needle

  • commonly 18-22 G

  • higher number = smaller diameter

• length: measurement in inches of the shaft portion

  • .25-5”

  • 1-1.5” used for IV injections

What are short and long bevels used for?

short: IV injections

long: subcutaneous and intramuscular

Explain angiocath/intravenous catheter needles

• over-the-needle cannula

• flexible catheter over a stylet

• even gauge numbers (18, 20, 22, etc.)

• primarily used for prolonged infusion

• safer device in venipuncture (because needle is drawn back up into the protective sheath)

• greater tendency for staying in veins (reduces risk of extravasation)

Explain butterfly/scalp vein needles

• has wings

• flexible tubing from shaft to hub

• gauge numbers 18, 20, 22, 23

• .25-1.25 inches

What must be done before inserting an IV?

verify patient

What are some indications of IVs?

• IV fluid

• medications

• contrast

• lab draws

• emergency access

What are some contraindications of IVs?

• edema to extremities

• breast or lymph surgeries

• fistula, shunt, vascular graft in arm

• scar, wound, rash, hematoma at site

• extravasation on the side

• vein is thrombosed

What are some complications that can occur with venipuncture?

• pain

• bleeding

• hematoma

• infection

• infiltration

• phlebitis (inflammation)

Explain the 3 layers of the vein

1. outer layer of fibrous connective tissue called adventitia

2. middle layer of smooth muscle called tunica media

3. inner layer of epithelial tissue called intima

What are the most common sites for venipuncture?

antecubital area of the arm

cephalic vein (lateral side of forearm), median cubital (midline of forearm), basilic (medial side forearm, elbow, arm

What are the best sites for venipuncture?

cephalic and basilic veins

Why is the back of the hand a less common site?

• painful

• veins tend to move around

• must use smaller catheter = slower injection rates

How do you select which vein to use?

• non-dominant arm when possible

• look for long, straight vein

• listen to the patients suggestions

How do you assess vein quality?

palpate to determine size, angle, and depth

How can you “bring up” a vein?

• have patient “pump” their hand

• hang arm down

• warm compress

• slap briskly

How do you know you have a vein and not an artery?

arteries pulse

What is a bolus?

entire dose is injected into the venous system at one time

What is a drip infusion?

dose is delivered more slowly over time

What is extravasation?

discharge or escape of fluid from a vessel into surrounding tissue

What is infiltration?

diffusion of a fluid into tissue

What supplies are needed for IV insertion?

• gloves

• tourniquet

• skin prep

• needles

• IV tubing

• prepared contrast

• gauze/cotton and tape or band aid

• sharps container

• emergency cart (for possible reactions)

What steps must be taken before IV insertion?

• identify patient

• explain procedure

• ask about allergies

List the steps for IV insertion

1. wash hands and put on gloves

2. select site, apply tourniquet 3-4 inches above site, clean the site

3. initiate puncture

4. stabilize needle and advance catheter

5. prepare for contrast insertion

6. remove needle and apply gauze

How should you use the IR on a hypersthenic patient?

always use IR crosswise

How should you use the IR on a sthenic patient?

generally use IR crosswise

How should you use the IR on a hyposthenic patient?

generally use IR lengthwise

How should you use the IR on an asthenic patient?

always use IR lengthwise

What vertebrae does the vertebral prominence correspond with?

C7

What vertebrae does the jugular notch correspond with?

T2/T3

What vertebrae does the inferior angle of the scapula correspond with?

T7

What are the breathing instructions for a chest x-ray?

double breath (for greater inspiration and more depressed diaphragm)

What is the difference between personal/controllable artifacts and medical/uncontrollable artifacts?

personal artifacts (jewelry, clothing, hair, bra, etc.) can be removed from the area of the body being imaged

medical artifacts (pacemakers, feeding tubes, stents, etc.) can not be moved

What are some reasons for ordering a CXR?

• pathology

• fluid levels

• foreign body (aspiration)

• movement of diaphragm

• rib detail

How far below the vertebral prominens should you center a PA chest projection?

7 inches lower in females

8 inches lower in males

What do you need to make sure is included in a chest x-ray?

apices, costophrenic angles, 10 ribs above diaphragm, and medial scapula borders lateral to lungs

Why are chest laterals done as left laterals?

reduces the heart magnification

What is considered acceptable rotation for a chest x-ray?

½ an inch or less

What does RIPA stand for? (Hint: it is used for critiquing PA/AP chest x-rays)

R-Rotation

I-Inspiration

P-Penetration

A-Angulation

How can you make sure that the rotation is acceptable in a PA/AP chest x-ray?

medial ends of clavicles should be equidistant from spine

How can you make sure that the inspiration is acceptable in a PA/AP chest x-ray?

minimum of 10 ribs above the diaphragm

How can you make sure that the penetration is acceptable in a PA/AP chest x-ray?

thoracic vertebrae are seen through the heart and mediastinum, lung markings are clearly demonstrated, penetration through costophrenic angles

How can you make sure that the angulation is acceptable in a PA/AP chest x-ray?

medial ends of clavicles should be at level of T3/T4 and 1in of apical lung tissue above clavicles should be demonstrated

What is lordotic position?

patient in AP position, one foot away from the bucky, hands on hips with palms up, patient leaning backward so shoulders and neck are against bucky

What is the purpose of a lateral decubitus CXR?

demonstrate air/fluid levels

How long should you (ideally) let patient lay on their side before taking a lateral decub?

5 minutes

If you are looking for air in the lungs, which side should patient lay on?

the side you are looking at should be up

If you are looking for fluid in the lungs, which side should patient lay on?

the side you are looking at should be down

On a decub, which side should the marker be on?

the side down

How should your technique change for emphysema?

reduce technique

How should your technique change for pleural effusion?

increase technique

How should your technique change for pneumothorax?

take an image on inspiration and on expiration

What is the purpose of a Swan Ganz catheter?

monitoring the heart’s function and blood flow, as well as pressures in and around the heart

What is a picc line?

peripherally inserted central catheter inserted into a vein in the arm that goes to the heart

What is a balloon pump?

mechanical device that allows the heart to pump more blood by inflating when heart relaxes

What is the purpose of an endotracheal tube (ETT)?

establishing and maintaining a patient airway to ensure the adequate exchange of oxygen and carbon dioxide

The tip of the ETT should be ___ to the carina

5 cm superior

What is the purpose of a nasogastric (NG) tube?

provide nutrition to patients who cannot obtain nutrition by mouth (or are unable to swallow safely)

What is the purpose of chest tubes?

removing something (air/fluid) frum intrathoracic space

tube remains in the chest until all/most of the fluid has drained

CXRs to check chest tube progress should be taken ___

upright (to show air/fluid levels)

What is the purpose of pacemakers?

steady electrical impulses to regulate the beating of the heart (treats bradycardia)

What is the purpose of implantable cardioverter-defibrillators(ICD)?

treating heart rhythm disturbances by means of electric shock (treats tachycardia)

What is the purpose of a heart valve replacement?

to repair or replace diseased heart valves (can be mechanical or biological)

What is a clavicle series?

AP and AP axial

Where do clavicle fractures usually take place?

80% in the middle, 15% on the lateral end

Explain the positioning for an AP clavicle

• 10×12 CW

• AP upright or supine with table bucky

• shoulders flat, arms at sides, chin raised, look forward

• on inspiration

What is a benefit of doing a clavicle PA?

shorter OID, increases the detail

Where should you center for an AP clavicle?

mid-clavicle

What SID is used for most clavicle and scapula images?

40”

What needs to be demonstrated on an AP clavicle image (film eval)?

• full body of the clavicle

• AC and SC joints in view

• half of clavicle unsuperimposed from thorax

  • clavicle at level of 3rd/4th rib

  • superior scapular angle should be superimposed on mid-clavicle

• marker lateral

How are clavicle and scapula images sent?

as if someone is standing in front of you in anatomic position

Explain the positioning for an AP axial clavicle image

• 10×12 CW

• AP upright or supine

• shoulders flat, arms at sides, chin raised, look forward

• on inspiration

Explain the centering/angulation for an AP axial clavicle image

• 15-30^o angle

  • if AP: cephalic

  • if PA: caudal

• patient may be in a lordotic position to decrease the angle

• asthenic patients use more angle

What needs to be demonstrated on an AP axial clavicle image (film eval)?

• inferior surface of clavicle (tubercles visible)

• lateral 2/3 of clavicle unsuperimposed

• clavicle above superior angle of scapula

• AC and SC joints visible

• medial aspect of clavicle at level of 1st/2nd rib

• marker lateral

What is a scapula series?

AP and Lateral (Y-View)

Explain the positioning for an AP scapula image

• 10×12 LW

• upright or supine

• abduct affected arm 90^o

  • moves scapula off of thorax

  • places scapula lateral to IR

• supinate the hand

• suspend breathing or breathing technique

Explain the centering for an AP scapula image

perpendicular 2 inches inferior to coracoid (with 2 in of IR above shoulder)

What needs to be demonstrated on an AP scapula image (film eval)?

• true AP

• lateral border free of superimposition of ribs

  • arm abducted

• includes inferior angle of scapula

• marker lateral

How is the arm placed for a lateral scapula that the scapular body is of primary focus?

arm (of affected side) brought across the chest

How is the arm placed for a lateral scapula that the acromion and coracoid are of primary focus?

arm tucked behind the back

Explain the positioning for a lateral scapula image

• upright (AP or PA)

• oblique body 45-60^o to place scapula perpendicular to IR

• arm placement (determined by whether you are looking at the body or the acromion and coracoid)

Where do you center for a lateral scapula image?

perpendicular to mid-vertebral border of scapula

What needs to be demonstrated on a lateral scapula image (film eval)?

• superimposed lateral and medial borders

• no superimposition of scapula on ribs

• marked lateral

• acromion and coracoid processes

What are AC and SC joint x-rays done for?

r/o separation or dislocation

What SID is used for AC joints?

72”

Explain the positioning and centering for AC joints

• 14×17 CW

  • centered 1 inch above jugular notch

• upright (standing or sitting) with back against bucky

• arms at sides (neutral rotation)

Explain the breathing recommendations for clavicle, scapula, AC, and SC images

clavicle: on inspiration

scapula: breathing technique

AC: suspend breathing

SC: on expiration

What is the AC joint routine?

without weights first, then with weights

Why do you put the weights around a patient’s wrists for AC images?

so they don’t try to hold their arms up

If the without weights image shows a clavicle fracture, can you still do the with weights image for AC joints?

NO

If the without weights image shows a clavicle dislocation, can you still do the with weights image for AC joints?

YES

What needs to be demonstrated on an AC joints image (film eval)?

• both AC joints, both SC joints, and full clavicle in view

• markers on both sides of patient

• annotate whether it was with or without weights

If a patient has broad shoulders that don’t fit on the IR together for AC joints, how can you alter the procedure?

• two separate images for each joint

  • do both shoulders without weights before doing with weights

• center 1 in below AC joint

• cone in more