Clerkship module 1
What are 2 legal theories for failure to obtain informed consent?
-Battery action ("touching" to which patient did not agree) -Negligent nondisclosure
Why is vastus lateralis used in children for IM injections?
-Large muscle mass -No proximal nerves or blood vessels -Limited subcutaneous fat layer -More developed muscle than other sites can accommodate larger volumes than other sites
Why are IV injections given?
-Meds reach parts of the body much faster than other methods of injection -Allow the medicine to reach the heart quickly and circulate through the body extremely fast.
Contraindications of scalp repair?
-Patients with other conditions of greater life threat that require stabilization -Suspicion of underlying skull fracture -Evidence of foreign body in the wound which cannot be removed
Contraindications of skin tags removal?
-Pigmented skin lesions -Fibroepitheliomas -Underlying skin infection or diagnosis uncertainty -Abnormally large lesions **cryosurgery MAY NOT be used if pathology requested or in areas with compromised circulation because surrounding tissue destruction will not heal
Pediatric considerations for Newborns/small infants regarding injections?
0.5mL is the maximum amount recommended per injection site for newborns and infants AND 1 mL is the maximum recommended amount to be administered in a single site for small children
What is the size of a 26G needle?
1/2", 1X1/2"
Intradermal injections are administered at what angle?
10-15 degree
How long should you wash your hands?
15 seconds
What size is a 16G, 18G, and 19G needle?
1X1/2"
Intravenous injections are administered at what angle?
25 degree
Intramuscular injections are only limited volumes which are?
2mL in the deltoid & thigh muscles Up to 5mL in the gluteus Maximus
Approximate drug reaction for IM or SC injection?
3-20 min
Approximate drug reaction time for an IV injection?
3-5 min
Written consent is valid for?
30 days
Approximate drug reaction time for PO?
30-45 min
Subcutaneous injections are administered at what angle?
45 degree
Intramuscular injections are administered at what angle?
90 degree
C/I of removing lipoma's?
>5cm in diameter uncooperative pt Displaying associated with calcification Invading nearby structures, growing rapidly INVADING deeper structures such as fascia In HIGH-RISK SITES such as the lower legs or shoulders
Complications of IM injection?
Abscesses Necrosis Skin slough Nerve injuries Lingering pain Periostitis (inflammation of the membrane covering a bone)
Indications for Z-track injection?
Adult IM injections
Site selection for IV injection?
Anterior forearm Posterior hand Radial aspect of wrist Antecubital space of elbow
Surgical hand scrub method
Antimicrobial soap or detergent preparation with brush to achieve friction for at least 120 seconds, or alcohol-based preparation designed for surgical hand antisepsis
Pediatric considerations for maximum volume of injection?
As children's muscles develop, a greater volume of medication can usually be tolerated per injection site
What should you avoid in IV injections?
Avoid areas of flexion
Identify [C]
Barrel
Identify [D]
Barrel flange
Where are intradermal injections placed?
Between the epidermis and dermis Onset of action is almost immediate
What is the correct bevel orientation?
Bevel facing up during needle placement= lumen unobstructed and allows for blood flow
When doing an IV injection which vein should you choose?
Choose straight vein w/Normal vasculature Distal veins first BUT PROXIMAL to any previous cannulation NON-DOMINANT ARM**** Choose vein that allows for ADL's & movement
What is the best method to clean your hands?
Cleansing between patients with alcohol based hand rub and hand washing with soap and water for gross contamination.
Expressed consent is?
Consent through direct words
What is the best defense against infections, either community or hospital acquired?
Consistent practices of hand hygiene and universal precautions
what is included in material facts?
Diagnosis (and purpose) Proposed treatment/ procedure Alternative treatment options (surgical or medical) including their risks and benefits Risks and benefits of treatment (major or minor complications) The risks of refusing treatment Prognosis
Volume of intradermal injections in adults?
Dosage given usually <0.5mL
What are the four ways you can remove skin tags?
Electrosurgery, excision, cryosurgery, ligation
When doing a scalp repair you close the galeal defect in the base of a scalp with a ?
Figure-of-eight
Post procedure instructions for lipoma removals
Follow up is required ONLY for suture removal If a RECURRENCE is brought to the physicians attention at a later date, standard surgical excision should be attempted Instruct the patient to gently wash an area that has been stitched after 1 day BUT TO NOT PUT THE WOUND INTO STANDING WATER FOR 3 DAYS Recommend wound elevation Instruct the patient NOT TO pick, break, or cut the stitches
If patient does not feel comfortable with packing after having an I&D you direct the patient to?
Go to a medical facility for repacking of the abscess every 1-2 days
What is the single most important measure to reduce transmission of micro-organisms from one person to another or from one site to another on the same patient?
Hand hygiene
Preferred site for IV's?
Hand veins (metacarpal) preferred site or forearm veins (Vasculature should accommodate gauge/length of catheter)
Incisions made parallel to langer's line generally?
Heal better and produce less scarring or less gape adequate closure and best cosmesis
Name the 3 parts of the needle?
Hub, shaft, bevel
I&D of an abscess indications are?
If it is a palpable, fluctuant abscess and an abscess that is larger > 5cm (but this is usually taken to an operating room)
In comatose or incompetent patients consent has to be?
In transiently incapacitated patients, they must be assessed and reassessed as necessary, for capacity, before healthcare decisions are made
IV injection are made where?
Injection is made directly into the vein
Post procedure instructions for skin tag removal?
Instruct the patient to gently wash the area the next day Have the patient clean and dry the area well after washing Use small amount of antibiotic ointment to promote moist healing
Intramuscular injections are delivered?
Into the muscle
Identify the 3 main route of injections?
Intradermal (ID) Subcutaneous (SC) Intramuscular (IM)
What is the shaft of the needle?
Is the long slender stem of the needle that is beveled at one end to form a point
What is the hub of the needle?
It is at one end of the needle and is the part that attaches to the syringe
Post procedure instructions for I&D's?
KEEP THE WOUND CLEAN, DRY, and COVERED with absorbent material Remove packing material and repack abscess EVERY 1-2 DAYS until the abscess cavity has resolved Instruct the patient to CHANGE the overlying dressing ONCE A DAY Inform the patient that he or she may take OTC PAIN RELIEVERS OR PRESCRIPTION PAIN RELIEVERS PRN.
Identify [A]
Leur lock
When do you use staples for wound closure
Linear lacerations through the dermis that have straight, sharp edges and are located on the scalp, trunk, arms and legs NOT the FACE
A surgical cut is carried out in the direction of ?
Lines of least tension (langer lines)
Consent for minors
MUST be obtained from either a parent or legal guardian - May be treated as adults if emancipated - Married - Being parents - Active military service
In order to meet the requirements for effective, informed decision making, a physician must disclose?
Material facts- facts that are relevant to decision making Appropriate additional disclosures
Subcutaneous injections can be given safely with how many mL's?
Meds administered include drugs that can be given in small volumes (usually <1mL but up to 2mL is safe)***
When an informed consent cannot be obtained due to an emergency situation/diminished capacity, what must be done?
Must document what facts were considered in determining patients ability to process information and make reasonable decisions
When documenting consent it is?
Not sufficient to state "the risks and benefits were discussed" Document if literature was provided, if patient had opportunities to ask questions
Areas of the body where subcutaneous injections can be administered ?
Outer arm , abdomen, hip area, thigh
How do you apply POvidone-iodine solution?
Outward concentric circles never going over the same area twice
When are Tissue Adhesive contraindicated?
Patients at higher risk of poor healing Contaminated Mucosal surfaces, groin, or axillae Wounds in hairy areas
When are staples contraindicated?
Patients that may require computed tomography or MRI
What is physician disclosure?
Physician must answer truthfully if a patient asks questions about the number of similar procedures performed and their success rates should also disclose the availability of specialty services provided elsewhere if there is a known difference in quality Must disclose financial conflicts of interest
Identify [F]
Plunger
Identify [E]
Plunger Flange
What should be cautioned when giving IM injections?
Point of injection should be as far as possible from major nerves and blood vessels to avoid neural damage and accidental intravenous administration
What is the rationale for outlining the tumor before surgical resection?
Preserve tumor margins after anesthesia
Benefits of informed consent
Protects the patients right of self determination Engages the patient in his/her health care Enhances the physician/ patient relationship Encourages physicians to thoroughly review the patients therapeutic options Reduces discontent and litigation when there are complications
Pediatric considerations for skin tag removal
Rare! Mildly painful procedures may be a challenge to most children
Skin tags in children are?
Rare!! This may be basal nevoid cell carcinoma
Complications of removing lipoma's?
Recurrence • Surgical infection/cellulitis/fasciitis • Ecchymosis • Hematoma/seroma formation • Injury to nearby nerves with permanent paresthesia/ anesthesia (rare) • Injury to nearby vessels/vascular compromise (rare) • Permanent deformity secondary to removal of a large lesion (rare) • Excessive scarring with cosmetic deformity or contracture (rare) • Muscle injury/irritation (rare) • Fat embolus (rare) • Periostitis/osteomyelitis (rare)
What are the indications for skin tags removal?
Removal of superficial, polyploid growths on characteristic surfaces of the neck, groin and axilla cosmetic, symptomatic For diagnosis if not certain
Identify [B]
Seal
What is important to remember when doing IM injections?
Select a safe site away from large nerves, bones, and blood vessels Sites for injecting IM medications should be rotated when therapy requires repeated injections
An approach to infection control as if all human, blood, tissue, and certain fluids are treated as if known to be infectious for HIV and Hep B virus and other blood-borne pathogens is called what?
Standard (Universal) precautions
What are some complications of staple closures?
Strangulation Infection Scarring Inflammation reactions Difficult removal
Cryosurgery of skin indications?
Superficial BCC, Milia, seborrheic keratosis, molluscum contagiosum
Indications for intradermal injections?
Tb skin testing Allergy skin testing Local anesthesia
Subcutaneous injections are administered in ?
The fat layer and underneath the skin
the hollow bore of the needle shaft is known as?
The lumen
What has become a weapon for a provider in defense of lawsuits and litigation?
The medical record!
In emergency situations the need for consent is?
The need for consent may be outweighed by the need for urgent intervention If possible: Contact family members Consult with living will or POA
Post-procedure instructions for scalp repair?
The patient should NOT GET THE WOUND WET FOR AT LEAST 48 HOURS Also every effort must be made TO KEEP THE WOUND DRY
Preferred site for Intramuscular injections in children?
Vastus lateralis (thigh)
Standard precautions apply to?
Visible blood and body fluids Non visible- semen, vaginal fluids, tissue and other fluids Other bodily excretions and secretions that do not require universal precautions unless blood is visualized or suspected (feces, nasal secretions, sputum, sweat, tears, urine and vomitus)
When do you do flaps?
When you have laceration but cannot use normal materials that are available, like sutures so you need to use adjacent skin to cover the laceration instead. Has to COME FOM ADJACENT AREA THAT HAS BLOOD SUPPLY VS SKIN GRAFT- NO BLOOD SUPPLY
When doing a scalp repair you tie the suture?
With the suture strings crossing over the top of the wound in an X-SHAPE CONFIGURATION
Technique: move skin to one side, administer medication & withdraw needle. Once needle is withdrawn, displaced tissue is allowed to return to its normal position
Z-track Injection- prevents solution from escaping from muscle tissue
I&D procedure
anesthetize around abscess
barriers and other precautions
gloves whenever there is potential for contact w/ blood or bodily fluid masks goggles PPE; gowns needleless systems, needle free products, vacutainers
general v surgical asepsis
state of being free from pathogenic micro-organisms that have the possibility of causing dz or illness stepwise approach to construction and continuation of sterile field in which the performance of any procedure that will create or expose a break in skin integrity can be performed gen- pt care procedures outside of the operating room surgical- within an OR to prevent surgical site infection
dorsogluteal injection
upper outer quadrant
scalp repair complications
• Excessive bleeding • Infection • Abscess (rare) • Scarring • Permanent hair loss
contraindications of I&D
• Extensively large or deep abscesses or perirectal abscesses that may require surgical debridement and general anesthesia • Facial abscesses in the nasolabial folds (risk of septic phlebitis secondary to abscess drainage into the sphenoid sinus) • Hand and finger abscesses should receive surgical or orthopedic consultation
