In & Out: Fluids

- Notes from mik when i hear him say something we should know :)
- When in doubt, use normal saline
- BUN is the fast responder
- Higher osmolality, the thicker it is
- Lower osmolality is more watery
Goal time to remove a foley is - in 48 hours

What kind of cath do you put in for a sterile sample and take right back out - straight cath

What kind of cath do you send patient's home with when they have to cath themselves - intermittent cath
same as straight cath

a foley is a __ cath - indwelling

AKA condom or texas cath is an - external cath

a residual bladder volume of more than__ is abnormal

more than__ is an increased risk of UTI -200= abnorma >l
>50= increased risk of UTI

management of non-traumatic hematuria , insert foley and ? - lavage until clear

What study do you do on a traumatic hematuria - one shot cystogram looks for leak

What scenarios do you NOT put a urinary cath in? - blood at the meatus
high riding prostate
pelvic fx
ie due one shot retrograde cysto before inserting

What type of cath is used for irrigating the bladder - 3 way cath

a foley cath has 2 lumens: one for __ and one for __ - one for urinary drainage
one for inflating the retention balloon

What urinary cath am I?

a general drain that is a single lumen and is radiopaque ie can see on xray - red rubber cath

What urinary cath am I?

single lumen, general drainage, separated fenestrations and a firmer tip - Robinson cath

What urinary catheter is used for men with BPH where a standard foley won't work, must keep the button
anterior - coude catheter
Urinary caths are measured in French- the higher the number the __ the diameter - the larger the
diameter (ie 20 french is larger than a 12)

how do you compute urinary french catheter size to millimeters - French/pi (3)= millimeter

average urinary cath size is - 16-18 french

average IRRIGATION urinary cath size - 20 french

how do you compute the urinary cath size for kids - divide the child's age by 2 and add 8

dependent urinary bag below the level of the patient reduces ___ CAUTI - intraluminal CAUTI

how often and how do you you do peri-care on a person with a foley cath - DAILY was with warm water
and soap and dry

If you can't place a foley try what approach - Suprapubic approach

bladder aspirations for a UA is most commonly done in what patients - kids under 12 months old, can't do
if they voided within the last hour

3 complications of a foley cath - cystitis/infection

urethritis
trauma to the urethra

steps to remove foley - DEFLATE THE BALLOON

gently pull out

hematuria is ___ until proven otherwise - malignancy

If you suspect a CAUTI what will you see on urine?

What will cause a false negative? - leuk esterase
concentrated urine, proteinuria, or glucosuria will cause false negative

When inserting a foley, if you do not see ___ do not inflate the balloon - urine

If you have a person in urinary retention and insert a cath, let the urine out very slow to avoid? -
hypotension

Absolute contraindication to inserting a foley cath - TRAUMA

for an IM injection what angle do you go in at - 90 degrees

for a subcutaneous injection what angle do you go in at - 45 degrees

for an intradermal injection what angle do you go in at - 10-15 degrees

What 3 muscle do you usually inject - deltoid

rectus femoris
vastus lateralis

The R's of medication prescribing/delivery - Right patient

Right dose
Right route
right time
right medication
expiration date

Which IM site provides a higher drug level, gluteus or deltoid - DELTOID is better

Which gets meds into your system faster, out in order (IM, IV, subcutaneous, po, per rectum) - fastest IV,
IM, subcutaneous, per rectum, po

If a person has what disorder they can't get an IM injection, and why? - Bleeding disorder, increased risk
of hematoma

For an IM injection, what needle do you use - 23-25 gauge 1-1.5"

for subcutaneous injection, what needle do you use? - 25-30 gauge 0.5'

2 parts of a syringe - plunger and cylinder

TB needles __ while the other screw - Slip

What size syringe for IM?

subcutaneous? - IM-3mL
subcutaneous-1mL

if getting meds out of a vial use what size needle - 16-18 gauge

What age can you do a gluteus max injection - >2 years old

Where do you inject in the gluteus maximus? - Upper out quadrant

6cm inferior to the iliac crest

What is the max amount of mLs that you can put in the gluteus max with one needle - 3-3.5mLs (if
question asks 7mLs you have to divide into 2 needles
What injections are preferred in the buttocks - Bicillin
Evusheld
oil based injections

Where do you inject in the deltoid muscle? - 3cm proximal to deltoid tuberosity
or 3cm distal to the acromion

Max IM volume in the deltoid - 1mL

What injections are preferred in the deltoid - Vaccines

Preferred injection site in infants, MAX AMOUNT? - 1mL

anterolateral thigh- vastus lateralis (outer mid third thigh)

make sure before you inject an IM med, you - pull back on the plunger to make sure you aren't in a vein

occurring elsewhere in the body than the mouth and alimentary canal. IV ACCESS - parenteral

involving or passing through the intestine, either naturally via the mouth and esophagus, or through an
artificial opening - enteral

Name some indications for inserting a Peripheral IV - fluid admin

medication admin
blood admin
admin of dye for diag study
nutrition admin (TPN)

3 contraindications of peripheral IV insertion - extremities with burns/edemas/infection

extremity with an indwelling fistula
any extremity with impaired circulation (like mastectomy, lymph nodes gone)

most common type of IV catheter we use is - angiocath(over the needle)

a butterfly IV cath uses what type of needle - hollow needle

the typical gauge needle used in a surgical patient is - 18-20 gauge

the typical gauge needle used in outpatient is - 22-24

the typical gauge needle used in trauma resuscitation is - 16-18 (12-14 if you have it)

the typical gauge needle for a blood transfusion is - 18-20 gauge

Yellow IV angiocath is what gauge - 24 gauge

Blue IV angiocath is what gauge - 22 gauge

Red IV angiocath is what gauge - 20 gauge

Green IV angiocath is what gauge - 18 gauge

Gray IV angiocath is what gauge - 16 gauge

how many drops (ggts) make an ml - 10 drops/ggt per ml

the __ number infusion set moves the most volume - lowest number infusion set moves the most volume,
want to be quick, chose 10 over 60 to move ALOT

to prevent the IV cath from getting clogged you need at least 1 drop every __ seconds - 3 seconds

Anything that is being connected to a IV catheter must be - FLUSHED OUT (with IVF) so no air is
introduced into the body

max time to have an IV in is how many days? - 2-4 days

a peripheral cannula that is not attached to IV tubing or fluid that allows IV access when needed, must be
flushed when not in use - Heplock/extension set

AKA plug, similar to a heplock but with NO tubing, must be flushed every 8 hours to keep patent - PRN
adapter

Hanging a bag higher than the primary line is called a - piggy-back

2 most common things associated with periodic infusions - heplock or IV piggy back

3 things that must be included in IV orders - type of fluid

rate
method of delivery

4 things you consider when troubleshooting an IV - infiltration

infection
clog/clot
not in vein

EKG lead I is how many degrees - 0 degrees

EKG lead aVL is how many degrees - -30 degrees

EKG lead II is how many degrees - 60 degrees

EKG lead aVF is how many degrees - 90 degrees

EKG lead III is how many degrees - 120 degrees

EKG lead aVR is how many degrees - -150

Where are the precordial leads placed for an EKG - V1- 4th intercostal space on the right
V2- 4th intercostal space on the left
V3 between V2 and V4
V4 mid clavicular line 5th intercostal space
V5 between V4 and V6
V6- 5th intercostal space midaxillary

how do you determine the heart rate on an EKG - 360/the number of large boxes from R to R

normal PR interval - 0.12-0.20 seconds

normal QRS interval - <0.12 seconds (less than 3 small boxes)

sawtooth pattern - atrial flutter

What AV block am I?
Just long PR interval (>0.20 seconds) - 1st degree AV block

What AV block am I?
PR interval gets longer, longer, longer and then a dropped QRS - 2nd degree type I (Wenckebach)

What AV block am I?
PR is normal (0.12-0.20) and then a dropped QRS - 2nd degree type II

What AV block am I?
Atria and ventricle not talking to each other, both marching on to their own beat - 3rd degree AV block

to determine the axis on an EKG look at what to leads - I and aVF

___ refers to a conduction block below the AV node, delaying depolarization of the ventricles . See ___
on EKG think this - bundle branch blocks
WIDE QRS (>0.12) think BBB

Bunny ears in V1-V2, up in V1/V2, down in V5/V6 - RBBB

Wide QRS in V5-V6, ie up in V5/V6 down in V1/V2 - LBBB

most common feature of RVH is - Right axis deviation

Right axis deviation with R>S wave in V1 and S>R in V6 - Right ventricular hypertrophy (RVH)

When R wave amp in V5 or V6 plus the S wave amp in Lead V1 or V2 exceeds 35mm or
AVL exceeds 11-13mm - LVH- left ventricular hypertrophy

inferior leads - II, III, aVF

lateral leads - I, aVL, V5, V6

anterior leads - V1, V2, V3, V4

early changes in EKG in ACS? late? - early=tall T waves, T wave inversions or ST depressions
LATE= Q waves in 2+ leads

Peaked T waves in all leads think - hyperkalemia

How often should you monitor a patient with an IV - twice daily

Standard IV fluid and rate is - normal saline is at 100cc/hr

Our body is 60% water, 2/3 of it is where - in the ICF/muscle

does an obese patient have more or less water - less water (42%)
slim patient is 60% water

a 70kg male has about how many liters of fluid in them - 42-45 liters

__ level determines our ECF - sodium level

3 examples of isotonic IV fluids - Lactated ringers

0.9% NaCl
D5W at first

hypertonic solution does what to the cells - SHRINKS the cells

4 examples of hypertonic fluids - D5 normal saline

D10W
3% NS
D5+0.45% NS

example of hypotonic fluids - 0.45% NaCl

What IV fluid SWELLS the cells - hypotonic

What IVF is used with PRBC infusions - lactated ringers (isotonic)

cheap readily available IVF that expands the ECF - 0.9% normal saline

when fluid goes into the interstitial tissues it is called? - third spacing

which contains anticoagulant, plasma or serum? - PLASMA has anticoagulant (PA)

which does NOT contain anticoagulant, plasma or serum? - SERUM does not have an anticoagulant

most people drink how many liters of water a day - 2-2.5L a day

average water loss in stool per day in mls - 150-400mls

average loss of urine a day - 800-1500mls

average insensible loss of fluids is how many mls per kg - 8-12mls/kg a day

a patient that is derived of all external access to water must still excrete a minimum of __mls of urine per
day - 500mls of urine per day

Pure water deficits occur in what patient populations - NPO patients

maintain all NPO patients on how many ccs of IVF per hour - 100cc/hour

replace fluids to what ratio, what about blood - fluids= 1:1

blood= 1:3

how much water is lost for every degree of fever - 250ml/per fever degree

urinary output is how many mls per hour minimum - 30mls/hr

calculation for 24 hour maintenance fluid rate - 100/50/20 rule:

100ml/kg for first 10kg
50ml/kg for next 10kg
20ml/kg for the rest and divide by 24

calculation for hourly fluid rate - 4/2/1 rule

4ml/kg for the first 10kg
2ml/kg for the next 10 kg
1mk/kf for the rest
in a patient with symptomatic, non-life threatening symptoms of volume depletion, replace 50% of what
is LOST in the first __ hours - 8 hours

a fluid bolus to __mls of isotonic fluids or __mls of colloid in less than an hour - 500-1000ml of isotonic
fluids or 250mls of colloid

a fluid challenge is __L over 30 minutes - 3-4Ls

What is used in surgery for fluid replacement?

how about EMS? - surgery= LR
EMS= NS

maintenance fluid examples - D5, 0.45% NS, 0.9% NS

example of colloids - albumin, FFP, Dextran

What is the most serious sign of real fluid overload? - S3/third heart sound

rapid acute SOB think - PE (pulmonary embolism)

How do you know if an IV is working - Look for flashback via gravity or suction

Slow onset SOB think - first sign of fluid overload

Who gets a fluid bolus - symptomatic patients, abnormal vital signs

who gets a fluid challenge - anyone who fails a fluid bolus

from a surgical viewpoint, a patient who fails a fluid challenge has only one problem, what should we do
about it? - fluid is going somewhere, need surgery to find the leak

best end organs that assess quality of hydration status - kidneys

wet to wet dressings need changes every __ hours - every 2 hours

Who is in charge of setting up and monitoring the infusion pumps - Nurses, we don't touch

Why would a patient get hyperension 2-3 days AFTER surgery - 3rd spacing of fluid and/or inflammatory
phase of wound healing

What 4 things do you want to include in a radiology order - What is the sign/symptom
Where
When did it start
concern for

What does PACS radiology stand for - picture archiving, communications, storage system

viewing objects from two slightly different angles to give a perception of depth - stereotatic

nuclear medicine, admin of nuclear tracer with an affinity for an organ then recording the distribution of
the tracer - scintigraphy

IR procedure delivering chemo directly to the tumor - chemoembolization

most common thing that PAs do in radiology?

second and third most common? - most common= wet readers
2nd= IR
3rd=general radiology

on Ultrasound, strong echos are ___

weak echos are - strong are white
weak are black

radiolucent= - dark

radioopaque - white

the __ an object is, the greater the ability it is to absorb an xr beam - denser

Rate from radiolucent to radiopaque the fab 5 - Most radiolucent:

Gas>Fat>Water>Bone>metal most radiopaque

the tip of the central venous cath should lie within the - SVC (lateral to thoracic spine, inferior to medial
end of right clavicle)

optimum position of an ET tube - tip should lie >5cm above the carina/bifurcation-between the clavicles

single chamber pacemakers are embedded where - in the right ventricular wall

dual chamber pacemakers are embedded where? - in the right atrial wall

most common position for lateral decubitus is - Left lateral, pt lays on left side

3 views for ER/surgical abdomen XR and what they show - supine abdomen- best detail
upright abdomen- air fluid levels
upright CXR- free air under diaphragm
funky abdomen XR what's next - order a CT

coffee bean sign on XR=?

treat how? - volvulus
treat= decompress via rectal signmoid/tube

admit all kids who swallow how many coins - 2+ (more likely to obstruct)

keyboard sign on ultrasound - small bowel obstruction

Which CXR is better because you get a more accurate heart size (less magnification) - PA

structures further away from the XR plate cast a __ shadow - larger

rust colored sputum think - pneumonia

treat mycoplasma pna with - azithromycin or doxy

best view for suspected pneumothorax - end expiratory film

more blood flow to apices on upright film - cephalization

horizontal white line in periphery of lungs, fluid in interlobular septa - Kerley B lines

bronchioles becomes surrounded by fluid, looks like little donuts on XR - peribronchial cuffing

batwing sign of alveoli indicates - CHF

how often do you flush a heplock/saline lock - every 8 hours

most of our blood is where - 60% in the systemic veins/venules

Pre-op trigger for blood transfusion - Hgb of <7

look out for ___ anemia during IV hydration and resuscitation - dilutional

ASA I/II what is the goal hemoglobin - 10

ASA 3+ what is the hemoglobin goal - 12

3 clinical signs that indicate that a patient needs a transfusion - tachycardia

hypotension
oliguria
one unit of PRBCs will raise the hematocrit by - 3%

premedicate a blood transfusion with - benadryl

Does this patient get a type and cross or type and screen?
general surgery without significant vessels - type and screen

Does this patient get a type and cross or type and screen?
general surgery vascular or with significant vessels, and how many units? - type and cross, 1-2 units

Does this patient get a type and cross or type and screen?
cardiovascular surgery patient, and how many units? - type and cross 2-6 units

Does this patient get a type and cross or type and screen?
Ortho surgery patient, and how many units? - type and cross, 2 units

Give platelets in a medicine or ER patient if the platelets are less than __ or the patient is bleeding - <150

Give patients in surgery platelets if they are less than - <50

Do an IO access after how many unsuccessful IV attempts or after __ seconds - 3 unsuccessful attempts
or >90 seconds of trying

Which IO placement site is less painful, flow rate 5L/hr, 3 seconds to the heart, no reported compartment
syndrome - Proximal humerus

Sternal IO is where and can only be done on adults - superior aspect of sternum

Confirm IO placement with __mm mark - 5mm mark

What angle do you go in when inserting an IO in the proximal humerus - 45 degrees

What do you flush an IO with first?

Then administer meds at same dose as if IV - Lidocaine, prevents pain

4 contraindications to an IO - fracture to tibia or femur on side of access

osteogenesis imperfecta/fragile bones
known osteoporosis
if you already have a peripheral or central line

naso/oro gastric tubes is what length tube , minimal action distal to? - SHORT TUBES
minimal action distal to ligament of trite

naso/oro enteric tubes, medium is for what 2 things? - distal duodenum or tube feedings
naso/oro enteric tubes, long tubes do what - small bowel obstruction or colonic

For an upper GI bleed, insert NG tube and lavage until - CLEAR

name some contraindications to an NG tube - nasal/basilar fracture

psych/AMS
esophageal obstruction
esophageal strictures
esophageal varices
ingestion of CAUSTIC substances

What type of NG tube am I?

10-18 french, single lumen with perforated tip and side holes for aspiration of stomach contents - Levin
tube

What type of NG tube am I?

double lumen, allows for continuous suction, better in emergencies, mostly used for decompression, 18
FRENCH - Salem-Sump

How do you measure an NG tube? - nostril to tip of ear lobe, ear lobe to xiphoid process

What position do you put the patient's head in for inserting an NG tube - sniffing position or head tilted
forward , have patient sip water

Most reliable way to assess NG tube position - Xray

or test gastric for pH (0-4)

before removing NG tube do what - flush out tube with 20cc of sterile water

If a patient has an NG tube and abdominal distention think? - Ileus

If a patient's NG tube output is bilious think? - NG tube is past the pylorus

If a patient is passing flatus or stool with an NG tube what does that mean? - GI function has returned

Chest tube AKA - thoracostomy

normal healthy pleural space has how much lubricating fluid - 50ml

excessive fluid in the pleural space - pleural effusion

air in the pleural space - pneumothorax

lymphatic fluid in the pleural space - chylothorax

pus in the pleural space - empyema

blood in the pleural space - hemothorax

What clamp is needed for a chest tube set up - pean clamp

most common chest tube sizes - 16-28 French

large pneumothorax in patient who is unstable use what size chest tube - 24-28 french

chest trauma with clots, use what size chest tube - 36-40 french

Do you want a pigtail or straight chest tube in a trauma or hemothorax? - straight catheter

Do you want a pigtail or straight chest tube in a simple effusion under ultrasound of CT guidance - pigtail
catheter

Where do you insert a chest tube - 4th intercostal space, anterior axillary line

What is the triangle of safety for inserting a chest tube - base of axilla to lateral border of pec major to
lateral dorsi to 4th/5th intercostal space

Do you point the chest tube up or down if you are draining air - up

do you point the chest tube up or down if you are draining fluid - down

closed chest drainage system a patient breaths into a __ seal - water seal, more water=greater seal

pleurovac is 3 chambers of __ and 2 chambers of __ - 3 of fluid

2 of air
drain right to left

typical suction in chest tube is __ -___ - -10 to -30

peak inspiratory pressures on a patient on a vent with a chest tube is __ -__ - 10-14

keep chest tube coiling on bed, never let it dangle and never let it go above __ level - chest level, MILK
THE TUBE

with a chest tube, bubbling in the water seal chamber indicates - AIR LEAK

with a chest tube, bubbling in suction chamber indicates - TUBE IS WORKING

What 3 things do you check when a chest tube is in place - the apparatus
the chest
the xray

no movement in water seal chamber, blood in collection chamber or bubbles in water seal think what with
chest tube - hemothorax

bubbles in water seal with inspiration and collection chamber is empty think what with chest tube or
levels in water seal moves up adn down with breathing - pneumothorax

Remove a chest tube when drainage is <___ccs/day or when the lung is inflated by CXR for >24 hours
with no air leak in water-seal - <200ccs/day

When do you pull a chest tube, have pt do what? - pull at end inspiration, have pt hum
Check CXR

Diagnosis codes are - ICD-10

Procedure Codes are - CPT codes

__code is initial vs established pt - E/M

An ICD code ending in A indicates - initial encounter

An ICD code ending in a D indicates - subsequent routine healing

An ICD code ending in G indicates - subsequent delayed healing

AN ICD code ending in S indicates - sequalae of fracture

CMS determines the __ ___ for reimbursement of the service - fee schedule

What CPT would you assign?

brief like a wound check, <10 minutes - 99211

What CPT would you assign?

problem-focused, brief HPI with no ROS or past history, 10 minutes - 99212

What CPT would you assign?

expanded focus, brief HPI, only pertinent ROS, no past history, 15 minutes - 99213

What CPT would you assign?

detailed, extended HPI, 2-9 ROS, pertinent past history, 25 minutes - 99214
What CPT would you assign?
comprehensive, extended HPI, full ROS >10, full past history, high complexity, 40 minutes - 99215

___ is the process of translating a description of a diagnosis or procedure into a letter/number code -
coding

What does SOAP stand for? - subjective (history), objective(exam), assessment, plan

What physical exam am I? review of medical/social health history and preventative services education.
Covered only once within 12 months of Part B enrollment, patient pays nothing - IPPE- initial
preventative physical exam

What physical exam am I? visit to develop or update a personalized prevention plan and perform a health
risk assessment, covered once every 12 months, patient pays nothing - AWV-annual wellness visit

What physical exam am I?

exam performed without relationship to treatment or diagnosis for specific illness, symptom, complaint,
or injury, not covered and patient pays 100% out of pocket - Routine physical exam

What percent do PA surgical first assistants make? - 13.6%

2 quality programs we will see on rotation - MIPS

APM

__ and __ are keys to primary care survival - Meaningful use and PCMH

3 goals of wound closure - no infection

normal function
excellent cosmetic result

Before closing a wound always check what? - sensory (2pt discrimination)

never do what to an eyebrow laceration - DO NOT SHAVE IT

max amount of lidocaine you can give is - 3-5mg/kg

2 amines of anesthetics are - lidocaine and bupivacaine

5 ways to help make anesthesia painless - use topical anesthetic prior to injection
warming the solution to body temp
buffer with sodium bicarb
inject slowly
inject through wound edges not through intact skin
make sure when injecting anesthetic that you - pull back to make sure you are not in a vein

injecting a large area with one injection to achieve anesthesia , good for ears - field block

so no more than __mLs of anesthesia in each finger - no more than 5mls

What should you irrigate a wound with? - NS or tap water

to explore a wound in a bloodless field you should not balloon or tourniquet for more than how many
minutes - 20-30 minutes

highly vascular areas such as the face and scalp can be closed up to how many hours after an injury - 24
hours

trunk and extremity lacerations have lower rates of healing when closure is delayed so how many hours
after an injury do you want to close - 8-12 hours

2 examples of non-absorbable sutures - nylon or polypropene (blue)- good for hairy places)

With sutures: the higher the number, the __ the suture size - smaller the suture size so 8 is small and 3 is
big

examples of absorbable sutures - -chromic "catgut"

-vicryl
-monocryl
-PDS

how do you hold needle drivers - 4 finger hold

What angle do you drive the needle in to close a wound - 90 degrees

most commonly used to repair lacerations is the __ stitch - simple-interrupted stitch, start in middle and
half wounds

What stitch is commonly used for gaping wounds with high tension and allow the wound edges to be
pulled together over a distance - mattress stitch (horizontal or vertical)

vertical mattress stitch uses what method - far-far, near-near

What stitch is ideal for low-tension , COSMETICALLY important wounds, goes under the skin - running
stitches
the needle is inserted at the level of the superficial fascia and exits at the dermal/epidermal junction, ties
in subcutaneous, follows the direction of the laceration. closes deep space - Deep/buried stitch

What stitch is the variation of the vertical mattress and is the technique of choice for angled wounds as it
does not compromise the blood supply which can lead to tissue necrosis - corner or half-buried mattress
technique

After a suture repair keep the wound dry for how long - 24 hours

prophylactic antibiotics are not generally prescribed to patients with lacerations unless - it was an
animal/human bite, intraoral lacerations, exposed joints/tendons and open fractures

most important prevention step in laceration repair is adequate - irrigation and debridement

Feet and back, remove sutures in how long? - 12-14 days

face, ear remove sutures when - 4-5 days

scalp remove sutures when - 6-8 days

chest/abdomen, arm/leg, hand sutures remove when - 8-10 days

fingertip sutures, remove when? - 10-12 days

a strand of material attached to a needle - suture

a strand of material with NO needle - free tie or ligature

a suture strand with a needle at each end - double-armed suture

a plastic disk from which continuous ligating material is unwound as blood vessels are tied - reel

a __ is going once around a suture - throw

a __ consists of a series of throws - knot

two opposite throws is a __ knot - square knot

2+ knots is called a ___ - pile

amount of suture left above the knot is the - tail

a suture knot too small ___ - slips

a suture knot that is too big becomes a - foreign body (FB)

tendency to return to the original shape/untie is - memory

expand when stretched and can't return to original length, loosens with edema is - plasticity

ability to return to original length, does not loosen with edema is - elasticity

__ are the most common foreign body implanted into a patient - sutures

Which filament has great tensile strength and has better knot security , multi or monofilament -
multifilament

Which filament has less tensile strength, has memory, more throws required to hold the knot, multi or
monofilament - monofilament

__knot extra first throws, followed by one opposite throw, tightens upon itself, great for securing a
structure - surgeon's knot

what is the most frequently used surgical knot - square knot

with braided material like silk, how many throws would be placed to secure a knot - 3 throws

with monofilament material like nylon, how many throws would be placed to secure a knot - 5-6 throws

With cutting skin sutures leave ___-___mm tail - 3-4mm tail

1. Apply concepts of fluid regulation and physiologic demands associated with various disease states to
assess a patient’s need for intravenous therapy.
-
2. Compare and contrast replacement and maintenance IV therapy.
-
3. Describe the types of solutions available for basic intravenous therapy.
-
4. Describe the mechanical considerations in initiating basic IV therapy.
-
5. Determine the calculations necessary to estimate fluid needs.
-
6. Construct the components of a written order for intravenous therapy.
-
7. Discuss the indications for intravenous cannulation.
-
8. Assemble the equipment used for intravenous therapy.
-
9. Describe the proper technique for insertion of an intravenous cannula into a peripheral vein.
-
10. Understand the role of IV catheter size and fluid/blood administration
-
11. Compare and contrast the indications and maintenance of a peripheral IV line or heparin lock.
-
12. Describe the basic steps to managing a nonfunctional IV
-
13. Discuss common complications of peripheral IV therapy, their associated signs and symptoms and
basic treatment of these complications
-
14. Calculate daily IV fluid rates. Be able to compensate for fluid losses (NG, Foley, etc.)
-
15. Properly recognize a patient in fluid overload from IV Fluids
-
16. Discuss the indications, technique, and complications of IO infusions.
- Indications:
- For critical situations when a peripheral IV is unable to be obtained
- Initiate after 90 seconds or three unsuccessful IV attempts.
- Why:
- Obtaining peripheral access in the critically ill patient may be difficult & time-consuming
- The vascular collapse of severe dehydration or a cardiac arrest can be profound and delay
administration of essential therapies.
- You can draw labs from it and give IV meds, even contrast!
- Administration of endotracheal medications may not provide rapid and reliable drug
absorption during a cardiorespiratory arrest n **Naloxone, atropine, vasopressin, epi,
lido**
- Better consistency
- Sites:
- PROXIMAL HUMERUS: Flow rate 5L/hr • 3 seconds to heart • Lower insertion &
infusion pain • Less medication required for pain management • No reported
compartment syndrome due to IO placement
- Proximal tibia: midline on the bone (adult), growth plate (infant/child)!
- Not see sternal IO access as fast as humorous
- Technique;
- Estimate tissue depth
- Confirm with 5mm mark
- EZ-IO: Battery-powered IO driver and needle set
- Palpate the puncture site and prep with an antiseptic
- Tiba: -90 degrees to the bone! -Aspirate & attach -IV admin tubing
- Humerus: easier - Insert needle set at 45deg. angle to the anterior plane and
posteromedial
- Rapid flush:
- INITIAL SHOULD BE LIDO!
 - Consider for blood typing and other commonly ordered labs
- •For optimal flow infuse with pressure •Administer medications in same dose,
rate and concentration as given via peripheral IV
- Complications:

- Fracture - PAIN (forgot lido flush!)

- Infiltration - Thrombophlebitis
- Growth plate damage - Air embolism
- Complete insertion - Circulatory overload
- Pulmonary embolism n - Allergic reaction
Infection
- CI:
- Fracture to tibia or femur on side of access
- Osteogenesis imperfecta
- congenital bone disease = fragile bones
- Known osteoporosis
- Establishment of a peripheral or central IV line
Notes:
- IV not drip, puffy → infiltration → remove IV

Human body = 60% water- 2/ 3 of this is ICF, and 1 / 2 of total body water is in the muscle

- Applying this: patients with higher body fat % need less IVF than muscular person of the
same weight (their

fat holds more fluid- they’re more prone to fluid overload)

Fluid Compartments

​ - ICF + ECF = Total Body Water, the classic anatomical “70kg male” is 42-45 L TBW
​ - EC SPACE (~15L)
​ - Broken down into Interstitial Space (Third Space), and Intravascular space
(where IV catheter goes)
​ - IV therapy allows direct regulation of EC space
​ - Na restricted to ECF, so sodium level determines ECF volume
​ - IC SPACE (~30L)

- Someone who is volume depleted = low in ICF by default

- Your best bet is giving IV Fluid to the EC space and hoping it moves into the IC space (water
moves freely across cell membranes)

- Electrolytes in cellular compartments: - In metabolic panel...

​ - Na should read higher than K because Na is n the ECF and K is in ICF

 ​ - A low osmolality means they’re hyponatremic- too much liquid in the blood diluting
the lytes

- Passage through membranes:

​ - Capillary membrane: passively permeable to all EXCEPT cells and protein; follows
pressure gradient
​ - Cellular membrane: passively permeable ONLY TO WATER, follows osmotic
pressure gradient
Fluids in patients with abnormal electrolyte ranges:

- A normally isotonic solution in a patient that is hypotonic (low osmolality/diluted blood) would
actually be

hypertonic to them

​ - If you gave the hypotonic patient this fluid, it would shift fluid out of ICF into ECF,
worsening the
volume depleted state
​ - Make sure to consider these relationships when deciding which fluids to give Na &
Fluid Relationship:

1. Apply concepts of fluid regulation and physiologic demands associated with various disease
states to assess a

patient’s need for intravenous therapy.

- In order to maintain body volume (especially ECF), salt intake must = salt output → we need
maintenance fluid containing salt (why we use saline instead of water)

Some more notes on fluid options:

​ - D5W good to give patients energy if they’re NPO postop etc for energy
​ - On the 3% NaCl below- good to “just move fluid around”

iso01stthenHYPOfnugurrutabid hypo
igo hyper
Random Key Questions:

- How much fluid to give if NPO? → 100cc/hr

​ - If SST tube is drawn + spun, will K or Na be higher? → Na

​ - If SST tube is drawn + allowed to sit, how will lytes change? Plasma rushes into RBC
→ clots, lysis
​ - MC cause of Hyperkalemia = Iatrogenic
​ - Improperly processed tube (sat out too long)
​ - If patient asymptomatic, recheck
Basic intake & losses:
​ - Average fluid intake: 2-2.5 L/d
​ - Avg water loss in stool (150-400ml/d) + urine (800-1500 ml/d) → 950-1900L/d
​ - Pt deprived of external access to water MUST still excrete minimum 500ml urine/d to
excrete waste products in
addition to mandatory insensible loss
​ - “How much can a patient lose?”
​ - Blood: “healthy” pts tolerate 500ml loss
​ - Sweat: up to 4L/d
​ - Skin 250ml/d per degree F of fever
​ - ET tube/vent: 1.5L/d
​ - Peritoneum: up to 1L/d
​ - Losses increased with stress

- For sx like fever/tachypnea- add 10ml/kg to maintenance rate of 100cc/hr - Insensible loss
(immeasurable- sweat, breath, etc)= ~8-12 ml/kg

​ - Skin 600ml/d, lung 400ml/d, kidney 1.5l/d, feces 100ml/d

​ - NGT 1.5L/d, Ileostomy 2L/d, Colostomy 150mL/d
Fluid Balance Key Points
​ - Body is more concerned maintaining volume over tonicity
​ - Water balanced regulated by ADH, thirst mechanisms
​ - Na regulated by kidneys , and Na level determines ECF vol

- ECF vol easily seen on UA → higher # = thicker urine

- Simplest form of vol depletion: water deficit without solute deficit (NPO, debilitated, comatose)

- Recognized by elevated electrolyte levels

- Surgical patients → water + solute deficit combo more common

2. Compare and contrast hydration, replacement, and maintenance IV therapy.

How much IVF to give? Think “Maintain and Replace”

1. Maintain everyone NPO @ 100cc/hr

2. Determine blood vs fluid loss
● Fluid replacement 1:1, Blood replacement 1:3
● Monitor drains, I&O when calculating losses
● Burn victims → high volume in first 24h, use Parkland Formula
3. Compensate for INSENSIBLE loss

a. 8-12ml/kg= avg, sick patients need more

b. Skin 250ml/d per degree F fever

4. Carefully judge fluid status

● VS: HR=early changer, BP look for oliguria or symptoms to indicate a problem

● Turgor, mucus membranes, edema, fever, JVD
● Central venous pressure (avg=3-4mmHg), UO 30ml/hr minimum, BUN (8-25, fast
changer)

Calculating Maintenance Rate- he said you can google this and not to memorize, involves body
weight calculations divided over a 24h period for daily rate or also an option to break down by
hourly rate

Adjusting IV Therapy

​ - If stable & no longer NPO, decrease IVF rate, let them get thirsty & start taking PO
fluid
​ - “If the gut works, use it”
​ - Don’t remove IV, they may need it
​ - If stable & good urine output, decrease IVF rate
​ - Continue to assess response- monitor I&Os and watch for...
​ - “Slow onset SOB”- earliest sign of fluid overload
​ - “Rapid, acute onset SOB”- pulm embolism
​ - MOST serious sign of REAL fluid overload → 3rd heart sound
(“Kentucky”)
​ - Typical sequence: Replace + maintain → Maintain → Decrease maintenance +
increase PO → Stop IVF + continue PO
Symptomatic Patient: non life threatening sx of vol depletion → replace 50% of loss in
first 8h
Urgent correction (Abnormal VS, Bleed):
 ​ - Fluid BOLUS → 500-1000mL isotonic or 250 of colloid in <1h
​ - Fluid CHALLENGE → 3-4L in 30min
​ - Challenge includes bolus and bolus may turn into challenged based on scenario

3. Describe the types of solutions available for basic intravenous therapy.

Options: Isotonic, hypertonic, hypotonic (free water), blood products (not covered in this lecture)

Replacement fluid: LR or NS (LR for surgery, NS for EMS)

Maintenance Fluid: D5 0.5NS, or if you don’t know what to use a safe bet is NS - Anyone with
GI problem gets 20mg KCl

Crystalloid→ mineral salts & water soluble minerals (Na, K)

- hypovolemia, free water deficit correction, replacing ongoing fluid loss, meeting NPO
requirements

Colloid→ large INSOLUBLE molecules (blood, Alb, FFP) low oncotic pressure (think ECF),
great in kids - Often combined w crystalloid

Blood → for hemorrhage, medical anemias

4. Describe the mechanical considerations in initiating basic IV therapy.

Look under contraindications- later objective

5. Determine the calculations necessary to estimate water and electrolyte needs.

Covered under fluid calculations

6. Construct the components of a written order for intravenous therapy.

Needs to have type of fluid, rate, route of delivery, and need to make adjustments as patient’s
condition changes

7. Discuss the indications for intravenous cannulation.

​ - Maintenance in NPO pt
​ - Fluid administration- illness, vol depletion, burn, bleed, lyte disturbance, heat illness,
shock, trauma
​ - Med administration- esp in circumstances with high first pass metabolism or where
bridging is beneficial
​ - Blood administration
 ​ - Diagnostic administration of contrast
​ - Nutritional
Contraindications= extremities with: significant burn/edema/injury (avoiding more
mechanical trauma), with cellulitis/significant infection (avoid introducing bacteria),
with indwelling fistula, with impaired circulation

8. Assemble the equipment used for intravenous therapy.

Types of IV Access: Peripheral (extremity), Central (SVC, Jugular), IO (emergency- usually

peds) - Remember things can be given with continuous slow infusion or periodic infusion

Equipment:

- IV Needle/Catheter

- Can be Hollow needle (butterfly), “Over the needle” (angiocath), Indwelling

- IV administration tubing

- MACRO Drip: labeled as <40 drops/mL on packaging (drops are bigger, takes less)

- Faster fluid movement → what we want!! - MICRO Drip: labeled as 40+ drops/mL

- Useful in the rare occasions that you need more precise med administration, etc

​ - Can always slow a macro, but can’t speed a micro → GO WITH THE MACRO
DRIP
​ - Tubing must be flushed (primed with IV fluid) before connecting so air isn’t introduced

- Extension set/Heplock (same thing)

- Peripheral cannula that’s not attached to IV tubing/fluid- allows IV access when needed

- (Basically dangles on patient’s arm so you can hook tubing up to cannula when you need to
give

something)

​ - Filled & flushed with anticoag (heparin) when not in use

​ - Plug: like Heplock but no tubing (just a little cap)- flush with heparin Q8h, clogs
easiliy
​ - Dressing (tape, tegaderm)
​ - Fully written & clear orders
Piggyback: 2 fluids hung that share 1 line downstream

​ - PRIMARY Set: the bag that runs longer/is the primary thing you give (usually fluids)-
hangs lower
​ - PIGGYBACK Set: shorter course (usually a med)- hangs higher

9. Describe the proper technique for insertion of an intravenous cannula into a peripheral Vein.

Steps to IV Insertion

​ - Properly ID patient
​ - Assemble equipment:
​ - IV catheter, Heplock, Tubing, IV solution
​ - Assemble IV bag and administration set, flush line to remove air bubbles
​ - Saline flush
​ - Usual phlebotomy supplies: tk, gauze, tape, alcohol, chux
​ - ID Vein
​ - Insert catheter- NEVER pull back on the needle once it is pushed down, can shear off
catheter into vein
​ - Flush line, begin infusion
​ - Secure with tape/tegaderm
​ - Document, monitor patient, adjust rate
10. Understand the role of IV catheter size and fluid/blood administration
​ - Smaller ga= larger needle= quicker fluid administration
​ - Typical in surgery & outpatient = 18ga, typical in trauma = 16 preferred but 18
acceptable, typical shock
resuscitation = 16 preferred, stable outpatient here for medication = 24ga (we know
they tolerate it well, no
need for a bigger one in case of emergency)
​ - Remembering colors (ok hear me out on this)

---

11. Compare and contrast the indications and maintenance of a peripheral IV line or heparin
Lock.

Covered in other objectives above

12. Describe the basic steps to managing a nonfunctional IV

Make sure patent by looking for flash in chamber, look at obj 14 for how to handle complications
13. Understand the method of calculating IV fluid rate.

For like the 5th time, covered above

Infiltration → Remove

Kink in tubing → Fix

Site bruising/cellulitis → Remove

24: yellow

→ when we got to PA school it was yellow like caution tape bc we were like wtf this is hard →
once we got over the wtf stage we were sad/blue bc we were exhausted

22: blue

20: red,

→ we had the holiday break (red/green for xmas) which helped a little bit Remembering which is
which here- remember 18 is green bc it’s good for most cases of use

18: green

16: grey → you use if ur patient is gonna die/it’s an emergency and at this point we’re dead
inside

14. Discuss common complications of peripheral IV therapy, their associated signs and
symptoms and basic treatment

of these complications

15. Calculate daily IV fluid rates. Be able to compensate for fluid losses (NG, Foley, etc.)

Above- fluid calculations

16. Properly recognize a patient in fluid overload from IV Fluids

Above- crackling lung sounds and S3

17. Discuss the indications, technique, and complications of IO infusions. He didn’t go over but i
believe peds trauma

Wrap Up Key Points:

​ - Before using an IV you can tell it’s working by: Suctioning with a syringe to see
blood flash (shows it’s patent)
​ - Who gets replacement fluid? Anyone who lost fluid. Which do you start with? NS or
LR. How do you know
how much to give? Replace amount lost.

- When might we consider giving 50% of lost volume over the first 8h of the day? Symptomatic
vol loss

​ - What is your ideal maintenance fluid? How much do you give? D5 0.5NS, 100cc/hr
​ - WHat is the first sign of fluid overload? Slow onset SOB
​ - What is the most serious sign of fluid overload? Audible S3
​ - What are the typical results we look for in a metabolic panel? What are the normal
ranges?

- Na, K, Cl, CO2, Ca, Urea nitrogen, Glucose, Creatinine, GFR (will be given on
exammaster)

​ - How would low K compare clinically to high K or low/high Na? What are common s/s
we look for? Na: vague
generalized malaise, K: muscular s/s
​ - Who gets a fluid bolus? How do you know if they need a challenge? Declining
patients get it. Challenge needed
if decline continues during bolus
​ - From surgical viewpoint, a pt who fails fluid challenge has only one problem, what do
we do? Internal bleed →
OR
​ - What IVF would you expect to see running in the ER/PACU/OR? LR (vol
replacement) Step down
unit/Medsurg? D5 0.5NS +/- KCl (Maintenance)
​ - D5W is given to a patient who is hypotensive + oliguric, what will happen? D5 will
move to IC, worsening
condition. They need isotonic fluid
​ - What is the best end organ to assess to eval quality of hydration status? Urine output
​ - Why might a nurse be upset if you write wet to wet dressing or I&O? Lots of work
​ - When in doubt, maintain someone with an isotonic fluid with a correct IV set up.
​ - 3% NS is given to a healthy ASA 1. What effect will you see? Fluid moves IC → EC,
pt looks vol depleted
 ​ - Who is in charge of setting up & monitoring infusion pump? RN
​ - Why would a patient get HTN 2-3d postop? Anesthesia causes 3rd spacing and
now fluid is returning &
rebalancing itself
Practice questions posted in this lecture folder
In and Out: The Blood Bank (done) - S
1. Discuss the indications for transfusion including anemia and bleeding ● Anemia

​ ○ Hg 7-12 → look at comorbidities, blood loss, surgical stress

​ ○ Hg < 10 = impaired perfusion

■ Increased LDH

■ Acidotic

■ Issues with ischemia

​ ○ *** Hg of 7 (Hct of 21) = trigger for infusion due to declined O2 delivery ***
​ ○ O2 delivery can be modified with clinical interventions, oxygen consumption cannot
● Indications
​ ○ Vitals NOT responsive to challenge
​ ○ Hypotensive, dizziness, weakness, etc
​ ○ Hypovolemic symptoms in the setting of blood loss
​ ○ Transfuse patient based on appearance, not number
​ ○ Infusion IF: Tachycardia, Hypotension, Oliguria

● Intraosseous Infusion:

​ ○ Critical situations when peripheral IV unable to be obtained

​ ○ Initiate after 90 seconds or three unsuccessful IV attempts
​ ○ Sites:
■ Arm (Proximal Humerus)
​ ● 3 seconds to heart
​ ● Less med required for pain management
​ ● No reported compartment syndrome
■ Leg
■ Sternum
■ Tibia
​ ○ Placement:
■ NOT in the SQ, confirm with 5 mm mark
■ 90 degrees to bone (unless humerus, then 45 degrees toward Xiphoid)
 ■ Aspirate and attach IV admin tubing
■ NOT through growth plate
■ Flush Lidocaine
■ Administer meds in same dose, rate, concentration as given peripheral IV
​ ○ Complications
2. Understand the role of transfusions in the pre-op setting
3. Based on a hemoglobin and patient presentation, calculate the amount of blood that
should be ordered.
4. Understand platelet transfusions & properly order them from the lab

● Typical Orders

○ Premedicate with Benadryl

○ Pre-op:

■ T&C 2 units to OR

​ ○ Anemia:
■ 1unitPRBCwillraiseHgby1andHctby3%
​ ○ General surgery with significant vessels:

■ T&C 1-2 units ○ Cardiovascular:

■ ○ Ortho:

■■

T&C: 2-6 units

Generally: T&S

Total joint/ORIF: T&S and T&C 2 units

● Platelets:

○ 1unit=6K

○ Indications

■ <10 K with or without bleed

■ <20 K with bleed or major bleed risk
■ < 50 K pre-op
■ 50-150 if bleeding and no other cause
 ■ <150 K for medicine eval or bleeding
5. Describe the indications for cryoprecipitate transfusion. Order properly from the lab
● Cryoprecipitate
○ Indications
■ 10 units to raise fibrinogen
■ VWf disease give cryo and DDAVP
■ Hemophilia A (Low factor VIII)
6. Compare and contrast a type and cross with a type and screen

● Ordering Blood Products:

​ ○ Type and Screen - blood type and Rh factor

​ ○ Type and Cross - blood bank MUST save and reserve blood of that patient’s type.
Order needs to
include how many units need to be reserved (more than 1 unit)

7. Recognize the patient that needs a plasma transfusion and write correct orders for plasma.

● Plasma

○ Indications

■ High INR → give plasma

■ Lack of Coag factors
In and Out: Chest tube (done) - S
1. Review the indications for chest tube placement. Describe the location of chest tube
placement. ● Chest tube (AKA Thoracostomy)

○ Indications

■ Pleural effusion

■ Hemothorax

■ Pneumothorax (16-22 French)

■ Chylothorax - lymphatic tissue in pleural cavity
■ Empyema - pus from infection (20 French)

● ALWAYS drained, no matter how small ■ Prevention

○ Location

■ Pneumothorax
 ​ ● Supine or head elevated
​ ● Inserted in 4th ICS between MCL and MAL ■ Effusions
​ ● Sitting on side of bed leaning over a pillow
​ ● Inserted in 4th ICS

○ Size of tube (French sizes)

■ Stable patient: 8-16

■ Drain blood: > 28 French
■ Trauma with clots: 36-40

● For trauma and hemothorax → NOT pigtail catheters

■ Children: Size of their little finger

■ Calculation: French Size / 3 = mm

2. Identify a proper and improperly placed chest tube on a chest x-ray ● Procedure

​ ○ Anesthetic
​ ○ Incision and tunnel with finger
​ ○ Direction of tube (must be clamped while directing)
■ Tube UP for removal of AIR
■ Tube DOWN for removal of FLUID
● Positioning

○ As long as it’s in the pleural space, it will work

3. Discuss the management of air bubbles in a pleur-evac system

● Pleur-Evac System - maintains negative intrathoracic pressure

​ ○ Air tight, hooked up to chest tube, drainage/suction

​ ○ Keep site moistened with sterile petroleum dressing

4. Understand the function/role of the ‘three bottle model’

● Components

○ Suction Control

○ Water Seal - one-way valve: Air can get out, water cannot be sucked in

■ Water rises in exhale

■ If no change, may be blocked
 ■ More water = greater seal
■ Pneumothorax → should see bubbles

● Bubbles any other time → LEAK ○ Collection chamber

5. Describe which patients need a chest tube to suction or water seal.

● Management:

​ ○ Suction → Water Seal

■ Promote to water seal when air/fluid draining is completed
■ Watch for signs of accumulation
■ Patients can walk around with water seal (disconnect from suction)
​ ○ Examine and change vaseline dressing daily
​ ○ Regular CV and pulm exam (2x/day minimum)
​ ○ XR for changes
​ ○ Monitor peak inspiratory pressure (PIP)
■ 10-14 usual setting
■ > 40 barotrauma
​ ○ Remove when drainage should be <200 ml/day or pneumo is resolved AND pt is
stable
● Maintenance:
​ ○ Encourage coughing and deep breathing
​ ○ Assess water levels 2x/day
​ ○ Correct fluid levels if not as ordered
​ ○ Inspect tubing q4 hours
​ ○ MILK tube, only if clots or stagnation

■ Towards the water seal ○ Keep tubing coiled on bed

■ Chest tubes are coiled and get milked

○ Bedside collection unit should NEVER go above chest level

● Complications

​ ○ Subcutaneous empyema - collection of free air/gas in the tissue under the skin
■ Swelling in face, neck, chest
■ Crackles on palpation
​ ○ Leak - bubbles in the water seal chamber

■ Run the system and do a leak check

● Clamp tubing momentarily at various points along the tube

■ Sources:
 ​ ● Chest tube is pulled or dislodged
​ ● Drainage holes are outside of patient’s chest sucking in air
​ ● Poor tubing connections
​ ● Cracked bedside collection unit
​ ○ Chest tube becomes dislodged - Tx as open chest wound
​ ○ Bleeding - usually minor

○ Infection - likelihood increases the longer the tube is in place ● Removal

​ ○ During END INSPIRATION and BREATH HOLD - remove tube QUICKLY

​ ○ Seal wound - apply sterile vaseline gauze to prevent air from entering
​ ○ Monitor pts respiratory status and order an XR to confirm lung re-expansion
​ ○ Monitor SpO2 for at least 2 hours after
6. Properly replace fluids lost via a chest tube
7. Describe why a chest tube is milked and not stripped
8. By evaluating a ‘three bottle model’ , discuss when a patient on suction can be moved to
water seal alone.

In and Out: Nasogastric Tubes (done)- K

General to Know: Naso vs Oro, then Gastric vs Enteric

​ - Gastric: short tubes, for stomach drainage, minimal action distal to ligament of
treitz
​ - Enteric:
​ - Medium tubes → distal duodenum for tube feedings
​ - Long tubes → intestines for SBO/Colonic problem
Needed to Insert: NGT, Lubricant (+/- Lido), Tape, Glass of water w straw,
Stethoscope, 50cc Toomey, Hurricane spray, Gown/goggles

1. Explain the indications and potential complications and the technique of nasogastric
intubation

Indications:

​ - Stomach pumping- poisoning, ice lavage for blood

​ - Prevent gas/fluid buildup if distal obstruction
​ - Relieve gastric distention
​ - Prevent aspiration in trauma/obtunded
​ - Remove enteric secretions
 ​ - Surgical decompression- laparoscopic surgery (make stomach smaller to get it out of
the way)--> Trendelenburg
or reverse Trendelenburg
​ - UGI Bleed- Lavage until clear, can also test gastric aspirate for occult blood
​ - Bowel rest- ie postop pancreatitis
​ - Instillation of agent- activated charcoal, contrast
Contraindications: obstructed esophagus, psych/AMS, nasal/facial injury/fx, ingestion of
caustic substances (burned the esoph, would tear if NG tried to go down)
Complications:

- Difficult placements

​ - Pain → line nasal cavity with Lido first

​ - Coiling of tube in oropharynx → remove, replace, use fingers to redirect
​ - Patient coughing/pain/vomit → coughing may indicate it’s in tracheal tree, pull it back

​ - Angled toward cribriform → could end up in brain (guessing this is if there’s trauma)
​ - Nasal trauma (weak nasal septum, polyp)
​ - Tracheal cannulation → cough
​ - Rupture of esophageal varices
​ - Longterm complications:

- Mucosal ulceration, sinusitis, esoph stricture, otitis media, perforation, nosebleed, erosive
gastritis from

suction

2. Discuss the daily care of an NG tube, comparing single vs. double lumen tubes

14, 16, 18 French used, 18=MC because smaller sizes may clog with stomach contents

Care:

​ - Change tape daily

​ - Document volume & quantity of aspirate
​ - Keep nose lubricated- bacitracin, vaseline
​ - IVF mgmt- if NGT is aspirating contents out, needs to be replaced 1:1
Single: ie Levin Tube (10-18French)- can be ran on intermittent suction

- Single lumen with perforated tip and side holes to aspirate stomach contents

Double: MC type is Salem-Sump tube- can be run on continuous suction

 ​ - Allows us to put in/take out more, so we use it more- MC used for decompression
​ - Large inner lumen drains fluid, Sump lumen (around circumference of inner lumen)
allows air in
​ - Never flush the BLUE side- it’s the air input

3. Discuss the work-up of no or low drainage from an NG tube

​ - Verify position of tube- auscultate, aspirate

​ - Verify function- clog? May need to flush- saline, or Simons says apparently Dr Pepper
fixes clogs
​ - Is bowel function returning?

“45yoF

with Crohn’s POD3 small bowel resection, sudden drop in NGT fluid” → bowel is probably
working

4. Understand the implications of increasing drainage in an NG tube

​ - DISTAL OBSTRUCTION developing

​ - Bleed
​ - Poor placement (too far below pylorus- suctioning out small bowel juices)
​ - Use gastroccult to eval for occult blood

- IF BLOOD IN NGT:

​ - Note volume, clots, color, stability of patient

​ - Irrigate until clear
​ - H2 blockers, Antacids

“56yoF POD4 from post splenectomy pancreatitis. SUdden increase in NGT aspirate” →
pancreatitis makes a lot of juices, as they recover and pancreas starts draining, more fluid =
normal

Questions to Ask with changing NGT output:

​ - Is there abd distention? → Ileus

​ - Is output bilious? → NGT is past pylorus
​ - Is pt passing flatus/stool? → GI function has returned
​ - Are they sneaking a drink on NPO status? Would increase output
​ - Is tube blocked?
​ - Can it be flushed properly?
 ​ - Is tube in the esophagus?

5. Describe the technique of NG tube removal

​ - After GI anastomosis procedure, leave in up to 48h

​ - Post anesthesia = until GI function returns
​ - Sm. bowel peristalsis 48h
​ - Left colon 36-72h
​ - Flush with 20cc sterile water before removing to get contents out (don’t want stomach
acid in patient’s nose)
​ - Remove in one smooth motion, examine nose

6. Properly replace fluids lost via NG tube suction Intravenous Cannulation

(1:1)

Steps to Insertion (not in obj. But probably need to know?)

​ - Assemble equipment, examine nose for larger nare and obstruction/bleed

​ - Measure the tube- note tube markings

- Measure nostril → tip of earlobe, then earlobe → tip of xiphoid process

​ - Have patient in Fowler’s (45 degree recline), secure airway first if induced
​ - Lubricate tube & nostril, tilt pt head forward to “Sniffing position” (may need to
hold their head in position)
​ - Advance tube 2-4cm at a time along floor of the nose (tube parallel to ground)- pt may
feel it in posterior pharynx
​ - May meet resistance until soft palate is passed (location of gag reflex)- asking pt to
swallow water helps
​ - Will feel a “drop” after soft palate passed- advance tube to pre-measured hash mark
​ - Confirm position

- XR most reliable, but other options:

- Test gastric fluid for pH 0-4, Inject 20mL air while auscultating epigastric area, POCUS, listen

for whistling sounds

- Correct placement on XR: tube seen in stomach, midline, tip below diaphragm

- MC misplacement = R mainstem bronchus

- Secure to nose with tape/bandaid, secure tube with pin to gown, apply LWS, lavage, etc as
seen fit
Injections (done) - S
1. Recognize the indications, equipment, technique and complications for intradermal,
subcutaneous and intramuscular injections.

MEDICATION ADMINISTRATION ● PerOs

​ ○ Safe, convenient, economical

​ ○ Drug delivery/concentration can be erratic
​ ○ GI environment makes absorption of some pills difficult for adequate absorption

■ TAKE WITH 25 cc WATER

​ ● Sublingual
​ ○ Rapid onset, easy access
​ ○ Avoids initial breakdown by GI
​ ○ No need to swallow
​ ● Per Rectum
​ ○ Faster than PO, good for patients who are NPO
​ ○ Safe in pediatric patients
​ ● Intraosseous
​ ○ Abx have lower peak concentrations
​ ○ All resuscitation meds can be used
INJECTIONS
​ ● Intradermal
○ Indications ○ Equipment ○ Technique

■ 10-15 degree angle ● Subcutaneous

○ Pros:

■ Rapid absorption and easy access points

​ ● Can self-administer
​ ● Immediate access to SQ space
○ Cons:
■ Small volumes
● Usually1cc(butupto5cc)
■ Absorption varies based on fat content
■ Slower than IM
○ Technique/Equipment

■ 45 degree angle

■ Locations:
● Belly, Thigh, Arm

● Intramuscular ○ Pros:

■ Faster than PO and SC/SQ. But slower than IV

● Some meds slow dissolution from muscle is advantageous over rapid IV delivery

or low absorption PO

○ Cons:

■ Cannot do large injections in pts with clotting problems or on anticoags

● Risk of abscess in large injections ■ Shots HURT

○ Technique/Equipment

■ 1 inch above the mid-way between posterior iliac crest and trochanter
■ Stretch skin tight
■ 90 degree angle
■ Locations:

​ ● Gluteus Maximus (> 2 years old)

​ ○ Large muscle, easy target
​ ○ 6 cm inferior to iliac crest
​ ○ Volume: 3-3.5 cc MAX
​ ○ Needle: 20-25 gauge, 1-2 inch needle
​ ● Deltoid
​ ○ Superficial, large, easy access
​ ○ 3 cm proximal to deltoid tuberosity
​ ○ 3 cm distal to acromion (3 fingers below)
​ ○ Volume: 1 cc MAX
​ ○ Needle: 23-25 gauge, 1 inch needle
​ ● Vastus Lateralis
​ ○ Preferred site for infants
​ ○ Can be used for adults for home IM therapy
​ ○ Anteriolateral thigh
​ ○ Volume: 1 cc MAX
​ ○ Needle: 25 gauge, 1 inch
● Intravenous ○ Pros:

■ Most RAPID response (good for emergencies)

■ High initial concentration

● But can cause toxicity

■ Able to titrate blood levels

■ Start on IV then BRIDGE to PO/IM
■ Lower stomach upset
■ Lowest variability in dose and response
○ Cons:
■ Take time to set up/skill to put in
■ More invasive and higher risk of infection
■ Rapid infusion → side effects (IV mag = palpitations)
■ Poorly soluble meds → toxicity (Valium = low BP)

● Contraindications:

​ ○ Allergy to any component

​ ○ Active infection or dermatitis at site of injection
​ ○ Coagulopathy
​ ○ On IV Heparin
● Equipment/Technique:
​ ○ Gloves
​ ○ Alcohol - to clean vial top
​ ○ Correct Med
■ Multi use
■ ● Clean with alcohol prior to insertion
■ ● Needle below fluid level (no bubbles)
■ Single use ■ Ampules ■ Pro-pens
​ ○ 2x2 gauze
​ ○ Bandaid
​ ○ Syringe
■ 3 ml for IM and 1 ml for SQ/intradermal
■ Components of Syringe
● Plunger

○ Measure volume at the base of the triangle or the most distal end

● Cylinder (graded) ○ Drawing needles

 ■ 16-18 gauge (better flow)
■ Inject volume of air required into vial
■ Turn vial upside down with needle still in, extract volume of medication needed
■ Check for bubbles

● Tap syringe to move bubbles to top, push plunger up to remove, pull down again to fill
remainder of syringe with correct amount of med

​ ○ Alcohol - to clean injection site

​ ○ Injection needle
■ 23-25 gauge (IM)
■ 25-30 gauge (SQ)
■ 1-1.5 inch
■ Components of Needle
​ ● Hub
​ ● Length
​ ● Bevel
​ ● Gauge
■ After needle insertion, PULL BACK to make sure not in vessel

● If you are in a vessel, remove needle, start over with new needle

● Complications

○ Minor irritation

​ ○ Nerve injury/pain after injection

​ ○ Arterial injury
​ ○ Abscess (sterile or septic)
​ ○ Bleeding

● Tips and Tricks

​ ○ R’s of medication delivery

■ Right PATIENT
■ Right DOSE
■ Right ROUTE
■ Right TIME
■ Right MEDICATION
■ AND check the expiration
​ ○ DO NOT inject cold medication
​ ○ Warn patient prior to injection
​ ○ DO NOT let needle linger on skin
 ■ This is where nerve ending are, this is the painful part
■ Go straight in, quick
​ ○ Operate the plunger and syringe with one hand
​ ○ Allow alcohol to dry
​ ○ Prepare everything outside the room
​ ○ Sharps in sharps container
​ ○ Be QUICK
Urinary Bladder Catheterization (done) - S
1. Discuss the indications and contraindications for performing urinary bladder
catheterization.
2. Understand the indications for a ‘straight cath.’

● Indwelling catheter = Foley ○ Indications:

■ Drain bladder
​ ● Bed-bound patient
​ ● Unconscious - OR/intubated
​ ● Retention: Neurogenic bladder, obstruction, clots
■ Monitor output
​ ● Trauma/Post-op
​ ● Anyone strict I&O
​ ● Medical (CHF, RF, sepsis)
■ Diagnostic studies

● Renal function for 24 hours

● Intermittent catheterization = Straight cath ○ Indications

■ Empty bladder in someone who cannot urinate

■ Eval of urinary incontinence

● Urodynamic testing

● Residual volume

○ RV>300mlisaproblem

○ RV> 50 ml = increased UTI risk ■ Sterile urine sample for diagnostic studies

● Sample in someone who cannot/will not cooperate with clean catch ■ Management of
hematuria

● Lavage until clear ■ Cystogram

● One shot retrograde for trauma diagnosis

​ ○ ABSOLUTE contraindication if trauma to urethra

​ ○ Blood in meatus - STOP

■ Oliguria work-up

3. Discuss the essential anatomy and physiology associated with the performance of
urinary bladder catheterization.
4. Identify the materials necessary for performing urinary bladder catheterization and
discuss their proper use.
Compare and contrast the types of bladder catheters.
● Materials

○ Some come in KITS with all required materials - Straight cath vc. Foley kit ○ Catheter

■ Flexible tubular instrument inserted into a body cavity

■ Silicone or rubber
■ Used to remove/introduce fluids
■ Types:
​ ● Foley catheter
​ ○ Inflatable balloon to secure the cath in the bladder
​ ○ Can be used to tamponade areas that are bleeding
​ ○ 2 lumens - one for urine, one for balloon retention
​ ● Red Rubber HO
​ ○ General drain
​ ○ Radiopaque
​ ○ 1 lumen
​ ● Straight cath

○ Temporary drainage

○ Urethral cath

​ ● Robinson
​ ○ General drain
​ ○ 1 lumen
​ ○ Fenestrations are separated (2 eyes)
​ ○ Firmer tip
​ ● Coude
​ ○ With or without balloon
​ ○ Indicated for LARGE PROSTATE
HO

■ First try standard foley

○ Curve pointed down???or up??, button anterior

● 3-way (irrigation)

​ ○ Post-urologic surgery
​ ○ ER-manage hematuria
​ ○ 1 to drain urine, 2 for fluid
​ ○ Sterile drapes
​ ○ Sterile gloves
​ ○ Sterile lubricant

■ Ideally 2% lido jelly

​ ○ Cotton balls
​ ○ Syringe
​ ○ Betadine
​ ○ Sterile collection cup
​ ○ Collection bag
​ ○ Saline
​ ○ Syringe
​ ○ C&S collection vac
● Procedure
​ ○ STERILE TECHNIQUE
​ ○ Lay out equipment
​ ○ Externally rotate legs
​ ○ Apply drapes
​ ○ Check balloon and valves
​ ○ Lubricate catheter
​ ○ Males:
■ Scrub tip of penis from meatus proximally with betadine (x3)
■ Inject urethra with lidocaine jelly
■ Penis up to the sky (90 degrees) - aligns urethra for better insertion
■ Grasp tip of cath in dominant hand
■ Grasp penis (this hand is no longer sterile)
■ Apply light/moderate traction to the penis and insert cath into meatus
■ Once urine is seen, then inflate balloon with hub at the meatus (for males)
​ ○ Females:
■ Patient supine, lithotomy, hips externally rotated
 ■ Insert into urethra
■ Once urine is seen, then inflate the balloon
​ ○ Pull back after balloon is inflated to sit in the bladder
​ ○ Secure catheter to upper inner thigh

■ Bag MUST BE dependent (not attached to bed) ● Reduces intraluminal CAUTI

​ ○ Bag below the level of the bladder at all times

​ ○ Acquire sample (if needed)

■ Have a urine cup with you when foley is placed

■ Urine dip and UA

■ If you suspect CAUTI → look for Leuk esterase
■ Concentrated urine may impede cell lysis = false negative
■ Proteinuria and glucosuria bay lead to false negative test

○ Clean up

○ Document ● Potential Problems

○ No flow

■ Oliguria or Acute Renal Failure

■ No gravity
■ Kink in line
■ Catheter tip obstruction
● Lubricant

● Bladder wall

​ ○ Urethral stenosis
​ ○ BPH

■ Lower urinary tract symptoms

○ Pain/discomfort ● Tips and Tricks

​ ○ POCUS helps to assess volume

​ ○ No urine, don’t inflate
​ ○ SLOW advance of cath
​ ○ If urologist places the foley, they need to be the person who removes foley
​ ○ Valsalva may help with placement
​ ○ IF pt has urinary retention → let urine out SLOW to avoid hypotensive event
5. Suprapubic approach

● Suprapubic approach/Bladder Aspiration

​ ○ Most commonly seen for pts <12 months

​ ○ Indicated:
■ Unable to place cath
■ Urethral abnormalities
■ Refractory UTI
■ Suprapubic drainage with IV cath
■ Identify bladder via percussion or US
​ ○ Contraindicated:
■ Recently voided (within last 1 hour)
■ Unable to locate bladder via percussion
​ ○ Procedure
■ Palpate bladder above pubic symphysis (POCUS is helpful)
■ Occlude urethra
■ 20 ml syringe with 23-25 gauge, 1.5 inch needle
■ Prep with povidone-iodine and alcohol
■ Needle at 90 degrees in the midline

6. Be able to convert French to millimeter sizes

● Average size:

​ ○ Usually a 16-18 French

​ ○ Irrigation/contrast: 20 French
​ ○ Urology: 20 French

■ Less extraluminal infection

○ Children: [ (Age) / 2 ] + 8 = size of catheter

● Conversion of FRENCH → mm

○ Higher the number, larger the diameter

7. Identify and describe common complications associated with performing urinary bladder
catheterization.

● Complications

​ ○ CAUTI: common healthcare associated infection

 ■ Consider a “never event”
■ Remove foley within 48 hours**
■ SCIP and ERAS
■ Give prophylactic abx for prosthetic heart valve and penile implants
​ ○ Bloodstream infections from CAUTI

■ Can spread → Pyelo or bypass kidney and trigger bacteremia

​ ○ Extraluminal CAUTI ■
​ ○ Intraluminal CAUTI

■ Contamination of catheter hub

8. Describe the presentation and etiology of extraluminal and intraluminal CAUTI

● Complications of Foley

​ ○ Cystitis/Infection
■ Urine is thick, smelly, mucous
■ Remove cath ASAP
■ Diagnosis with clean catch
​ ○ Urethritis

■ Urethra swells around the catheter

​ ○ Trauma to urethra
​ ○ Trauma to prostate

■ MUST see urine before inflating balloon

9. Discuss the management of a patient who cannot void after Foley catheter removal ● IF
unable to void after removal

​ ○ Encourage ambulation
​ ○ Encourage water intake

10. Properly replace fluids lost from a Foley. ● Fluid Replacement

11. Understand why air or saline is never used to inflate a Foley balloon
12. Describe the method for Foley catheter removal

● Removal Technique
 ​ ○ Deflate balloon
​ ○ Gently pull out
​ ○ If resistance, check for balloon deflation Radiology Review - K

1. Demonstrate a systematic approach for the clinical interpretation of commonly utilized

methodologies for

diagnostic imaging.

2. Demonstrate a basic knowledge of radiologic interpretation including the ability to recognize

common radiologic

findings.

3. Summarize radiographic findings to patients and other health care providers.

Wound Closure (done) - S

1. Describe the indications, contraindications and rationale for performing wound closure.

● Wound Closure

○ Goal: Achieve healing with - no infection, normal function, excellent cosmetics

2. Identify and describe common complications associated with wound closure.

3. Describe the essential anatomy and physiology of the skin and subcutaneous structures
associated with the performance of wound closure.

● Wound Physiology

​ ○ Contract during healing

​ ○ Minimize tension → best scar results
​ ○ 1-2 years for complete skin remodeling

4. Identify the materials and tools necessary for performing wound closure and their proper use.

● Procedure:

○ Materials
 ■ Needle holder/driver
■ Pick ups (grab skin)
■ Scalpel (debridement/rid of dead skin)
■ Scissors
■ Sutures:

● Depends on:

​ ○ Type of wound
​ ○ Anatomical location of wound
​ ○ Skin thickness
​ ○ Degree of tension

​ ○ Risk of infection
​ ○ Desired cosmetic outcome ● Types:
​ ○ Nonabsorbable - must be removed ■ Nylon

● Easy to work with, secure knot ■ Polypropylene (blue)

​ ● Scalp, eyebrows
​ ● Stronger than nylon
​ ● Lower tissue reactivity

○ Absorbable - absorb within 4-8 weeks

■ Deep within wound along with nonabsorbable to decrease

deadspace
■ NOT to be used in contaminated wounds or adipose tissue due to
risk of infection
■ Vicryl
■ Dexon
■ Monocryl

■ Tissue Adhesive:

​ ● Sterile, liquid adhesive to repair low tension laceration

​ ● Procedure:
​ ○ Clean wound
​ ○ Hold edges together
​ ○ Apply product using light brushing stokred
​ ○ Thin layers (1-2)
​ ○ Flexible bond in 45-60 seconds
​ ● Advantages:
 ​ ○ More convenient and comfy
​ ○ Gentler on skin
​ ○ No removal required
​ ○ Easier and quicker to apply
​ ○ Reduces risk of needle sticks
​ ● Contraindications
​ ○ Evidence of infection, gangrene
​ ○ Mucosal surfaces
​ ○ Skin exposed to body fluids/water
​ ○ Dense natural hair
■ Staples:
​ ● Less reactive than sutures
○ Steps

■ Sterile prep

● Clean surrounding site → **Betadine**, Peroxide, NS, Alcohol ■ Local/general anesthesia

● Topical:

​ ○ LET: Lidocaine, Epinephrine, Tetracaine

​ ○ EMLA cream 25 mg/ml of Lidocaine and 25 mg/ml Prilocain in oil/water
emulsion cream
​ ○ Leave dressing in place for 60 minutes
​ ○ BEST in highly vascularized locations (ex: face)
​ ○ Epinephrine should NOT be used distally or near mucous membranes

■ Vasoconstriction = stops blood supply

● Injection:

○ Lidocaine 3-5 mg/kg

■ Immediate acting:

​ ● Onset: 4-6 minutes

​ ● Duration: 20-60 minutes (local), 72-120 min (nerve)
​ ○ Allergies: If allergic to esters, try amines and vice versa
■ Esters
■ ● Procaine, Tetracaine, Benzocaine
■ Amines
■ ● Lidocaine and Bupivacaine
​ ○ Limiting pain
 ■ Small needle (25-27 gauge)
■ Topical anesthesia prior to injection
■ Warm solution to body temp
■ Buffer with sodium bicarb to decrease acidity (1:10 solution)
■ Inject SLOWLY
■ Inject into the wound, NOT around the wound
​ ● Fewer nerve endings
​ ● Fanlike pattern into the wound
​ ● Pull back to ensure not in a vessel
​ ○ Field Block: large area with one injection
​ ○ Nerve Block
​ ○ Digital blocks - more complete anesthesia to fingers
■ Prevent distorted tissue
■ < 5 ccs in each finger (generally 1-2 ccs)
■ Volar (less painful) vs Dorsal approach
■ Hemostasis
​ ● Examine wound in bloodless field
​ ● IF uncontrolled bleeding → sphygmomanometer cuff or tourniquet

○ Should not exceed 20-30 minutes ■ Irrigation and debridement

​ ● Irrigate with NS
​ ○ Syringe with 16-19 gauge catheter attached to a 35-60 mL syringe
​ ○ Copious irrigation for contaminated wounds and wounds >3 hours old
​ ● DO NOT irrigate puncture wounds
​ ● Clean surrounding tissue with Betadine

​ ● Ensure intact tendon through exploration - just because they can bend their finger,
does not mean their tendon is intact
​ ● Debride devitalized tissue to minimize risk of infection

○ Scalpel #15 blade

● Keep jagged wounds jagged if blood supply is good

​ ○ Less tension
​ ○ Better closure
​ ○ Minimize scarring

■ Closure in layers

​ ● Goals:
​ ○ Optimal anatomic function and reapproximation of tissue
 ​ ○ Wound edge eversion
​ ○ Approach at 90 degrees
​ ○ Minimize tension
​ ● Types of stitches
​ ○ Simple interrupted stitch **MC**
■ Low tension wounds
■ Equal bites
■ First suture in the middle of the wound, the rest symmetrical
■ Square knots
​ ○ Horizontal mattress stitch
■ Long, gaping wounds
■ High tension wounds
■ Thin/fragile skin
​ ○ Vertical Mattress
■ Deep and superficial wound closure
■ NOT for Cosmetically sensitive areas
​ ○ Running sutures
■ Low tension
■ Cosmetically important wounds
​ ○ Deep/buried stitch

■ Deep knot ● Technique

​ ○ Needle enters at 90 degrees

​ ○ Equal bites
​ ○ Proportional to thickness of tissue being approximated

■ Dressing and bandage ● Covered vs Open

​ ○ Moist = faster epithelialization

​ ○ Petroleum-based antibacterial ointment
​ ○ Dressing
■ Nonadherent base
■ Absorbent gauze ■ Wrap

■ Tape

​ ● Time interval varies

​ ● Tensile strength
​ ● Secondary protection
​ ● Railroad tracks - marks from sutures staying in too long
​ ● Technique: CUT BELOW THE KNOT
5. Describe important aspects of patient care after wound closure including dressings, education
and follow up care.

● Timing of Closure

​ ○ Highly vascularized - can be closed up to 24 hours after injury

​ ○ Trunk and extremity - should be closed in 8-12 hours
​ ○ Generally DO NOT close animal bites
■ High risk of infection
■ Some can be closed with loose sutures
Coding and Billing (done)- K
1. Understand the basis for development of coding systems for medical diagnosis

Coding = ICD code = how PA’s get paid

​ - Inpatient: everything assigned a code on discharge / Outpatient: done each visit &
every time
​ - Old way of thinking = “if it wasn’t charted it didn’t happen”, new way = “if charted but
not medically necessary,
it won’t be reimbursed”
Diagnosis Codes- ICD10 (International Classification of Disease 10)

- ICD-10-CM (Clinical Modification)= MC

- Assigns/interprets a diagnosis

- ICD-10-PCS (Procedural Coding System)

- For inpatient procedures- independent of ICD10 & unique to the USA

​ - Procedure Code/CPT (Current Procedural Terminology)- for service, treatment, test

- Category 1: Devices, drugs, vaccines
- Category 2: Performance measures, quality of care (ie alcohol screen) - Category 3:
Services/procedures using emerging technology
- PLA (Proprietary Lab Analyses): for lab testing
​ - E/M (Eval, Management) codes: for complex cases
​ - Modifiers = for special situations- a 2 digit character added to EM code or CPT code

■ Removal

- 25: “significant, separately identifiable eval & mgmt by same physician on same day as a
procedure/other service”- ie COPD visit + broken toe
- Comorbidities: not involved in selection of EM services unless they’re addressed & their
presence increases the amount/complexity of data to be reviewed or the risk of complication in
patient management

- 82: no resident or surgeon available

Coding Process Overview:

1. New patient needs eval for symptom- H&P performed (medical decision making)

a. Exam translated into ICD, CPT codes

2. Diagnostic studies (if needed) ordered with codes

3. Rx for treatment generated based on your dx

Translating SOAP note to ICD

S: What are pt’s current complaints? → History component

O: Relevant physical findings, diagnostic info → Exam summary

A: Assessment, DDx, Problem list → ICD codes

P: Further dx, tx → medical decision making

Billing for Decision Making:

​ - Decision making code = 9920_ for a new patient, or 9921_ for established patient
​ - Then _ is filled with 1-5 based on complexity (5 most complex)
​ - *** Know 99215 means you were in the room for >40 min (complex)**

- Remember if you’re at a PCMH (Patient centered medical home) and meaningful use, they
get incentives for doing things like preventative screenings and comprehensive exams, so be
thorough to document so they don’t miss out on reimbursements

2. Develop basic skills necessary for coding medical diagnosis and procedures
3. Confirm the importance of proper coding for billing of medical services
4. Understand the need to become involved with billing and coding in your future medical
practice setting.
5. Understand the significant impact that meaningful use has had on the primary care
community.

Meaningful Use
“Meaningful use: is using (MU certified) electronic health record (EHR) technology to:
Improve quality, safety,

efficiency, and reduce health disparities. Engage patients and family. Improve care
coordination, and

population and public health. Maintain privacy and security of patient health information.

The Medicare and Medicaid EHR Incentive Programs provide financial incentives for the
“meaningful use” of

certified EHR technology. To receive an EHR incentive payment, providers have to show
that they are

“meaningfully using” their certified EHR technology by meeting certain measurement

thresholds that range

from recording patient information as structured data to exchanging summary care records.
CMS has

established these thresholds for eligible professionals, eligible hospitals, and critical access
hospitals.”

​
- Protect confidential info
​ - Use clinical decision support- tracks codes
​ - Use computer provider order entry
​ - Generate & transmit Rx electronically
​ - Use health information exchange for care transitions or referrals
​ - ID & provide patient specific education
​ - Perform med reconciliation
​ - Give pts electronic access to health info
 ​ - Use secure electronic messaging to communicate with pts
​ - Actively engage in public health reporting
​ - Support coordinated care
​ - Use health information exchange to support transitions & referrals

6. List the meaningful use components required for most primary care charting.

Above

7. Discuss the impact of ‘surgical bundles’ on billing, profits, and PA practice

​ - PAs reimbursed 16% vs other assistants at 13.6%- makes hospital more money
​ - PAs also involved in pre&postop care → more reimbursement to PA at that 16% rate

8. Discuss the role of incident-to in PA practice

Incident To: PA can bill at MD rate when MD physically in office vs 85% if they’re not in office

- Problem: often just billed under MDs name- you make hospital money without getting
recognition

9. Summarize the goals of risk management in the health care setting Also mentioned:

Review of Electrocardiography and Rhythm Strip Interpretation (done) - S

1. Demonstrate the proper lead placement when performing a 12-lead electrocardiogram.

● Limb leads:

​ ○ Lead I - right arm to left arm

​ ○ Lead II - right arm to left leg

○ Lead III - left arm to left leg

● Chest Leads:V1 → V4 has R-wave progression

​ ○ V1 - 4th intercostal space on the R of sternum

​ ○ V2 - 4th intercostal space to the L of the sternum
​ ○ V3 - between V2 and V4
​ ○ V4 - 5th intercostal space in the midclavicular line
 ​ ○ V5- between V4 and V6
​ ○ V6 - 5th intercostal space, midaxillary line

2. Calculate the atrial and ventricular rates from the EKG, and be familiar with normal and
abnormal rate ranges.

● SYSTEMATIC APPROACH ○ Rate

■ Bradycardia: < 60 bpm

■ Normal: 60-100 bpm
■ Tachycardia: > 100 bpm
■ 6 second method

● Count # of r-waves in 6 second rhythm strip then X by 10 ■ Divide by # of large boxes

​ ● Start at R-wave that is on a bold line

​ ● Then find next R-wave

■ Count boxes

● 1500 / ( # of boxes between R-waves )

​ ○ Rhythm
​ ○ QRS width
​ ○ ST segment - elevation/depression

○ Q-waves/R-wave progression

3. Evaluate EKG’s for significant arrhythmias and abnormalities.

● Sinus Arrhythmia

● Atrial Fibrillation

● Atrial Flutter

● AV Blocks
○ First Degree

○ Second Degree

■ Mobitz Type I

■ Mobitz Type II

○ Third Degree

● Ventricular Tachycardia

● Ventricular Fibrillation

● Asystole

● Bundle Branch Blocks

​ ○ Block below the AV node, delayed depolarization of the ventricle → two conjoined
QRS
​ ○ Right Bundle Branch Block:
■ V1-V2: initial upward deflection, RSR’ = RABBIT EARS
■ V5-V6: small downward deflection
■ Widened QRS complex > 0.12 seconds
​ ○ Left Bundle Branch Block
■ V1-V2: downward deflection
■ V5-V6: upward deflection
■ Widened QRS > 0.12 seconds

● Enlargement/Hypertrophy
 ​ ○ Right Ventricular Hypertrophy
■ Right axis deviation
■ Lead I QRS is slightly more negative than positive
■ R-wave progression is disrupted
​ ● V1: R-wave > S-wave
​ ● V6: S-wave > R-wave
​ ○ Left Ventricular Hypertrophy
■ R-waveinV5ORV6+S-waveinV1ORV2>35mm
■ R-waveinV5>26mm
■ R-wave in V6 > R-wave in V5
■ R-wave in AVL > 11/13 mm
■ Lead AVF > 21
■ LeadI>14

● Acute Coronary Syndrome

○ Ischemia

■ T-waves may become tall and narrow

■ T-waves then invert

● Should NOT be > 2⁄3 of R-wave

■ ST segment falls > 1 mm below baseline (ST depression)

○ Injury
■ ST segment elevation
​ ● Significant IF:
​ ● > 1 mm above baseline in limb leads
​ ● > 2 mm above baseline in precordial leads
○ Infarction
■ Q-wave >0.04 seconds wide
■ Depth > 25-33% of height of R-wave
■ Present in 2+ contiguous leads ● Hyperkalemia

○ Potassium rises, T-wave rises across entire EKG leads

Documentation (after exam?) ← yes! :)

1. Define patient “problem” and recommend examples of various types of problems.
2. Compose a problem list.
3. Summarize the rules for updating a problem list.
4. Develop clinical thinking skills that lead to the recognition and assessment of patient’s
problems.
5. Create a list of information that is commonly included in a patient assessment.
6. Construct 3 types of patient plans and give examples of each.
7. Organize the information included when documenting a patient assessment and plan.
8. Describe the indications for and use of patient progress notes.
9. Formulate S-O-A-P notes and evaluate which type of patient information belongs in each
section.
10. Illustrate the association between the problem list and the patient assessment, plans and
progress notes.
11. Review the proper technique for writing orders.
12. Explore the importance of documentation and identify the general guidelines to follow
when making an entry into the medical record