CPSS Centesis Exam 77 Questions with Verified Answers,100% CORRECT

CPSS Centesis Exam 77 Questions with Verified Answers What is the indication of a paracentesis? - CORRECT ANSWER ascites - new onset - therapeutic - diagnostic What are the relative contraindications for a parac ...

CPSS Centesis Exam 77 Questions with Verified Answers What is the indication of a paracentesis? - CORRECT ANSWER ascites - new onset - therapeutic - diagnostic What are the relative contraindications for a paracentesis? - CORRECT ANSWER Coagulopathy Overlying anatomical or infectious abnormalities Distended abdominal organs (i.e. ileus, megacolon) Surgical scars: May have attached bowel T/F: using an US is the standard of care for a paracentesis? - CORRECT ANSWER TRUE What is the best approach for a paracentesis? Why? - CORRECT ANSWER Lateral Bc when the pt is supine, the fluid will pool to the posterior wall and avoiding bowel perforation is easier. How should the pt be positioned for a paracentesis? - CORRECT ANSWER Pt supine and/or with head elevated to 10-30 degrees (pic on lecture says 30-45 degrees) What do you need to careful of when using the anterior approach for a paracentesis? - CORRECT ANSWER avoid the inferior epigastric arteries. T/F: For a paracentesis, it is considered a complete sterile technique, when the practitioner must be gowned up as well? - CORRECT ANSWER FALSE- Sterile technique but do not have to fully scrub in (don't have to fully gown in) When inserting the needle for a paracentesis, you want to pull the skin taught in what direction? - CORRECT ANSWER caudad (approx 1-2 cm) How will fluid on an US appear? - CORRECT ANSWER anechoic/hypoechoic (DARK) This is where the needle will go to drain! How can you recognize and locate the bowel in an US prior to performing a paracentesis? - CORRECT ANSWER Bowel will glisten (more than other tissue) and you will be able to see peristalsis. While inserting the needle for a paracentesis, how can you tell you're in the peritoneal cavity? - CORRECT ANSWER loss of resistance will be felt Paracentesis procedure: a. Hold syringe with (_) hand b. Rest (_) surface of (_) hand on patient's abdomen, and use (_) of this hand to steady shaft of needle c. Keep nondominant hand in this position during needle advancement and continue to hold the (_) - CORRECT ANSWER a. dominant b. dorsal; nondominant; thumb and index finger c. nondominant; shaft of needle What type of drainage tubing is used for a paracentesis? - CORRECT ANSWER High-pressure drainage tubing T/F: Want to insert the needle for a paracentesis into the wheal of the local anesthetic? - CORRECT ANSWER TRUE What should always be done after you advance the needle in for a paracentesis? - CORRECT ANSWER aspirate- want to do that after moving the needle every time until the fluid pocket is reached. T/F: When performing a paracentesis, you want to make sure to push the catheter all the way flush with the skin to ensure all fluid will be drained? - CORRECT ANSWER FALSE! Catheter does NOT have to be flush with skin, better to keep partially out than perforate the bowel or visceral organ What should be done after removing the catheter of the abdomen when doing a paracentesis? - CORRECT ANSWER apply firm, direct pressure to the site for several minutes What types of lab samples are commonly collected during a paracentesis? - CORRECT ANSWER Albumin, protein: exudative vs. transudative Cell count, differential Gram stain, cytology Aerobic & anaerobic cultures: blood culture What is the most common complication of a paracentesis? How can you fix this? - CORRECT ANSWER Ascitic fluid leak- apply dermabond or sutures Dermabond= best bc it provides a perfect seal. What types of circulatory dysfunction complications can occur with a paracentesis? - CORRECT ANSWER Critical HYPOtension Increased RAAS and catecholamine activity What is the indication for a thoracentesis? - CORRECT ANSWER pleural effusion Diagnostic Therapeutic (resp distress, CHF, cirrhosis, trauma, cancer) What are the relative contraindications of a thoracentesis? - CORRECT ANSWER Mechanical ventilation Overlying infection or anatomical abnormalities Respiratory instability Coagulopathy What is the best XR view for detecting effusions? - CORRECT ANSWER lateral chest (can detect smaller effusions >50mL) (upright PA chest- detect effusions >200 mL) A lateral chest XR can detect effusions >_____ - CORRECT ANSWER >50mL An upright PA chest XR can detect effusion >_____ - CORRECT ANSWER >200 What type of finding in a lateral chest XR supports the dx of a pleural effusion? - CORRECT ANSWER partial "blunting" of the CP angle Pleural cavity extends to (_) posteriorly - CORRECT ANSWER 12th rib What position does the pt need to be in for a thoracentesis? - CORRECT ANSWER Must be sitting up right Where will the needle be inserted for a thoracentesis? - CORRECT ANSWER Mid-thoracic line (medial edge of scapula) One interspace BELOW level of effusion detected with percussion/tactile fremitus For a thoracentesis, where should the needle NEVER be inserted? - CORRECT ANSWER NEVER inferior to the 9th rib The tip of the scapula is approx at what rib? - CORRECT ANSWER 7th How would you perform a thoracentesis if you have a pt that is unable to sit up? - CORRECT ANSWER Mid-axillary (need to use US assistance) In relation to the rib, where should the needle need to be inserted for a thoracentesis? Why? - CORRECT ANSWER Just above the inferior rib of the two ribs- in order to avoid the neurovascular bundle. How do you determine the level of effusion prior to performing a thoracentesis? - CORRECT ANSWER percuss- transition between dullness and resonance tactile fremitus- transition from normal to absent Per JCAHO, what needs to be done prior to any thoracentesis? - CORRECT ANSWER Verify the pt with 2 identifiers and review all relevant clinical data mark the side of the effusion (must be visible after drape has been applied) Take a "time-out" immediately before the procedure (verify the pt, the procedure, and the site are correct) How do you anesthetize the area you are going to perform a thoracentesis or a tube thoracostomy? - CORRECT ANSWER Direct needle until it comes in contact with the superior border of ribs (so it contacts the bone) Gently "walk" needle OVER rib (just superior to the rib in order to avoid the neurovascular bundle) Alternate aspirating and injecting anesthetic as advancing needle Sudden loss of resistance= in the cavity For a thoracentesis, you need to IMMEDIATELY stop advancing needle once (_) - CORRECT ANSWER pleural fluid enters the syringe After advancing catheter into place during a thoracentesis, you want to remove the needle and then what? Why? - CORRECT ANSWER Place finger over exposed catheter hub immediately after needle is removed to prevent air from entering pleural cavity When performing a thoracentesis, the stopcock should be (_) to patient at all times, except when actively draining fluid. Failure to do so may result in (_) - CORRECT ANSWER closed pneumothorax When performing a thoracentesis, you want to time the removal of the catheter with patient (inhalation/exhalation)? - CORRECT ANSWER *Exhalation* (to avoid the negative pressure pulling air into the area) T/F: you always need to get a chest XR post- thoracentesis? - CORRECT ANSWER FALSE When would it be indicated to get a chest XR post-thoracentesis procedure? - CORRECT ANSWER If air was aspirated Pt develops chest pain, dyspnea or hypoxemia If it is a critically ill pt If on a mechanical ventilation What is re-expansion pulmonary edema? - CORRECT ANSWER Stretching and distention of pulmonary parenchyma (alveoli) during re-expansion leads to increased pulmonary blood flow and alveolar-capillary membrane disruption, leading to pulmonary edema Why would a mini-catheter insertion (aka pleural pigtail catheter) be indicated over a tube thoracostomy? - CORRECT ANSWER When the pt has a constant pleural effusion (more of a permanent placement) What are the absolute contraindications for a tube thoracostomy? - CORRECT ANSWER NONE What is the most sensitive test for a pneumothorax? - CORRECT ANSWER CT (air will be pitch black) What kind of clamp is used for a tube thoracostomy? - CORRECT ANSWER Kelly clamps (Large clamps) What scissors are used for a tube thoracostomy? - CORRECT ANSWER Mayo scissors (large, curved) What indications would you want to make sure to use a larger tube size (minimal 36 Fr) for a tube thoracostomy? - CORRECT ANSWER a HTX or empyema T/F: For a tube thoracostomy, it is considered a complete sterile technique, when the practitioner must be gowned up as well? - CORRECT ANSWER TRUE- requires full scrub in! What is the most common location for a tube thoracostomy? - CORRECT ANSWER *5th intercostal space*, midaxillary line/nipple line (lateral to pectoralis muscle and breast tissue) Go to the *4th intercostal space* if you failed the 5th or you got a recurrent PTX) What is the other location that a tube thoracostomy can be place, but is only used if desperate! - CORRECT ANSWER second intercostal space, midclavicular line How do you measure the tube prior to performing a tube thoracostomy? - CORRECT ANSWER Estimate the distance between *incision to apex*. Ensure *ALL* holes within pleural space. Mark max insertion length with *clamp* T/F: tube location does not affect ability to drain? - CORRECT ANSWER TRUE How do you position the pt for a tube thoracostomy? - CORRECT ANSWER elevate head of bed to 30-60 degress restrain ipsilateral arm over head What do you ALWAYS want to ensure your pt has on before/during/after a tube thoracostomy? - CORRECT ANSWER Cardiac monitoring and pulse ox! T/F: Most patients are sedated for a tube thoracostomy? - CORRECT ANSWER True What medication do you want to give your pt prior to a tube thoracostomy since the pleura is VERY sensitive to pain? - CORRECT ANSWER Etomidate and a local anesthetic Why is Etomidate the best drug to give for a pt getting a tube thoracostomy? - CORRECT ANSWER bc it has the LEAST cardiopulmonary risk What are the steps for performing a tube thoracostomy? - CORRECT ANSWER Anesthetize region Make incision over 4th or 5th rib (anterior axillary line) Create tunnel with Kelly clamp Penetrate pleural space with Kelly clamp Finger sweep & maintain the tunnel with finger Insert chest tube Secure chest tube What size scalpel is used to make the incision for the tube thoracostomy? - CORRECT ANSWER No. 10 scalpel Where do you do the incision for a tube thoracostomy? - CORRECT ANSWER transverse incision 3-5 cm long (through skin and SQ tissue), over the 4th or 5th rib on the anterior axillary line (1-2 ribs below pleural entry point) How do you create a tunnel for a tube thoracostomy? - CORRECT ANSWER By using a long kelly clamp, bluntly dissect over TOP of rib. *Separate the tissue (YOU ARE NOT CUTTING)*. - Advance with clamp closed - Pull back with clamp spread When you are trying to do a tube thoracostomy, how will you know that you are in the pleural space? - CORRECT ANSWER "pop" will be felt when pleura is penetrated (may require significant force) rush of air of fluid will signify penetration into the pleural space as well. What do you use as a guide for the chest tube to ensure it's entry into pleural space? - CORRECT ANSWER your finger ** when preparing the tube to insert , make sure NOT to remove finger (bc hole can be easily lost) How should the tube be inserted for a tube thoracostomy? - CORRECT ANSWER Direct posterior, medial and superior should travel along the posterior thoracic wall Once inserting the chest tube during a tube thoracostomy, what shoudl you do in order to reduce likelihood of kinking? - CORRECT ANSWER rotate tube 360 degrees How far do you insert the chest tube? - CORRECT ANSWER up to the marker clamp OR when resistance felt T/F: you always need to get a chest XR post- tube thoracostomy placement? - CORRECT ANSWER TRUE *ALWAYS get a CHEST XR to confirm placement BEFORE securing tube!* How do you dress the tube/skin incision of a tube thoracostomy? - CORRECT ANSWER Wrap base of tube at skin incision with petroleum-impregnated dressing (Xeroform gauze) Then, place two layers of gauze sponges (Y-shaped cut centered)- the second layer will be placed at a 90 degree from the first layer The heimlich valve on the drainage system for a chest tube is only for (_) - CORRECT ANSWER pneumothorax! You start to notice that there may be a complication after placing a chest tube when monitoring the patient. What should be the first thing to check? - CORRECT ANSWER check the equipement first, there could be a damaged collection system/ air leaks What s/p tube thoracostomy complication typically occurs due to the surgical hole being made too large? - CORRECT ANSWER SQ emphysema Before pulling out the chest tube, what do you want to make sure to do first? - CORRECT ANSWER discontinue the suction maintain a water seal or clamp chest tube "clamping trail" What monitoring needs to be done after removing the chest tube? - CORRECT ANSWER repeat chest XR after 6-12 hours (looking for resolution of PTX, lungs are fully expanded and no evidence of air leak) When removing a chest tube, you want to have the pt do what? - CORRECT ANSWER Fully INHALE and do a valsalva maneuver Once the chest tube is pulled out, what do you want to do? - CORRECT ANSWER suture the wound and place OCCLUSIVE dressing on the wound to prevent air from escaping back into the pleural space.