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371 Pillow Safety strap Heel pad Padded foot rest FIGURE 19. 5 Fowler'sposition. Source:Goodman, T.,& Spry,C. (2017). Essentials of perioperative nursing (6th ed. ). Burlington, MA: Jones & Bartlett. h. Once in the operating room, hands and arms should be dried with a sterile towel and aseptic tech-nique prior to placing on the gown and gloves. B. Sterile field in operating room. 1. From nipple area to waist. 2. Only in the front. 3. Neck can be contaminated by mask and is not con-sidered a sterile part of the field. C. Prepping the surgical patient. 1. Skin antisepsis. a. Decrease the burden of skin flora and reduce the rate of surgical site infections. b. Common examples. i. Chlorhexidine—alcohol is the preferred scrub prep for surgeons and assistants. ii. Povidone-iodine—must be used when prep-ping an open wound or mucous membrane, such as the vagina or rectum. iii. Iodine and isopropyl alcohol. iv. Iodine-impregnated adhesive covering. 2. Draping. a. Sterile draping of the surgical field is performed by the surgical assistants in order to: i. Provide a sterile field. ii. Provide adequate surgical area exposure. iii. Cover all nonsterile area in the operative field. Wound Classifications A. Clean: Uninfected wounds without inflammation. B. Clean-contaminated: Controlled entering of viscus entered during sterile operation. C. Contaminated. 1. Open, fresh accidental wounds. 2. Major breaks in sterile techniques. 3. Gross spillage of viscous contents. D. Dirty: Old, traumatic wounds with retained devitalized tissue, foreign bodies, or fecal contamination. Wound Healing A. Primary intention. 1. Used for clean incisions. 2. Suturing is performed early. 3. Minor cosmetic scar. B. Secondary intention. 1. Used for wider wounds. 2. Allow granulation tissue to fill the base of the wound with no suturing. Pillow Safety strap Break in table Chest roll Donut under face FIGURE 19. 6 Jackknifeposition. Source:Goodman, T.,& Spry,C. (2017). Essentials of perioperative nursing (6th ed. ). Burlington, MA: Jones & Bartlett. a. The key to healing is through granulation of the tissue. 3. Larger cosmetic scar. C. Tertiary intention. 1. Used for irregular wounds. 2. Allow granulation tissue to fill the base of the wound with delayed primary closure. 3. Usually used for larger cosmetic scars. Role of the First Assistant A. The main role of a surgical first assistant is to provide sup-port for the primary surgeon during a surgical procedure. B. The first assistant's scope of practice will vary from state-to-state and by hospital. These roles can be dictated by the surgeon and/or the institution and can include any of the following. 1. Providing exposure. 2. Hemostasis. 3. Surgical tying and suturing. 4. Suctioning. C. First assistants are generally positioned opposite of the surgeon's preferred side or based on the procedure being performed. Documentation Requirements A. What to include in brief operative notes. 1. Procedure—state what procedure was done. 2. Complications—indicate any complications that occurred during surgery. 3. Intake/output—list how much fluid was given and what the urinary output was. 4. Estimated blood loss (EBL)—indicate the amount of EBL during the case. In some surgeries, this amount may be minuscule. The EBL can be very subjective. 5. Postoperative vital signs—the vital signs at the end of the case. 6. Discuss postoperative checks—indicate if any specific physical examination was completed. For instance, after a spine case, motor function would be assessed. Bibliography Anderson, K., & Hamm, R. (2012). Factors that impair wound healing. Journal of the American College of Clinical Wound Specialists, 4 (4), 84-91. doi:10. 1016/j. jccw. 2014. 03. 001 Berríos-Torres, S. I., Umscheid, C. A., Bratzler, D. W., Leas, B., Stone, E. C., Kelz, R. R.,... Schecter, W. P. (2017). Centers for disease control and prevention guideline for the prevention of surgical site infection. JAMA Surgery, 152 (8), 784-791. doi:10. 1001/jamasurg. 2017. 0904 Care Principles
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372 Gardner, D., & Anderson-Manz, E. (2001). How to perform surgical hand scrub. Retrieved from http://www. infectioncontroltoday. com/articles/ 2001/05/how-to-perform-surgical-hand-scrubs. aspx Goodman, T., & Spry, C. (2017). Essentials of perioperative nursing. (6th ed. ). Burlington, MA: Jones & Bartlett. Leaper, D. J. (2006). Traumatic and surgical wounds. British Medical Jour-nal, 332 (7540), 532-535. doi:10. 1136/bmj. 332. 7540. 532 Medication Management Kristopher R. Maday Preoperative Antibiotics A. Antimicrobial prophylaxis to prevent surgical site infec-tions depends on several factors. 1. Cost. 2. Safety. 3. Pharmacokinetic profile. 4. Bactericidal activity. 5. Type of surgical specialty and/or specific operation. B. Given within 60 minutes of surgical incision to have optimal tissue concentration. C. Common examples. 1. First generation cephalosporin: Cefazolin. 2. Second generation cephalosporin (broader gram-negative coverage): Cefuroxime, cefoxitin, cefotetan. 3. Penicillin-allergy alternatives: Vancomycin, clin-damycin. 4. Metronidazole is typically added in colorectal cases. Bibliography Anderson, D. J., Podgorny, K., Berríos-Torres, S. I., Bratzler, D. W., Dellinger, E. P., Greene, L.,... Kaye, K. S. (2014). Strategies to pre-vent surgical site infections in acute care hospitals: 2014 update. Infection Control & Hospital Epidemiology, 35 (6), 605-627. doi:10. 1086/676022 Berríos-Torres, S. I., Umscheid, C. A., Bratzler, D. W., Leas, B., Stone, E. C., Kelz, R. R.,... Schecter, W. P. (2017). Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surgery, 152 (8), 784-791. doi:10. 1001/jamasurg. 2017. 0904 Bratzler, D. W., Dellinger, E. P., Olsen, K. M., Perl, T. M., Auwaerter, P. G., Bolon, M. K.,... Weinstein, R. A. (2013). Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surgical Infections, 14 (1), 73-156. doi:10. 1089/sur. 2013. 9999 Spruce, L., & Van Wicklin, S. (2014). Back to basics: Positioning the patient. AORN Journal, 100, 299-303. doi:10. 1016/j. aorn. 2014. 06. 00419. Perioperative and Intraoperative Management
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373 20Postoperative Evaluation and Management John Hurt and Catherine Harris Scope of Chapter John Hurt and Catherine Harris The postoperative period is a vulnerable time for the patient. The advanced practice provider (APP) must perform a timely physical assessment, anticipate postoperative complications, manage surgical wounds, and treat pain. This section provides an overview on managing patients during this time frame. Outcomes John Hurt & Catherine Harris A. Patient assessment. B. Postoperative complications. C. Wound healing. D. Pain management. Patient Assessment A. Patient assessment. 1. Physical examination. 2. Vital signs. 3. Skin integrity. 4. Pain management. B. Two phases of the postanesthesia care unit (PACU). 1. Phase I: Patient assessment ensuring that a patient recovers fully from anesthesia and has return of normal vital signs; includes pain management and monitoring for postoperative complications. 2. Phase II: Focuses on wound assessment, patient com-fort, review of medications, and hand-off to the nurse from the inpatient unit. C. Hand-off communication. 1. Communication between the OR and PACU is crit-ical and should contain the following elements at mini-mum. a. Type of anesthesia used during case. b. Type of procedure performed and duration. c. Medications given in the OR. d. Positioning of patient. e. Intake and output including amount of estimated blood loss. f. Complications or unusual events during the case. g. Wound closure. h. Types of dressings, lines, and monitoring devices. D. Postoperative orders for inpatient stays. 1. Admit to team, physician, type of unit. 2. Diagnosis and procedure done. 3. Condition postoperatively. 4. Allergies. 5. Vital signs and frequency. 6. Activity. 7. Any specific nursing procedures such as wound care, when to notify house officer, or incentive spirometry. 8. Deep vein thrombosis (DVT) prophylaxis. 9. Intake and output, intravenous (IV) fluids, and drains. 10. Medications. 11. Any special laboratory tests and when they should be drawn. 12. Radiology per surgeon for postoperative evaluation of procedure. 13. Pain management. 14. Enhanced recovery after surgery (ERAS) guidelines. a. Diet—patients should be advanced to oral nutri-tion within the first 24 hours of uncomplicated surgery. Consider oral supplements with meals if unable to tolerate food. b. Early intake of oral fluids—offer day of surgery. c. Early removal of urinary catheters and discontin-uing IV fluids. d. Early ambulation—ambulate patient day of surgery as tolerated. e. Multimodal approach to opioid—sparing pain control and mitigate nausea and vomiting. f. Early discharge when possible. 15. Oxygen requirements. 16. Consults such as physical therapy, social work, dieti-cian. Common Postoperative Complications A. Pulmonary. 1. Tachypnea (respiratory rate >30 breaths/minute). a. Inadequate pain control. i. Supplemental analgesia if inadequate pain control. b. Laryngospasm. i. Jaw thrust/chin lift to promote airflow. c. Airway edema. i. May need to be reintubated for airway protec-tion. d. Negative pressure pulmonary edema. i. Provide positive pressure ventilation. e. Pulmonary embolism. i. Management depends on cardiopulmonary compromise. f. Fever. i. Add fluids and antipyretics as needed. 2. Bradypnea (respiratory rate <8 breaths/minute). a. Oversedated from anesthesia or narcotic use; typi-cally seen in PACU setting. Outcomes
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374 i. Consider adding anesthesia reversal agents if oversedated. B. Cardiovascular. 1. Hypotension (systolic blood pressure <90 mm Hg). a. Most often due to volume depletion, anesthetic medications (opioids, benzodiazepines, propofol), regional anesthesia techniques, and drug reactions to antibiotics. b. Management: Give crystalloid bolus, may start with 250 to 500 m L and reassess blood pressure. Repeat as needed to maintain adequate blood pres-sure and urine output. May need to add vasopressors if nonresponsive. Review anesthesia record for accu-rate reflection of intake and output. 2. Hypertension. a. Most commonly due to inadequate pain control and agitation emerging from anesthesia. b. Management: Provide analgesia to maintain blood pressure within defined parameters. 3. Dysrhythmias. a. Tachycardia (heart rate >100 beats/minute). 1. Typically due to pain, hypovolemia, or anemia from blood loss. b. Bradycardia (heart rate <40 beats/minute). 1. Usually due to reversal agents for neuromuscu-lar blockade such as neostigmine or regional anes-thesia techniques. 2. Hypoxemia and myocardial infarction can also cause bradycardia. c. Atrial fibrillation, atrial flutter, and ventricular tachycardia should be managed by Advanced Cardiac Life Support algorithms. For more information, refer to Chapter 3. C. Gastrointestinal. 1. Nausea/vomiting. a. Most common postoperative complication. b. Often rated worse than pain by patients. c. Management. 2. Elevate head of bed. 3. Antiemetic medication options. a. Serotonin receptor agonists: Ondansetron 4 mg IV. b. Glucocorticoids: Dexamethasone 4 to 8 mg IV. c. Anticholinergics: Scopolamine patch. d. Phenothiazines: Promethazine 5 to 10 mg IV. e. Butyrophenones: Droperidol 0. 625 mg IV or haldol 1 mg IV. D. Genitourinary. 1. Acute renal failure. a. Persistent oliguria and elevated creatinine. b. Management. i. May need diuretics if overloaded. ii. Need to balance effective circulating volume with output. iii. Avoid nephrotoxic agents. iv. Avoid contrast agents. 2. Urinary infection. a. Management. i. Early removal of urinary catheter. ii. Maintain adequate hydration. iii. Early ambulation. 3. Postoperative urinary retention (POUR). a. Risk greater in patients who: i. Have neuropathy or neurological damage. ii. Have chronic constipation. iii. Take anticholinergic medications. iv. Had bladder or anorectal procedures. v. Had long duration of anesthesia. vi. Use of opioid medications. b. Strategies to reduce risk. i. Adequate hydration perioperatively. ii. Early mobilization. iii. Use of commode. 4. Metabolic derangements. a. Monitor and replace electrolytes to maintain nor-mal values. i. Potassium. ii. Magnesium. iii. Phosphorous. b. Maintain acid base balance. E. Postoperative pain control. 1. Early intervention and better pain management essential. 2. Untreated surgical pain can limit cough and deep breathing, which contributes to a decrease in alveolar ventilation. 3. Inadequate relief may result in psychological changes such as: a. Minor depression. b. Pain-related catastrophizing. c. Chronic postsurgical pain. F. Neuropsychiatric. 1. Transient ischemic attack or stroke. a. Avoid ischemia. b. Avoid hypotension or hypertension. 2. Delirium during emergence is highest during the first hour postanesthesia. a. Management. i. Reassurance with familiar family/friends at the bedside. ii. Assess for signs of uncontrolled pain and treat. iii. Consider low-dose benzodiazepine for sedation. 3. Discharge from PACU. a. Postanesthetic Discharge Scoring System (PADSS): Score of 9 or greater can be safely dis-charged to the accepting unit. Vital Signs 0=Blood pressure and pulse ≥40% preoperative base-line. 1=Blood pressure and pulse 20%-40% preoperative baseline. 2=Blood pressure and pulse <20% preoperative base-line. Activity 0=Unable to ambulate. 1=Requires assistance. 2=Ambulates without assistance, no dizziness. Nausea and Vomiting 0=Severe/continuous despite treatment. 1=Moderate/treated with parenteral medications. 2=Minimal/treated with oral medications. Pain Controlled with Oral Analgesics and Acceptable by Patient 1=No. 2=Yes. 20. Postoperative Evaluation and Management
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375Surgical Bleeding 0=Severe, or ≥3 dressing changes. 1=Moderate, or up to 2 dressing changes. 2=Minimal, or no dressing changes. Source:Reproducedwithpermissionfrom Chung,F.,Ghan,V. W. S.,& Ong,D. (1995). Apost-anestheticdischargescoringsystemforhome readiness after ambulatory surgery. Journal of Clinical Anesthesia, 7, 500-506. doi:10. 1016/0952-8180(95)00130-A G. Fever. 1. Fever is a common complication after surgery that can be attributed to many different causes. Always consider the following. a. Fever immediately after surgery. i. Atelectasis (“Wind”). ii. Medication reactions (“Wonder Drugs”). iii. Endocrine emergencies (“Wonky Glands”). b. Fever 48 to 72 hours after surgery. i. Urinary tract infection (“Water”). ii. Wound infection (“Wound”). iii. DVT (“Walking”). iv. Alcohol or drug reactions (“Withdrawal”). H. DVT. 1. Patients should be encouraged to ambulate as early and as often as safely possible. a. Improves pulmonary function, prevents atelecta-sis, prevents DVT. 2. Optimal timing for pharmacological thrombopro-phylaxis in nonorthopedic patients is unknown and should be individualized. 3. If risk of bleeding is low, pharmacological agents can begin 2 to 12 hours preoperatively. 4. Initiate pharmacological treatment for DVT preven-tion in patients not considered suitable for preoperative pharmacological thromboprophylaxis or who have a high risk of bleeding 2 to 72 hours postoperatively. a. Low-dose unfractionated heparin. b. Low molecular weight heparin. c. Factor Xa inhibitors and direct thrombin inhibitors are used less commonly for DVT pro-phylaxis and more frequently in patients with allergy to heparin or in some vascular patients for full treat-ment. 5. The Modified Caprini Risk Assessment Score provides an individualized risk assessment for DVT prevention (see Table 20. 1). Bibliography Aarts, M. A., Okrainec, A., Glicksman, A., Pearsall, E., Victor, J. C., & Mc Leod, R. S. (2012). Adoption of enhanced recovery after surgery (ERAS) strategies for colorectal surgery at academic teaching hospitals and impact on total length of hospital stay. Surgical Endoscopy, 26 (2), 442-450. doi:10. 1007/s00464-011-1897-5 Apfel, C. C., Korttila, K., & Abdalla, M. (2004). A factorial trial of six inter-ventions for the prevention of postoperative nausea and vomiting. The New England Journal of Medicine, 350 (24), 2441-2451. doi:10. 1056/ NEJMoa032196 Apfelbaum, J. L., Silverstein, J. H., & Chung, F. F. (2013). Practice guide-lines for postanesthetic care: An updated report by the American Soci-ety of Anesthesiologists task force on postanesthetic care. Anesthesiology, 118(2), 291-307. doi:10. 1097/ALN. 0b013e31827773e9 Caprini, J. A. (2005). Thrombosis risk assessment as a guide to qual-ity patient care. Disease-a-Month, 51, 70-78. doi:10. 1016/j. disamonth. 2005. 02. 003Caprini, J. A. (2010). Risk assessment as a guide for the prevention of the many faces of venous thromboembolism. American Journal of Surgery, 199(Suppl. 1), S3-S10. doi:10. 1016/j. amjsurg. 2009. 10. 006 Chung, F., Ghan, V. W. S., & Ong, D. (1995). A post-anesthetic discharge scoring system for home readiness after ambulatory surgery. Journal of Clinical Anesthesia, 7, 500-506. doi:10. 1016/0952-8180(95)00130-A Gould, M. K., Garcia, D. A., Wren, S. M., Karanicolas, P. J., Arcelus, J. I., Heit, J. A.,... Samama, C. M. (2012). Prevention of VTE in non-orthopedic surgical patients antithrombotic therapy and pre-vention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 141 (2), e227S-e277S. doi:10. 1378/chest. 11-2297 Macario, A., Weinger, M., Carney, S., & Kim, A. (1999). Which clinical anesthesia outcomes are important to avoid? The perspective of patients. Anesthesia and Analgesia, 89 (3), 652-658. Maday, K. R., Hurt, J. B., Harrelson, P., & Porterfield, J. (2016). Evaluating postoperative fever. Journal of the American Academy of PAs, 29 (10), 23-28. doi:10. 1097/01. JAA. 0000496951. 72463. de Whitlock, E. L., Vannucci, A., & Avidan, M. S. (2011). Postoperative delir-ium. Minerva Anestesiologica, 7 (4), 448-456. Wound Management John Hurt and Catherine Harris Infection Prevention A. Surgical site infections (SSI). 1. Can be superficial (skin/subcutaneous tissue), deep (muscle/fascia), or organ and surrounding space specific. 2. Occurs within 30 days of surgery. 3. Majority of cases of SSI superficial infections (83%), deep infections (7%), and the rest were organ-specific infections. 4. Factors associated with SSI. a. Previous surgery. b. Prolonged surgery time. c. Hypoalbuminemia. d. History of chronic obstructive pulmonary disease (COPD). e. Obesity. f. Diabetes. g. American Society of Anesthesiologists (ASA) score. h. Wounds classified as “dirty. ” i. Type of surgical procedure such as bowel surgery may increase risk of infection. 5. Organisms associated with SSI. a. Staphylococci. b. Streptococci. c. Enteric bacilli; enterococci. d. Pseudomonas. e. Clostridia. f. Mycobacterium tuberculosis. g. Multidrug-resistant organisms. 6. Prevention strategies. a. Standard precautions. b. Perioperative antibiotics. i. Administer 1 hour before skin incision. ii. Discontinue within 24 hours. c. Clip operative site, but avoid shaving. d. Control of perioperative glucose values less than 180 mg/d L. e. Aseptic technique. B. Classification of surgical wounds. 1. Class I: Clean—uninfected operative wound. Wound Management Kearon, C., Akl, E., Ornelas, J., Blaivas, A., Jimenez, D., Bounameaux, H.,... Moores,L. (2016). Antithrombotictherapyfor VTEdisease. Chest, 149, 315-352. doi: CHESTGuideline and expert panel report. 10. 1. 16/j. chest. 2015. 11. 026
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376 TABLE 20. 1 Modified Caprini Risk Assessment Score 1 Point 2 Points 3 Points 4 Points Age41-60 years Age61-74 years Age≥75years Strokewithin 1 month Minorsurgery Arthroscopicsurgery Historyof VTE Electivearthroplasty BMI≥25 Majoropen surgery Familyhistory of VTE Pelvis,hip, or leg fracture Swollenlegs Laparoscopicsurgery Geneticclotting disorder Acutespinal cordinjury Varicoseveins Malignancy Pregnancy/postpartum Confinedto bed >72hr Historyof spontaneous abortion Lowerextremityimmobilization Oralhormone medication Centralvenous access Historyof sepsis <1month Underlyinglung disease Abnormalpulmonary function Historyof AMI CHF Historyof IBD Score Surgical Risk Intervention for DVT Prevention 0 Verylow Early mobilization 1-2 Low Early mobilization +mechanical compression devices 3-4 Moderate Pharmacologic prophylaxis ≥5 High AMI, acute myocardialinfarction;CHF,congestive heart failure;DVT,deep vein thrombosis;IBD, inflammatory bowel disease; VTE, venous thromboembolism. Sources: Caprini, J. A. (2005). Thrombosisrisk assessment as a guide to quality patient care. Disease-a-Month, 51,70-78. doi:10. 1016/j. disamonth. 2005. 02. 003; Kearon,C., Akl, E., Ornelas, J., Blaivas, A., Jimenez, D., Bounameaux, H.,... Moores,L. (2016). Antithrombotictherapy for VTE disease. CHEST Guideline and expert panel report. Chest, 149,315-352. doi:10. 1016/j. chest. 2015. 11. 026 2. Class II: Clean-contaminated—operative wound in which respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions. 3. Class III: Contaminated—open, fresh, accidental wounds; major breaks in sterile technique; gross spillage from gastrointestinal tract; incisions in acute nonpuru-lent inflammation is encountered. 4. Class IV: Dirty/infected—old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera; organisms present before procedure. C. Wound healing. 1. Classified by etiology. a. Surgical. b. Traumatic. 2. Classified by initial presentation. a. Closed wound (preferred). b. Open wound (based on amount of tissue lost). 3. Types of wound healing. a. Primary intention—wound is clean, little loss of tissue. i. Preferred technique. ii. Heals quickly with minimal scarring. b. Secondary intention—occurs in open wounds due to difficulty of reapproximating edges secondary to amount of tissue loss. i. Granulation tissue fills defect. ii. Healing takes longer. iii. Results in more scarring. 1)May inhibit normal physiologic function in that area. c. Tertiary intention. i. Delayed primary closure. ii. Cannot close wound due to concern for infection. iii. Wound remains open until resolution of infection. iv. Increased granulation and inflammatory reaction compared to primary intention. 4. Factors that delay wound healing. a. Age. b. Immunosuppressed states. i. HIV/AIDS. ii. Diabetes. iii. Cancer. c. Autoimmune disorders. d. Altered nutritional status. e. Smoking. f. Anemia. g. Inadequate oxygenation (i. e., COPD). h. Vascular disease. 5. Medications that impair wound healing. a. Anticoagulants. b. Anti-inflammatory agents (aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs]). c. Steroids. d. Colchicine. 20. Postoperative Evaluation and Management
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377 6. Herbal medicines that may impair wound healing. a. Ephedra—increases heart rate and blood pressure. b. Feverfew—inhibits platelet activity. c. Garlic—inhibits platelet aggregation. d. Gingko—inhibits platelet activation. e. Nicotine—impairs oxygen delivery. D. Wound assessment. 1. Dressings. a. Applied under sterile conditions in the OR. b. Prevent contamination of wound. c. Protect wound from further trauma. d. Absorb exudate. e. Provide physical support. 2. High risk patients may require wound care consult. 3. Compressive wraps must not impair blood flow. a. Assess for: i. Pulses. ii. Cyanosis. iii. Capillary refill. iv. Temperature of body around dressing. 4. Types of dressings. a. Primary intention closure. i. Transparent polyurethane dressings. 1)Protect wound. 2)Check incision site without disturbing dressing. 3)Can be left in place for 3 to 5 days. ii. Semipermeable films. 1)Provides a barrier against bacteria. iii. Surgical glue. b. Secondary intention closure. i. Alginates. 1)Maintains moist wound surface. 2)Removal of cellular debris. ii. Polyurethane foams. 1)Absorbent. 2)Maintains optimum healing environ-ment. 3)Reduces trauma during dressing changes. iii. Hydrocolloids. 1)Absorbent. 2)Maintains moist wound surface. iv. Hydrogels. 1)Rehydration of tissues. 2)Some absorbency. v. Low-adherent wound contact layers. 1)Minimizes risk of trauma at wound surface. 2)Decreases pain during dressing change. vi. Antimicrobial carrying dressings. 1)Stimulates immune system for wound healing. Mu, Y., Edwards, J. R., Horan, T. C., Berrios-Torres, S. I., & Fridkin, S. K. (2011). Improving risk-adjusted measures of surgical site infection for the National Healthcare Safety Network. Infection Control & Hospital Epidemiology, 32 (10), 970-986. doi:10. 1086/662016 National Collaborating Centre for Women's and Children's Health (UK). (2008). Surgical site infection: Prevention and treatment of surgical site infection. London, UK: RCOG Press. National Healthcare Safety Network, Centers for Disease Control and Pre-vention. (2019, January). Surgical site infection (SSI) event. Retrieved from http://www. cdc. gov/nhsn/pdfs/pscmanual/9pscssicurrent. pdf Medication Management John Hurt and Catherine Harris Pain Management A. Should be a multimodal approach. B. Types of pain. 1. Nociceptive pain. a. Somatic pain—associated mostly with surgery, results from damage to connective tissue, muscle, bone, and skin. b. Visceral pain—associated with pain in internal organs. 2. Can be described as aching, pressure, or sharp. 3. Associated with periosteum, joints, muscle injury, colic, and muscle spasm. 4. Can have effects on various systems such as: a. Cardiovascular—increased heart rate and blood pressure. b. Pulmonary—decreased deep breathing. c. Endocrine—decrease in insulin production, fluid retention. d. Metabolic—increased blood sugar. e. Gastrointestinal—delayed gastric emptying, nausea, decreased motility, and potential for ileus. 5. Neuropathic pain—may result from injury to nerves during surgery. 6. Psychogenic pain—may be due to psychological factors that exaggerate pain problem. C. Assessment of pain. 1. Wong-Baker Visual Analog Scale—uses pictures to help the patients express how much pain they are in. 2. Numerical rating scale—rating scale that rates pain from 0 to 10 with 0 being no pain and 10 being the worst pain imaginable. 3. Verbal rating scale—patient reports pain on four possible points: No pain, mild pain, moderate pain, severe pain. 4. Elements of pain assessment. a. Onset and pattern of pain. b. Location. c. Quality of pain. d. Intensity of pain. e. Aggravating or relieving factors. f. Previous treatment. g. Effect on physical function, emotional distress. h. Consider barriers that might affect reliability of pain assessment. D. Nonpharmacological management of pain. 1. Relaxation therapy. 2. Hypnosis. 3. Cold or heat. 4. Splinting of wounds. 5. Compression binders. 6. Teach patient about benefits of transcutaneous elec-trical nerve stimulation (TENS unit) and acupuncture in the outpatient setting. Medication Management Bibliography Anderson, K., & Hamm, R. (2012). Factors that impair wound healing. Journal of the American College of Clinical Wound Specialists, 4 (4), 84-91. doi:10. 1016/j. jccw. 2014. 03. 001 Berríos-Torres, S. I., Umscheid, C. A., Bratzler, D. W., Leas, B., Stone, E. C., Kelz, R. R.,... Schecter, W. P. (2017). Centers for Disease Control and Prevention guideline for the prevention of surgical site infection. JAMA Surgery, 152 (8), 784-791. doi:10. 1001/jamasurg. 2017. 0904 Dumville,J.,Gray,T.,Walter,C.,Sharp,C.,Page,T.,Macefield,R.,&... Blazeby, J. (2016). Dressings for the prevention of surgical site infec-tion. Cochrane Database of Systematic Reviews, 2016 (12). doi:10. 1002/ 14651858. CD003091. pub4 Maver, T., Maver, U., Kleinschek, S., Smrke, D., & Kreft, S. (2015). A review of herbal medicines in wound healing. International Journal of Dermatology, 54 (7), 740-751. doi:10. 1111/ijd. 12766
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378 E. Pharmacological management of pain. 1. World Health Organization (WHO) analgesic ladder. a. Mild pain—nonopioids. b. Moderate pain—use weak opioids with or without nonopioids. c. Severe pain—use strong opioids with or without nonopioids. 2. Pain medication options. a. Nonopioids. i. Nonsteroidal anti-inflammatory drugs (NSAIDs): Use cautiously due to their anti-platelet effect and concern for delayed bone heal-ing and acute renal failure. Caution in elderly, may need to adjust doses. ii. NSAIDs such as ketorolac are commonly used after major orthopedic surgery and spine surgery. They are highly effective, but carry the perceived risk of increased bleeding. To date there are NO human studies that exist to support this belief, only animal studies. NSAID use remains contro-versial after surgery. 1)Ketorolac: 15 to 30 mg every 6 ×48 hours. 2)Ibuprofen: 800 mg every 8 hours. 3)Diclofenac: 50 mg every 8 hours. iii. Acetaminophen: 1,000 mg every 6 hours— maximum dosage per day is 4 g in a patient with-out liver dysfunction. iv. Adjuvant medications. 1)Steroids such as dexamethasone. 2)Antidepressants such as nortriptyline, desipramine, and amitriptyline. 4)N-methyl-D-aspartate (NMDA) receptor antagonists for neuropathic pain—ketamine infusion. 5)Cannabinoids. 6)Lidocaine patch. 7)Lidocaine infusion. b. Opioids—weak. i. Codeine oral 30 mg every 4 to 6 hours. ii. Tramadol oral 50 to 100 mg every 4 to 6 hours. iii. Propoxyphene oral 100 mg every 4 hours. iv. Oxycodone low dose oral 5 mg every 4 to 6 hours. v. Hydrocodone oral 5 to 10 mg every 4 to 6 hours. 1)Contains acetaminophen and needs to be calculated in 4 g/day limit. c. Opioids—strong. i. Morphine intravenous (IV) 5 to 10 mg q3 hours. ii. Fentanyl IV 25 mg per hour for breakthrough. iii. Hydromorphone IV 1 to 2 mg q3 hours. 1)Elderly patients consider starting with 0. 25 to 0. 5 mg. iv. Oxycodone high dose oral—10 to 15 mg every 4 hours. d. Special considerations of opioid use in the elderly. i. Start with low doses. ii. Consider longer dosing intervals. iii. Slow titration to find optimal dose. e. Interventional therapy. i. Nerve blocks. ii. Epidural analgesia with or without opioids. iii. Spinal analgesia (intrathecal opioid). F. Delivery of pain medications. 1. Oral is preferred route of delivery for patients who can take oral medications. a. Scheduled. b. PRN. 2. Subcutaneous. a. Good absorption. b. Onset more rapid. c. Can have longer duration of action. d. Be aware that absorption may be unpredictable, especially if the peripheries are poorly perfused. 3. Intravenous push. a. Scheduled. b. PRN. 4. Patient-controlled analgesia (PCA) pumps. a. Used when parenteral route is needed for systemic analgesia for more than a few hours. b. Avoid basal rate in opioid naïve adults. c. Dosed until pain relief, or patient becomes symptomatic—increased somnolence, hypoxemia, or hypotension. Bibliography American Society of Anesthesiologists Task Force on Acute Pain Manage-ment. (2012). Practice guidelines for acute pain management in the peri-operative setting: An updated report by the American Society of Anes-thesiologists task force on acute pain management anesthesiology. Anes-thesiology, 116 (2), 248-273. doi:10. 1097/ALN. 0b013e31823c1030 Buvanedran, A., & Kroin, J. S. (2009). Multimodal analgesia for controlling acute postoperative pain. Current Opinion Anesthesiology, 22 (5), 588-593. doi:10. 1097/ACO. 0b013e328330373a Dahl, J. B., Nielsen, R. V., Nikolajsen, L., Hamunen, K., Kontinen, V. K., Hansen, M. S.,... Mathiesen, O. (2014). Postoperative analgesic effects of paracetamol, NSAID's, glucocorticoids, gabapentinoids and their combination: A topical review. Acta Anaesthesiologica Scandinav-ica, 58 (10), 1165-1181. doi:10. 1111/aas. 12382 De Cosmo, G. (2015). The use of NSAIDs in the postoperative period: Advantages and disadvantages. Journal of Anesthesia & Critical Care, 3(4), 00107. doi:10. 15406/jaccoa. 2015. 03. 00107 Garimella, V., & Cellini, C. (2013). Postoperative pain control. Clinics Colon Rectal Surgery, 26 (3), 191-196. doi:10. 1055/s-0033-1351138 Roden, A., & Sturman, E. (2009). Assessment & management of patients with wound-related pain. Nursing Standard, 23 (45), 53-62. doi:10. 7748/ns. 23. 45. 53. s52 World Health Organization. (2009). WHO's pain relief ladder. Retrieved from http://www. who. int/cancer/palliative/painladder/en World Union of Wound Healing Societies. (2007). Principles of best practice: Minimizing pain at wound dressing-related procedures. A consensus docu-ment Toronto:Wound Pedia. 20. Postoperative Evaluation and Management 3)Anticonvulsants—gabapentin,pregabalin, and carbamazepine..
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Adult-Gero Acute Care Practice Guideline by Catherine Harris Ph.d. z-lib.org 1.pdf
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III Procedures ■Ankle-Brachial Index Measurement ■Arterial Lines ■Bone Marrow Aspiration and Biopsy ■Bronchoscopy ■Central Venous Access ■Chest Tube Insertion ■Chest Tube Removal ■Digital Nerve Blocks ■Extracorporeal Membrane Oxygenation ■Endotracheal Intubation ■Endotracheal Extubation ■External Ventricular Drain ■Intraosseous Vascular Access■Long Leg Casting ■Lumbar Puncture ■Peripherally Inserted Central Catheter Placement ■Reduction of the Ankles ■Reduction of the Fingers ■Reduction of the Hip ■Reduction of the Patella ■Reduction of the Shoulder ■Splinting ■Synovial Fluid Aspiration ■Thoracentesis ■Transpyloric Feeding Tube Placement
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Adult-Gero Acute Care Practice Guideline by Catherine Harris Ph.d. z-lib.org 1.pdf
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Adult-Gero Acute Care Practice Guideline by Catherine Harris Ph.d. z-lib.org 1.pdf
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381 PROCEDURE ANKLE-BRACHIAL INDEX MEASUREMENT Kelly Cimino Procedure: Ankle-Brachial Index Measurement DESCRIPTION A. A tool used to objectively detect the presenceof lower-extremityperipheral arterial disease (PAD). B. Comparesthe blood pressuremeasuredin the ankles with that of the arms. INDICATIONS A. Primary caresetting. 1. Used in a symptomatic patient, to diagnose PAD. 2. Used in an asymptomatic patient, to assess the vascular risk for PAD. B. Emergencyor trauma setting. 1. Useful to evaluate patients at risk for lower-extremityarterial injury,as follows. 2. Anankle-brachialindex(ABI)lessthan0. 90suggestsaneedforfurthervascularimaging:Angiographyinastable patient, and operative exploration in an unstable patient. 3. An ABIgreaterthan0. 90decreasedthelikelihoodofanarterialinjury;thus,thepatientmaybeobservedwithserial ABI assessments or may undergoa vascular study on a delayed basis. PRECAUTIONS A. ABI measurementis contraindicated in the following patients. 1. Patients with the presence of deep vein thrombosis. Obtaining an ABI measurement could lead to a thrombus dislodgement. 2. Patients with excruciating pain in their legs. EQUIPMENT REQUIRED A. Blood pressurecuff—appropriatesize for upper and lower extremities. B. Sphygmomanometer. C. Doppler device. D. Ultrasound transmission gel. E. Examination table. PROCEDURE A. Place the patient in the supine position, with the arms and legs at the same level as the heart, for a minimum of 10 minutes beforemeasurement. B. Obtain brachial systolic pressuresof both arms using the Doppler device. C. Choose the higher of the two values as the “brachial systolic pressure. ” D. Obtaintheposteriortibialanddorsalispedissystolicpressuresoftheextremityinquestion,andchoosethehigherof the two values as the “ankle pressuremeasurement”(see Figure1). E. Divide the ankle pressureby the brachial artery pressure;the resultis the ABI. EVALUATION AND RESULTS A. Valuesobtained for the ABI areinterpretedin Table1. CLINICAL PEARLS A. Patientswhoareunabletoremainsupineforthedurationoftheexaminationarenotcandidatesforanadequate ABI. B. Anyformofsedativeoranestheticmayaffecttheaccuracyoftheexaminationbecauseoftheeffectonbloodpressure. C. Patients with an ABI less than 0. 90 have a higher risk of coronary artery disease, stroke, and death, and therefore should be referredto a credentialedvascular laboratory for further testing. D. Claudication is a specific, but not a sensitive, finding in patients with PAD. 1. One study reports that up to 90% of patients with a documented ABI of less than 0. 90 did not report claudication as a symptom. (continued )
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382 PROCEDURE ANKLE-BRACHIAL INDEX MEASUREMENT (continued ) Brachial artery Ultrasound device Blood pressure cuff FIGURE 1 Ankle-brachial index test. E. An ABI of 0. 91 to 0. 99 is borderline. 1. Thepatientmaybeasymptomaticatrest,butmayexperiencesymptomsrelatedtothecompromisedvascularflow when ambulating. 2. Exercisetest may help evaluate a patient who has borderline ABI results. F. Heavily calcified vessels may falsely elevate ankle pressuremeasurements,providinga false positive. BIBLIOGRAPHY Bailey, M. A., Griffin, K. J., & Scott, D. J. (2014, December). Clinical assessment of patients with peripheral arterial disease. Seminars in Interventional Radiology, 31 (4),292-299. doi:10. 1055/s-0034-1393964 Davies,J. H.,Kenkre,J.,&Williams,E. M. (2014,April17). Currentutilityoftheankle-brachialindex(ABI)ingeneralpractice:Implications for its use in cardiovasculardisease screening. BMC Family Practice, 15,69. doi:10. 1186/1471-2296-15-69 Ferket,B. S.,Spronk,S.,Colkesen,E. B.,&Hunink,M. G. (2012). Systematicreviewofguidelinesonperipheralarterydiseasescreening. The American Journal of Medicine, 125 (2),198. doi:10. 1016/j. amjmed. 2011. 06. 027 Rooke,T. W.,Hirsch,A. T.,Misra,S.,Sidawy,A. N.,Beckman,J. A.,Findeiss,L. K.,... Zierler,R. E. (2011,November1). 2011ACCF/AHA focusedupdateoftheguidelineforthemanagementofpatientswithperipheralarterydisease(updatingthe2005guideline):Areport of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 58 (19), 2020-2045. doi:10. 1016/j. jacc. 2011. 08. 023Procedure: Ankle-Brachial Index Measurement Interpretation of Values Obtained for the ABI ABI Reading Interpretation of the ABI for PAD 1. 00-1. 29 Normal 0. 91-0. 99 Borderline 0. 41-0. 90 Mild to moderate disease—sufficientto cause claudication ≤0. 40 Severedisease—sufficientto cause restingpain or gangrene ≥1. 30 Noncompressibledisease—severelycalcified vessel Source:Data from Rooke, T. W.,Hirsch, A. T.,Misra, S., Sidawy,A. N., Beckman, J. A., Findeiss, L. K.,... Zierler,R. E. (2011, November 1). 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): A reportof the American College of Cardiology Foundation/American Heart Association Task Forceon Practice Guidelines. Journal of the American College of Cardiology, 58 (19), 2020-2045. doi:10. 1016/j. jacc. 2011. 08. 023 TABLE 1
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Adult-Gero Acute Care Practice Guideline by Catherine Harris Ph.d. z-lib.org 1.pdf
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383 PROCEDURE ARTERIAL LINES Heather Warren Cook Procedure: Arterial Lines DESCRIPTION A. Insertion of arterial catheter. 1. Radial. 2. Brachial. 3. Femoral. 4. Dorsalis pedis. 5. Axillary. INDICATIONS A. Frequentblood gas monitoring: Patient in respiratorydistressor metabolic derangements. B. Continuous blood pressuremonitoring. 1. Sepsis. 2. Patient on vasopressors. C. Continuous monitoring of cardiacoutput and strokevolume. PRECAUTIONS A. When inserting an arterial line therearea few precautionsto be awareof. B. Pain at the insertion site may cause the patient to pull away or move the arm. C. Bleeding can occur with arterial punctures and multiple attempts, especially if the patient is on anticoagulants or antiplatelet agents; holding pressurewith the arm elevated may help hemostasis to occur. D. Any puncturethroughthe skin can provideaccess for potential infection. E. Hematomas can occur at the insertion site. 1. Nervesrunlaterallyalongarteriesandcanbeinjuredduringinsertion;makesuretopalpatethepulsewheninserting the arterial catheter (see Figures1 and 2). EQUIPMENT REQUIRED A. Sterile gloves. B. Sterile gauze/towels. C. Sterile drape. D. Sterile clear adhesive dressing. E. Chlorhexidine/Betadine for skin preparation. (continued ) Aorta Inferior vena cava External illiac vein Inguinal ligament Femoral triangle Femoral nerve Femoral artery Sartorius muscle Anterior superior illiac spine Femoral vein Symphysis pubis Greater saphenous vein Adductor longus muscle FIGURE 1 Illustration depicting femoral anatomy. F. Appropriatecatheter size for cannulation of the artery. G. Sutures.
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384 PROCEDURE ARTERIAL LINES (continued ) H. Adhesive tape. I. Arm-board. J. Pressuretubing. K. 500 to 1,000 m L 0. 9 NSS bag. L. Pressurebag for 0. 9 NSS bag. M. 1% Lidocaine 5 m L vial. N. Pressuretubing. O. Transducer. PROCEDURE A. Arteriallineplacementistypicallydoneatthebedsidewhilethepatientisinasupineposition. Anyarteriallineplace-ment collateral blood flow to the limb should be checked. For example: Perform the Allen test on the wrist prior to radial artery cannulation. B. Explain the procedureto the patient and family. C. Obtain informed consent unless the procedureis an urgent/emergentneed. D. Washhands/perform hand hygiene. E. Perform a procedural“time out” with the nursing staff. F. Perform Allen test/check pulses. G. R/L extremityis supinated. H. Position patient with tape and arm-board(if using radial). I. Sterilize areawith chlorhexidine/Betadine as per protocol. J. Place sterile drape over the extremity. K. Open all equipment needed for cannulation. L. Have pressurebag/saline/transducer cordpreparedby RN for monitoring. (continued )Procedure: Arterial Lines Super/f_icial palmar arch Deep palmar arch Ulna Ulnar nerve Ulnar artery Radius Radial artery Cephalic vein Tendon of /f_lexor carpi radialis Median nerve FIGURE 2 Illustration depicting radial anatomy.
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385 PROCEDURE ARTERIAL LINES (continued ) Procedure: Arterial Lines M. Don sterile gloves, personal protectiveequipment, and goggles/face shield. N. Palpate pulse and visualize with bedside ultrasound. O. Inject aroundthe site with 1% lidocaine to numb the area. P. Using the appropriate catheter with introducer needle, hold with dominant hand (like a pencil) at a 35∘angle to the extremity. Q. Insert needle below areaof palpation and view window of catheter for a flash of blood. R. Simultaneously,visualize needle advancement into vessel lumen with bedside ultrasound (see Fig ure 3). S. After obtaining flash, using the nondominant hand advance the wire to secure the position of the catheter (the wire should advance smoothly). T. Slowly advance the catheter over the wire/needleinto the vessel. U. Hold pressureabove the catheter insertion site and removethe wire/needle. V. Attach pressuretubing and view monitor for an appropriatewaveform. W. Once this is confirmed, sutureline in place and cover insertion site with sterile clear adhesive dressing. X. Remove sterile drape and dispose of all sharps in sharps container. Y. Document procedure,number of attempts, and any complications in the patient'srecord. EVALUATION AND RESULTS A. Have the nurse level, zero,and flush the arterial line showing the squarewave test and adequate whip. B. Assess the arterial waveform for the systolic upstroke,dicroticnotch, and diastolic runoff. C. Thelineisnowusefulforcloserbloodpressuremonitoring,trendingarterialbloodgasses,anddrawingfrequentlabs in the critically ill patient. (continued ) FIGURE 3 Ultrasound-guidedinsertion of a radial arterialcatheter.
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386 PROCEDURE ARTERIAL LINES (continued ) CLINICAL PEARLS A. Notify the nurse prior to performing procedure. B. Always perform “time out” prior to any procedure. C. Have all of the equipment needed for the procedureset up and opened beforedonning sterile gloves. D. Hold firm pressure or cover catheter opening with thumb, preventing pulsatile blood from coming out of the catheter beforeattaching pressuretubing. E. If hematoma occurs, hold firm pressureand apply pressuredressing. F. Always start at the most distal place on the extremityif possible. BIBLIOGRAPHY Koyfman, A., Radwine, Z., & Sawyer, J. L. (2018, March 16). Arterial line placement. In V. Lopez Rowe (Ed. ), Medscape. Retrieved from https://emedicine. medscape. com/article/1999586-overview Tegtmeyer,K.,Brady,G.,Lai,S.,Hodo,R.,&Braner,D. (2006). Placementofanarterialline. The New England Journal of Medicine, 354, e13. doi:10. 1056/NEJMvcm044149Procedure: Arterial Lines
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387 PROCEDURE BONE MARROW ASPIRATION AND BIOPSY Jerrad M. Stoddard DESCRIPTION A. Bone marrow. 1. Consists of hematopoietic stem cells, which produce red blood cells, white blood cells, and platelets. 2. Found in axial bones including the sternum, ribs, vertebral bodies, skull, and pelvis. B. Used for the diagnosis and staging of hematologic conditions/malignancies, such as aplastic anemia, multiple myeloma, leukemias, and lymphomas. C. Bone marrow examination includes the assessment of bone marrow cellularity (age dependent), cellular morphology, and maturation. D. Ancillary tests are often performed on a bone marrow specimen. 1. Cytogenetics. 2. Fluorescent in situ hybridization (FISH). 3. Molecular testing. INDICATIONS A. Evaluation of unexplained abnormal peripheral blood counts or suspected hematologic disease. B. Diagnosis and staging of lymphoma or solid tumors. C. Evaluation of fever of unknown origin. PRECAUTIONS A. Primary risks of the procedure are bleeding or infection. B. Absolute contraindications include uncorrected coagulopathies or thrombocytopenia. 1. Disseminated intravascular coagulopathy. 2. Severe hemophilia. 3. Severe thrombocytopenia (platelet count <10,000/ μL). C. The only relative contraindication is anticoagulation. 1. Consider holding anticoagulation (if clinically appropriate) prior to procedure. 2. Anticoagulants can be resumed the day after the bone marrow procedure. 3. MD Anderson guidelines for holding common anticoagulants are listed in Table 1. D. Patients with suspected multiple myeloma should NEVER undergo sternal aspiration due to bone fragility and risk of sternal perforation. E. Assess for allergies to anesthetics (e. g., lidocaine). EQUIPMENT REQUIRED A. Bone marrow aspiration/biopsy kits contain all required materials, as noted in steps C and D in the text that follows. B. Anxiolytics (e. g., midazolam or alprazolam) if patient is anxious. C. Equipment required for procedure. 1. Sterile gloves. 2. Drape for sterile field. 3. Iodine or chlorhexidine solution. 4. Buffered lidocaine (1% or 2%) ±epinephrine solution. 5. Luer lock syringes. a. 5 m L syringe for local anesthesia. b. 20 m L syringe for aspiration. 6. Needles for local anesthesia. a. ∼25 ga ×5/8² needle for subcutaneous administration. b. ∼20 ga ×1-1/2² needle for deep administration. 7. Sterile gauze and bandages. 8. Bone marrow needle with stylet for aspiration. 9. Jamshidi biopsy needle with stylet. D. Equipment required for obtained specimens. 1. All tubes and slides should be labeled with patient information. 2. Labeled collection tubes. 3. Labeled glass slides and coverslips. 4. Petri dish and pipette. (continued ) Procedure: Bone Marrow Aspiration and Biopsy
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388 PROCEDURE BONE MARROW ASPIRATION AND BIOPSY (continued ) PROCEDURE A. Can be performed on posterior iliac crest (most common), anterior iliac crest, sternum, or tibia. As bone marrow aspiration and biopsy on sites other than the posterior iliac crest are not commonly performed, the focus of this procedure will be on the preferred site of the posterior iliac crest. B. Sternal biopsies are contraindicated, and only aspiration can be performed. C. Some facilities use ultrasound or CT guided aspirations/biopsies; however, the procedure is commonly done with palpation alone. D. The procedure. 1. Explain the procedure to the patient and family and obtain informed consent. 2. Wash hands/perform hand hygiene. 3. Perform a proper time out. All present in the room must identify the patient and agree on the correct procedure and correct site of the procedure. 4. Administer premedications (e. g., alprazolam) if needed. 5. Position patient in prone (recommended) or lateral decubitus position. 6. Palpate for posterior iliac crest. 7. Select and mark site. a. Approximately three finger widths from the midline and two finger widths (see Figure 1A, B) inferior to the posterior iliac crest. b. Avoid areas concerning for skin or soft tissue infection (e. g., erythema or induration). 8. Using sterile technique, open the bone marrow tray and inspect all components. 9. Cleanse the marked area with povidone-iodine solution or chlorhexidine and drape the sterile field. 10. Anesthetize the skin and subcutaneous tissue of the marked site with 1% or 2% lidocaine solution using a 23-gauge needle. a. Perform aspiration. (continued )Procedure: Bone Marrow Aspiration and Biopsy TABLE 1 Guidelines for Holding Anticoagulation Prior to Bone Marrow Procedure Medication When to Hold Aspirin or NSAIDs No need to hold Heparin products Heparin Enoxaparin (Lovenox) Dalteparin (Fragmin)Morning of procedure Factor Xa inhibitors Apixaban (Eliquis) Rivaroxaban (Xarelto) Fondaparinux (Arixtra)2 days prior to procedure Direct thrombin inhibitors (univalent) Argatroban (Acova) Dabigatran (Pradaxa)2 days prior to procedure Warfarin (Coumadin) 3 days prior to procedure (and INR <2. 0) Platelet inhibitors Prasugrel (Effient) Clopidogrel (Plavix)5 days prior to procedure INR, international normalized ratio; NSAIDs, nonsteroidal anti-inflammatory drugs. Sources: Patel, I. J., Davidson, J. C., Nikolic, B., Salazar, G. M., Schwartzberg, M. S., Walker, T. G.,... Saad, W. A. (2012). Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. Journal of Vascular and Interventional Radiology, 23 (6), 727-736. doi:10. 1016/ j. jvir. 2012. 02. 012; Pudusseri, A., & Spyropoulos, A. C. (2014). Management of anticoagulants in the periprocedural period for patients with cancer. Journal of the National Comprehensive Cancer Network, 12 (12), 1713-1720. doi: https://doi. org/10. 6004/ jnccn. 2014. 0173. Spyropoulos, A. C., & Douketis, J. D. (2012). How I treat anticoagulated patients undergoing an elective procedure or surgery. Blood, 120(15), 2954-2962. doi:10. 1182/blood-2012-06-415943.
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389 PROCEDURE BONE MARROW ASPIRATION AND BIOPSY (continued ) A Vertical line Safe injection region Horizontal line Sciatic nerve Ischial tuberosity Upper lateral quadrant Upper medial quadrant Lower lateral quadrant Lower mediall quadrant Upper lateral quadrant Upper medial quadrant Lower lateral quadrant Lower mediall quadrant Highest point iliac crest Posterior Superior Iliac Spine B Lumbar vertebrae Ilium Sacroiliac joint Sacrum Posteriorsuperior iliac crest Iliac crest FIGURE 1 (A ) Pelvic anatomy for bone marrow procedures. (B) The posterior superior iliac crest is a bony prominence located superolateral to the coccyx (indicated by the gray box) i. Place middle finger and index finger on either side of the marked site. ii. Insert a 21-gauge needle into the marked site between the fingers and advance to the periosteum at a perpendicular angle. iii. Anesthetize the periosteum by continually injecting small amounts of lidocaine on the bone surface (approximately a quarter-sized area). iv. Make note of the angle of the needle and the landscape of the bone (particularly flat areas). v. Allow 2 to 3 minutes for local anesthesia to take effect. In the meantime, prepare the bone marrow tray. vi. Insert the bone marrow needle with stylet in place perpendicular to the marked site (see Figure 2) with the same approach and angle as the anesthetic needle. vii. Gently approach the periosteum and ensure that area is anesthetized (patients should only experience dull sensations). viii. Steadily rotate the needle back and forth in a twisting motion to advance through the bone cortex. ix. Once the needle enters the marrow space, a “give” is felt, and the patient may note discomfort. x. Ensure the needle is anchored in the bone and remove the stylet. xi. Attach a 10 to 20 m L syringe to the aspiration needle. xii. Aspirate 1 m L of marrow initially and aliquot for the clot section. xiii. Additional aspirates will be required for smears and ancillary testing (e. g., flow cytometry, cytogenetics, molecular testing). An assistant should handle the smears while the proceduralist continues to aspirate. xiv. In general, it is not recommended to aspirate greater than 5 m L at a time as the contents may clot. b. Perform biopsy (if required). i. Using the same site, advance a Jamshidi needle into the cortical bone with a steady twisting motion until the needle is firmly lodged (see Figure 2). ii. Remove the stylet. iii. Advise the patient that he or she should anticipate a dull, aching pressure. iv. Advance the needle 1 to 2 cm with a rotating motion applying pressure. v. Once an adequate core biopsy depth is attained, rotate the needle 360∘in both directions several times to separate the biopsy from surrounding tissue. vi. Slowly remove the biopsy specimen by gently pulling and rotating the needle. vii. Insert the stylet into the distal end of the needle after it has been removed from the body to expel the biopsy specimen onto a slide. viii. Inspect the biopsy specimen for adequate size (1-2 cm). A second attempt may be required to obtain a complete specimen. ix. Send specimen to pathology with the equipment used to collect it. c. Apply dressing. i. Hold pressure over the site for hemostasis. ii. Use alcohol prep pads to cleanse the area. iii. Apply sterile gauze and affix a pressure bandage. iv. Advise patient to leave dressing intact and dry (no bathing/swimming) for 24 or 48 hours (if biopsy per-formed). (continued ) Procedure: Bone Marrow Aspiration and Biopsy
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390 PROCEDURE BONE MARROW ASPIRATION AND BIOPSY (continued ) Bone Marrow Aspiration and Biopsy Bone marrow Skin Hip bone Jamshidi needle FIGURE 2 Bone marrow aspiration and biopsy. The Jamshidi needle is perpendicularly inserted into the posterior iliac crest through the outer bony cortex and into the spongy bone marrow. EVALUATION AND RESULTS A. Evaluation of the bone marrow aspiration and biopsy includes the following. 1. Microscopic evaluation. 2. Immunohistochemical staining. 3. Flow cytometry, cytogenetics. 4. FISH. 5. Molecular testing, and/or cultures. CLINICAL PEARLS A. Maintain dialog with the patient throughout the procedure and guide him or her through the process so the patient anticipates needles, aspiration, and so on. B. Once the periosteum is anesthetized, the patient should only experience a dull, aching sensation. 1. If the patient experiences sharp pain during the procedure, consider repositioning the needle to the anesthetized area or giving additional local anesthetic. C. If the initial aspirate does not yield any contents, replace the stylet and advance the needle further. 1. If multiple attempts are unsuccessful, consider another site. D. Disease-specific issues. 1. Use caution when advancing the aspirate or biopsy needle through the bony cortex in elderly patients or patients with multiple myeloma. Osteoporotic bone is weak, and the needle can penetrate the bone with little pressure. 2. Aspiration for patients with myeloproliferative disorders (e. g., myelofibrosis) may result in a “dry tap” due to increased marrow fibrosis. Consider repositioning the needle to another anesthetized site. BIBLIOGRAPHY Bain, B. J. (2001, September). Bone marrow aspiration. Journal Clinical Pathology, 54 (9), 657-663. Patel, I. J., Davidson, J. C., Nikolic, B., Salazar, G. M., Schwartzberg, M. S., Walker, T. G.,... Saad, W. A. (2012). Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. Journal of Vascular and Interventional Radiology, 23 (6), 727-736. doi:10. 1016/ j. jvir. 2012. 02. 012 Pudusseri, A., & Spyropoulos, A. C. (2014). Management of anticoagulants in the periprocedural period for patients with cancer. Journal of the National Comprehensive Cancer Network, 12 (12), 1713-1720. doi: https://doi. org/10. 6004/jnccn. 2014. 0173. Radhakrishnan, N. (2017). Bone marrow aspiration and biopsy. In E. C. Besa (Ed. ), Medscape. Retrieved from https://emedicine. medscape. com/article/207575-overview Spyropoulos, A. C., & Douketis, J. D. (2012). How I treat anticoagulated patients undergoing an elective procedure or surgery. Blood, 120(15), 2954-2962. doi:10. 1182/blood-2012-06-415943Procedure: Bone Marrow Aspiration and Biopsy
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391 PROCEDURE BRONCHOSCOPY E. Mone ́e Carter-Griffin DESCRIPTION A. Direct visualization of the lower airways (e. g., trachea, bronchi, and bronchioles) with a scope containing a camera. B. Most institutions have a bronchoscopy cart with all the required equipment, including a video screen to allow for visualization. C. Typically, a respiratory therapist and/or a nurse will assist with the procedure. INDICATIONS A. Identifying the cause of hemoptysis or other symptoms that indicate endobronchial disease. B. Obtaining samples for pathology of abnormal spots or lesions noted on imaging. C. Diagnosis and staging of lung carcinomas. D. Removal of excessive secretions, mucus plugs, polyps, and so on. E. Removal of foreign objects. F. Assistance with difficult intubations and to verify endotracheal tube placement. G. Use during and postprocedural (e. g., dilation of tracheal stenosis). H. Postoperative assessment of lung transplants. PRECAUTIONS A. Patients with coagulopathies: Aggressive suctioning or endobronchial interventions can cause bleeding. B. Avoid in patients with severe hypoxemia and/or those requiring increased ventilatory support (e. g., acute r espiratory d istress syndrome [ARDS]), if possible. C. Can cause irritation to the vocal cords and airways leading to laryngospasm and bronchospasm, respectively. EQUIPMENT REQUIRED A. Bronchoscopy cart. B. Bronchoscope with light source. C. Bite block (only placed in intubated patient prior to bronchoscope insertion). D. Swivel adapter for the bronchoscope. E. Water-soluble lubricant. F. Gauze (used to wipe secretions from the bronchoscope). G. Suction tubing and suction device (e. g., wall suction unit or device on bronchoscopy cart). H. Sterile bowl. I. 10 to 20 m L syringes (2-3). J. Saline (nonbacteriostatic). K. Sputum trap if collecting a specimen. L. Gloves, mask, and eye protection. M. Moderate sedation medications. PROCEDURE A. Explain the procedure to the patient and family. B. Always identify the patient and obtain informed consent. C. Ensure the patient has intravenous (IV) access and hemodynamic monitoring (e. g., blood pressure, O2saturations, etc. ) throughout the entirety of the procedure. (continued ) Procedure: Bronchoscopy
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392 PROCEDURE BRONCHOSCOPY (continued ) D. Assemble all equipment prior to procedure. E. Ensure the light source is working on the bronchoscope. F. Connect suction tubing to the bronchoscope and a suction device. G. Add saline to the sterile bowl. H. Fill the syringes with saline prior to starting the procedure. The saline can be used to help with secretion clearance and for collection of a bronchoalveolar lavage (BAL). I. Determine the entry route for the bronchoscope. 1. Nonintubated patient: Nose is preferred entry site. 2. Intubated patient: Bronchoscope will enter through the existing endotracheal tube. J. If the patient has a preexisting endotracheal tube, adjust the ventilator settings by increasing the fraction of inspired oxygen to 100% and placing the patient on assist control. Connect the swivel adapter to the endotracheal tube. K. If the patient is not receiving mechanical ventilation, then an oxygen source is typically applied (e. g., nasal cannula). L. Prior to procedure initiation, don a gown, gloves, mask, and eye protection. M. Instruct the assistant to administer moderate sedation to assist with comfort and tolerance of the procedure. N. Apply the water-soluble lubricant to the bronchoscope. O. In a nonintubated patient: Insert the bronchoscope through the nose. In an intubated patient: Insert the bronchoscope through the swivel adapter connected to the endotracheal tube (see Figure 1). P. Advance the bronchoscope through the trachea and into the lungs. 1. The indications for performing bronchoscopy will determine what interventions are completed (e. g., aspiration of secretions, biopsy of a lesion, removal of foreign objects, etc. ). 2. Prior to removing the bronchoscope, inspect the lungs for hemostasis or evidence of possible complications from the procedure. Q. Once the procedure is complete, remove the bronchoscope. R. Send a specimen collected in sputum trap to pathology and/or microbiology. S. Obtain a chest x-ray postprocedure to assess lungs. T. Document the procedure, indication, diagnostics sent, any complications, and the patient's tolerance of the procedure. EVALUATION AND RESULTS A. Results will vary on the rationale for performing the procedure. B. Results could include clearance of secretions and mucus plugs, resulting in better oxygenation, identification of lesions for appropriate treatment, and so on. Bronchoscope Fibre-optic tube Bronchoscope Bronchi viewed on monitor FIGURE 1 Illustration depicting bronchoscopy procedure. (continued )Procedure: Bronchoscopy
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393 PROCEDURE BRONCHOSCOPY (continued ) CLINICAL PEARLS A. If using a traditional bronchoscope, the patient will need at least a 7. 5 size endotracheal tube to pass the bronchoscope into the lungs. B. The use of saline can help remove thick secretions from the airway. BIBLIOGRAPHY Du Rand, I. A., Blaikley, J., Booton, R., Chaudhuri, N., Gupta, V., Khalid, S.,... Munavvar, M. (2013, August). British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: Accredited by NICE. Thorax, 68 (Suppl. 1), i1-i44. doi:10. 1136/thoraxjnl-2013-203618 Lessnau, K.-D., & Lazo, K. (2017, March 23). Transbronchial biopsy techniques.,In Z. Mosenifar (Ed. ), Medscape. Retrieved from https: //emedicine. medscape. com/article/1894323-technique Procedure: Bronchoscopy
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394 PROCEDURE CENTRAL VENOUS ACCESS Alison M. Kelley and Heather Meissen DESCRIPTION A. A central venous catheter (CVC), also called a central line, is a thin, flexible catheter which is percutaneously placed and whose tip sits in the central circulation (see Figure 1). B. Ideal location of the tip is the superior vena cava (SVC). INDICATIONS A. Rapid administration of intravenous (IV) fluids (in the setting of sepsis, trauma, shock, burns) or blood products. B. Inadequate peripheral access. C. Emergent venous access. D. Administration of medications more likely to cause vascular damage when administered peripherally, including: 1. Vasopressors. 2. Inotropes. 3. Chemotherapy. 4. Total parenteral nutrition. 5. Hypertonic solutions such as 3%, 7. 5%, and 23. 4% saline. E. Administration of incompatible drugs. F. Access for placement of pulmonary artery catheters (PACs), hemodialysis catheters, and plasmapheresis catheters. G. Hemodynamic monitoring, including central venous pressure (CVP). H. Measurement of central venous oxygen saturation (SVO2). I. Cardiac pressures via PAC including CVP, pulmonary artery systolic and diastolic pressures, and pulmonary artery wedge pressure. J. Measurement of mixed venous oxygen saturation, SVO2, from a PAC. K. Frequent blood draws (in patients without arterial lines). L. Transvenous cardiac pacing. FIGURE 1 Illustration of a CVC. CVC, central venous catheter. (continued )Procedure: Central Venous Access
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395 PROCEDURE CENTRAL VENOUS ACCESS (continued ) PRECAUTIONS A. In order to help prevent complications, the following precautions, taken by an experienced provider, should be utilized when inserting a CVC. B. Ultrasound (US) guidance. 1. Use of US guidance for placement of internal jugular (IJ) CVCs is now considered gold standard (see Figure 2). a. US guidance has been proven to decrease complications, especially arterial cannulation. b. US guidance for insertion of central venous access in subclavian and femoral veins has less evidence and requires further research. C. Manometry is one of three ways of measuring pressure during CVC insertion in order to ensure venous rather than arterial puncture. 1. Once the operator has inserted the needle into a vessel and has blood return, a sterile tube is connected to the hub of the needle or catheter. 2. Tubing should then be filled with blood. This is done by lowering the sterile tubing below the level of the vein. 3. The tubing is then held vertically over the patient. This allows for the blood level to equilibrate with venous pressure. a. If the needle is in an artery, the blood will continue to rise up the tube. b. If the needle is in the vein, the blood will begin to travel back down the column. D. Operators should choose US guidance and pressure manometry (see Figure 3) as techniques to reduce complications. While dynamic US guidance helps reduce the risk of arterial sticks, pressure manometry reduces the risk of arterial cannulation. Procedure: Central Venous Access FIGURE 2 US showing IJ and CA. CA, carotid artery; IJ, internal jugular; US, ultrasound. (continued )
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396 PROCEDURE CENTRAL VENOUS ACCESS (continued ) FIGURE 3 Image of a advanced practice provider demonstrating pressure manometry on a mannequin. E. Additional precautions. 1. The nurse must be present during all portions of the procedure. 2. The provider must confirm correct catheter tip location via chest x-ray prior to use. 3. Antibiotic impregnated CVCs are sometimes used when available; the provider should check institutional policies. 4. The Pronovost Checklist has been shown to reduce CVC-related bloodstream infections when utilized together. 5. Prior to donning sterile gloves, the practitioner should use an antimicrobial soap or alcohol sanitizer. 6. Chlorhexidine. a. Prior to draping a patient, a sterile solution of chlorhexidine or Betadine should be applied to the site by scrubbing for 30 seconds. b. The site should then be allowed to air dry for at least 2 minutes. 7. Maximal barrier precautions. a. A full body drape should be placed over the patient. b. All those performing the procedures should wear a mask, cap, sterile gown, and sterile gloves. c. Any additional persons present in the room should wear a mask and cap. 8. Timely removal of CVC is desired when deemed no longer necessary. 9. Avoid femoral vein insertion, which is associated with greater risk of infection as compared to the subclavian vein or jugular vein. F. Multiple complications are associated with CVC placement, including but not limited to: 1. Catheter-related infection. 2. Catheter-related thrombosis. 3. Arterial puncture. 4. Arterial cannulation. 5. Vascular injury. 6. Arrhythmia. 7. Bleeding. 8. Venous air embolism. 9. Pneumothorax. 10. Hemothorax. EQUIPMENT REQUIRED A. CVC kit. B. Caps and mask for everyone present in the room. C. Sterile gown for all operators. D. Extra pair of sterile gloves. (continued )Procedure: Central Venous Access
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397 PROCEDURE CENTRAL VENOUS ACCESS (continued ) E. Sterile full body drape. F. Sterile US probe cover. G. Chlorhexidine. H. Sterile saline. I. Pressure tubing for manometry. J. Central line dressing. K. If provider does not have access to an US, consider using smaller gauge needles as a finder needle. PROCEDURE A. Placement of IJ CVC. 1. Explain the procedure to the patient and family. 2. Obtain consent for CVC placement based on the institution's policy. 3. Wash hands/perform hand hygiene. 4. Perform a proper time out. All present in the room must identify the patient and agree on the correct procedure and correct site of the procedure. 5. US patient anatomy prior to positioning of patient. 6. Place the patient in the Trendelenburg position. If the patient cannot tolerate the Trendelenburg, place the patient as flat as possible or consider placing a femoral line. 7. Have the patient turn his or her head 45∘in the opposite direction of the side where the operator is placing the catheter (see Figure 4). 8. Prior to beginning procedure, use the US to identify the IJ vein and the carotid artery. The IJ is compressible when gentle pressure is applied. The artery is not (see Figure 5). 9. If not using an US, please see section on anatomical landmarks. 10. Ensure that everyone who will remain present in the room has on a surgical cap and mask. 11. Place a cap on the patient. 12. Open up the CVC tray. 13. Don sterile gown and sterile gloves. 14. Prepare the skin with chlorhexidine, per Centers for Disease Control and Prevention ( CDC) guidelines. 15. Remove the sterile full body drape from the central line kit and drape it over the patient. There will be a hole, which should be placed over the site previously identified. 16. Set up a sterile kit in an orderly fashion. Ensure that all equipment is within arm's reach. B AIpsilateral nipple Ipsilateral nipple Sternocleidomastoid muscle Internal jugular vein FIGURE 4 Landmarks for accessing the IJ vein. (A) Aim the needle toward the ipsilateral nipple. (B) Insert the needle at the apex of the SCM. IJ, internal jugular; SCM, sternocleidomastoid muscle. (continued ) Procedure: Central Venous Access
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398 PROCEDURE CENTRAL VENOUS ACCESS (continued ) FIGURE 5 The IJ is being compressed with gentle pressure as evidenced by the oblong shape that is formed from the previous circular shape in Figure 2. The muscles around the CA make it much more difficult to compress the CA; therefore, it maintains its shape. Compression allows the practitioner to easily differentiate the two vessels. CA, carotid artery; IJ, internal jugular. 17. Flush all ports of the catheter with sterile saline to ensure they are functioning properly. 18. Place a sterile US probe cover on the US probe. 19. Most kits provide 2% lidocaine without epinephrine. a. Draw up the desired amount of lidocaine in an available syringe. b. Replace the needle used to draw up lidocaine with a subcutaneous needle. c. Using the US, identify the IJ vein and center it in the middle of the US screen. d. While watching the US screen to identify the needle, make an initial stick with the needle. e. Prior to injecting lidocaine, draw back to ensure you do not have blood return. f. Inject lidocaine into the subcutaneous tissue. 20. Maintain visualization of the IJ in the center of the US field. 21. Continue to hold the US probe in the nondominant hand while picking up the introducer needle with the dominant hand. 22. With the bevel up, insert the needle at a 30∘to 45∘angle to the patient directed at the ipsilateral needle (see Figure 6). Aspirate the syringe the entire time the needle is being advanced. 23. Maintain visualization of the carotid artery and IJ vein on the US screen. 24. If one does not immediately aspirate venous blood. a. Slightly withdraw the needle, without withdrawing the needle from the skin, and attempt to angle more laterally. b. If this position also does not result in blood return, withdraw the needle again and attempt to angle more medially. 25. Once venous blood is aspirated, remove the syringe while securely holding the needle. Place finger over the needle hub in order to reduce the risk of air embolism. 26. Now, attach tubing for pressure measurement as discussed earlier. Other pressure measurements may also be used. 27. If the carotid artery was accessed, remove the needle and hold pressure for 10 to 15 minutes. 28. After venous entry is confirmed, remove the pressure tubing and insert the guide wire through the needle. a. It should advance with minimal resistance. b. While advancing the guide wire, have the nurse watch the telemetry screen for ectopy. c. It is also important to listen for telemetry alarms while advancing. d. Patients may experience some PVCs. e. If the patient goes into ventricular tachycardia ( VT), completely remove the wire. 29. While holding the guide wire, remove the introducer needle. Never let go of the guide wire while it is in the patient. (continued )Procedure: Central Venous Access
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399 PROCEDURE CENTRAL VENOUS ACCESS (continued ) FIGURE 6 Accessing the IJ with US. (A) Direct the needle toward the center of the US probe. (B) Advance the needle forward and look for penetration of the needle into the vessel. IJ, internal jugular; US, ultrasound. Source: Reproduced with permission from Saugel, B., Scheeren, T. W. L., & Teboul, J.-L. (2017). Ultrasound-guided central venous catheter placement: A structured review and recommendations for clinical practice. Critical Care, 21, 225. doi:10. 1186/s13054-017-1814-y 30. An additional confirmation of venous entry can be performed by obtaining a transverse view via US of the IJ vein and following the guide wire down to the vein. 31. Once the introducer needle has been removed, make a small nick in the skin at the site of entry while continuing to hold the guide wire. The nick should be made with the scalpel facing away from the operator and should be a small in-out stabbing motion. 32. Now, pass the dilator over the guide wire while continuing to hold the guide wire. 33. Dilate and retract the dilator while continuing to hold the guide wire. 34. Make sure the distal port does not have a cap on it so the guide wire can pass through. 35. Pass the catheter over the guide wire. The guide wire will come out the distal port. 36. Continue advancing the catheter while holding the guide wire. a. Once the guide wire can be seen coming out of the distal port of the catheter, grasp the guide wire. b. Finish advancing the catheter until the appropriate depth is reached. 37. While holding the catheter in place, pull out the guide wire. It should remove without any resistance. 38. Aspirate and flush each port to confirm blood return. 39. Suture the central line into place at the insertion site. 40. Clean the area again with the antiseptic of choice, most often chlorhexidine or Betadine. 41. Place a sterile dressing over the insertion site. 42. Obtain a chest x-ray for radiograph placement and to rule out a pneumothorax. 43. Proper placement on chest x-ray will demonstrate the tip of the catheter in the SVC. 44. Document the procedure appropriately in the patient's record. B. Placement of subclavian CVC. 1. Explain the procedure to the patient and family. 2. Obtain consent for CVC placement based on the institution's policy. 3. Wash hands/perform hand hygiene. 4. Perform a proper time out. All present in the room must identify the patient and agree on the correct procedure and correct site of the procedure. 5. US guidance is not able to be used in subclavian procedures due to the obstruction of the view of the vein by the clavicle. (continued ) Procedure: Central Venous Access
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400 PROCEDURE CENTRAL VENOUS ACCESS (continued ) 6. Place the patient in the Trendelenburg position. If the patient cannot tolerate the Trendelenburg, place the patient as flat as possible or consider placing a femoral line. 7. Have the patient turn his or her head 45∘in the opposite direction of the side where the operator is placing the catheter. 8. Prior to beginning the procedure, identify the landmarks—the sternal notch and the curve of the clavicle (see Figure 7). 9. Ensure that everyone who will remain present in the room has on a surgical cap and mask. 10. Place a cap on the patient. 11. Open up the CVC tray. 12. Don a sterile gown and sterile gloves. 13. Prepare the skin with chlorhexidine. 14. Remove the sterile full body drape from the central line kit and drape it over the patient. There will be a hole, which should be placed over the site previously identified. 15. Set up a sterile kit in an orderly fashion. Ensure that all equipment is within arm's reach. 16. Flush all ports of the catheter with sterile saline to ensure they are functioning properly. 17. Most kits provide 2% lidocaine without epinephrine. a. Draw up the desired amount of lidocaine in an available syringe. b. Replace the needle used to draw up lidocaine with a subcutaneous needle. c. Advance the subcutaneous needle into the subcutaneous tissue at the clavicular angle. d. Prior to injecting lidocaine, draw back to ensure you do not have blood return. e. Inject with lidocaine. 18. To access the subclavian vein, pick up the introducer needle with the dominant hand. 19. With the bevel up, insert the needle at a 30∘to 45∘angle to the patient directed at the sternal notch. Aspirate the syringe the entire time the needle is being advanced. 20. If one does not immediately aspirate venous blood. a. Slightly withdraw the needle, without withdrawing the needle from the skin, and attempt to angle more cepha-lad. b. If this position also does not result in blood return, withdraw the needle again and attempt to angle more caudal. 21. Once venous blood is aspirated, remove the syringe while securely holding the needle. Place a finger over the needle hub in order to reduce the risk of air embolism. 22. Now, attach tubing for pressure measurement as discussed earlier. Other pressure measurements may also be used. B A Clavicle First rib Subclavian vein Domeof pleura Subclavian vein FIGURE 7 Advancing the needle in subclavian access. Direct the tip of the needle toward the sternal notch. Source: Reichman, E. F. (Ed. ). (2013). Emergency medicine procedures (2nd ed. ). New York, NY: Mc Graw-Hill/Medical. Retrieved from https://accessemergencymedicine. mhmedical. com/content. aspx?bookid =683§ionid =45343634. Copyright © The Mc Graw-Hill Companies, Inc. All rights reserved. (continued )Procedure: Central Venous Access
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401 PROCEDURE CENTRAL VENOUS ACCESS (continued ) 23. If the subclavian artery was accessed, remove the needle and hold pressure for 10 to 15 minutes. The clavicle may make it difficult or impossible to hold direct pressure over the subclavian artery. Call a stat vascular consult if bleeding cannot be controlled. 24. After venous entry is confirmed, remove the pressure tubing and insert the guide wire through the needle. a. It should advance with minimal resistance. b. While advancing the guide wire, have the nurse watch the telemetry screen for ectopy. c. It is also important to listen for telemetry alarms while advancing. d. Patients may experience some PVCs. e. If the patient goes into VT, completely remove the wire. 25. While holding the guide wire, remove the introducer needle. Never let go of the guide wire while it is in the patient. 26. Once the introducer needle has been removed, make a small nick in the skin at the site entry while continuing to hold the guide wire. The nick should be made with the scalpel facing away from the operator and should be a small in-out stabbing motion. 27. Now, pass the dilator over the guide wire while continuing to hold the guide wire. 28. Dilate and retract the dilator while continuing to hold the guide wire. 29. Make sure the distal port does not have a cap on it so the guide wire can pass through. 30. Pass the catheter over the guide wire. The guide wire will come out the distal port. Continue advancing the catheter while holding the guide wire. a. Once the guide wire can be seen coming out of the distal port of the catheter, grasp the guide wire. b. Finish advancing the catheter until the appropriate depth is reached. 31. While holding the catheter in place, pull out the guide wire. It should remove without any resistance. 32. Aspirate and flush each port to confirm blood return. 33. Suture the central line into place at the insertion site. 34. Clean the area again with the antiseptic of choice, most often chlorhexidine or Betadine. 35. Place a sterile dressing over the insertion site. 36. Obtain a chest x-ray for radiograph placement and to rule out a pneumothorax. 37. Proper placement on a chest x-ray will demonstrate the tip of the catheter in the SVC. 38. Document the procedure appropriately in the patient's record. C. Anatomical landmarks for CVC placement without US guidance. 1. US guidance for placement of IJ CVCs is considered the gold standard. However, not all hospitals have access to bedside US. 2. When US is not readily available for CVC insertion, it is important that an experienced operator use the following anatomical markings. a. IJ landmarks. i. Identify the triangle formed by the sternum and two heads of the sternocleidomastoid muscle (SCM). After identifying this triangle, palpate the carotid pulse. ii. While maintaining palpation of the carotid pulse, pull the carotid medially and insert your needle lateral to the carotid. b. Subclavian vein landmarks. i. Identify the sternal notch. ii. Find the curve of the clavicle, which is generally two-thirds of the distal length of the clavicle from the sternal notch (see Figure 8). iii. Palpation of the subclavian artery is not possible and visualization with US is not possible due to the clavicle obstructing the view. iv. While maintaining the landmarks with the nondominant hand, use the dominant hand to insert the introducer needle at a 45∘angle to the curve of the clavicle, then walk the needle down the height of the clavicle until the needle is easily able to pass under the clavicle. c. Femoral vein. i. Identify the femoral triangle created by the inguinal ligament, sartorius muscle, and adductor longus muscle in the inguinal femoral area (see Figure 9). Whenever possible, use US to access the vein using these landmarks. ii. Palpate the femoral artery. iii. The femoral vein will be medial to the femoral artery, and the bladder is in the pelvis medial to the vein. Use the femoral artery as a guide to avoid being too medial and inserting the needle into the bladder. iv. Insert the needle with a 20∘to 30∘angle with the skin toward the umbilicus. EVALUATION AND RESULTS A. Maintain all ports flushed and patent. B. Aspiration of blood from the ports should be nonpulsatile. (continued ) Procedure: Central Venous Access
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402 PROCEDURE CENTRAL VENOUS ACCESS (continued ) Subclavian vein FIGURE 8 Accessing the subclavian vein. Femoral triangle Femoral nerve Femoral artery Femoral vein Lymphalics Femoral Triangle Inguinal ligament Pectineus Adductor longus Iliopsoas Sartorius FIGURE 9 Anatomy of the femoral triangle. C. Connect to pressure tubing if uncertain to ascertain if a waveform is present. A catheter in the vein will produce a single nonpulsatile wave on the monitor, whereas a catheter in the artery will produce a waveform consistent with a peak and dicrotic notch. D. If arterial access is achieved with placement of the catheter, consult vascular surgery immediately. E. Confirm placement with abdominal x-ray. F. Tip of catheter should be located above the confluence of the iliac vein. CLINICAL PEARLS A. Always maintain sterile technique; having nursing presence will help ensure sterility is maintained. B. Always use US guidance if available. C. Choose a method of pressure measurement and use it along with US guidance. D. Always confirm line placement with a chest x-ray for IJ and subclavian lines, and abdominal x-ray for femoral lines. E. Never hesitate to ask for help or supervision when first learning to perform central lines. (continued )Procedure: Central Venous Access
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403 PROCEDURE CENTRAL VENOUS ACCESS (continued ) BIBLIOGRAPHY CAE Healthcare. (n. d. ) Gen I Central Venous Access Ultrasound Training Model Tissue Insert. Retrieved from http://www. bluephantom. com/product/Gen-I-Central-Venous-Access-Ultrasound-Training-Model-Tissue-Insert. aspx?cid =562 Institute of Healthcare Improvement. (n. d. ) Central line insertion team checklist. Retrieved from http://www. ihi. org/resources/Pages/ Tools/Central Line Insertion Care Team Checklist. aspx Marino, P. L., & Sutin, K. M. (2006). The ICU book (3rd ed., pp. 107-128). New York, NY: Lippincott Williams & Wilkins. Reichman, E. F. (Ed. ). (2013). Emergency medicine procedures (2nd ed. ). New York, NY: Mc Graw-Hill/Medical. Retrieved from https://accessemergencymedicine. mhmedical. com/content. aspx?bookid =683§ionid =45343634 Rupp, S. M., Apfelbaum, J. L., Blitt, C., Caplan, R. A., Connis, R. T., Domino, K. B.,... Tung, A. (2012). Practice guidelines for central venous access: A report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology, 116 (3), 539-573. doi:10. 1097/ALN. 0b013e31823c9569 Saugel, B., Scheeren, T. W. L., & Teboul, J. L. (2017). Ultrasound-guided central venous catheter placement: A structured review and recommendations for clinical practice. Critical Care, 21, 225. doi:10. 1186/s13054-017-1814-y Procedure: Central Venous Access
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404 PROCEDURE CHEST TUBE INSERTION E. Mone ́e Carter-Griffin DESCRIPTION A. The insertion of a chest tube into the pleural space to drain collected fluid or air. INDICATIONS A. Any fluid collection in the pleural space. 1. Pleural effusion. 2. Hemothorax (blood collection). 3. Empyema (pus collection). 4. Hydrothorax(serousfluid collection). 5. Chylothorax (lymphatic fluid collection). B. Pneumothorax (air collection). C. Postoperative drainage of the thoracic cavity. PRECAUTIONS A. Assess coagulation profile. A patient with a coagulopathy may have excessive bleeding during and post insertion. B. Avoidareaswith adhesions or lung adherenceto the pleura. C. Carefulconsideration should be given to differentiatebetween pulmonary bullae versus a pneumothorax. EQUIPMENT REQUIRED A. Personal protectiveequipment. 1. Sterile gloves, gown, and drape. 2. Cap, mask, and protectiveeyewear. B. Chest tube drainage system with a water seal. C. Suction tubing and connector. D. Variousthoracostomy tube sizes: Size used depends on collection being drained. E. Antiseptic solution with chlorhexidine or povidone-iodine. F. Lidocaine 1% with or without epinephrine for local anesthesia. G. A 5 and 10 m L syringe. H. 25-gauge, 5/8-1 inch needle. I. 20 to 23 gauge, 1-1/2 inch needle. J. Chest tube insertion tray. 1. 4×4 sterile gauze. 2. Hemostats (2). 3. Kelly clamps (2—largeand medium). 4. No. 10 scalpel. 5. Suturescissors. 6. Needle driver. 7. Nylon or silk suture. K. Occlusive dressing:Vaselinegauze, 4 ×4s,and tape. L. Surgicalmarker: Not requiredbut helpful in identifying the point of entry. PROCEDURE A. Explain procedureto patient and family. B. Always identify the patient and obtain informed consent. C. Ensurepatient has intravenous (IV) access and hemodynamic monitoring (e. g., blood pressure,O 2saturations,etc. ). D. Choose a chest tube size. A smaller chest tube, less than 24 Fr, can typically be used for pneumothoraces and a largerchest tube, greaterthan 24 Fr,is indicated for fluid collections. E. Washhands/perform hand hygiene. F. Place patient in the supine position with the ipsilateral arm raised above the head (see Figure1). (continued )Procedure: Chest Tube Insertion
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405 PROCEDURE CHEST TUBE INSERTION (continued ) Lateral edge of pectoralis major Lateral edge of latissimus dorsi Base of axilla 5th intercostal space FIGURE 1 Patient positioning for chest tube insertion. G. Verifylocation for chest tube placement. 1. Use a marker to identify location/point of entry. 2. Locate the fifth intercostalspace and midaxillary line. 3. The incision is typically made in between the anterior and midaxillary lines. H. Don sterile attire and prepare sterile field prior to initiating the procedure: Can also be completed with help of an assistant after providerhas donned sterile attire. 1. Ensureall equipment is available in the chest tube insertion tray. 2. The chest tube may be added during set up or the assistant can add it to the sterile field. I. Administer moderate sedation. J. Cleanse areawith chlorhexidine or a povidone-iodine solution. Allow to passively dry. K. Usethe larger Kelly clamp to grasp the proximalend of the chest tube and placeit to the side within the sterile field. L. Perform a time out. M. Cleanse the areaagain with chlorhexidine or a povidone-iodine solution. N. Drape the identified areawith the sterile drape. O. Use the 25 gauge, 5/8 inch needle and the 5 m L syringe to inject a small wheal of lidocaine. P. Use the 20 gauge, 11/2 inch needle and the 10 m L syringe to infiltrate lidocaine into a wide area of subcutaneous tissue, periosteum, and pleura. Q. Makeanincisionwitha No. 10scalpelinthesamedirectionastheribandbelowthedesiredentrylevel. Theincision should be slightly largerthan the chest tube size. R. Insert the medium Kelly clamp downward through the incision, creating a tunnel by opening and closing the clamp (blunt tissue dissection). Create the tunnel tack over the fifth rib. Aim toward superior aspect until the pleura of the fourth intercostalspace is reached. S. Once the pleura is reached, close the clamp, advance through the parietal pleura into the pleural space, then open/ close the clamp to widen the hole. T. Insert a finger into the tract to ensureit ends at the upper borderof the rib above the incision (see Figure2). U. Grasp the other Kelly clamp with the chest tube connected. 1. Advance proximalend into the pleural space, remove Kelly clamp, and guide tube further into the pleural space. 2. Air and/or fluid may be in the space. V. Connectchesttubetodrainagesystemandhavetheassistantconnecttosuction. Typicalsuctionsettingis-40cm H2O,but the providerwill indicate the desiredamount of suction. W. Suture chest tube in place to the chest wall using a purse string technique and wrap additional suture around the chest tube. (continued ) Procedure: Chest Tube Insertion
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406 PROCEDURE CHEST TUBE INSERTION (continued ) FIGURE 2 Illustration demonstrating index finger inserted into the tract. X. Place petroleumgauze aroundthe test tube, add 4 ×4,and securewith tape. Y. Dispose of all equipment. Z. Obtain a chest x-ray immediately following placement. AA. Document the procedure,indication, complications, and postprocedureimaging. EVALUATION AND RESULTS A. Depending on indication for placement, expect air or fluid removal. B. Reexpansion of the lung tissue should occur. CLINICAL PEARLS A. The insertion site for chest tube placement depends on the indication for chest tube insertion. B. In order for thoracostomy tubes to function properly, all of the fenestrations in the tube must be within the thoracic cavity. The last side-hole in a thoracostomy tube is indicated by a gap in the radiopaque line; if it is not within the thoracic cavity or thereis evidence of subcutaneous air,the tube may not have been completely inserted. C. Ultrasound guidance is beneficial for identification of fluid accumulation and may reducerisk of complications. D. Continuous bubbles indicate there is a leak within the patient or the chest tube system. Small fluctuations during inspiration and expiration arenormal and expected. BIBLIOGRAPHY Roberts, J. R., Custalow, C. B., & Thomsen, T. W. (Eds. ). (2013). Roberts and Hedges' clinical procedures in emergency medicine (6th ed. ) Philadelphia, PA:WB Saunders. Sethuraman, K. N., Duong, D., Mehta, S., Director, T., Crawford, D., St George, J.,... Rathlev, N. K. (2011, January). Complications of tubethoracostomyplacementintheemergencydepartment. The Journal Emergency Medicine, 40 (1),14-20. doi:10. 1016/j. jemermed. 2008. 06. 033Procedure: Chest Tube Insertion
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407 PROCEDURE CHEST TUBE REMOVAL E. Mone ́e Carter-Griffin DESCRIPTION A. Removal of a chest tube from the pleural space when it is no longer needed for drainage of air or fluids. INDICATIONS A. Reexpansion of the lung tissue. B. Resolution of air leaks (continuous bubbling) for at least 24 hours. C. Pleural effusions: Tubes should have output less than 200 m L for greater than 24 hours prior to removal. D. Cardiac surgery: Tubes can be removed once the fluid has changed from sanguineous to serosanguineous, no air leak is present, and less than 100 m L of fluid observed in the preceding 8 hours. PRECAUTIONS A. Avoid the introduction of air or contaminants during the removal to minimize further complications. EQUIPMENT REQUIRED A. Gloves, gown, mask, and eye protection. B. Waterproof pad(s) to place under the removal site/area. C. Suture removal kit. D. Chlorhexidine or povidone-iodine antiseptic swabs/solution. E. Kelly clamps (2). F. Petrolatum gauze. G. 4×4 gauzes. H. Steri-Strips or some other form of elastic closure device. I. Tape. PROCEDURE A. Prior to removal, verify there is no air leak and/or chest tube output. B. Review imaging and assess respiratory status. C. Explain procedure to patient and family. D. Always identify the patient and obtain informed consent. E. Ensure patient has intravenous ( IV) access and hemodynamic monitoring (e. g., blood pressure, O 2saturations). F. Wash hands/perform hand hygiene. G. Don clean gloves. H. Place patient in semi-Fowler's position with waterproof pads directly under patient and chest tube site. I. Gather all supplies. Open the suture removal kit, petrolatum gauze, and 4 ×4 gauzes. J. Remove the suction from the drainage system. Assess for an air leak. K. Remove dressing/tape and cleanse area with chlorhexidine. L. Clip and remove the sutures. Ensure chest tube is free from sutures. M. Pleural chest tubes: Cover insertion site with the petrolatum gauze and the mediastinal chest tube site with 4 ×4 gauzes. N. Clamp chest tube with Kelly clamps. O. Instruct patient to take a deep breath, hold it, and perform the Valsalva maneuver for removal of each chest tube. P. Remove chest tube quickly and smoothly in one rapid motion while patient is performing the Valsalva maneuver. Immediately apply pressure once tube is removed. (continued ) Procedure: Chest Tube Removal
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408 PROCEDURE CHEST TUBE REMOVAL (continued ) Q. Secure the dressing in place. R. Assess patient's respiratory and hemodynamic status immediately following procedure. S. Dispose of all equipment. T. Obtain a chest x-ray 1 to 2 hours following removal. U. Document procedure, indications, complications, and patient tolerance. EVALUATION AND RESULTS A. Lung tissue should remain expanded post tube removal. B. Chest tube insertion site should remain infection free. C. Patient should have no signs and symptoms of respiratory distress postremoval. CLINICAL PEARLS A. Patients on invasive mechanical ventilation should have chest tube removed during peak inspiration. B. Examine each chest tube postremoval to ensure the tube is intact. BIBLIOGRAPHY Bell, R. L., Ovadia, P., Abdullah, F., Spector, S., & Rabinovici, R. J. (2001). Chest tube removal: End-inspiration or end-expiration? Trauma, 50(4): 674-677. Procedure: Chest Tube Removal
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409 PROCEDURE DIGITAL NERVE BLOCKS Frank O. Amanze DESCRIPTION A. A method of providinganesthesia to digit (finger or toe). B. Performed by injecting a prescribed amount of anesthetic into the subcutaneous space forming a ring around the proximalportion of the affecteddigit. C. Anesthetic can be: 1. A short-acting drug, such as lidocaine 2%. 2. A long-acting drug, such as bupivacaine 0. 5%. 3. A 50:50 mixtureof both to provideboth short and longer action. D. Differs from standard local anesthetic of a wound, as it avoids the difficulty of distorting a laceration site with large amounts of infiltration. INDICATIONS A. Needforlocalanesthetictothedistalportionofadigitinordertoperformashort,painfulprocedure,suchassuturing. PRECAUTIONS A. Inject no morethan 4 m L into any digit to avoid risk of compartment syndrome. B. As with all blind injections, aspirate syringe prior to instillation to avoid injecting anesthetic into a blood vessel. EQUIPMENT REQUIRED A. Povidone iodine or chlorhexidine prepfor cleansing site. B. 22 to 30 gauge needle for injection. C. Separate 18 to 20 gauge needle/blunt for drawing up anesthetic. D. 2 to 3 m L syringes. E. Vial of selected anesthetic (lidocaine/bupivacaine). F. Sterile gloves. PROCEDURE A. Goal is to surroundnerves in a bath of anesthetic (not reachnerves directly). B. Washhands/perform hand hygiene. C. Don clean gloves. D. Preparethe skin with antibacterial solution. E. Using a blunt or 18 to 22 gauge needle and syringe, draw up anesthetic. F. Change needle to smaller gauge for injection of anesthetic into the affecteddigits. G. Make one to threepunctureson palmer surface of base of digit (see Figure1). 1. Fan puncturesout in a circumferentialmanner. 2. Instill maximum total of 4 m L into the space aroundthe proximalphalange. H. Make two punctures from the dorsal surface: One into the web spacing on each side of the phalange/phalanx (see Figure2). EVALUATION AND RESULTS A. Testareasof effectivenessprior to beginning the intended painful procedure. B. If needed, administer additional blocking agent (maximum 4 m L total per digit). CLINICAL PEARLS A. If using one puncture, try to withdraw the needle almost to the base of the skin before redirecting toward the other side of the bone to get the most coverage fromone puncture. (continued ) Procedure: Digital Nerve Blocks
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2019/5/22 11:14 Page 410 #2 410 PROCEDURE DIGITAL NERVE BLOCKS (continued ) Flexor tendon Common digital nerve Distal palmar crease FIGURE 1 Illustrationshowing the digital nerve block. FIGURE 2 Digitalblock aroundnerves. Source:Campo, T. M., & Lafferty,K. A. (Eds. ). (2016). Essential procedures for emergency, urgent, and primary care settings (2nd Ed. ). New York,NY: Springer Publishing Company. B. If using two puncture sites, when instilling blocking agents to the opposite surface, try to numb the intended site of the second punctureto minimize pain of the second puncture. C. If the intended procedurewill be performed immediately (e. g., suturing), then lidocaine alone is sufficient. D. Ifthepatientwillbeanesthetizedandthensentforradiologicimagingforanextendedperiod,thena50:50mixtureof lidocaine/bupivacaine will be advantageous due to a much longer duration. BIBLIOGRAPHY Baldor, R., & Mathes, B. (2017, June 19). Digital nerve block. In J. Grayzel (Ed. ), Up To Date. Retrieved from https://www. uptodate. com/ contents/digital-nerve-block Okur, O. M., Şener, A., Kavakli, H. Ş., Çelik, G. K., Do ğan, N. Ö., Içme, F.,... Günaydin, G. P. (2017). Two injection digital block versus singlesubcutaneouspalmarinjectionblockforfingerlacerations. European Journal Trauma and Emergency Surgery, 43,863. doi:10. 1007/s00068-016-0727-9Procedure: Digital Nerve Blocks
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411 PROCEDURE EXTRACORPOREAL MEMBRANE OXYGENATION Heather H. Meissen and Alison M. Kelley DESCRIPTION A. Extracorporeal membrane oxygenation (ECMO) was created as an adaptation to conventional cardiopulmonary bypass. B. ECMO can be divided into veno-venous (VV) ECMO and veno-arterial (VA)ECMO. 1. VV ECMO is used for oxygenation in patients with severe acute respiratory distress syndrome (ARDS) and does not providehemodynamic support. 2. VAECMO supports cardiacoutput in addition to providingoxygenation. C. This chapter will primarily discuss VV ECMO in the adult population. Although use of VA ECMO has grown in recent years, the incidence of VAECMO is still less than VV ECMO. D. Although this procedure is outside the scope of practice for an advanced practice provider (APP), the APP is often involved in the procedureand in managing the system after the line is placed. INDICATIONS A. Hypoxemic respiratoryfailure. B. Pneumonia. C. ARDS. D. Pulmonary contusions. E. Smoke inhalation. F. Status asthmaticus. G. Aspiration. H. Bridge to lung transplant. PRECAUTIONS A. ECMO cannulation is considered a surgical procedure and is to be performed only by a cardiovascular or thoracic surgeonwiththeassistanceofanexperiencedsurgicalteam. Thepresenceofan ECMO-trainedsurgicalteamanda multidisciplinaryteamtrainedinmanagementof ECMOfollowingcannulationreducestherisksofcomplications. The surgicalteam includes: 1. Cardiovascularor thoracic surgeon. 2. ECMO-trained physician. 3. Cardiacanesthesiologist. 4. Respiratory therapist to manage ventilator settings. 5. ECMO-trained critical carenurse. 6. Cardiovascularperfusionist. 7. Surgicalscrub tech/nurse. 8. Circulatingnurse. 9. ECMO-trainedacutecarenursepractitionerorphysicianassistantmayormaynotbepresentduringcannulation. However,APPs play a vital rolein the management of the critically ill ECMO patient after cannulation. B. After a proper time out has been completed, the patient should be sedated and paralyzed prior to placement of the venous cannula. C. Patient should be typed and crossmatchedfor blood products. 1. Whether cannulation is taking place at bedside or in the operating room, continuous vital signs, telemetry, and pulse oximetry must be continuously monitored. 2. Equipment and medications areneeded for treatmentof arrhythmias and bradycardia. 3. Aorticdissection(during VAECMO)orvesselrupturewillresultintheneedforemergentsternotomy. Properequip-ment and personnel should be available. (Modified from ECMO Specialist Training Manual,thirdedition). D. Complications of ECMO. 1. Aortic dissection 2/2 to arterial cannulation. 2. Venousrupture. 3. Acute anemia 2/2 blood loss. 4. Venousspasm: Preventedby avoiding excessive manipulation. 5. Arrhythmias. 6. Bradycardia2/2 to stimulation of vagus nerve. 7. Distal extremitythrombosisand ischemia. (continued ) Procedure: Extracorporeal Membrane Oxygenation
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412 PROCEDURE EXTRACORPOREAL MEMBRANE OXYGENATION (continued ) EQUIPMENT REQUIRED A. Sterile gowns and gloves. B. Sterile saline. C. Syringes and needles. D. Povidone-iodine solution. E. Povidone-iodine ointment. F. Semipermeable transparentmembrane type dressing. G. Absorbable gelatin sponge. H. Surgicallubricant. I. Blood. 1. Emergencysituation: Uncrossmatchedblood should be available. 2. Difficultcannulation: 10 to 20 m L/kg of blood is often requiredfor appropriateresuscitation. J. Surgicalcaps and masks. K. Electrocautery. L. Wallsuction. M. Tubingclamps. N. Pump (rolleror centrifugal). O. Membrane oxygenator. P. Venouscatheters. 1. Patient'soxygenation is directlyrelatedto blood flow. 2. Toallow for maximal blood flow,largestpossible internal diameter should be utilized. PROCEDURE A. Discuss procedurewith patient and/or family. B. Selectcannula(decidedbyprimaryoperator:Cardiovascularorthoracicsurgeon);cannulasizeandselectiondirectly affectthe support patient is receivingfrom ECMO circuit. C. Perform a time out. D. Sedate patient; may also be paralyzed depending on surgeonpreference. E. Prime ECMO circuitwith albumin (12. 5 g) and Ca Cl (1 g). F. Venousaccessobtainedwithintroducer/sheath. Inemergencycannulationsituations,the APPmaybethefirstprovider on scene and can initiate this step. G. Twomain percutaneoustechniques performed for VV ECMO by a trained cardiovascularor cardiothoracicsurgeon. 1. Placement of two cannulae; internal jugular and femoral vein, or bilateral femoral veins (see Figure1). a. Cannula (23-29 French)placed for drainage of blood frominferior vena cava (IVC) via femoral vein. b. Cannula (21-23 French)placed for reinfusionof blood throughjugular vein. 2. Double lumen cannula is used to allow blood to drain from both the IVC and superior vena cava (SVC). The can-nula's internal membrane directs blood across the tricuspid valve to minimize recirculation, avoiding femoral vein cannulation, and allowing patients to be moremobile while on ECMO. H. Followingcannulation,managementofthepatienton VVECMOincludesmanagingflowandventilatorsettings,seda-tion, gas exchange, and anticoagulation, as well as Sa O2and Sv O2monitoring. EVALUATION AND RESULTS A. ECMO circuit. 1. Primary purpose is exchange of both carbon dioxide (CO2)and oxygen. 2. Oxygenator is responsible for oxygenation and CO2elimination; has semipermeable membrane to allow diffusion by blood and gas flow in countercurrentdirections. (continued )Procedure: Extracorporeal Membrane Oxygenation
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413 PROCEDURE EXTRACORPOREAL MEMBRANE OXYGENATION (continued ) Jugular vein Deoxygenated blood Returning oxygenated blood FIGURE 1 Illustrationshowing ECMO connectors. ECMO,extracorporealmembrane oxygenation; VV,veno-venous. 3. Determine rate diffusionoccurs by adjusting gas sweep rate and blood flow rate. a. Gas sweep is the primary factor in CO2clearance. i. Other factors affecting CO2removal:Blood flow,total body surface area. ii. Sweep gas flow rate is measuredin liters per minute. iii. Initial cannulation: Set at 2 to 4 L/min. iv. As rate of gas sweep increases,so does rate of decarboxylation. b. Bloodflowrateisrateatwhichbloodflowsthrough ECMOcircuit'soxygenator;oneoftheprimarydeterminants of oxygenation. i. Other factors influencing oxygenation include fraction of inspiredoxygen (Fi O2)and hemoglobin. ii. Measuredin liters per minute and recommendedthat blood flow rates be 3 m L/kg/min. B. Ventilatormanagement for patient on ECMO. 1. Varies from institution. Further research is needed to understand which ventilator settings in ECMO patients have the best outcomes. 2. Many centers practice ultraprotective ventilation for patients on ECMO to allow for lung rest; targets low tidal volumes, often 3 to 4 m L/kg/ideal body weight, and positive end-expiratory pressure (PEEP) of 10 to 15 cm H2O while maintaining peak pressureless than 20 to 25 cm H2O. 3. Respiratoryratesoftensetanywherefrom4to10breathsperminute. Patientson ECMOareabletotoleratesuch low respiratory rates due to the high rate of CO2clearance provided by the ECMO circuit. As the ECMO circuit is responsibleforfullyoxygenated blood,Fi O2settingsontheventilator canbeminimal,often settoless than30%. C. Continuous management and monitoring. 1. Requiredmonitoring. a. Daily chest x-ray (CXR). b. Daily labs including: i. Complete blood count (CBC). ii. Lactate dehydrogenase(LDH). iii. D-Dimer. iv. Comprehensive metabolic panel (CMP). v. Erythrocyte sedimentation rate (ESR). vi. Prothrombin time/international normalized ratio (PT/INR). vii. Fibrinogen level. c. Plasma freehemoglobin when concern for hemolysis. (continued ) Procedure: Extracorporeal Membrane Oxygenation
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414 d. Heparin is gold standard anticoagulant to use while a patient is on ECMO. Based on institution, monitoring of heparin may vary and include activated partial thromboplastin time (APTT), activated clotting time (ACT), or heparin assays. These labs should be checked every 6 hours. e. Blood culturesas indicated. f. Electrolytemonitoring and repletion. g. Thorough inspection of entirecircuitevery shift. h. Frequent pulse checks. i. Monitoring of hematuria. j. Maintain minimal ventilator settings. 2. Suggested monitoring and management. a. Avoiding percutaneousproceduresdue to bleeding concerns. b. Avoiding subcutaneous injections due to bleeding concerns. c. Limiting invasive proceduresto those that can be performed with a bovie. d. Removing any excessive lines, which may lead to bleeding. e. Gentle suctioning and gentle placement of nasogastric (NG) and orogastric(OG) tubes. f. Passive range of motion exercisesto avoid contractures. g. Provide full nutritional support as soon as possible. h. Minimizing sedation while maintaining adequate pain control. i. Daily Sv O2or Scv O2monitoring. 3. Weaning ECMO. a. Weaning trial should be performed often once there has been significant clinical improvement while on ECMO, as evidenced by sufficient oxygenation with gas flow rate 0 L/min. Note that the ECMO blood flow cannot be decreasedto 0 due to risk of thrombosis;only the gas flow is decreasedto 0 L/min. b. Increaseventilator settings to ensureadequate CO2removalduring trial. c. Once ventilator settings have been increased, slowly decrease gas flow rate until reaching 0 L/min; decrease rate is at discretionof attending physician. d. While gas flow rate is maintained at 0 L/min, blood gases should be drawn and evaluated for a goal Pa O2of greaterthan 60 mm Hg and a goal Pa CO2of30 to 45 mm Hg. e. Eachinstitutionhasvaryingrequirementsforweaningtrials. Ensuringapatientisstableforanywherefrom4to 24 hours with a gas flow rate of 0 L/min is desiredprior to decannulation. f. Turn heparin off at least 2 hours prior to cannula removal once a patient has passed the designated weaning trial. g. Decannulationshouldbeperformedbyexperienced ECMO-trainedmedicalstaffduetosignificantbleedingrisk and potential need for vascular repair. CLINICAL PEARLS A. Watch ECMO lines for clotting or cannula movement, which could indicate hypovolemia or anemia. B. Follow arterial blood gases (ABGs) and coagulation frequently. C. Success of patient on ECMO is dependent on teamwork and collaboration among a multidisciplinary team of skilled providers. D. Pay attention to details of patient's care including nutrition, daily diuresis, skin integrity, and pain management/ sedation. BIBLIOGRAPHY Allen, S., Holena, D., Mc Cunn, M., Kohl, B., & Sarani, B. (2011). A review of the fundamental principles and evidence base in the use of extracorporeal membrane oxygenation (ECMO) in critically ill adult patients. Journal of Intensive Care Medicine, 26 (1), 13-26. doi:10. 1177/0885066610384061 Marasco, S. F., Lukas, G., Mc Donald, M., Mc Millan, J., & Ihle, B. (2008). Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients. Heart, Lung and Circulation, 17 (Suppl. 4), S41-S47. doi:10. 1016/j. hlc. 2008. 08. 009 Short,B. L.,&Williams,L.,(eds. ). (2010). ECMO specialist training manual (3rded. ). Ann Arbor,MI:Extracorporeal Life Support Organi-zation. Procedure: Extracorporeal Membrane Oxygenation PROCEDURE EXTRACORPOREAL MEMBRANE OXYGENATION (continued )
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415 PROCEDURE ENDOTRACHEAL INTUBATION E. Mone ́e Carter-Griffin DESCRIPTION A. Insertion of an endotracheal tube (ETT) into the airway to maintain patency, protection, delivery of oxygen, and/or ventilate a patient. INDICATIONS A. Inability to protectthe airway (e. g., alteredlevel or loss of consciousness). B. Inadequate ventilation (e. g., hypercapnicrespiratoryfailure). C. Inadequate oxygenation (e. g., acute respiratorydistresssyndrome[ARDS], pneumonia). D. Anticipated clinical decline/impending respiratoryfailure(e. g., septic shock). E. Airway obstruction (e. g., facial trauma, burns, angioedema). F. Ineffectiveability or inability to clear secretionswith high risk for aspiration. G. Cardiac/respiratoryarrest. PRECAUTIONS A. Surgicalintervention is warranted in patients with total airway obstruction or loss of oropharyngeallandmarks. EQUIPMENT REQUIRED A. Ambu bag, mask, and oxygen source. B. Sedatives and paralytics. C. Laryngoscope handle and blade. 1. Ensurelight sourceworks prior to intubation. 2. Have morethan one blade available. 3. Standardblade sizes for adults area threeand four. 4. Know the differencesbetween blades. a. A Macintosh is a curved blade. b. A Miller is a straight blade. D. Use videolaryngoscope as alternative to allow for directvisualization of oropharynxvia camera (see Figure1). E. ETT. 1. Variesin size: The size refersto the internal diameter of the tube. 2. Size 7 to 7. 5 mm for an average-sized female; a size 8 mm is usually adequate for an average-sized male. F. Stylet. G. 10-m L syringe. H. Water-solublelubricant. I. Suction catheter and source. J. Oral airways. K. End-tidal CO2detector. L. Bougie may be needed for difficultairways; keep at bedside. M. ETT securing device/holder or tape postintubation. N. Mask, eye protection,gloves, gown. PROCEDURE A. Preparation. 1. Explain the procedureto patient and family. 2. Obtain informed consent frompatient if possible or family if moreappropriate. 3. Inquire if patient has a history of a difficult airway or prior upper airway or neck injuries, disorders, or surgeries that may make intubation difficult. (continued ) Procedure: Endotracheal Intubation
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416 PROCEDURE ENDOTRACHEAL INTUBATION (continued ) FIGURE 1 Glide Scope video-assisted laryngoscopy. Source:Campo,T. M.,&Lafferty,K. (Eds. ). (2016). Essential procedures for emergency, urgent, and primary care settings: A clinical companion (2nd ed. ). New York,NY:Springer Publishing Company. 4. Washhands/perform hand hygiene. 5. Don clean gloves. 6. Assess oral cavity for oropharyngeallandmarks, dentures,missing teeth, or other potential obstructions. 7. Ensurepatient has a functional intravenous (IV) line. 8. Patient should have telemetry,blood pressure,respiratory,and O2saturationmonitoring. 9. Vital signs should be visible and checked frequently. 10. Ensureall equipment is available. B. Procedure. 1. Choose appropriatesize ETT. 2. Check ETT cuffby attaching 10-m L syringe and inflating cuff. 3. Ensurethereareno leaks and cuffis inflating appropriately. 4. Remove air fromcuffuntil it is completely deflated. 5. Insert stylet into ETT ensuring it does not pass beyond the tip of the ETT. Lubricate deflated balloon with water-soluble lubricant. 6. Choose blade size and attach it to laryngoscope handle or select blade size for videolaryngoscope. 7. Ensurelight is working on traditional laryngoscope and camera on videolaryngoscope. 8. Prior to performing the procedure, the provider should obtain gloves, a mask, and eye protection. If there is a concern for vomiting, copious secretions,or bleeding, then the providermay need a gown. 9. Position patient with head extended and neck flexing forward(“sniffingposition”). 10. Assess patient'smouth and removeany dentures. 11. Suction mouth as needed for a clear view of oropharynx. 12. Preoxygenatepatient for 3 to 5 minutes with 100% oxygen. a. If breathing:Passive oxygenation with a mask is sufficient. b. If inadequate respirationsor apnea, bagging is needed. 13. Administer orderedsedative first. 14. Administer orderedparalytic second. 15. Use scissor-likemotion to open mouth with the right hand. 16. Using the left hand, insert the laryngoscope at the right side of the mouth, moving midline while pushing the tongue to the left. 17. Advance blade into oropharynx past base of tongue, toward epiglottis using a “lift up and away” movement of the left hand until vocal cordsarevisible (see Figure2). 18. Use the right hand to take ETT and insert it into the right side of the mouth; under direct visualization, advance ETT into the oropharynxuntil the cuffpasses throughthe cords. Advance an additional 1 to 2 cm. 19. Remove stylet and inflate cuffon ETT. (continued )Procedure: Endotracheal Intubation
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417 PROCEDURE ENDOTRACHEAL INTUBATION (continued ) Epiglottis Trachea A B Epiglottis Trachea FIGURE 2 Illustration showing use of laryngoscope. Expiratory upstroke Inspiratory downstroke Respiratory baseline (should be 0 mm Hg)IIIIII 0Alveolar plateau Measured Et CO2 FIGURE 3 Thepoint of measuredend-tidal CO2. 20. Ifthepatientisobservedtohaveadifficultairway,theprovidermayinsertabougieintotherightsideofthemouth andadvanceitthroughthecords. The ETTwillbeinsertedoverthebougieuntilitpassesthroughthevocalcords. Once the ETT is through the vocal cords, the bougie is removed and the cuff inflated. The provider will continue the processwith steps 21 to 23. 21. Attach CO2detectororcapnographyandobserveforcolorchange(goldindicatescorrectplacement)orend-tidal CO2reading (a plateaued waveform, as shown in Figure 3, with a value of at least 35 mm Hg). Auscultate breath sounds over the stomach and over the lungs bilaterally. 22. Hold ETT carefullyin place until securementdevice or tape has been applied. 23. Attach patient to ventilator and immediately obtain chest x-ray to confirm placement. EVALUATION AND RESULTS A. Correctand secureplacement of the ETT. B. Adequate ventilation and oxygenation. C. Secretionclearance. (continued ) Procedure: Endotracheal Intubation
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418 PROCEDURE ENDOTRACHEAL INTUBATION (continued ) CLINICAL PEARLS A. If unable to get an adequate “sniffingposition,” place a rollunder the patient'sshoulders. B. Ensurea patent airway prior to administering any paralytic. C. Laryngoscope handle should always lift up and away fromthe providerdoing the procedure. D. Never lever laryngoscope back in the oropharynxbecause it can cause trauma/damage to the teeth. BIBLIOGRAPHY Al-Shaikh, B., & Stacey,S. (2013). Essentials of anaesthetic equipment (4th ed. ). London, England: Churchill Livingstone/Elsevier. Bennett,L.,&Cohen,F. M. (2017). Endotrachealintubation. In N. Multak(Ed. ), Clinical procedures for health professionals (pp. 169-172). Burlington, MA: Jones & Bartlett. Campo, T. M., & Lafferty, K. (Eds. ). (2016). Essential procedures for emergency, urgent, and primary care settings: A clinical companion (2nd ed. ). New York,NY:Springer Publishing Company. O'Connor, M. F., & Glick, D. B. (2015). Airway management. In J. B. Hall, G. A. Schmidt, & J. P. Kress (Eds. ), Principles of critical care (4th ed., pp. 384-395). New York,NY:Mc Graw-Hill. Salhi,B. A.,Taylor,T. A.,&Ander,D. S. (2017). Intubationandairwaysupport. In S. C. Mc Kean,J. J. Ross,D. D. Dressler,&D. B. Scheurer (Eds. ), Principles and practice of hospital medicine (2nded., pp. 895-899). New York,NY:Mc Graw-Hill. Procedure: Endotracheal Intubation
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419 PROCEDURE ENDOTRACHEAL EXTUBATION E. Mone ́e Carter-Griffin DESCRIPTION A. Removal of an endotracheal tube, allowing the patient to breatheusing his or her own upper airway. INDICATIONS A. Initial condition that led to the need for invasive mechanical ventilation has improvedor resolved. B. Hemodynamic stability has been obtained. C. Patient can adequately protecthis or her airway,clear secretions,and/or maintain minimal risk for aspiration. PRECAUTIONS A. Ensure patient has met parameters usually outlined in a protocol or by provider prior to extubation to avoid need for reintubation. EQUIPMENT REQUIRED A. Gloves, eye protection,and mask. B. Oxygen delivery device (e. g., nasal cannula, face mask) and source. C. Suction catheter and source. D. 10-m L syringe. E. Scissors for patients with an endotracheal tube securedwith tape. F. Ambu bag and mask connected to oxygen source. G. Supplies for endotracheal intubation in case emergentreintubationis required. PROCEDURE A. Explain the procedureto the patient and/or family and obtain informed consent. B. Assess the patient'sreadinessfor extubation, hemodynamic status, and ability to cough. C. Ensurethe patient has a functional intravenous (IV) line. D. Patient should have telemetry,blood pressure,respiratory,and O2saturationmonitoring. E. Washhands/perform hand hygiene. F. Don clean gloves. G. Place patient in semi-or high Fowler'sposition prior to extubation. H. Hyperoxygenateand suction throughthe endotracheal tube. I. Ifthepatienthastape,thenusescissorstocut. Ifthepatienthasasecurementdevice,thendisconnectandremove. J. Suction oral cavity. K. Attach 10-m L syringe to pilot balloon and deflate cuff. L. Instruct the patient to take a deep breathin and removethe endotracheal tube. M. Once the tube has been removed,instruct the patient to take a deep breathand cough. N. Suction mouth and apply supplemental oxygen. O. Discardused supplies and equipment. P. Document procedure,indication, postextubation physical assessment, complications, and patient tolerance. EVALUATION AND RESULTS A. Stable respiratorystatus and oxygenation. B. Atraumatic extubation. (continued ) Procedure: Endotracheal Extubation
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420 PROCEDURE ENDOTRACHEAL EXTUBATION (continued ) CLINICAL PEARLS A. Assessment of an air leak may be indicated in patients suspected of having ongoing upper airway edema. B. A decreasedair leak does not always suggest patient will fail postextubation. BIBLIOGRAPHY Hyzy, R. (2019, February 6). Extubation management in the adult intensive care unit. In G. Finlay (Ed. ), Up To Date. Retrieved from https://www. uptodate. com/contents/extubation-management Procedure: Endotracheal Extubation
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421 PROCEDURE EXTERNAL VENTRICULAR DRAIN Catherine Harris DESCRIPTION A. External ventricular drains aretubes that areused to drain and monitor cerebrospinalfluid in the brain. INDICATIONS A. Reduce intracranial pressureby allowing cerebrospinalfluid to be removedfromthe lateral ventricles. B. Monitor and measurecerebrospinalfluid chemistry and cytology. C. Monitor intracranial pressurein the perioperative setting. PRECAUTIONS A. Any opening createdin the skull increaseschances of infection; strict sterile technique is mandatory. B. Aggressivedrillingcancauseintracranialbleedingatthesite;exercisecautionpastthesecondlayerofcompactbone. EQUIPMENT REQUIRED A. Ventriculostomykit. B. Cranial access kit: Drill, drill bit, scalp retractor,needles/syringes, forceps,trochar. C. Sterile gown, gloves, drapes, mask, hat. D. Betadine. E. Hair clippers. F. Lidocaine with epinephrine. G. External ventricular setup. PROCEDURE A. Explain procedureto patient and/or family and obtain informed consent. B. Washhands/perform hand hygiene. C. Place patient supine with head elevated 30∘. D. Perform a proper time out. All present in the room must identify the patient and agree on the correct procedure and correctsite of the procedure. E. Clip hair aroundsite of drain insertion. F. Pre-prepsite with betadine. G. Mark superficial landmarks for the planned incision. Kocher's point: Found 10 to 11 cm back from nasion, as shown in Figure1A and B, and 2. 5 to 3 cm lateral to middle (midpupillary point). H. Set up sterile field: Prepand drape site. I. Infiltrate marked skin incision with 1% lidocaine with epinephrine. J. Make a straight sagittal 1-inch incision with a #11 blade down to the bone. K. Use self-retainingclamps to hold skin back. L. Use a handheld twist drill with a quarter inch bit to createa burr hole down to the dura. M. Once the dura has been exposed, puncturewith a sharp spinal needle. N. Advance ventricular catheter about 5 cm into the lateral ventricle. O. After catheter placement, removethe stylet and assess for cerebrospinalfluid. 1. If present,recordopening pressure. 2. If not present,removecatheter,then reintroducestylet and attempt a second pass. P. Attach a trochar to the distal end of the catheter and tunnel it under the scalp about 3 cm away from the burr hole. Do not move the intracranial catheter. Q. Once in place, confirm catheter position with flow of cerebrospinalspinal. (continued ) Procedure: External Ventricular Drain
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422 PROCEDURE EXTERNAL VENTRICULAR DRAIN (continued ) Nasion A BKocher's point FIGURE 1 (A)Location of the nasion and (B) Kocher'spoint. R. Attach plastic connector fromexternal drain system and securewith 3-0 silk tie. S. Anchor catheter to scalp with 3-0 nylon to preventdislodgement. T. Confirm catheter still drips cerebrospinalfluid. U. Return to initial incision, irrigate with saline, and achieve hemostasis. V. Close scalp wound with running 3-0 monocryl suture. Do not puncture underlying catheter. W. Follow institution'spolicy for dressingdrain site. EVALUATION AND RESULTS A. Confirmation of properplacement evidenced by return of cerebrospinalfluid. CLINICAL PEARLS A. Ifthereisalotofbloodintheventricle,clotsmaygetintoholesofthecatheterandimpedespontaneousflow;catheter may need to be repositioned,or another catheter may need to be placed. B. Positioning catheter toward landmarks is critical, but watch trajectory of placement. If ventricle is not entered after a couple passes, seek expert guidance. C. Do not go further than 7 cm deep. Critical brain structuresmay be damaged. BIBLIOGRAPHY Muirhead, W. R., & Basu, S. (2012). Trajectories for frontal external ventricular drain placement: Virtual cannulation of adults with acute hydrocephalus. British Journal of Neurosurgery, 26,710-716. doi:10. 3109/02688697. 2012. 671973 Toma,A. K.,Camp,S.,Watkins,L. D.,Grieve,J.,&Kitchen,N. D. (2009). Externalventriculardraininsertionaccuracy:Isthereaneedfor change in practice? Neurosurgery, 65,1197-1200. doi:10. 1227/01. NEU. 0000356973. 39913. 0BProcedure: External Ventricular Drain
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423 PROCEDURE INTRAOSSEOUS VASCULAR ACCESS Laura A. Santanna Lonergan DESCRIPTION A. Method for utilizing noncollapsible venous plexuses through the bone marrow cavity to achieve systemic circulation for fluid and medication administration. B. Intraosseous(IO)accessandinfusionispossiblebecauseofthepresenceofveinsthatdrainthemedullarysinusesin the bone marrowof long bones. C. Any intravenous (IV) drug or routineresuscitationfluid can be administeredsafely by the IO route. INDICATIONS A. In patients of all ages when venous access cannot be quickly and reliablyestablished during circulatorycollapse. PRECAUTIONS A. Proximalipsilateral fracture. B. Ipsilateral vascular injury. C. Severeosteoporosis. D. Osteogenesis imperfecta. EQUIPMENT REQUIRED A. Commerciallyavailable and approvedrapid IO drill device. B. Standardbone aspiration needle or specialized IO infusion needle. C. Standardprecautionsand safety equipment. PROCEDURE A. Explain the procedureto the patient and/or family and obtain informed consent. B. Washhands/perform hand hygiene. C. Select site. 1. Primary site in all age groups should be proximal tibia, unless otherwise contraindicated. Landmark for proximal tibia. a. Aim for insertion two finger breadthsbelow the patella and 1 to 2 cm medial to the tibial tuberosityin adults. 2. Other sites indicated with landmarks. a. Distal femur (under 12 months of age). i. Aim for the anterolateralsurface, 3 cm above the lateral condyle. b. Distal tibia or fibula (over 12 months of age). i. Aim for 3 cm proximalto the most prominentaspect of the medial malleolus. c. Proximalhumerus (over 18 years of age). i. Aimforapproximately1cmabovethesurgicalneckontheanteriorshaftofthehumerus,whichisthegreater tubercle. d. Manubrium (over 12 years of age). i. Superior one thirdof the sternum may be accessed. ii. Requiresa specialized device and training for insertion. D. Establish the patient in a comfortable position. E. Don sterile gloves. F. Ensuresterile preparationof the site using chlorhexidine solution or povidone iodine. G. Infiltrate site to include skin and periosteum with 1% to 2% lidocaine if patient is conscious. H. Stabilize leg with nondominant hand. I. Hold IO needle in dominant hand (see Figure1). J. Directneedle perpendicular to bone and away fromjoint spaces. K. Twistand apply constant pressureuntil sudden loss of resistance. L. Remove stylet. (continued ) Procedure: Intraosseous Vascular Access
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424 PROCEDURE INTRAOSSEOUS VASCULAR ACCESS (continued ) Medial malleolus FIGURE 1 Illustrationdepicting IO needle insertion. IO,intraosseous. M. Confirm placement by aspiration or infusion. N. Secureplacement with dressing. EVALUATION AND RESULTS A. Confirm placement and rule out procedure-inducedfracturewith x-ray. B. Complications: Cellulitis, osteomyelitis, iatrogenicfracture,physeal plate injury,fat embolism. CLINICAL PEARL A. The2005American Heart Association(AHA)Guidelinesfor CPRand Emergency Cardiovascular Carerecommendfor the first time IO access over endotracheal drug administration during resuscitation. BIBLIOGRAPHY ECCCommittee,Subcommitteesand Task Forcesofthe American Heart Association. (2005). 2005American Heart Associationguidelines for cardiopulmonaryresuscitationand emergencycardiovascularcare. Circulation, 112 (24Suppl), IV-1-IV-203. Ngo,A.,Oh,J.,Chen,Y.,Yong,D.,&Ong,M. (2009). Intraosseousvascularaccessinadultsusingthe EZ-IOinanemergencydepartment. International Journal of Emergency Medicine, 2 (3),155. doi:10. 1007/s12245-009-0116-9Procedure: Intraosseous Vascular Access
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425 PROCEDURE LONG LEG CASTING Joanne Elaine Pechar DESCRIPTION A. Long leg cast is an immobilization device that covers and encases the entirecircumferenceof the leg and foot. B. Long leg cast is used to stabilize and hold anatomical structuresin place until healing is achieved. INDICATIONS A. Immobilize and treatacute nondisplaced fractures,dislocations, and injuredligaments. B. Allow earlier ambulation by stabilizing fracturesof the lower extremity. C. Improvefunction by stabilizing or positioning a joint. D. Correctand treatcongenital deformities, such as clubfoot and joint contractures. E. Manage chronicfoot and ankle ulcers. PRECAUTIONS A. Ensuresufficientgauze or other dressingmaterial is applied to absorb blood if cast is applied over a wound. EQUIPMENT REQUIRED A. Stockinette. 1. Stretchable,sock-like material in varying widths. 2. Acts as a barrier between skin and cast padding. 3. Pulled over roughedges of cast to providecomfortable padded cast borders. B. Fiberglasscasting material. 1. Comes in rollsof varying widths. 2. Commonly used (as opposed to plaster) because of its strength,durability,light weight, and ease of application. 3. Begins to harden in 3 to 4 minutes. Fully hardens in 1 to 2 hours. Must be kept in its airtight foil package before application. 4. Due to its sticky resincontent, gloves should be worn when handling fiberglass. C. Webril(cotton) or synthetic undercastpadding. 1. Availablein 2-, 3-, 4-, 5-, and 6-inch widths, packaged in individual rolls. 2. 3-or 4-inch padding is used on lower leg; 5-or 6-inch padding is used on upper leg. D. Basin full of cool or roomtemperaturewater. 1. Avoid lukewarm water: Can increase probability of exothermic reaction of cast materials, which can increase risk of thermal injury to the skin. E. Bandage scissors. F. Cast cutter and spreader. G. Gloves and gown. PROCEDURE A. Position the patient. 1. Supine, with the ankle over the edge of the table. 2. Knee flexed to approximately20∘to35∘torelaxthe gastrocnemiusmuscle and reducepossible hyperextension. B. Apply stockinette. 1. Support the leg (an assistant should support the leg to be casted). 2. Measure the length of stockinette (see Figure 1). Cut stockinette to appropriate length with an extra 4 inches of stockinette on each end of the cast. 3. Apply stockinette, which is placed beyond the anticipated cast border. 4. Proximal edge of cast should lie below the greater trochanter on the lateral side, and just below the groin on the medial side. Distal edge of cast will be located at the level of metatarsal heads, while toes should remainfree. 5. Important positioning of foot: Plantigrade with toes pointing up (see Figure2). (continued ) Procedure: Long Leg Casting
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426 PROCEDURE LONG LEG CASTING (continued ) FIGURE 1 A nurse measuring the length of stockinette. FIGURE 2 Foot should be plantigrade with toes pointing up. FIGURE 3 Providetwo to threepadding layers before applying cast. C. Apply Webrilor synthetic undercastpadding. 1. Selectappropriatecastpaddingsize. Startingatdistalborder,gentlyrollandwindthepadding,smoothlyoverlap-ping each time about 50% aroundthe foot. Twoto threepadding layers is usually sufficient(see Figure3). 2. To protect pressure points against pressure ulcers, apply additional webril padding over the patella, malleoli, and heel. 3. When rolling padding, keep the roll in continuous contact with the extremity to avoid undesirable wrinkles that occur when the rollis lifted during application. 4. Wind cast padding towardknee with an overlap of 50%, creatinga double layer of padding. 5. Castpaddingshouldextendslightlybeyondtheplannedlengthofthecast,sothatwhentheendofthestockinette is folded over,the end of the cast will be well-padded. (continued )Procedure: Long Leg Casting
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427 PROCEDURE LONG LEG CASTING (continued ) 6. Extendpaddingabout2inchesbeyondintendedproximalanddistalcastborders,andaddanadditionaltwolayers of padding at proximaland distal bordersof cast (see Figure4). D. Apply fiberglassbandage. 1. Use 3-to 6-inch bandage rollsto providesufficienttime for molding. 2. Twoor threelayers of fiberglassareusually adequate, and construct a cast with uniform thickness. 3. Completelysoakandimmersetherolloffiberglassbandageinabasinofcoolwaterfor10seconds,gentlysqueeze thebandagetoremoveexcessmoistureandwater,andremovefiberglassbandagesfromwaterassoonasbubbling stops. 4. Starting with the bottom of the foot, roll fiberglass bandage on smoothly around ankle, overlapping each time by 50%. 5. Inthesamemanneraswebrilpadding,passfiberglassbandageoverheelandthentowardkneewith50%overlap. 6. Where the first bandage ends, apply a second fiberglass bandage, continuing proximally toward planned upper edge of cast and then returning towardfoot. 7. As additional fiberglass bandages are required, they should begin at the end of the previous bandage to ensure even thickness of cast. 8. Avoidwrinkling by folding or tucking fiberglassroll. E. Form the proximalend of the cast. 1. Fold loose end of the stockinette over the proximaledge of the cast. 2. Starting below the proximal edge, add another fiberglass bandage to secure the loose end of the stockinette and fiberglass(see Figure5). F. Form the distal end of the cast. 1. To create a padded and rolled edge border, pull the stockinette and cast padding over the distal end of the cast edge prior to rollingand securing the final layer of the fiberglassbandage. G. Final molding. 1. Whilethefiberglassisstillsoft,moldthecasttothecontouroftheextremitybygently,butfirmly,rubbingthecast between the palm of gloved hands. 2. Toensurethe foot is plantigrade, apply gentle pressureto the sole of the forefoot. FIGURE 4 Padding extends beyond cast. FIGURE 5 Secureloose ends of stockinette and fiberglass. (continued ) Procedure: Long Leg Casting
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428 PROCEDURE LONG LEG CASTING (continued ) FIGURE 6 Long leg cast completed. 3. Apply liquid soap for fiberglassto harden. 4. Application of gentle pressureshould be continued until fiberglasshardens. H. Completed cast. 1. Application of the long leg circularcast is now complete (see Figure6). 2. Place a small pillow under ankle until cast is fully hardand dry. 3. Weightbearing is restrictedfor 1 to 2 hours until cast has fully hardenedto avoid denting and cracking. 4. Ifcastistobeusedforwalking,applyextralayersofpaddingandfiberglassbandagetosoleandheelareas. Finally, place a cast shoe for ambulation. EVALUATION AND RESULTS A. Ask patient if cast feels loose or tight to ensurecomfortable fit. B. Check if cast extends to properboundaries while not interfering with range of motion. C. Check for any cast indentations or sharp edges. Trimsharp edges using a cast saw or bandage scissors. D. Instruct patients regarding: 1. Signs and symptoms of compression,such as swelling within the cast. 2. Requiredelevation of injuredextremityfor 2 to 3 days. 3. Timing for being able to walk on cast. 4. Weightbearing and ambulation, which include crutch or walker training. 5. Avoidanceof insertion of any objects under cast in an attempt to relieveitching. 6. Return to officefor a cast check in 5 to 7 days. 7. Prompt notification for any tingling, numbness, weakness, skin ulcerations or discoloration, pallor, paresthesias, paralysis, or worsening pain in the casted extremity. CLINICAL PEARLS A. In orderto sufficientlyprotectthe injuredlimb, the ideal cast must be thick and rigid. B. During the setting process,do not place the patient at risk for thermal injury. C. When supporting the extremity,be carefulnot to indent the cast with fingertips. D. “Bivalve”(split)thecastimmediatelyifunexpectedswellingoccursinalonglegcasttoavoidriskofacutecompartment syndrome. BIBLIOGRAPHY Gravlee, J. R., & Van Durme, D. J. (2007, February 1). Braces and splints for musculoskeletal conditions. American Family Physician, 75(3), 342-348. Retrieved fromhttps://www. aafp. org/afp/2007/0201/p342. html Halanski, M., & Noonan, K. J. (2008, January). Cast and splint immobilization: Complications. Journal of the American Academy of Orthopaedic Surgeons, 16 (1), 30-40. doi:10. 5435/00124635-200801000-00005Procedure: Long Leg Casting
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429 PROCEDURE LUMBAR PUNCTURE Courtney Connolley DESCRIPTION A. Also known as a spinal tap. B. Performed in the lower back to removea sample of cerebrospinalfluid (CSF). INDICATIONS A. Toobtain analysis of CSF for diagnostic purposes. 1. Meningitis/encephalitis. 2. Subarachnoid hemorrhage. 3. Demyelinating diseases. 4. Carcinomatousdiseases. B. Toevaluate and treatvarious neurologicalconditions. 1. Guillain-Barresyndrome. 2. Normal pressurehydrocephalus. 3. Pseudotumor cerebri. C. Toinstill substances into the subarachnoid space. 1. Chemotherapy. 2. Contrast media. PRECAUTIONS A. Stay in L4-L5 region to avoid puncturing spinal cord (ends around L1). Identify highest point of iliac crest bilaterally with palpation to site of L4 (see Figure1). B. Maintain sterile field to preventinfection. C. Do not drain too much CSF to avoid risk of cerebralherniation (20-40 m L of CSF can be safely removed). D. Bleeding at level of lumbar puncturecould cause nerve irritation and damage to surroundingstructures. EQUIPMENT REQUIRED A. Sterile gown, mask, gloves. B. Lumbar punctureneedle. C. Lumbar puncturekit. 1. 3-m L Luer lock syringe. 2. 25G 5/8 inch needle. 3. Lidocaine 1%. 4. Four specimen tubes with caps; tubes should be numbered1 through4. 5. Sponge applicators. 6. Threegauze pads. 7. Fenestrated drape. 8. Band-Aid. 9. One stopcock—threeway. 10. Twopiece manometer. 11. 22G 1-1/2 inch needle. 12. Infiltration with 20G ×31/2 inch needle. D. Sterile prepwith chlorhexidine or povidone iodine solution. PROCEDURE A. Explain the procedureto the patient and/or family and obtain informed consent. B. Washhands/perform hand hygiene. C. Position the patient in the lateral decubitus position with knees flexed. D. Perform a proper time out. All present in the room must identify the patient and agree on the correct procedure and correctsite of the procedure. E. Palpate the highest level of iliac crests bilaterally to assess level of L3-L4, or L4-L5 interspace. Palpate midline, in space between spinous processes(see Figure2). (continued ) Procedure: Lumbar Puncture
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430 PROCEDURE LUMBAR PUNCTURE (continued ) L5 L4 L3 L2 L1 L5 L4 L3 L2 L1Spinal cord Iliac crest Iliac crest Cauda equina FIGURE 1 Anatomicallandmarks for lumbar puncture. Lumbar puncture needle Lumbar puncture Sacral anesthesia needle End of spinal cord at L2 FIGURE 2 Illustration depicting placement of lumbar punctureneedle. Source: http://blogs. brown. edu/emergency-medicine-residency/lumbar-puncture-part-2-pearls-pitfalls-and-troubleshooting/ F. Mark point of entry. G. Preparesterile field; drape the area. H. Preparethe skin in usual sterile fashion. I. Skin and fascia of marked interspace should be infiltrated with 2% lidocaine with a 25-gauge needle. J. Introducespinalneedle(includingstylet)withbevelparalleltospinetodissectthefiberslongitudinally;avoidstrauma to tissues. K. Advance needle parallel to floor and perpendicular to back of patient, aiming towardhead with a 20∘to 30∘angle. 1. Bone should be felt superiorly and needle redirectedin caudal direction. 2. Slight resistanceshould be felt as needle is advanced into ligamentum flavum. 3. Smooth pop should be felt as needle penetrates dural sac. 4. Stop advancing needle. L. Rotate bevel towardthe head of the patient. (continued )Procedure: Lumbar Puncture
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431 PROCEDURE LUMBAR PUNCTURE (continued ) M. Remove stylet and assess for drainage of CSF. N. If CSF comes out, then use the manometer to measurethe pressureof the subarachnoid space and record. O. Use the collection tubes in the lumbar puncture kit to collect CSF. Fill in numerical order. The amount collected in each tube will vary depending on the purpose of the lumbar puncture. P. After CSF collection is completed, reinsertthe stylet and removethe needle. Q. Hold pressureat the site and then place a Band-Aid over the site. R. Recommend the patient lay flat for 1 to 2 hours after the procedure. EVALUATION AND RESULTS A. Observe color of CSF. B. Apply a manometer promptlyto the needle. C. Recordan opening pressure. D. State volume of CSF collected and sent to the laboratory. CLINICAL PEARLS A. Lumbar punctureis a blind stick. 1. It is possible to hit one of the nerves of the cauda equina. 2. If patient complains of pain down left leg, repositionneedle right to stay central, and vice versa. B. Positioning is the most important part of a successful lumbar puncture. 1. If interspace of spinal processesis difficultto palpate, have patient pull both knees up towardchest. 2. The morethe knees arepulled up, the morethe spinous processeswill open up, making them easier to palpate. C. A traumatic tap will be evidenced by blood in the CSF that diminishes in quantity collected in the specimen tubes. In subarachnoid hemorrhage, the amount of blood will not vary significantly. D. As blood breaks down it creates xanthochromia, which is seen as a yellow tinge in CSF. This is indicative of blood beingpresentforseveralhours. Itisveryimportanttogetthespecimentubestothelaboratoryasquicklyaspossible to distinguish between a traumatic tap (which will have no xanthochromia) and bleeding in the subarachnoid space, which may be caused by the ruptureof a vessel such as an aneurysm. BIBLIOGRAPHY Burke-Doe, A. Ventricles and coverings of the brain. Retrieved from https://accessphysiotherapy. mhmedical. com/data/Multimedia/ grand Rounds/ventricles/media/ventricles_print. html Doherty, C., & Forbes, R. (2014). Diagnostic lumbar puncture. Ulster Medical Journal, 83 (2), 93-102. Retrieved from https://www. ums. ac. uk/umj083/083(2)093. pdf Fastle, R., & Bothner, J. (2018). Lumbar puncture: Indications, contraindications, technique and complications in children. In J. F. Wiley, 2nd. (Ed. ), Up To Date. Retrieved from https://www. uptodate. com/contents/lumbar-puncture-indications-contraindications-technique-and-complications-in-children Procedure: Lumbar Puncture
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432 PROCEDURE PERIPHERALLY INSERTED CENTRAL CATHETER PLACEMENT Jingyi Deng DESCRIPTION A. A 3 French to 6 French catheter is inserted into the upper arm via the basilic or brachial vessel until the tip reaches the superior vena cava junction. INDICATIONS A. According to the Centers for Disease Control and Prevention ( CDC), the peripherally inserted central catheter (PICC) line is the safest central vascular catheter (CVC) capable of remaining indwelling for over a year. B. Long-term antibiotics, total parenteral nutrition (TPN), vasopressors, and multiple incompatible medications. PRECAUTIONS A. Chronic kidney disease/end-stage renal disease (CKD/ESRD). 1. Extended PICC line dwell time in peripheral vasculature can lead to stenosis of brachial or basilic vessel due to intima hypertrophy/scarring; can complicate future fistula formation or graft placement. 2. If renal replacement therapy (RRT) is imminent, nephrology should be consulted to decide if PICC would be suitable for the patient. 3. Patient should receive tunneled jugular line placed by intervention radiology (IR) instead. B. Bacteremia: Can result in central line-associated bloodstream infection (CLABSI). If cultures are pending, 48 hours of negative cultures or infectious disease approval is needed for PICC placement. C. Permanent pacemaker: PICC lines should never occupy the same vessel as pacemaker wires as this could potentially lead to wire displacement. D. Coagulopathy: Cut off for platelets, international normalized ratio (INR), partial thromboplastin time (PTT), and so forth, will differ based on facility. Determine if static parameters should delay an intervention (e. g., a patient with disseminated intravascular coagulopathy will not improve and this could prohibit placement of PICC). EQUIPMENT REQUIRED (continued )A. Ultrasound. B. Insertion kit with PICC line. 1. 2. One bag, poly, 7′′×10′′×2 Mil. 3. One band bag, 36′′×28′′clear. 4. One basin, emesis, 700 m L. 5. Two cups, 2 oz each. 6. One drape, 53′′×77¾′′. 7. One dressing, 4¾′′×4. 8. One forcep. 9. 10 gauze 4 ×4′′. 10. One gown. 11. One needle 18 G ×11/2′′length. 12. One pouch 17¼′′×22¾. 13. One scalpel #11. 14. One scissor. 15. One skin marker. 16. Two syringes 10 m L. 17. One table cover, 44′′×76′′×3 Mil. 18. Seven towels. C. Probe cover. D. Chlorhexidine solution. E. Lidocaine 2%. F. Extra wire. Onebag,bedsidewhite′′×31/2′′×11¾′′. 5Procedure:Peripherally Inserted Central Catheter Placement
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433 PROCEDURE PERIPHERALLY INSERTED CENTRAL CATHETER PLACEMENT (continued ) PROCEDURE A. Explain the procedure to the patient and/or family and obtain informed consent. B. Perform a proper time out. All present in the room must identify the patient and agree on the correct procedure and correct site of the procedure. C. Abduct patient's arm to 90∘and proceed to identify vessel. D. Measure from insertion site to right supraclavicular notch, then add 6 cm to the measurement. E. Wash hands and open insertion tray. F. Apply tourniquet to procedure arm. G. Don sterile gown and gloves. H. Drape patient's body with whole body drape. I. Drape patient's arm with window dressing. J. Prepare site with chlorhexidine for 30 seconds and allow 1 minute for dry time. K. Flush all lumens of PICC line. L. Apply probe cover to ultrasound probe. M. Inject lidocaine to desired insertion site and wait 60 seconds. N. Use ultrasound to identify target vessel and access vessel with needle or angiocatheter. O. Upon seeing flashback, proceed to walk needle into the vessel. P. Slide wire into the needle, then remove the needle or angiocatheter. Q. Undo tourniquet. R. Slide peelaway introducer onto wire, then remove wire. The peelaway introducer allows the introducer to be peeled away and removed, leaving the catheter in place. S. Confirm insertion site is the same as measured in step C, then cut catheter to that length. T. Remove introducer from sheath, then insert PICC into sheath. U. Continue to advance catheter until PICC is at the hub of the sheath. V. Proceed to peel away the sheath. W. Confirm blood return and flush all ports. X. Place probe on the jugular of the procedure side and flush the catheter. Ensure no sparkles appear on screen to confirm PICC is not in jugular. Y. Apply occlusive dressing and discard sharps in appropriate container. Z. Return patient room to preprocedure state. AA. Page for x-ray for radiographic confirmation. AB. Document procedure in the patient's record. CLINICAL PEARLS A. In a difficult catheter advancement, additional wire could increase stiffness and increase success. B. A j looped wire could potentiate success as this can maneuver around difficult anatomy. C. Larger French equates to higher risk of upper extremity deep vein thrombosis (DVT). Catheter-associated DVTs are more likely to originate from the fibrin sheath that forms from decreased blood flow around the catheter due to decreased lumen size. D. Using an angiocatheter for initial pads allows for catheter threading and decreased risk for unintentional posterior wall puncture. (continued ) Procedure:Peripherally Inserted Central Catheter Placement
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434 PROCEDURE PERIPHERALLY INSERTED CENTRAL CATHETER PLACEMENT (continued ) BIBLIOGRAPHY Kelly, L. (2013). A practical guide to safe PICC placement. British Journal of Nursing, 22 (Suppl. 5), S13-S19. doi:10. 12968/bjon. 2013. 22. Sup5. S13 O'Grady, N. P., Alexander, M., Dellinger, E. P., Gerberding, J. L., Heard, S. O., Maki, D. G., & Weinstein, R. A. (2002). Guidelines for the prevention of intravascular catheter-related infections. MMWR Recommendations and Reports, 51 (RR-10), 1-26. Retrieved from https://www. cdc. gov/mmwr/preview/mmwrhtml/rr5110a1. htm?vm =r Sansivero, G. E. (2000). The microintroducer technique for peripherally inserted central catheter placement. Journal of Intravenous Nurs-ing, 23, 345-351. Wallace, B. A., & Taylor, T. (n. d. ). Ultrasound-guided venous access. Retrieved from https://saem. org/cdem/education/online-education/m3-curriculum/bedside-ultrasonagraphy/venous-access Procedure:Peripherally Inserted Central Catheter Placement
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435 PROCEDURE REDUCTION OF THE ANKLES Laura A. Santanna Lonergan DESCRIPTION A. Ankle dislocations seen after a traumatic injury. B. May be associated with fracture/ligamentousinjury. INDICATIONS A. Promptreductionof ankle fracturesreducestension on skin and preventssoft tissue swelling. B. Most ankle fracturesthat requirereductionwill also requiresurgicalintervention. C. Goal of reductionis restorationof the ankle mortise. EQUIPMENT REQUIRED A. 18 g needle. B. 10 m L syringe. C. 1% Lidocaine. D. Facility approvedconscious sedation protocol. E. Sugar-tongsplint. F. Assistive device as needed. PROCEDURE A. Explain the procedureto the patient and/or family and obtain informed consent. B. Position the patient in the supine position with the affectedlimb flexed at the knee over the end of the bed. 1. May perform intra-articular joint block of affectedankle for pain control. 2. Conscious sedation may be necessary to perform adequate reduction. C. Perform a proper time out. All present in the room must identify the patient and agree on the correct procedure and correctsite of the procedure. D. Internallyrotateandsupinateorpronatewhilegivinglimbdistaltractionuntilaudibleorpalpablereductionisachieved (see Figure1). E. Splint patient with lower extremitysugar-tongsplint with propermolding aroundankle joint for added stability. EVALUATION AND RESULTS A. Postreductionimaging to evaluate success of reductionand ensureno proceduralinjuries. B. Perform postreductionneurovascularexamination of bilateral lower extremities. FIGURE 1 Illustration demonstrating manual traction of ankle. (continued ) Procedure: Reduction of the Ankles
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436 PROCEDURE REDUCTION OF THE ANKLES (continued ) C. Providepatient with appropriateassistive device (crutches, cane, walker) and instruct no weight bearing on limb. D. Follow-up with orthopedics for surgicalevaluation of fracture/dislocation. CLINICAL PEARLS A. Repeated forcefulattempts at reductioncan cause additional injury. B. Failureof reductionafter two to threeattempts may warrant surgicalintervention. C. If a closed injury converts to an open injury,tetanus prophylaxisand antibiotic coverage should be administered. BIBLIOGRAPHY Arnold, C., Fayos, Z., Bruner, D., & Arnold, D. (2017, December). Managing dislocations of the hip, knee, and ankle in the emergency department. Emergency Medicine Practice, 19 (12), 1-28. Melenevsky,Y.,Mackey,R. A.,Abrahams,R. B.,&Thomson,N. B.,3rd. (2015,May-June). Talarfracturesanddislocations:Aradiologist's guide to timely diagnosis and classification. Radiographics, 35 (3), 765-779. doi:10. 1148/rg. 2015140156 Rammelt, S., & Goronzy,J. (2015, June). Subtalar dislocations. Foot and Ankle Clinics, 20 (2), 253-264. doi:10. 1016/j. fcl. 2015. 02. 008 Wight, L., Owen, D., Goldbloom, D., & Knupp, M. (2017, October). Pure ankle dislocation: A systematic review of the literature and estimation of incidence. Injury, 48(10),2027-2034. doi:10. 1016/j. injury. 2017. 08. 011Procedure: Reduction of the Ankles
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437 PROCEDURE REDUCTION OF THE FINGERS Laura A. Santanna Lonergan DESCRIPTION A. Loss of alignment of a digit joint: Distal interphalangeal (DIP), proximal interphalangeal (PIP), and metacarpophalangeal (MCP) joint. INDICATIONS A. Finger reduction is indicated when diagnosis of dislocation has been determined and likelihood of fracture has been eliminated. PRECAUTIONS A. Prior to reduction, obtain imaging to rule out associated fracture. EQUIPMENT REQUIRED A. Lidocaine 1% or 2% without epinephrine for digital block (optional). B. Finger splint. C. Tape. PROCEDURE A. Explain the procedure to the patient and family and obtain informed consent. B. Wash hands/perform hand hygiene. C. Perform a proper time out. All present in the room must identify the patient and agree on the correct procedure and correct site of the procedure. D. Administer digital block in the proximal aspect of the affected finger. 1. Reduction of dorsal dislocation. a. Apply axial traction with simultaneous flexion of joint (see Figure 1). b. If unsuccessful, try again but first hyperextend the distal portion to “unlock” the joint. Continue with axial traction and flexion. c. DIP dorsal dislocation splint in full extension while allowing full range of motion of the PIP joint. d. PIP dorsal dislocation splint with PIP in 20∘to 30∘of flexion. E. Reduction of volar dislocation. 1. Gently hyperflex while pushing the base of the dislocated phalanx into place (see Figure 2). 2. Splint the PIP in 20∘to 30∘of flexion. Pressure to the middle phalanx Gentle distal traction Counterpressure to the proximal phalanx FIGURE 1 Reduction technique of dorsal dislocation. (continued ) Procedure: Reduction of the Fingers
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438 PROCEDURE REDUCTION OF THE FINGERS (continued ) F. Reduction of lateral joint dislocation. 1. Gently hyperextend the joint while correcting the ulnar or radial deformity (see Figure 3). 2. DIP lateral dislocation splint in full extension. 3. PIP lateral dislocation; apply dorsal splint with the PIP 20∘to 30∘of flexion. EVALUATION AND RESULTS A. Perform postreduction imaging to evaluate the success of reduction and to ensure no procedural injuries. B. Refer to orthopedic or hand surgeon if: 1. Joint cannot be reduced (may require open reduction). 2. Patient has fracture dislocations. 3. Patient has open-fracture dislocations. FIGURE 2 Closed reduction of PIP joint dislocation. PIP, proximal interphalangeal. Source: Campo, T. M., & Lafferty, K. (Eds. ). (2016). Essential procedures for emergency, urgent, and primary care settings: A clinical companion (2nd ed. ). New York, NY: Springer Publishing Company. FIGURE 3 Lateral joint dislocation. (continued )Procedure: Reduction of the Fingers
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439 PROCEDURE REDUCTION OF THE FINGERS (continued ) CLINICAL PEARLS A. An aggressive attempt at reducing fingers can cause a fracture of the joint being reduced. B. Infection is a concern if there is an open fracture. C. Inadequate mobilization can lead to redislocation. BIBLIOGRAPHY Campo, T. M., & Lafferty, K. (Eds. ). (2016). Essential procedures for emergency, urgent, and primary care settings: A clinical companion (2nd ed. ). New York, NY: Springer Publishing Company. Leggit, J. C., & Meko, C. J. (2006). Acute finger injuries: Part II. Fractures, dislocations, and thumb injuries. American Family Physician, 73, 827. Muelleman, R. L., & Wadman, M. C. (2004). Injuries to the hand and digits. In J. E. Tintinalli, G. D. Kelen, & J. S. Stapczynski (Eds. ), Emergency medicine: A comprehensive study guide (6th ed., pp. 1665-1673). New York, NY: Mc Graw-Hill. Procedure: Reduction of the Fingers
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440 PROCEDURE REDUCTION OF THE HIP Laura A. Santanna Lonergan DESCRIPTION A. The displacement of the femoral head fromthe acetabulum. B. Posterior dislocation morecommon than anterior dislocation. INDICATIONS A. Needed in all hip dislocations. B. Less emergentin patients status post hip arthroplasty,as risk of osteonecrosisof femoral head is not present. PRECAUTIONS A. Contraindicated in patients with associated femoral neck fracture. EQUIPMENT REQUIRED A. Facility approvedconscious sedation protocol. B. Second provider/assistantfor traction. C. Abduction pillow. PROCEDURE A. Explain the procedureto the patient and/or family and obtain informed consent. B. Position the patient supine in bed. C. Perform a proper time out. All present in the room must identify the patient and agree on the correct procedure and correctsite of the procedure. D. Place sheet aroundthe proximalthigh of the affectedlimb. E. Administer conscious sedation per facility protocol. F. Stand on the patient'sbed, straddling lower extremities. G. Use Allis method for posterior dislocations. 1. Have a provider or assistant stabilize the pelvis by applying direct, downward (see Figure 1) pressure on patient's bilateral anterior superior iliac spines (ASISs). H. Apply traction in-line with femur. I. While traction is maintained, slowly flex hip to 70∘(see Figure2). J. If necessary, gently rotate the hip as well as having second provider/assistant pull laterally on the sheet around the thigh. K. Continue traction and manipulation until palpable reductionis felt. L. Place abduction pillow between the patient'slegs. EVALUATION AND RESULTS A. Postreductionimaging to evaluate success of reductionand ensureno proceduralinjuries. B. Postreduction CT scan of the hip recommended to verify concentric reduction as well as evaluate for intra-articular bony fragments. C. Follow-up with orthopedics for continued evaluation. CLINICAL PEARLS A. Another option for positioning the patient for a hip reduction is to place the patient on a backboard using a strap acrossthe pelvis. This may work better than having an assistant apply pressureor may provideextra stabilization. B. Make sureto use a steady sustained forceduring reduction. C. If thereis not any movement of the joint, try rockingback and forth with internal and external rotationat the hip. (continued )Procedure: Reduction of the Hip
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441 PROCEDURE REDUCTION OF THE HIP (continued ) FIGURE 1 Nurses performing the Allis technique on a patient. Source:Campo, T. M., & Lafferty,K. (Eds. ). (2016). Essential procedures for emergency, urgent, and primary care settings: A clinical companion (2nd ed. ). New York,NY:Springer Publishing Company. Adduction and internal rotation Counter traction Traction FIGURE 2 Adductionand internal rotation ofhip. BIBLIOGRAPHY Campo, T. M. & Lafferty, K. (Eds. ). (2016). Essential procedures for emergency, urgent, and primary care settings: A clinical companion (2nd ed. ). New York,NY:Springer Publishing Company. Hendey,G. W.,&Avila,A. (2011). The Captain Morgantechniqueforthereductionofthedislocatedhip. Annals of Emergency Medicine, 58, 536-540. doi:10. 1016/j. annemergmed. 2011. 07. 010 Nordt,W. E.,3rd.,(1999). Maneuversforreducingdislocatedhips:Anewtechniqueandliteraturereview. Clinical Orthopedic and Related Research, 360,260-264. doi:10. 1097/00003086-199903000-00032 Waddell, B., Mohamed, S., Glomset, J., & Meyer, M. (2016). A detailed review of hip reduction maneuvers: A focus on physician safety and introductionof the Waddelltechnique. Orthopedic Reviews, 8 (1),6253. doi:10. 4081/or. 2016. 6253 Procedure: Reduction of the Hip
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442 PROCEDURE REDUCTION OF THE PATELLA Laura A. Santanna Lonergan DESCRIPTION A. Loss of patellar alignment. B. Most typical is lateral dislocation. INDICATIONS A. First-time dislocations can be treatedwith reductionand immobilization. B. Recurrentdislocations or those dislocations unable to be reducedneed operative open reduction. PRECAUTIONS A. Do not attempt closed reductionif thereareassociated injuries to dislocation. EQUIPMENT REQUIRED A. 18 g needle. B. 20 m L syringe. C. 5 to 10 m L lidocaine. D. Knee immobilizer brace. PROCEDURE A. Explain the procedureto the patient and/or family and obtain informed consent. B. Traumatic hematoma present: Instill lidocaine at insertion site of needle if performing aspiration to decompress hematoma, allowing patella to sit within the trochleargroove. C. Extend affectedknee (see Figure1). D. If extension alone does not relocatethe patella, apply medially directedforceto the laterally dislocated patella. E. Brace with knee immobilizer. EVALUATION AND RESULTS A. Postreductionimaging to evaluate success of reductionand to ensureno proceduralinjuries. B. Follow-up with orthopedics and/or physical therapy. A B FIGURE 1 Illustrationshowing reduction of the patella. (continued )Procedure: Reduction of the Patella
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443 PROCEDURE REDUCTION OF THE PATELLA (continued ) CLINICAL PEARLS A. Patellar dislocations area common musculoskeletal injury. B. Reductions of the patella typically do not requireimaging or proceduralsedation. C. Recurrentdislocations should be followed up with rehabilitation. BIBLIOGRAPHY Davenport, M. (2017, April 13). Reduction of patellar dislocation technique. In E. Schraga (Ed. ), Medscape. Retrieved from https:// emedicine. medscape. com/article/109263-technique Mehta, V. M., Inoue, M., Nomura, E., & Fithian, D. C. (2007, June). An algorithm guiding the evaluation and treatment of acute primary patellar dislocations. Sports Medicine and Arthroscopy Review, 15 (2),78-81. doi:10. 1097/JSA. 0b013e318042b695 Stefancin, J. J., & Parker, R. D. (2007, February). First-time traumatic patellar dislocation: A systematic review. Clinical Orthopedics Related Research, 455,93-101. doi:10. 1097/BLO. 0b013e31802eb40a Procedure: Reduction of the Patella
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444 PROCEDURE REDUCTION OF THE SHOULDER Laura A. Santanna Lonergan DESCRIPTION A. A shoulder joint is considered dislocated or subluxed when the articular surfaces of the joint have lost all contact through displacement. B. The head of the humerus becomes displaced from the glenoid fossa. INDICATIONS A. Joint is displaced. B. Determined by imaging studies. C. Palpable or visual shoulder deformity with a mechanism of injury suggestive of dislocation. PRECAUTIONS A. Obtain imaging of shoulder prior to reduction to rule out evidence of fracture. EQUIPMENT REQUIRED A. Stretcher. B. Weights. C. Analgesia. D. Shoulder immobilizer. PROCEDURE A. Stimson technique (gravity-assisted reduction). B. Explain the procedure to the patient and/or family and obtain informed consent. C. Perform a proper time out. All present in the room must identify the patient and agree on the correct procedure and correct site of the procedure. D. Administer analgesia as indicated. E. Perform neurological examination of the bilateral upper extremities to include, but not limited to, function of axillary, musculocutaneous, median, radial, and ulnar nerves. F. Place the patient prone on a stretcher with the dislocated extremity hanging off the side edge of the stretcher. G. Have the assistant sit on the floor and apply gentle downward traction to the arm OR attach 5 to 15 pounds of weight to the patient's arm (Stimson maneuver; see Figure 3. 44). H. While traction is performed, place the left thumb on the patient's acromion and left fingers on the front of the humeral head (see Figure 3. 45). I. Gently push the humeral head downward until it reduces into the glenoid fossa. J. Brace shoulder using immobilizer. EVALUATION AND RESULTS A. Postreduction imaging to complete reduction with no procedural injuries. B. Perform postreduction bilateral upper extremity neurovascular examination and document findings. C. Follow-up with orthopedic surgeon for continued evaluation. D. Perform physical therapy/exercises for strength building and return of preinjury function. CLINICAL PEARLS A. Many shoulder dislocations can easily be reduced by medical professionals after injury in many cases before muscles go into spasm. B. Recurrences of shoulder dislocations are common after the first injury. (continued )Procedure: Reduction of the Shoulder
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445 PROCEDURE REDUCTION OF THE SHOULDER (continued ) FIGURE 1 Illustration depicting the Stimson maneuver. Patient should lie prone on the table. A 5-to 15-pound weight should be attached to the affected arm, hanging off of the edge of the table as shown. FIGURE 2 The Cunningham technique. Face the patient diagonally and instruct him or her to relax and pull back his or her shoulders. BIBLIOGRAPHY De Lee, J., Drez, D., & Miller, M. D. (Eds. ). (2003). De Lee and Drez's orthopaedic sports medicine (2nd ed., pp. 1038-1040). Philadelphia, PA: Elsevier Science. Marinelli, M., & de Palma, L. (2009, March). The external rotation method for reduction of acute anterior shoulder dislocations. Journal of Orthopedics and Traumatology, 10 (1), 17-20. doi:10. 1007/s10195-008-0040-4 Westin, C. D., Gill, E. A., Noyes, M. E., & Hubbard, M. (1995, May-June). Anterior shoulder dislocation. A simple and rapid method for reduction. American Journal of Sports Medicine, 23 (3), 369-371. doi:10. 1177/036354659502300322 Procedure: Reduction of the Shoulder
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446 PROCEDURE SPLINTING Laura A. Santanna Lonergan DESCRIPTION A. Mechanism used to immobilize an injuredextremity. B. A splint is similar to a cast in that its function is to immobilize, but its main advantage allows for soft tissue swelling during the acute phase of an injury. INDICATIONS A. Immobilization of acute fractures. B. Immobilization of dislocation after it has been reduced. C. Treatmentof soft tissue injuries not limited to sprains and strains. PRECAUTIONS A. Do not place over broken,undressedskin/lacerations. B. Ensurepropersplint padding and placement to defer pressuresore. C. Ensurepatient'sproperposition of function while splinted to avoid further injury to the patient. EQUIPMENT REQUIRED A. Length-and width-appropriateprefabricatedsplint. B. Additional padding. C. Bucket of cool water. D. Dry towel. E. Elastic bandage wraps. PROCEDURE A. Short arm ulnar gutter (see Figure1). 1. Totreatfracturesof the fourth and fifth metacarpals and phalanges. 2. Apply splint on ulnar aspect of upper extremity,fromthe tip of the little finger to just distal to the elbow. 3. Place wrist in 20∘extension, metacarpophalangeals (MCPs) flexed to 50∘, and distal interphalangeal (DIP) and proximalinterphalangeal (PIP) joints in slight flexion. 4. Pad upper extremityas indicated per patient presentation. 5. Immerse splint in bucket of cool water. 6. Remove excess water fromsplint with towel. A B FIGURE 1 Shortarm ulnar gutter: (A) supine view; (B) proneview. (continued )Procedure: Splinting
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447 7. Applysplintwithpatientholdingpositionoffunction,securingwithangiotensin-convertingenzyme(ACE)bandages. 8. Perform postsplint application neurovascularexamination to bilateral upper extremities. B. Long arm posterior splint (see Figure2). 1. Used for acute immobilization of midforearmor proximalforearmfractures. a. It can also be used for fracturesof the distal humerus. 2. Place elbow in 90∘flexion,with forearm in neutral pronationor supination. 3. Applysplinttotheulnaraspectoftheforearm,extendingfromthepalmercreasetoseveralinchesabovetheelbow. 4. Pad the upper extremityas indicated per patient presentation. 5. Immerse the splint in a bucket of cool water. 6. Remove excess water fromthe splint with a towel. 7. Apply the splint with the patient holding the position of function, securing with ACE bandages. 8. Perform a postsplint application neurovascularexamination to the bilateral upper extremities. C. Upper extremitysugar-tongsplint (Figure3). 1. Can be used for acute splinting of forearmfractures. a. May providemorestability than a volar splint. 2. Splintbeginsatthepalmarcrease,movesalongthevolarforearm,movesaroundtheelbowjoint,andendsatthe dorsal aspect of the MCP joints. 3. Pad the upper extremityas indicated per patient presentation. Long arm posterior splint Indications-Distal humerus #-Both-bone forearm #-Unstable proximal radius or ulna # (sugar-tong better) FIGURE 2 Long arm posterior splint. A B FIGURE 3 Upperextremitysugar-tongsplint: (A) completed wrapping; (B) wrap aroundunderlying pad. (continued ) Procedure: Splinting PROCEDURE SPLINTING (continued )
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448 4. Immerse the splint in a bucket of cool water. 5. Remove excess water fromthe splint with a towel. 6. Apply the splint with the patient holding the position of function, securing with ACE bandages. 7. Perform a postsplint application neurovascularexamination to the bilateral upper extremities. D. Volarwrist splint (Figure4). 1. Can be used for sprains of the wrist or for stable fracturesof the distal radius and/or ulna. 2. Splint extends fromthe volar surface of the MCP joints to the proximalforearm. 3. Pad the upper extremityas indicated per patient presentation. 4. Immerse the splint in a bucket of cool water. 5. Remove excess water fromthe splint with a towel. 6. Apply the splint with the patient holding the position of function, securing with ACE bandages. 7. Perform a postsplint application neurovascularexamination to the bilateral upper extremities. E. Thumb spica splint (Figure5). 1. Used for sprains or fracturesof the scaphoid, first metacarpal, or thumb proximalphalanx. 2. Splint runs along the thumb from above the interphalangeal (IP) joint, along the radial aspect of the wrist to the forearm. 3. Wrist is splinted in the neutral position while the thumb is splinted slightly flexed: Have the patient oppose the thumb towardthe index finger as if to make the “OK” sign. 4. Pad the upper extremityas indicated per patient presentation. 5. Immerse the splint in a bucket of cool water. 6. Remove excess water fromthe splint with a towel. 7. Apply the splint with the patient holding the position of function, securing with ACE bandages. 8. Perform a postsplint application neurovascularexamination to the bilateral upper extremities. FIGURE 4 Volarwrist splint. FIGURE 5 Thumb spica splint. (continued )Procedure: Splinting PROCEDURE SPLINTING (continued )
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449 PROCEDURE SPLINTING (continued ) F. Short leg posterior splint (Figure6). 1. Used for acute immobilization of severeankle sprains and fracturesof the distal leg, ankle, and foot. 2. Splint is applied along the posterior aspect of the lower leg from 1 inch distal to the popliteal fossa to the distal ends of the toes. 3. Pad the lower extremityas indicated per patient presentation. 4. Immerse the splint in a bucket of cool water. 5. Remove excess water fromthe splint with a towel. 6. Apply the splint with the patient holding the position of function, securing with ACE bandages. 7. Perform a postsplint application neurovascularexamination to the bilateral lower extremities. G. Lower leg sugar-tongsplint. 1. Can be used as an alternative to the short leg posterior splint when morestability is desired. 2. Itisa“U”-shapedsplintstartingatthelateralaspectoftheknee,whichgoesundertheproximalfootandheeland moves upward,stopping at the medial aspect of the knee (see Figure7). 3. Pad the lower extremityas indicated per patient presentation. 4. Immerse the splint in a bucket of cool water. 5. Remove excess water fromthe splint with a towel. 6. Apply the splint with the patient holding the position of function, securing with an elastic bandage wrap. 7. Perform a postsplint application neurovascularexamination to the bilateral lower extremities. A B FIGURE 6 Shortleg posterior splint: (A) lateral view; (B) supine view. FIGURE 7 Lower leg sugar-tongsplint. (continued ) Procedure: Splinting
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450 PROCEDURE SPLINTING (continued ) EVALUATION AND RESULTS A. After splint placement, carefullyassess to ensurethe splint: 1. Is in extension (not flexed). 2. Does not interferewith range of motion of necessary joints. 3. Does not have finger indentations or sharp edges puncturing the patient'sskin. B. The splint is never to be removedby the patient; only by a professionalafter follow-up with the specified specialist. C. Ifthesplintisonthelowerextremity,gooverweight-bearingstatuswiththepatientandmakesureheorshehassuf-ficient and safe means of mobility (crutches, cane, walker,etc. ). D. The splint is to stay dry at all times. If the splint gets wet, a new splint needs to be placed. E. Educatethepatientthatsplintsareusuallytemporaryandheorshewillmostlikelyneedtofollow-upwithaspecialist for continued careand treatmentof the injury. CLINICAL PEARLS A. Extremitiesshould be splinted in their correctanatomical position unless thereis resistanceor loss of circulation. B. A poorly immobilized fracturecan be moreharmful than no splint at all. C. When in doubt, splint an extremityeven if it is not clear if thereis a fracture. BIBLIOGRAPHY Do, T. (2017). Splinting. In E. D. Schraga (Ed. ), Medscape. Retrieved fromhttps://emedicine. medscape. com/article/1997864-overview Egol, K. A., Koval, K. J., & Zuckerman, J. D. (2015). Handbook of fractures (5thed., pp. 1-72). Philadelphia, PA:Wolters Kluwer. Nackenson, J., Baez, A. A., & Meizoso, J. P. (2017). A descriptive analysis of traction splint utilization and IV analgesia by emergency medical services. Prehospital and Disaster Medicine, 32 (6),631-635. doi:10. 1017/S1049023X17006859Procedure: Splinting
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451 PROCEDURE SYNOVIAL FLUID ASPIRATION Joanne Elaine Pechar DESCRIPTION A. Joint aspiration, also known as joint arthrocentesis, is a procedure to drain and remove fluid from the joint space using a needle and syringe. B. Joint aspiration, commonly done under local anesthesia, offers both therapeutic and diagnostic benefits and is com-monly done to relieve swelling or to obtain fluid for analysis. INDICATIONS A. Therapeutic. 1. Hemarthrosis or bleeding into joint space. 2. Symptomatic relief of joint effusion. B. Diagnostic. 1. Septic joint. 2. Crystal-induced joint disease. 3. Unexplained joint effusion. PRECAUTIONS A. Infection of overlying tissues is considered a relative contraindication. B. In some cases, joint aspiration is still performed as it provides critical diagnostic information. EQUIPMENT REQUIRED A. Betadine swab. B. Alcohol swab. C. Ethyl chloride or cold anesthetic spray. D. One pair of hemostats. E. 16 or 18 gauge needle. F. 10 to 60 m L syringe. G. Gauze. H. Tape. I. Pen marker. J. Three vacutainer lab tubes for joint fluid analysis (gram stain, cell count, culture, and crystals). K. Gloves. PROCEDURE A. Explain the procedure to the patient and/or family and obtain informed consent. B. Use standard precautions to prep for procedure. C. Perform a proper time out. All present in the room must identify the patient and agree on the correct procedure and correct site of the procedure. D. Assess for any evidence of infection or inflammation. E. Place the patient supine with knee in extension. F. Use medial approach when effusion is small and lateral approach with larger effusions. G. Identify bony landmarks, namely the superior pole and lateral edge of the patella and the soft spot approximately 1 to 2 cm below the lateral edge of the patella. H. Mark entry site. I. Prep site with Betadine and alcohol swab. J. Ethyl chloride spray can be used to anesthetize the site. (continued ) Procedure: Synovial Fluid Aspiration
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452 PROCEDURE SYNOVIAL FLUID ASPIRATION (continued ) K. Lightly hold patella between thumb and index finger. L. Using an anteromedial or anterolateral approach, insert the needle into the joint space (see Figure 1). M. Once the needle enters the joint space, aspirate fluid. Advance needle until synovial fluid is obtained (see Figure 2). N. Resistance to the flow of synovial fluid can be met at the level of the joint capsule. O. To “milk” additional fluid, have the assistant apply manual pressure to the opposite side of the joint. P. In order to maximize extraction of effusion or blood, directing the needle in multiple angles inside the joint space may be needed. Q. If the syringe becomes full of fluid, empty it by removing the syringe from the hub of the needle and replace it with an empty syringe. Repeat aspiration until synovial fluid can no longer be aspirated or until knee effusion is no longer visible. FIGURE 1 Insertion of needle into the joint space. FIGURE 2 Extraction of synovial fluid. (continued )Procedure: Synovial Fluid Aspiration
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453 PROCEDURE SYNOVIAL FLUID ASPIRATION (continued ) R. When procedure is completed, hold direct pressure for at least 5 minutes. S. Apply dressing. T. Send fluid to the laboratory for analysis. If infection is suspected, obtain gram stain, cell counts, and cultures. U. Instruct patients to avoid use of the joint for at least 1 day. EVALUATION AND RESULTS A. Review the results of the synovial fluid (see Table 1). TABLE 1 Synovial Fluid Findings Findings Normal Joint Noninflammatory Inflammatory Septic Hemorrhagic Clarity Transparent Transparent Translucent or cloudy Opaque or turbid Bloody Color Clear Straw to yellow Yellow Yellow, green, purulent Red Fluid cell count: WBC <200 <2,000 2,000-50,000 >50,000 200-2,000 Segmented neutrophils or PMNs<25% <25% >70% >90% 50%-75% Fluid culture Negative Negative Negative Positive Negative PMN, polymorphonuclear leukocyte; WBC, white blood cell. B. Most purulent synovial fluid or effusions are due to septic arthritis. C. Noninflammatory conditions include degenerative joint disease (DJD), osteochondritis dissecans, and neuropathic arthropathy. D. Inflammatory conditions include rheumatoid arthritis (RA), gout, pseudogout, reactive arthritis, ankylosing spondylitis, and rheumatic fever. E. Hemorrhagic conditions include hemarthrosis, hemophilia or other hemorrhagic diathesis, and trauma with or without fracture. CLINICAL PEARLS A. If there is a suspicion of joint infection, cell count, culture, and gram stain should be urgently sent for lab analysis. B. Patients receiving anticoagulation at therapeutic levels can generally undergo arthrocentesis safely, but bleeding is to be expected. BIBLIOGRAPHY Shlamovitz, G. (2019, February 28). Knee arthrocentesis technique. In E. D. Schraga (Ed. ), Medscape. Retrieved from https://emedicine. medscape. com/article/79994-technique Zhang, Q., Zhang, T., Lv, H., Xie, L., Wu, W., Wu, J., & Wu, X. (2012, July). Comparison of two positions of knee arthrocente-sis: How to obtain complete drainage. American Journal of Physical Medicine & Rehabilitation, 91 (7), 611-615. doi:10. 1097/PHM. 0b013e31825a13f0 Zuber, T. J. (2002, October 15). Knee joint aspiration and injection. American Family Physician, 66 (8), 1497-1501. Retrieved from https://www. aafp. org/afp/2002/1015/p1497. html Procedure: Synovial Fluid Aspiration
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454 PROCEDURE THORACENTESIS E. Mone ́e Carter-Griffin DESCRIPTION A. Needle insertion into the pleural space to removeexcess fluid. INDICATIONS A. Therapeutic drainage of symptomatic pleural effusions. B. Diagnostic evaluation of pleural fluid. PRECAUTIONS A. Patients with coagulopathies. B. Avoidareasof skin infections on the chest wall. C. Increasedrisk of pneumothorax in patients receivingpositive pressureventilation. D. Patient'shabitus or anatomy may hinder identifying landmarks. EQUIPMENT REQUIRED A. Sterile gloves, drape, and towels. B. Antiseptic solution with chlorhexidine or povidone-iodine. C. Lidocaine 1% with or without epinephrine for local anesthesia. D. Keep atropineat the bedside for potential emergencyadministration. E. 25-gauge, 5/8 to 1 inch needle. F. 20 to 23 gauge, 11/2 inch needle. G. 14 to 18 gauge needle. H. 12 to 16 gauge catheter. I. Pressuretubing. J. Three-waystopcock. K. 5 m L syringe. L. 20 m L syringe. M. 60 m L syringe. N. Specimen vials and tubes, aerobic/anaerobicmedia bottles. O. Vacutainers,evacuated bottles, or drainage bag. P. Pressure/connectortubing. Q. Sterile 4 ×4 gauze. R. Adhesive dressing. S. Keep a thoracostomy tray with supplies available in case of a pneumothorax. 1. Chlorhexidine solution. 2. Drapes. 3. Gauze. 4. Curved hemostat. 5. Curved Kelly clamp. 6. Scissors. 7. Needle holder. 8. Sterile thoracotomy tube. 9. Scalpel. 10. 4-0 silk sutureon cutting needle. 11. Petroleum-soakedgauze. 12. Underwater sealed drainage system. (continued )Procedure: Thoracentesis
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455 PROCEDURE THORACENTESIS (continued ) PROCEDURE A. Explain the procedureto the patient and family and obtain informed consent. B. Always identify patient. C. Washhands/perform hand hygiene. D. Ensureintravenous (IV) access and hemodynamic monitoring (e. g., blood pressure,O 2saturations). E. Position patient (help of an assistant may be needed). 1. Position patient on edge of bed with feet on a solid surface (e. g., ground,stool). 2. The assistant will stand in front of the patient or patient will lean on a bedside table directly in front with the head on his or her arms. F. Verifylocation for pleural drainage with ultrasound. 1. If ultrasound is unavailable, utilize physical examination to locate areaof effusion. 2. Optimal site for needle insertion is posterolateral (midaxillary and midline) between seventh and ninth intercostal space, 6 to 8 cm lateral to spine (see Figure1). G. Don sterile attire. H. Assemble all equipment and set up sterile field. I. Perform a proper time out. All present in the room must identify the patient and agree on the correct procedure and correctsite of the procedure. J. Cleanse areaagain with chlorhexidine or a povidone-iodine solution. K. Drape identified area. L. Use 25 gauge 5/8 inch needle and 5 m L syringe to inject small wheal of lidocaine. M. Use 20 gauge 11/2 inch needle and 10 m L syringe to infiltrate lidocaine into a wide area of subcutaneous tissue, periosteum, and pleura. N. Fortherapeuticthoracentesis,insert14or18gaugeneedlewitha20m Lsyringeattachedintoanesthetizedareauntil pleural fluid is obtained. O. Remove syringe and occlude needle with a finger. P. Insert 16 or 12 gauge catheter through gauged needle, positioned downward toward the diaphragm into the pleural space. Q. Once the catheter is in place, removethe needle and attach the three-waystopcock and 60 m L syringe. Area for needle insertion Skin Rib Lung tissue Pleura Fluid in pleural space FIGURE 1 Illustration showing insertion site. (continued ) Procedure: Thoracentesis
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456 PROCEDURE THORACENTESIS (continued ) R. Fill 60 m L syringe with pleural fluid, turn stopcock off to catheter, and remove syringe. Fill each specimen vial with pleural fluid. S. Attach pressuretubing to three-waystopcock and vacutainer. T. Openstopcocktovacutainerandallowpleuralfluidtoflowintovacutainer. Limitdrainageto1to1. 5Ltoreducerisk of reexpansionpulmonary edema. U. Remove catheter and apply pressureto puncturesite. V. Apply adhesive bandage and aid patient back into bed. W. Dispose of all equipment. X. Obtain chest x-ray to evaluate for improvement in pleural effusion and to assess for complications (e. g., pneumo-thorax). Y. Documentprocedure,indication,amountoffluidremoval,diagnosticssent,andpatient'stoleranceoftheprocedure. EVALUATION AND RESULTS A. Resolution of pleural effusionand reexpansionof lung tissue. B. Resolution of respiratorydistressin patients with excess pleural fluid. C. Etiology of pleural effusiondetermined based on pleural fluid analysis. CLINICAL PEARLS A. Ultrasound guidance to reducecomplications and drainage location. B. Some institutions may have prepackagedthoracentesis kits. C. If the patient is unable to sit up, have him or her lay in the lateral recumbentposition on the unaffectedside. D. Cease procedureif patient develops a cough. E. Emergencymedications such as atropinefor symptomatic bradycardiashould be placed at bedside. F. Keep thoracostomy supplies available in case patient develops a pneumothorax. BIBLIOGRAPHY Dimov, V., & Altaqi, B. (2005). Thoracentesis: A step-by-step procedure guide with photos [Blog post]. Retrieved from http://note3. blogspot. com/2004/02/thoracentesis-procedure-guide. html Schildhouse, R., Lai, A., Barsuk, J. H., Mourad, M., & Chopra, V. (2017, April). Safe and effective bedside thoracentesis: A review of the evidence for practicing clinicians. Journal of Hospital Medicine, 12 (4),266-276. doi:10. 12788/jhm. 2716 Seneff,M. G.,Corwin,R. W.,Gold,L. H.,&Irwin,R. S. (1986,July). Complicationsassociatedwiththoracocentesis. Chest, 90 (1),97-100. doi:10. 1378/chest. 90. 1. 97Procedure: Thoracentesis
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457 PROCEDURE TRANSPYLORIC FEEDING TUBE PLACEMENT Catherine Harris DESCRIPTION A. Dobhofftubesareflexible,nasogastrictubesusedtoadministernutritionandmedicationstopatientsunabletoreceive them by mouth. B. The tube is inserted into the stomach via the nasal passages. INDICATIONS A. Sedated or mechanically ventilated patients who need to receivenutrition and/or medications. B. Critical illness. C. Severemalnutrition. D. Prolongedanorexia. E. Difficultyswallowing. F. High risk aspiration. PRECAUTIONS A. Impropersetup and placement may resultin placing tube in lung, causing pneumothorax. B. Inpatientswithabasilarskullfracture,placementshouldbedonewithaclearvisualpathway,typicallyperformedwitha scope by a member of the ear, nose, and throat (ENT) service. In very rare cases, a tube can circumnavigate to the brain without directvisualization. C. Spinal cordfractures. 1. Patient is typically encouraged to bend his/her neck forwardfor placement. 2. Avoidthis movement in patients with confirmed or suspected cervical spine fractures. 3. Directplacement may be required. D. Patients on a ventilator or who are sedated may have a decreased or absent cough reflex: Pay special attention to ANY changes in tidal volume, decreasein oxygen saturation, or persistent coughing. EQUIPMENT REQUIRED A. 10 Fr feeding tube with guidewire(see Figure1). B. Water-solublelubricant. C. 60 m L syringe. D. Nasal strip tape to hold feeding tube in place. E. Gloves. FIGURE 1 Photograph of a 10 Fr feeding tube with guidewire. (continued ) Procedure: Transpyloric Feeding Tube Placement
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458 PROCEDURE TRANSPYLORIC FEEDING TUBE PLACEMENT (continued )Procedure: Transpyloric Feeding Tube Placement PROCEDURE A. Measuretube fromtip of nose to subxyphoid process(about 30-35 cm in most patients). B. Have patient sit upright and lean head forward. C. Removethefeedingtubefromthepackageandplacesomewater-solublelubricantonthetiptohelpfacilitatepassage of the tube throughthe nasal passages. D. Place tube through one nare and ask the patient to swallow as the tube passes down the oropharynx. Patients may gag but should not start coughing: Persistent coughing may be a warning sign that the tube is in the airway rather than the esophagus. E. At 35 cm, STOP and confirm with chest x-ray that the tube is in the esophagus and not the mainstem bronchus. 1. Confirmation is made if feeding tube follows path of trachea straight below carina. 2. If placement is in airway, the tube will curve into either the right or left mainstem bronchus; remove feeding tube and start again. F. Once x-ray confirms the feeding tube is in the esophagus, advance into stomach. G. Check placement by insufflatingwith air. H. Advance feeding tube to about 80 to 100 cm. I. Leave guidewirein place and obtain an abdominal x-ray (not chest). J. If tube is postpylorus, secureit and removewire;start feeds. K. If tube is not postpylorus, advance it further and obtain another abdominal x-ray. EVALUATION AND RESULTS A. Verify placement of feeding tube with chest x-ray first to establish that tube is below carina and not in right or left mainstem bronchus. B. Verifyplacement of feeding tube with abdominal x-ray once tube is advanced and expected to be postpylorus. C. Once visual placement is made, removewireand start tube feeds. CLINICAL PEARLS A. Positioning and setup areessential for success. B. If patient is awake, have the patient bend his or her neck as far forwardas possible. C. Aimthetip ofthe feedingtube towardthe veryback ofthe nasalpassage andallow thenatural curvatureof thetube to guide itself. D. If thereis significant resistance,try another naris. 1. Strictures,polyps, and dried mucus may cause obstruction. 2. After a couple unsuccessful attempts, consult an ENT for the directvisual approach. E. Whenplacingfeedingtubesinpatientsonaventilator,rememberanendotrachealtube(ETT)cuffballoonwillprevent placing the feeding tube in the lung, but not always. Never forcethe catheter past the balloon. 1. Sometimes after hitting the ETT cuffballoon, the tube will curl back and come out of the patient'smouth. 2. After a couple unsuccessful tries, consult an ENT for the directvisual approach. F. Do NOT relyon air insufflationto check correctposition; always get an x-ray beforebeginning any tube feeds. BIBLIOGRAPHY Powers, J., Chance, R., Bortenschlager, L., Hottenstein, J., Bobel, K., Gervasio, J., & Mc Nees, T. (2003). Bedside placement of small-bowel feeding tubes in the intensive care unit. Critical Care Nurse, 23 (1), 16-24. Retrieved from http://ccn. aacnjournals. org/content/23/1/16. long Simons, S. R., & Abdallah, L. M. (2012). Bedside assessment of enteral tube placement: Aligning practice with evidence. The American Journal of Nursing, 112 (2), 40-46. doi:10. 1097/01. NAJ. 0000411178. 07179. 68
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IV Special Topics ■End-of-Life Considerations ■Health Prevention and Screening ■Hemodynamic Monitoring Devices ■Telemedicine in Acute Care ■Transitional Care
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461 SPECIAL TOPICS END-OF-LIFE CONSIDERATIONS Jennifer Coates INTRODUCTION With life, comes death. The dying process is not only an inevitable part of the life cycle, but it is also an important aspect of healthcare. Although discussions surrounding death and dying can be difficult for patients, caregivers, and even healthcare providers, such discussions are essential to ensure supportive and compassionate end-of-life care aligns with the patient's and his or her family's desires. Advances in healthcare treatment mean that people are living longer. Currently, life expectancy in the United States is 78. 8 years. Annually, there are 823. 7 deaths per 100,000 people. Increased life expectancy means that people are not only living longer in general, but also that people are living longer with chronic diseases. Nearly 75% of all deaths in the United States are from the following 10 causes. A. Heart disease. B. Cancer. C. Chronic lower respiratory diseases. D. Unintentional injuries. E. Stroke. F. Alzheimer's disease. G. Diabetes. H. Influenza and pneumonia. I. Kidney disease. J. Suicide. Of these conditions, seven are chronic conditions. Of further note, two of these diseases (heart disease and cancer) together accounted for nearly 48% of all deaths. This information helps the advance practice provider (APP) consider important aspects of discussing and providing end-of-life care, including the role of institutions and acute care during the death experience. DISCUSSING THE DEATH EXPERIENCE Discussing the death experience requires a shift in the healthcare provider's mind-set. In tertiary care, the overall goal of care is to extend the patient's life in an attempt to delay death. However, the first step in planning and providing end-of-life care is acceptance that death is the likely outcome. Specifically, the goal in acute care should be that the dying patient and his or her family are supported as the patient completes his or her life cycle. Understanding the overall goal of end-of-life care prepares the APP to discuss the patient's and the family's preferences for end-of-life care and the dying experience. When entering into this discussion with a patient and his or her family, the APP should remember that when a patient will die is only one factor in that patient's death experience. Where the patient will die and how he or she will die are also important aspects of the death experience that need to be discussed. In general, where a patient dies has changed over time. In the early part of the 20th century, most people died at home; however, today most people will die in an institution. The increased number of patients who experience cognitive impairment and dementia is one possible reason for this change. Some people have preferences about where they would like to die, so it is important to discuss this with the patient and his or her family. DEFINING A “GOOD DEATH” Another important factor to discuss is how the patient prefers to die. Every patient's experience with death is unique. To help the patient complete his or her life cycle in a way aligned with his or her preferences and beliefs, healthcare providers need to have a firm grasp on what a “good” death means for each patient. Defining a “good” death requires the APP to engage in an honest, open discussion that is focused on several important themes. PREFERENCES FOR THE DYING PROCESS Each patient has different preferences regarding where he or she prefers to die, the manner in which he or she will die, and who will be present when the patient completes his or her life cycle. In order to respect the patient's preferences, the APP should encourage the patient to express these preferences, both verbally in conversation and in written form via an advance directive. (continued ) Special Topics: End-of-Life Considerations
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462 SPECIAL TOPICS END-OF-LIFE CONSIDERATIONS (continued ) PAIN Assessing and effectively managing pain is an important part of providing compassionate and comprehensive end-of-life care. Conversations about pain assessment, pain management, and side effect management will vary based on the patient's diagnosis. However, these discussions should center on how the patient's comfort level will be assessed, and which interventions will be used to manage pain and side effects. EMOTIONAL WELL-BEING AND SUPPORT SYSTEM Another important part of completing one's life cycle includes having the opportunity to discuss the meaning of death and to identify the role of a support system in death. The APP should be sure to allow the patient to discuss his or her personal wishes and ensure that an emotional support system is in place. People and organizations that are included in a patient's emotional support system vary, but may include church, family, friends, a community, and/or beloved pets. In addition to identifying an emotional support system, the APP should also help the patient determine the role of his or her support system as the patient completes the life cycle. For example, how will family and friends be involved in the process? The APP plays an important role in emotionally supporting and preparing the patient's friends and family for the patient's death. The APP should help the patient's family and friends accept and prepare for the patient's death. This may include facilitating discussions, being available to answer questions, and providing resources as needed. DIGNITY Respecting all patients as individuals is central to providing end-of-life care. The APP can achieve this by empowering the patient to be independent and in control of his or her care. Dignity in death can take on many forms and it is highly individualized. Asking the patient open-ended questions about what he or she feels is important will help the APP provide appropriate and respectful care during the patient's final months and days of life. LIFE COMPLETION AND SPIRITUALITY Saying goodbye and receiving religious/spiritual comfort are important aspects of life completion. When discussing this theme with patients, the APP should be sure to inquire about the role of religion and spiritual comfort in the patient's life completion. During this discussion, the APP also should ask how he or she can help facilitate the opportunity for the patient to meet with clergy, if he or she desires, and how he or she can help the patient see friends and family at life's completion. TREATMENT PREFERENCES As previously noted, the focus of treatments and interventions provided during end-of-life care shift from prolonging the patient's life to supporting the patient and his or her family as the patient's life completes. During this time, the APP should take care to answer any questions the patient and his or her family may have. Often, the patient and his or her family want to know if all available treatments were offered, and that they have control over treatment decisions. QUALITY OF LIFE The APP should be sure to discuss how he or she could help the patient maintain hope, pleasure, and gratitude as the patient completes his or her life cycle. Discussion should focus on how the disease is affecting the patient's physical mobility, emotional well-being, and social well-being. Conversation with the patient should center on strategies to help the patient feel that he or she has a life that is worth living. RELATIONSHIP WITH TREATMENT TEAM Building a strong relationship between the patient and the healthcare team is essential to providing supportive and com-prehensive end-of-life care. The patient needs to trust as well as feel supported and comforted by the healthcare team. This relationship may be garnered in a variety of ways, but stems from the healthcare provider being comfortable with death and dying. Such a relationship will enable the patient to be at ease, which will, in turn, allow the patient to freely discuss his or her preferences, spiritual beliefs, and fears with the healthcare provider. PORTABLE ORDERS FOR LIFE-SUSTAINING TREATMENT As part of the ongoing discussion surrounding the type of death experience the patient desires, it is important that the APP also discusses the role of Portable Orders for Life-Sustaining Treatment (POLST) in ensuring the patient's desires are upheld. Sometimes called Physician Orders for Life-Sustaining Treatment, the POLST is a form that provides standing medical orders that healthcare providers can act on immediately when the patient is in an acute situation. It outlines the type of care a patient wishes to receive, or does not wish to receive, during end of life. POLST topics include the patient's preferences concerning CPR, antibiotics, mechanical ventilation, and artificial nutrition. The POLST form is intended (continued )Special Topics: End-of-Life Considerations
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463 SPECIAL TOPICS END-OF-LIFE CONSIDERATIONS (continued ) to help healthcare providers, including first responders, provide the type of treatment the patient wants, even if the patient is unable to communicate at the time care is provided. It has been shown to be more effective than traditional advance directives at limiting unwanted life-sustaining treatments. The APP should initiate discussion about a POLST form with any patient with a serious or chronic illness who may not be expected to live past 1 year. Without a POLST form (see Table 1), emergency responders will provide all appropriate medical interventions. PALLIATIVE CARE As end-of-life approaches, palliative care may be offered to the patient. Palliative care focuses on symptom assessment and treatment, and it may be offered simultaneously with life-prolonging and curative therapies. During end of life, palliative care typically focuses on assessing and treating pain, dyspnea, anxiety, fatigue, depression, constipation, and delirium. PAIN Pain is the most common symptom a patient experiences at end of life. Effective pain control can be achieved by using a combination of several treatments. Nonpharmacologic treatments are those interventions that do not require the use of medications. This may include imagery, aromatherapy, relaxation, music therapy, massage, and distraction techniques. Pharmacologic treatments, or those that involve medications, may include the use of opioids and nonsteroidal anti-inflammatory agents, and acetaminophen. Ideal pain management in end of life can be achieved through a long acting agent with the addition of an immediate release agent for breakthrough pain. DYSPNEA Dyspnea is another common symptom during the end-of-life phase. The APP should aim to treat reversible causes, if possible. Nonpharmacologic interventions can also be especially helpful. These interventions can include providing reassurance, offering distraction techniques, and encouraging relaxation exercises. ANXIETY When a patient in an end-of-life situation experiences anxiety, it is important for the APP to first assess the cause of anxiety, identifying both physical and psychological contributors. After the cause or causes are identified, the APP should find ways to modify any anxiety contributors, if possible. Nonpharmacologic interventions include supportive counseling and reassurance. When considering pharmacologic intervention, the APP should use benzodiazepines cautiously, as they may increase delirium in older adults. (continued ) Special Topics: End-of-Life Considerations TABLE 1 POLST Form POLST Medical Order Who completes POLST? Healthcare professional such as MD, NP, PA, but will vary from state to state who can sign the order What does it communicate? Code status Would the patient want CPR? Check one Attempt resuscitation/CPR Do not attempt resuscitation/DNR What type of medical interventions are available? Check one Full treatment—No limitation in aggressive treatment options Limited treatment—use medical treatment such as antibiotics, IV fluids, and cardiac monitor. No intubation, advanced airway interventions, or mechanical ventilation Comfort measures only—Comfort through symptom manage-ment Artificially administered nutrition? Check one Long-term artificial nutrition by tube Defined period of artificial nutrition by tube No artificial nutrition by tube Review By health-care professionals DNR, do not resuscitate; IV, intravenous; POLST, Portable Orders for Life-Sustaining Treatment.
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464 SPECIAL TOPICS END-OF-LIFE CONSIDERATIONS (continued ) FATIGUE Fatigue may be caused by a number of medical problems. When considering the best intervention for fatigue, the APP should address any contributing medical problems. These may include anemia, electrolyte imbalances, infection, or hypoxemia. Depending on the cause of fatigue, nonpharmacologic and/or pharmacologic therapies may be indicated. Nonpharmacologic therapy may include energy conservation, frequent naps, occupational therapy, and physical therapy. Pharmacologic therapy may include considering corticosteroids and psychostimulants on a case-by-case basis. DEPRESSION Many patients will experience some degree of depression at the end of their life cycle. Some patients who experience depression in end of life may benefit from supportive psychotherapy. Pharmacologic therapy may be considered depend-ing on the patient's life expectancy, since many antidepressants need several weeks to take effect. CONSTIPATION The APP should be sure to assess the end-of-life patient for constipation. Preventive treatment for constipation should be given to all patients taking opioid pain medicine. Stool softeners may be given; the patient may also benefit from increased consumption of prune juice as well as taking a pharmacologic stimulant or osmotic laxative. DELIRIUM The APP should identify underlying and reversible causes of delirium to determine the most appropriate interventions. Nonpharmacologic intervention primarily focuses on ensuring a calm environment with family, friends, or caregivers at the bedside. Pharmacologic interventions may be warranted if delirium is severe. Benzodiazepines should be avoided, as they may worsen delirium. HOSPICE CARE Hospice care provides support and services to a patient with a terminal illness and focuses on providing comfort for the patient in the final weeks and months of his or her life, not curing the patient's illness. Hospice referral occurs when patients are entering their final weeks and months of life and when patients and their families choose to focus on the patients' comfort. In many cases, hospice occurs in the home, but it may also occur in other settings, such as the hospital, a nursing home, or a resident living facility. U. S. MEDICARE HOSPICE ELIGIBILITY Hospice care is delivered by a multidisciplinary team and it is covered under Medicare, Medicaid, and many private insurance plans. Those eligible for Medicare Part A include U. S. citizens or legal residents who are: A. Eligible for Social Security or railroad retirement benefits and are over age 65. B. Under age 65 and eligible for Medicare because of a long-term disability. To be covered, a referral must be made to a hospice that is Medicare certified by the Centers for Medicare and Medicaid Services. Certification from the healthcare provider should state that the patient has a terminal diagnosis and most likely has less than 6 months to live. If patients outlive their estimated 6-month prognosis while on hospice, the benefit can be renewed indefinitely as long as there is clinical evidence of continued decline consistent with disease progression. Some examples of end-stage disease that would make patients candidates for hospice referral include cancer, dementia due to Alzheimer's disease, heart disease, liver disease, pulmonary disease, renal disease, stroke, and amyotrophic lateral sclerosis. DELIVERING BAD NEWS When and How to Deliver Bad News Caring for patients in the end of life may require the APP to communicate bad news to patients and their families. Bad news is any information that will have a significant negative impact on an individual's view of the future. Sharing bad news is a complex communication task that requires more than just stating the words; it requires responding to a patient's emotions. The APP can achieve this by: A. Identifying the important information. B. Talking honestly and in a straightforward way. (continued )Special Topics: End-of-Life Considerations
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465 SPECIAL TOPICS END-OF-LIFE CONSIDERATIONS (continued ) C. Being willing to talk about death/dying. D. Delivering bad news in a sensitive way. E. Listening. F. Encouraging questions. G. Being sensitive to patients when they want to talk about difficult issues. SPIKES SPIKES refers to a method for delivering bad news. It is comprised of six steps, which are outlined in the following sections. Step 1: Setting Up the Interview It is important to consider the setting where the news will be delivered as well as what will be said. Arrange for a place that will provide some privacy, and involve significant others in the interview. It is also helpful to engage in a mental rehearsal of what will be said. During the interview, the APP should sit down with the patient, maintain eye contact, and effectively manage time constraints and interruptions. Step 2: Assess the Patient's Perception During the interview, use open-ended questions to ask the patient what he or she understands about the disease process. Listen to the patient's level of comprehension, and be sure to correct any misinformation. Step 3: Obtain the Patient's Invitation It is important to assess how much or how little information the patient would like to have. Some people want to know detailed information, while other patients prefer not to know. Accept the patient's right not to know, and offer to answer questions later, if needed. Step 4: Giving Knowledge When speaking to patients, use vocabulary words and terminology that are aligned with the comprehension level of the patient. Giving information in small chunks, and pausing in between each chunk, can help increase the patient's understanding. It is also helpful to check in with the patient as you are giving information to ensure the patient understood what you said. Step 5: Address the Patient's Emotions When receiving difficult news, patients often feel shock, isolation, and grief. It is important for the APP to acknowledge these feelings and to offer support. Give the patient time to express his or her feelings. Step 6: Strategy and Summary After speaking with the patient and answering any questions, it is important to close the meeting by discussing plans for the future or next steps. FINAL DAYS AND HOURS OF LIFE In the final days and hours of life, patients may experience several symptoms, including: A. Loss of appetite. B. Excessive fatigue and sleep. C. Increased physical weakness. D. Mental confusion or disorientation. E. Labored breathing. F. Social withdrawal. G. Changes in urination (oliguria or anuria). (continued ) Special Topics: End-of-Life Considerations
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Adult-Gero Acute Care Practice Guideline by Catherine Harris Ph.d. z-lib.org 1.pdf
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466 SPECIAL TOPICS END-OF-LIFE CONSIDERATIONS (continued ) H. Swelling in the feet and ankles. I. “Death rattle,” which refers to a gurgling sound created by air moving through uncleared secretions in the trachea and vocal cords. During this time, the APP should continue to provide compassionate care aligned with the patient's and family's pref-erences. The patient and family may ask questions about food and water intake, express fears of the unknown, and have concerns about symptom management. The APP should answer any questions the family and the patient have, and provide continued support. DEATH PRONOUNCEMENT The following medical procedures should be followed during the clinical examination for pronouncing death. A. Properly identify the patient using the ID bracelet. B. Check the pupils for position and response to light. C. Check response to tactile stimuli—examine respectfully, refraining from sternal rubs or nipple pinches. D. Check for spontaneous respiration for 1 minute. E. Check for apical heart tones and pulses for 1 minute. F. Record the time of death. The following items should be included in the death note. A. Date and time of death. B. Name of provider pronouncing death. C. Brief statement of cause of death. D. Documentation of the absence of a pulse, respiration, and pupil response. E. Notation of family presence at the death and/or family notification of the death. F. Document notification of attending physician, pastoral care staff, social work staff, or other staff as appropriate. A death certificate needs to be filled out, with all marked sections completed using black ink. This is often the duty of the attending healthcare provider. SUMMARY It is important to remember that death is a natural part of life. When providing end-of-life care, the APP should remember that his or her primary role is to support the patient and the patient's family and to empower the patient to articulate the type of death he or she would like. This is achieved by facilitating open and honest communication, asking and answering questions, and eliciting information about the patient's specific priorities and goals. BIBLIOGRAPHY Baile, W. F., Buckman, R., Lenzi, R., Glober, G., Beale, E. A., & Kudelka, A. P. (2000). SPIKES—A six-step protocol for delivering bad news: Application to the patient with cancer. The Oncologist, 5, 302-311. doi:10. 1634/theoncologist. 5-4-302 Bailey, F. A., & Williams, B. R. O. S. A. (2005). Preparation of residents for death pronouncement: A sensitive and supportive method. Palliative & Supportive Care, 3, 107-114. doi:10. 1017/S1478951505050182 Bloomer, M. J., Moss, C., & Cross, W. M. (2011). End-of-life care in acute hospitals: An integrative literature review. Journal of Nursing and Healthcare of Chronic Illness, 3, 165-173. doi:10. 1111/j. 1752-9824. 2011. 01094. x Buck, H. G., & Fahlberg, B. (2014). Using POLST to ensure patients' treatment preferences. Nursing, 44, 16-17. doi:10. 1097/01. NURSE. 0000443322. 11726. 91 Buckman, R. (1992). How to breakbad news: A guide for health care professionals (p. 15). Baltimore, MD: Johns Hopkins University Press. Byock, I. (2004). The four things that matter most: Essential wisdom for transforming your relationships and your life, (c. 240p). Free Pr: S. & S. Chronic Disease Overview. (n. d. ). Retrieved from https://www. cdc. gov/chronicdisease/pdf/nccdphp-overview-508. pd Electronic Code of Federal Regulation. (2017, March 15). U. S. government publishing office. Retrieved from https://www. ecfr. gov/cgi-bin/ECFR?page=browse Halter, J. B., Ouslander, J. G., Studenski, S., High, K. P., Asthana, S., Supaino, M. A., & Ritchie, C. S. (Eds. ). (2017). Hazzard's geriatric medicine and gerontology (7th ed. ). New York, NY: Mc Graw-Hill. Meier, E. A., Gallegos, J. V., Thomas, L. P. M., & Depp, C. A. (2016). Defining a good death (successful dying): Literature review and a call for research and public dialogue. The American Journal of Geriatric Psychiatry, 24, 261-271. doi:10. 1016/j. jagp. 2016. 01. 135 National Health Center for Statistics. (n. d. ). Retrieved from https://www. cdc. gov/nchs/data/factsheets/nchs_overview. pdf Special Topics: End-of-Life Considerations
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Adult-Gero Acute Care Practice Guideline by Catherine Harris Ph.d. z-lib.org 1.pdf
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SPECIAL TOPICS HEALTH PREVENTION AND SCREENING Michele De Castro INTRODUCTION Prevention and screening are important parts of providing comprehensive acute care. Appropriate prevention and screen-ing can help keep diseases from occurring, detect diseases in their earliest stages, and improve healthcare outcomes. As such, it is of vital importance that the advanced practice provider (APP) in the acute care setting be familiar with the different levels of prevention and the different types of prevention. It is also important to understand common vaccinations and screening recommendations. LEVELS OF PREVENTION There are three main levels of prevention dispensed by the APP: Primary prevention, secondary prevention, and ter-tiary prevention. Primary prevention refers to interventions that focus on preventing disease from occurring. Examples of primary prevention include recommending smoking cessation to a patient to reduce his or her risk of lung cancer, admin-istering influenza immunizations, and recommending a mastectomy for the breast cancer 1 ( BRCA) positive patient. Secondary prevention focuses on interventions that detect disease early and prior to when symptoms and effects present. Examples of secondary prevention include performing regular PAP smears on female patients to detect precancerous lesions and testing for HIV in at-risk populations even in the absence of symptoms. Tertiary prevention refers to any-thing that prevents diseases from becoming worse or decreases the complications from a particular disease process. Examples may include recommending that a patient use a beta-blocker after having a myocardial infarction (MI), or treat-ing hypertension (HTN) and hyperlipidemia in diabetic patients. Ophthalmology examinations in patients with diabetes mellitus (DM) may also be considered a form of tertiary prevention. TYPES OF PREVENTION As mentioned previously, prevention can be provided in different ways. Common types of prevention include screening, immunization, and recommending lifestyle modifications to prevent disease. For APPs in the acute care setting, understanding screening and immunizations is especially important, as many patients will present without access to these preventive measures. Knowing which high-risk conditions they are most at-risk for developing can help with diagnosis, inpatient treatment, and posthospital care planning. SCREENING For APPs in the acute care setting, understanding screening guidelines is essential to practice. It is important to know which common conditions the patient should have been screened for based upon his or her age and risk factors. Most screening recommendations used by healthcare providers in the United States are created by one of several expert groups. The U. S. Preventive Services Task Force (USPSTF) is the leading creator of screening recommendations. The USPSTF is an independent panel of nonfederal experts who specialize in prevention and evidence-based medicine and who come from a variety of fields. They complete thorough reviews of current research and make recommendations for primary care screening and prevention. In their review, the USPSTF assigns a letter grade to each of their recommenda-tions based on the strength of evidence to support the recommendation and the balance of benefits against harms of the recommendation. The benefits of a recommendation must outweigh risks, and the USPSTF's focus is on overall health and quality of life of patients, not just on the identification of disease. Other expert bodies make prevention and screen-ing recommendations on their clinical area of expertise. Some of these organizations include the American College of Cardiology (ACC), the American Heart Association (AHA), the American Cancer Society (ACS), and the American College of Physicians (ACP). Screening and prevention of the two leading causes of death in the United States, cardiovascular disease (CVD) and cancer, are discussed in further detail later in this section. IMMUNIZATIONS Another form of prevention is immunization. Immunizations may be indicated based on the patient's age, lifestyle, health factors, or risk factors. It is important for the APP to know immunization status and immunization needs in order to make an appropriate diagnostic assessment, create an inpatient plan, and to coordinate and recommend any appropriate follow-up care. Age-appropriate immunization schedules are provided in Tables IV. 1 and IV. 2. The following sections outline other common immunizations that may be indicated for adult patients. Haemophilus influenzae Type B Haemophilus influenzae type B vaccine is administered to patients with anatomical or functional asplenia (including sickle cell disease). These patients, if immunized as children, are vaccinated by giving one dose of the immunization in adulthood. Patients undergoing hematopoietic stem cell transplant should also receive vaccination. Regardless of Hib vaccination history, the patient receives three doses (at least 4 weeks apart) beginning 6 to 12 months after transplant. Evidence of immunity occurs with documented vaccination. (continued ) Special Topics: Health Prevention and Screening467
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Adult-Gero Acute Care Practice Guideline by Catherine Harris Ph.d. z-lib.org 1.pdf
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SPECIAL TOPICS HEALTH PREVENTION AND SCREENING (continued ) Hepatitis A Hepatitis A immunization is indicated for patients who use illicit substances, for men who have sex with men (MSM), for patients with chronic liver disease and/or receive clotting factor concentrates, and for patients who work in or travel to areas of high endemic disease. For adults, two separate 1 m L vaccinations are done 6 to 12 months apart. Hepatitis B Immunization against hepatitis B may be indicated based on the patient's age or lifestyle. The following factors indicate immunization is recommended. A. Sexually active persons who are not in a long-term, mutually monogamous relationship. B. Persons seeking evaluation or treatment for a sexually transmitted disease (STD). C. Current or recent injection drug users. D. MSM. E. Healthcare personnel and public safety workers who are potentially exposed to blood or other infectious body fluids. F. Persons with diabetes who are younger than age 60 years as soon as feasible after diagnosis. G. Persons with end-stage renal disease. H. Persons with HIV infection. I. Persons with chronic liver disease. J. Household contacts and sex partners of hepatitis B surface antigen-positive persons. K. Healthcare workers. L. Persons working in institutional settings. M. Persons with DM who are older than 60 years. Primary vaccination consists of three intramuscular doses of hepatitis B vaccine given at months 0, 1, and 6. An alternative regimen consists of a combined Hep A and Hep B vaccine (Twinrix) given in the same dosing schedule for patients with risk factors for both diseases. Evidence of immunity occurs with documented administration of the vaccine for most patients. However, serologic testing for immunity is recommended for persons whose subsequent clinical management depends on knowledge of their immune status, certain healthcare and public safety workers, chronic hemodialysis patients, HIV-infected persons, and sex or needle-sharing partners of hepatitis B positive patients. Influenza Although most adults in general good health will recover from influenza, certain populations, such as the very young, the very old, and those with immunocompromising conditions, may be especially susceptible to more severe infections with influenza. As such, the Centers for Disease Control and Prevention (CDC) recommend that all adults receive the influenza vaccination annually. Influenza vaccination is contraindicated in adults with a history of egg allergy more severe than hives, including difficulty breathing, respiratory distress, or angioedema. Patients who have only hives after exposure to egg should receive age-appropriate vaccine. Measles, Mumps, and Rubella Adult patients are immune to measles, mumps, and rubella (MMR) if: 1. They were born before 1957. 2. There is documentation of receipt of MMR 3. There is laboratory evidence of immunity. This immunization is contraindicated for patients who are pregnant and immunocompromised adults. The CDC recom-mends adult immunization to students in postsecondary education, those who work in healthcare, and patients who travel internationally. Patients should receive second immunizations, 28 days after the first. (continued )Special Topics: Health Prevention and Screening468
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Adult-Gero Acute Care Practice Guideline by Catherine Harris Ph.d. z-lib.org 1.pdf
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Special Topics: Health Prevention and Screening TABLE 1 Vaccines for Teenagers 13-18 Years Meningococcal Flu (Influenza)Tdap (Tetanus, Diphtheria, Pertussis)HPV Men ACWY Men B Pneumococcal Hepatitis BHepatitis APolio MMR Chickenpox (Varicella) Age 11-12 years Yearlya Vaccine recommended x 1Vaccine recom-mended x 1Vaccine recom-mended x 1Vaccine for high risk recom-mended x 1c Vaccine for high risk recom-mended x 1c Catch up/missed dosed Catch up/missed dose Catch up/missed dose Catch up/missed dose Catch up/missed dose 13-15 years Yearly Catch up/missed dosea Catch up/missed dose Catch up/missed dose Vaccine for high risk recom-mended x 1c Vaccine for high risk recom-mended x 1c Catch up/missed dose Catch up/missed dose Catch up/missed dose Catch up/missed dose Catch up/missed dose 16-18 years Yearly Catch up/missed dose Catch up/missed dose Booster at age 16Optional vaccined Vaccine for high risk recom-mended x 1c Catch up/missed dose Catch up/missed dose Catch up/missed dose Catch up/missed dose Catch up/missed dose Note:a Yearly means that the vaccine is recommended every year. b Catch up/missed dose indicates that the vaccine should be given if the patient is catching up on missed doses. c Vaccine recommended for patients with certain health or lifestyle conditions that put them at risk for serious diseases. d Optional vaccine is for patients who are not at increased risk, but wish to be vaccinated after speaking with a healthcare provider. HPV, human papillomavirus; MMR, measles, mumps, rubella. 469
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Adult-Gero Acute Care Practice Guideline by Catherine Harris Ph.d. z-lib.org 1.pdf
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TABLE 2 Pneumococcal Meningococcal Flu (Influenza)Td/Tdap (Tetanus, Diphtheria, Pertussis)Shingles (Zoster) PCV13 PPSV23 Men ACWY or MPSV4 Men B Age 19-21 years Yearly Recommended May be recommendeda May be recommendeda May be recommendeda May be recommendeda 22-26 years Yearly Recommended May be recommendeda May be recommendeda May be recommendeda May be recommendeda 27-59 years Yearly Recommended May be recommendeda May be recommendeda May be recommendeda May be recommendeda 60-64 years Yearly Recommended Recommended May be recommendeda May be recommendeda May be recommendeda May be recommendeda 65+years Yearly Recommended Recommended Recommended Recommended May be recommendeda May be recommendeda Get flu vaccine every year Get Td booster every 10 years. You also need 1 dose of Tdap vaccine. Women should get Tdap vaccine during EVERY pregnancy You should get shingles vaccine if you are 60 + years even if you have previously had shingles You should get 1 dose of PCV13 and at least 1 dose of PPSV23 depending on your age and health condition (continued )Special Topics: Health Prevention and Screening470 Vaccines for Adults by Age: 19 +Years
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Adult-Gero Acute Care Practice Guideline by Catherine Harris Ph.d. z-lib.org 1.pdf
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