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ESSENTIAL CLINICAL PROCEDURES
ISBN-13:
ISBN-10:
978-1-4160-3001-0
1-4160-3001-8
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Knowledge and best practice in General and Internal Medicine are constantly changing. As new
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Previous edition copyrighted 2002
Library of Congress Cataloging-in-Publication Data
Essential clinical procedures / [edited by] Richard W. Dehn, David P. Asprey — 2nd ed.
p. ; cm.
Rev. ed. of: Clinical procedures for physician assistants. c2002.
Includes bibliographical references and index.
ISBN-13: 978-1-4160-3001-0 ISBN-10: 1-4160-3001-8
1. Physicians' assistants. I. Dehn, Richard W. II. Asprey, David P. III. Clinical procedures for physician assistants.
[DNLM: 1. Diagnostic Techniques and Procedures. 2. Physician Assistants. WB 141 E776 2006]
R697.P45C56 2006
610.7372069— dc22
2006028605
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ELSEVIER
Sabre Foundation
This book is dedicated to all physician assistants who are learning the science
and art of practicing medicine as a physician assistant. While working on this
edition, my father, Frank W. Dehn, suddenly contracted leukemia and died on
October 3, 2005, at the age of 85, and I would also like to dedicate this book in
loving memory of him. Additionally, I would like to thank my wife Elizabeth,
and my children Jonathan, Michael, Clare, and Kelley, without whose support I
could not have finished this project.
—RWD
To my wife Jill and my children Laura, Nolan, and Caleb thank you for
supporting me in each of my endeavors and for the sacrifices that each of you
has made to help me complete this text. I dedicate this edition of the text to my
brother Randy Asprey, who died on July 1 7, 2006, at age 38 after a long and
valiant battle with colon cancer. The courage and love you demonstrated as a
husband, father, son, brother, and friend in the midst of this trial was truly
remarkable and you will be greatly missed.
—DPA
Contributors
David P Asprey, PhD, PA-C
Associate Professor and Program Director, Physician Assistant Program,
University of Iowa Carver College of Medicine, Iowa City, Iowa
Documentation
Patrick C Auth, PhD, PA-C
Program Director and Assistant Professor, Drexel University Hahnemann
Physician Assistant Program, Philadelphia, Pennsylvania
Incision and Drainage of an Abscess
Salah Ayachi, PhD, PA-C
Associate Professor and Associate Director, Physician Assistant Studies,
School of Allied Health Sciences, University of Texas Medical Branch,
Galveston, Texas
Recording an Electrocardiogram
George S Bottomley DVM, PA-C
Associate Professor and Program Director, Physician Assistant Program,
Pennsylvania College of Optometry, Elkins Park, Pennsylvania
Incision and Drainage of an Abscess
Anthony Brenneman, MPAS, PA-C
Assistant Clinical Professor and Director of Clinical Education, Physician
Assistant Program, University of Iowa Carver College of Medicine, Iowa
City, Iowa
Procedural Sedation
Darwin Brown, MPH, PA-C
Assistant Professor, Physician Assistant Program, University of Nebraska
Medical Center, Omaha, Nebraska
Obtaining Blood Cultures; Draining Subungual Hematomas
Lynn E. Caton, MPAS, PA-C
Assistant Professor of Family Medicine/PA Education and Associate
Director for Clinical Education, Oregon Health & Science University
School of Medicine, Physician Assistant Program, Portland, Oregon
Outpatient Coding
L. Gail Curtis, MPAS, PA-C
Assistant Professor, Wake Forest University School of Medicine,
Department of Family and Community Medicine, Winston-Salem, North
Carolina
The Pelvic Examination and Obtaining a Routine Papanicolaou Smear
viii Contributors
Randy Danielsen, PhD, PA-C
Professor and Dean, Arizona School of Health Sciences, A.T. Still University,
Mesa, Arizona
Blood Pressure Measurement
Ellen Davis-Hall, PhD, PA-C
Academic Coordinator and Associate Professor, Department of Pediatrics,
University of Colorado Health Sciences Center, Child Health Associate
Physician Assistant Program, Aurora, Colorado
Inserting Intravenous Catheters
Richard W. Dehn, MPA, PA-C
Clinical Professor and Assistant Director, Physician Assistant Program,
University of Iowa Carver College of Medicine, Iowa City, Iowa
Examination of the Male Genitalia
Michelle DiBaise, MPAS, PA-C
Adjunct Assistant Professor, Arizona School of the Health Sciences,
A.T. Still University, Mesa, Arizona
Local Anesthesia; Dermatologic Procedures
Roger A. Elliott, MPH, PA-C
Associate Professor and Associate Director, University of Oklahoma
Physician Associate Program, University of Oklahoma College of
Medicine, Oklahoma City, Oklahoma
Office Pulmonary Function Testing
Donald R. Frosch, MS, PA-C
Assistant Professor and Research and Assessment Coordinator, Physician
Assistant Program, Butler University/Clarian Health, Indianapolis,
Indiana
Casting and Splinting
El Gianola, PA
Lecturer, MEDEX Northwest Physician Assistant Program, Division of
Physician Assistant Studies, School of Medicine and Center for Health
Sciences Interprofessional Education and Research, University of
Washington, Seattle, Washington
Giving Sad and Bad News
Jonathon W. Gietzen, MS, PA-C
Assistant Professor, Pacific University School of Physician Assistant
Studies, Forest Grove, Oregon
Trauma-Oriented Ocular Examination, Corneal Abrasion, and Ocular
Foreign Body Removal
Contributors ix
Kenneth R. Harbert, PhD, CHES, PA-C
Dean, South College, Knoxville, Tennesse
Venipuncture
Theresa E. Hegmann, MPAS, PA-C
Assistant Clinical Professor and Director of Curriculum and Evaluation,
Physician Assistant Program, University of Iowa Carver College of
Medicine, Iowa City, Iowa
Cryosurgery
Paul C Hendrix, MHS, PA-C
Associate Clinical Professor of Surgery and Director of the Physician
Assistant Surgical Residency Program, Duke University School of
Medicine, Durham, North Carolina
Sterile Technique
Paul E Jacques, EdM, PA-C
Assistant Professor and Associate Chair for Clinical Research, Department
of Clinical Services, Medical University of South Carolina, Charleston,
South Carolina
Wound Dressing Techniques
P Eugene Jones, PhD, PA-C
Professor and Chair, Department of Physician Assistant Studies; Editor-in-
Chief, Journal of Physician Assistant Education, University of Texas
Southwestern Medical Center, Dallas, Texas
Cryosurgery
Nikki L. Katalanos, PhD, CDE, PA-C
Professor and Chair, Department of Physician Assistant Studies; Editor-in-
Chief, Journal of Physician Assistant Education, University of Texas
Southwestern Medical Center, Dallas, Texas
Foot Examination of the Patient with Diabetes
Patricia Kelly, EdD, MHS, PA-C
Associate Professor and Chair, Department of Health Science, and Director,
Doctor of Health Science Program, Nova Southeastern University, Fort
Lauderdale, Florida
Clinical Breast Examination
Charles S King, PA-C
Clinical Coordinator, Physician Assistant Program, University of Utah
School of Medicine, Salt Lake City, Utah
Exercise Stress Testing for the Primary Care Provider
x Contributors
Patrick Knott, PhD, PA-C
Associate Professor and Chair, Physician Assistant Department, Rosalind
Franklin University of Medicine and Science, North Chicago, Illinois
Casting and Splinting
Daniel L. McNeill, PhD, PA-C
Professor and Director, Physician Associate Program, University of
Oklahoma College of Medicine, Oklahoma City, Oklahoma
Office Pulmonary Function Testing
Dawn Morton-Rias, EdD, PA-C
Dean and Assistant Professor, College of Health Related Professions, State
University of New York, Downstate Medical Center, Brooklyn, New York
Flexible Sigmoidoscopy
Richard D. Muma, PhD, MPH, PA-C
Chair and Associate Professor, College of Health Professions, Department of
Physician Assistant, Wichita State University, Wichita, Kansas
Patient Education Concepts
Karen A. Newell, MMSc, PA-C
Academic Coordinator, Emory University School of Medicine, Physician
Assistant Program, Atlanta, Georgia
Wound Closure
Sue M Nyberg, MHS, PA-C
Assistant Professor, Department of Physician Assistant, College of Health
Professions, Wichita State University, Wichita, Kansas
Treating Ingrown Toenails; Anoscopy
Claire Babcock O'Connell, MPH, PA-C
Associate Professor, Physician Assistant Program, University of Medicine
and Dentistry of New Jersey Robert Wood Johnson Medical School,
Piscataway, New Jersey
Arterial Puncture
Daniel L. O'Donoghue, PhD, PA-C
Associate Professor, Physician Associate Program, University of Oklahoma
College of Medicine, Oklahoma City, Oklahoma
Office Pulmonary Function Testing
Martha Petersen, MPH, PA-C
Assistant Professor, Department of Physician Assistant, Rangos School of
Health Sciences, Duquesne University, Pittsburgh, Pennsylvania
Endometrial Biopsy
Contributors xi
Richard R. Rahr, MBA, EdD, PA-C
Professor and Chair, Physician Assistant Studies, School of Allied Health
Sciences, University of Texas Medical Branch, Galveston, Texas
Recording an Electrocardiogram
Tammy Dowdell Ream, MPAS, PA-C
Assistant Professor and Coordinator of Clinical Education, Texas Tech
University Health Sciences Center, School of Allied Health Sciences,
Physician Assistant Program, Midland, Texas
Removal of Cerumen and Foreign Bodies from the Ear
Conrad J. Rios, NPy PA, MSN
Clinical Coordinator and Faculty, University of California at Davis Family
Nurse Practitioner/Physician Assistant Program, Sacramento, California
Injections
Ted J. Ruback, MS, PA-C
Associate Professor and Head, Division of Physician Assistant Education,
and Director, Physician Assistant Program, Oregon Health & Science
University School of Medicine, Portland, Oregon
Informed Consent
Virginia Fallaw Schneider, PA-C
Assistant Professor, Departments of Pediatrics and Family and Community
Medicine, Baylor College of Medicine, Houston, Texas
Lumbar Puncture
Gary R. Sharp, MPH, PA-C
Associate Professor and Clinical Coordinator, Physician Associate Program,
University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
Office Pulmonary Function Testing
ShepardB. Stone, MPS, PA
Associate Clinical Professor of Anesthesiology, Yale University School of
Medicine; Physician Associate Anesthesiologist, Yale-New Haven Hospital,
New Haven, Connecticut; State Aviation Medicine Officer, Connecticut
Army National Guard, Niantic, Connecticut
Endotracheal Intubation
Kirsten Thomsen, PA-C
Adjunct Assistant Professor, The George Washington University School of
Medicine and Health Sciences, Physician Assistant Program, Washington, DC
Standard Precautions
Dan Vetrosky, MEd, PA-C
Assistant Professor and Academic Coordinator, Department of Physician
Assistant Studies, University of South Alabama, Mobile, Alabama
Nasogastric Tube Placement; Urinary Bladder Catheterization
xii Contributors
M.F. Winegardner, MPAS, PA-C
Physician Assistant, Department of Radiation Oncology, Mayo Clinic,
Rochester, Minnesota
Joint and Bursal Aspiration
Pref
ace
In writing this book regarding common clinical procedures for medical
practitioners, we hope to fill a unique need for an area of clinical practice
that is vital to clinical education and the practice of medicine. Members of
both the physician assistant (PA) and nurse practitioner (NP) professions
have prided themselves on their ability to function as a part of the health
care team that can fill almost any role that is needed, including the
performance of clinical procedures. As the professions have evolved,
using PAs and NPs in roles that provide greater autonomy and
responsibility has served to increase the importance of a curriculum that
incorporates common clinical procedures as part of the preparation of
competent clinicians.
In attempting to accomplish this goal we have turned to our colleagues
who are involved in clinical education, as either core faculty or clinical
preceptors, who are very aware of the clinical procedure skills that clinical
practice requires. Although we recognize that this textbook does not
cover every procedure that a PA or NP may be asked to perform in
practice, it does address a majority of the commonly occurring clinical
procedures, and most were selected based on data that support the
frequency with which PAs perform these procedures in primary care
settings.
We are forever indebted to the hundreds of bright, caring,
compassionate, and pioneering men and women who founded our
profession. They ventured into this career with little assurance that they
would have a job or a career, much less a dependable income. They have
made it into one of the most rewarding professions in existence today.
Their vision, dedication, endurance, ingenuity, and concern for the best
interest of their patients continue to be a motivating force for us as PA
educators.
We would also like to recognize the hundreds of colleagues with whom
we share the role and title of PA educator. These individuals often give up
freely the opportunity for the greater income and greater control of their
schedule that can often be found in private practice to help prepare the
next generation of PAs. We find the dedication and commitment of PA
educators to their profession truly inspiring.
We owe a great debt of gratitude to students. Without their eager thirst
for information and knowledge, we would find our responsibility to teach
them clinical procedures to be simply work. However, their passion and
excitement about learning clinical procedures for the purpose of taking
care of their patients make this task a true pleasure.
Finally, we would like to acknowledge our publisher for its commitment
to making educational materials available to PAs and NPs. Specifically, we
would like to thank Shirley Kuhn for pursuing the idea of this book with us
and encouraging us to take the leap of faith necessary to publish the first
edition. We would also like to thank Rolla Couchman for his help in
preparing the second edition.
Chapter
Informed Consent
Ted J. Ruback
Procedure Goals and Objectives
Goal: To provide clinicians with the necessary knowledge and
understanding of the principles of informed consent for all clinical
procedures.
Objectives: The student will be able to ...
• Describe the historical basis of informed consent.
• Describe the philosophical doctrine of informed consent.
• Describe the underlying principles of informed consent.
• List the three essential conditions that must be met to ensure
effective informed consent.
• Describe exceptions to the requirement for informed consent.
2 Chapter 1 — Informed Consent
BACKGROUND AND HISTORY OF
THE PATIENT-PROVIDER
RELATIONSHIP
Over the last four decades, there has been a dramatic shift in the character
of the physician-patient relationship, from one traditionally paternalistic or
physician-focused in nature, to one that recognizes patient autonomy and
is predominantly patient-centered. This struggle between paternalism and
autonomy has been central to the discussions of ethically acceptable medical
practice and has formed the basis for the doctrine of informed consent.
Paternalism is based on the principle of beneficence, the desire to do good
for the patient. The concept of informed consent asserts that the desire to do
good is not a justification for overriding a competent patient's right to
personal autonomy and self-determination. Although there is some question
about whether consent to medical procedures can ever be truly informed,
the process of obtaining informed consent from a patient has been incor-
porated into American society's expectation of good medical practice.
PURPOSE OF INFORMED CONSENT
In May 2000 (amended May 2004), the House of Delegates of the American
Academy of Physician Assistants adopted a policy of comprehensive "Guide-
lines for Ethical Conduct for the Physician Assistant Profession." The guidelines
address the profession's responsibility in protecting a patient's autonomy.
Physician assistants have a duty to protect and foster an individual
patient's free and informed choices. The doctrine of informed consent
means that a PA provides adequate information that is comprehendible to
a competent patient or patient surrogate. At a minimum, this should
include the nature of the medical condition, the objectives of the proposed
treatment, treatment options, possible outcomes, and the risks involved.
PAs should be committed to the concept of shared decision making, which
involves assisting patients in making decisions that account for medical,
situational, and personal factors.
(American Academy of Physician Assistants, 2004)
Informed consent should be obtained from a patient before all medical
interventions that have the potential for harm, including diagnostic and
therapeutic procedures. A patient, through the exercise of personal autonomy,
may either agree to or refuse a proposed procedure or treatment, but it is the
responsibility of the practitioner to make sure that the decision is based on
complete and appropriate information.
At the present time, the United States has no federal statute that compre-
hensively sets national standards of practice regarding patient consent for
medical procedures. There is an implied moral obligation on professionals to
disclose the necessary information to the patient, but the nature and extent
Chapter 1 — Informed Consent 3
of the legal obligation varies from one jurisdiction to another (Beauchamp,
2001). In most states, health care providers have an "affirmative duty" to
disclose information regarding medical treatments, which means that inform-
ation must be volunteered and not just provided in response to questions
posed by the patient. Once the information has been disclosed, the provider's
obligation has been met. Weighing the risks and deciding on a course of action
then becomes the responsibility of the patient or the patient's surrogate.
Legal actions against health care professionals for failure to obtain informed
consent to treatment have been pursued under two separate theories of
liability — one based on the concept of battery and the other on the concept
of negligence (Applebaum, 1987).
Most early litigation involving informed consent argued that the provision
of treatment without consent constituted battery — an intentional, noncon-
sensual touching of the patient. The concept of battery protects a person's
physical integrity against unwanted invasion.
After 1957, most suits alleging lack of informed consent were brought
under the legal theory of negligence. Under this theory, an injured patient
argues that he or she was harmed by the provider's unintentional failure to
satisfy a professional standard of care. When applied in an informed consent
case, the alleged negligence results from a failure to disclose sufficient
information about the risks or complications of a treatment.
ESSENTIAL COMPONENTS OF
INFORMED CONSENT
There are three essential conditions that must be met to ensure effective
informed consent. First, the patient must have the capacity, or competence,
to make an informed decision. A distinction is sometimes made between the
medical judgment of a patient's capacity to consent and the legal judgment
of his competence; however, in clinical practice the two are closely linked
(Beauchamp, 2001). Second, the patient must be given sufficient information
about the procedure or treatment and the alternatives available, to allow him
or her to make an informed choice. Third, the patient must give consent to
treatment voluntarily, without coercion, manipulation, or duress.
Patient Capacity
There is no universally accepted test of a patient's capacity to consent to
treatment. In general, an adult is presumed to be legally competent unless he
or she has been formally and legally declared incompetent. Conversely, a
minor is generally presumed to be legally incompetent to make medical
decisions, although a number of exceptions to this rule exist and are often
state-specific (e.g., emancipation). Additionally, specific legislation sometimes
grants minors legal status to make some medical decisions for themselves
(e.g., testing for sexually transmitted diseases, reproductive decisions).
4 Chapter 1 — Informed Consent
Competency is usually established by assessing whether the patient has
the capacity to understand the nature of his or her condition and the various
options available and whether he or she is capable of making a rational
decision. To make a rational choice, patients must be able to understand the
treatments available and the likely outcomes in each case. They must also be
able to deliberate and consider their options and weigh them against one
another to choose the best alternative. To do so effectively, they must assess
the options available in relation to a set of values and goals, without which
they would have no basis for preferring one outcome to any other (Moskop,
1999). They must also be able to communicate their understanding and their
decision in some intelligible way.
Adequate Information
The second requirement of informed consent is that the patient must be
provided with adequate information with which to make a decision. The right
to informed consent is embedded in the nature of fiduciary relationships,
wherein one party has differential power, and thus that party has the
inherent responsibility to share necessary information with the other.
General categories of information that must be provided are the diagnosis;
the nature of the proposed procedure; the risks, consequences, and benefits
of the procedure; an assessment of the likelihood that the procedure(s) will
accomplish the desired outcomes; and any reasonable and feasible alter-
natives to treatment (including the alternative of not having the procedure)
and the risks and benefits of each. In clinical practice, the information
required to be disclosed is frequently summarized by using the abbreviation
PARQ: P (the recommended medical procedure), A (the reasonable alter-
natives to the recommended procedure), and R (the risks of the procedure);
Q represents the additional step of asking the patient if he or she has any
questions about the proposed procedure not adequately disclosed in the
discussion.
States are far from uniform in their views of how much information should
be disclosed for meaningful informed consent. Various criteria have been
proposed as both legal and moral standards for adequate disclosure. The
"reasonable physician" standard bases disclosure of information on the
prevailing practice within the profession. What would a typical health
care provider in the same specialty and "community" disclose about this
procedure? This legal standard, the only judicial standard by which courts
judged physicians prior to 1972, allows the practitioner to determine what
information is appropriate to disclose. It is often argued that this more
paternalistic approach, although still dominant in the courts, is inconsistent
with the goals of informed consent and true patient autonomy.
The second standard of disclosure, introduced in 1972, is the "reasonable
person" standard. The reasonable person standard requires a health care
provider to disclose to a patient any material information that the practi-
Chapter 1 — Informed Consent 5
tioner recognizes that a reasonable person in the patient's position would
consider to be significant to his or her decision making about the recom-
mended medical intervention. Risks that are not serious, or are unlikely, are
not considered material. Under this standard, the critical requirement shifts
from whether the disclosure met the profession's standard to whether the
undisclosed information would have been material to a reasonable patient's
decision making.
The great advantage of the reasonable person standard is the focus on the
preferences of the patient. A requirement for this standard is that the type
and amount of information provided must be at the patient's level of under-
standing if he or she is truly to be an autonomous decision maker. The
disadvantages of this standard include its failure to articulate the nature of
the "hypothetical" reasonable person. In addition, the retrospective
application of this standard presents a significant problem in that any
complication of a procedure is likely to seem material after it has occurred
(Nora, 1998).
Although the reasonable person standard does focus more on the patient,
it does not require that the disclosure be tailored to each patient's specific
informational needs or desires. Instead, it bases the requirements on what a
hypothetical reasonable person would want to know. The third standard of
disclosure, the "subjective" standard, addresses this limitation by asking the
question, What would this particular patient need to know and understand in
order to make an informed decision? This patient-centered approach allows
greater differentiation based on patient preference, relying on the unique
nature and abilities of the individual patient to determine the degree of
disclosure needed to satisfy the requirements of informed consent. This
standard is the most challenging to implement in practice due to its require-
ment to tailor information specifically to each patient.
In addition to providing information, the clinician has the ethical
obligation to make reasonable efforts to ensure comprehension. Communi-
cating highly technical and specialized knowledge to someone who is not
conversant in the subject presents a formidable challenge. Patient-centered
barriers to informed consent — such as anxiety, language differences, and
physical or emotional impairments — can impede the process. Lack of
familiarity or sensitivity to the patient's cultural and health care beliefs
on the part of the provider can act as a significant barrier to providing
effective informed consent. Process-centered barriers, including readability
of consent forms, timing of the consent discussion, and amount of time
devoted to the process, also may reflect disrespect for the autonomy of the
patient.
To optimize information sharing, explanations should be given clearly and
simply, and questions should be asked frequently to assess understanding.
Whenever possible, a variety of communication techniques should be used,
including written forms of educational materials, videotapes, CDs, DVDs,
and additional media sources. Computers have taken on a new and ever-
expanding role as an effective tool in patient education when integrated into
the clinical setting.
6 Chapter 1 — Informed Consent
Voluntary Choice
In a clinical setting, voluntariness may be influenced by the vulnerability of
the patient and the inherent imbalance in knowledge and power between the
health care professional and the patient. Care needs to be exercised in
advising patients carefully so that what professionals construe in good faith
as rational persuasion does not unintentionally exert undue influence on a
patient's decision making (Messer, 2004). Consent to treatment obtained using
manipulation or coercion, or both, is the antithesis of informed consent.
Although a health care provider's recommendation regarding treatment
typically can have a strong influence on a patient's decision making, a recom-
mendation offered as part of the clinician's responsibility to inform and guide
a patient in his or her decision making is not considered coercion.
TYPES OF INFORMED CONSENT
Consent may take many forms, including implied, general, and special.
Implied consent is often used when immediate action is required. In the
emergency room, consent is presumed when inaction may cause greater
injury or would be contrary to good medical practice. General consent is
often obtained on hospital admission to provide consent for routine services
and routine touching by health care staff. Such "blanket" forms generally do
not list specific procedures, risks, benefits, or alternatives that might be
encountered by a patient during a hospitalization. Additionally, the risk
associated with a procedure may be variable depending upon a patient's
condition. Therefore, a consent to "general treatment" upon hospital
admission may not be adequate to meet the requirements of informed
consent (Manthous, 2003). Finally, special consent is required for specific
high-risk procedures and medical treatments.
State laws vary as to which interventions require a signed consent form.
Some states require a written consent only for surgical interventions,
anesthesia, or other more invasive procedures. Other states require informed
consent be documented for a broader range of procedures.
In order to ensure that informed consent is properly obtained, the health
care provider should actually discuss with the patient each of the procedures
to be performed, including the nature, risks, and alternatives. Consent
obtained verbally is as binding as written consent because there is no legal
requirement that consent be in written form; however, when disagreements
arise, oral consent becomes difficult to prove. The health care provider
should always document verbal consent explicitly in the medical record.
Written consent is the preferred form of consent. The consent form
provides legal, visible proof of a patient's intentions. A well-drafted informed
consent document can provide concrete evidence that some exchange of
information was communicated to, and some assent obtained from, the
patient. Such a document, supported by an entry in the patient's medical
record, is often the key to a successful malpractice defense when the issue
of consent to treatment arises.
Chapter 1 — Informed Consent 7
Some states have laws that specify certain language on consent forms for
certain procedures. In cases that do not require specific forms, a general
consent form that identifies the patient, the date, and precise time of
signature and documents the procedure, the risks associated with it, the
indications, and the alternatives can be used. Most states require a consent
form to be witnessed. Because of the potential conflict of interest, office
personnel (nursing or other staff) should not act as the sole witness to a
consent document.
A written informed consent document should be prepared with the patient's
needs in mind and should verify that the patient was given the opportunity
to ask questions and discuss concerns. Consent forms are often written in
great detail and use medical and legal terminology that is far beyond the
capacity of many patients. For true autonomy to exist in informed consent,
consent forms should be understandable and should include the patient's
primary language or languages whenever possible. When appropriate, an
interpreter should be made available during the informed consent con-
ference. The issue of comprehension is vital to the process. Health care
providers should not make the mistake of equating the written and signed
document with informed consent. The provider should always take care to
make sure that information-transferring communication did occur.
PATIENT'S RIGHT TO REFUSE
TREATMENT
Patients have the right to refuse treatment. In such circumstances, it is
essential to document carefully such refusals and, most importantly, the
patient's understanding of the potential consequences of refusing treatment.
The signature of a witness is helpful in these circumstances.
EXCEPTIONS TO INFORMED
CONSENT REQUIREMENTS
Several types of legitimate exceptions to the right of informed consent have
been described. In rare instances, courts have recognized limited privileges
that potentially can protect health care providers from claims alleging a lack
of informed consent. Such exceptions include emergencies, patients unable
to consent, a patient waiver of consent, public health requirements, and
therapeutic privilege. In all these instances, the provider has the burden of
proving that the claimed exception was invoked appropriately.
According to the emergency exception, if treatment is required to prevent
death or other serious harm to a patient, that treatment may be provided
without informed consent. Courts have upheld that the emergent nature of
the situation and the impracticality of conferring with the patient preclude
the need for informed consent. This exception is based on the presumption
that the patient would consent to treatment to preserve life or health if he or
8 Chapter 1 — Informed Consent
she were able to do so and if there were sufficient time to obtain consent.
Despite this exception, a competent patient may refuse interventions even if
they are life-saving. For example, courts have repeatedly recognized the
rights of Jehovah's Witnesses to refuse blood products.
Care of patients who lack decision-making capacity can be provided
without the patient's informed consent. This exception, however, does not
imply that no consent is necessary; instead, informed consent is required
from a surrogate acting on behalf of the patient. Some surrogate decision
makers are clearly identifiable (e.g., the legal guardians assigned to protect
the best interests of persons judged to be incompetent and the parents of
minor children). In other cases, surrogates are more difficult to determine.
The decision-making authority of surrogates is directed by defined
standards. These standards require surrogates to rely first on any treatment
preferences specifically indicated by the patient, either written or oral,
before he or she lost decision-making capacity. Lacking such direction,
surrogates are then empowered to exercise "substituted judgment," — that is,
to use their knowledge of the patient's preferences and values to choose the
alternative they believe the patient would choose if he or she were able to do
so. In some instances, prior knowledge of a patient's preferences or values is
lacking. In such situations, surrogates are directed to rely on their assess-
ment of the patient's best interests and are encouraged to pursue the course
of action they deem most likely to foster the patient's overall well-being
(Buchanan, 1989).
When a surrogate's treatment choice appears clearly contrary to a patient's
previously expressed wishes or best interests, the patient's provider is duty-
bound to question that choice. The health care provider does not have the
authority to unilaterally override the surrogate's decision but must bring the
issue to the attention of an appropriate legal authority for review and
adjudication.
In the "Guidelines for Ethical Conduct for the Physician Assistant Profession,"
the clinician's role with regard to surrogates is clearly delineated.
When the person giving consent is a patient's surrogate, a family member,
or other legally authorized representative, the PA should take reasonable
care to assure that the decisions made are consistent with the patient's
best interests and personal preferences, if known. If the PA believes the
surrogate's choices do not reflect the patient's wishes or best interests, the
PA should work to resolve the conflict This may require the use of
additional resources, such as an ethics committee.
(American Academy of Physician Assistants, 2004)
Informed consent, although clearly recognized as a patient's right, is not a
patient's duty. Patients can choose to waive their right to receive the relevant
information and give informed consent to treatment. The provider may honor
the patient's right to choose someone else to make treatment decisions on
his or her behalf as long as the request is made competently, voluntarily, and
with some understanding that the patient recognizes that he or she is
relinquishing a right. Health care providers should not feel obligated to
Chapter 1 — Informed Consent 9
accept the responsibility for making treatment decisions for the patient if
they are asked to do so. Instead, they can request that the patient make his
or her own choice or designate another person to serve as surrogate.
Sometimes medical interventions have a potential benefit not only to the
patient but also to others in the community. In such rare instances, public
health statutes may authorize patient detention or treatment without the
patient's consent. This exception overrides individual patient autonomy in
specific circumstances to protect important public health interests.
The final exception to informed consent is the concept of therapeutic
privilege, which allows the health care provider to let considerations about
the physical, mental, and emotional state of the patient affect what information
is disclosed to the patient. The practitioner should believe that the risk of
giving information would pose a serious detriment to the patient. The anti-
cipated harm must result from the disclosure itself and not from the potential
influence that the information might have on the patient's choice. The sole
justification of concern that the patient might refuse needed therapy is not
considered adequate to justify invoking this exception. The therapeutic
privilege is extremely controversial and not universally recognized. Thus,
the value of therapeutic privilege as an independent exception to informed
consent is limited.
CONCLUSIONS
The moral and legal doctrine of informed consent and its counterpart, the
refusal of treatment, are products of the last half of the 20th century. During
this time, judges sought to protect patient autonomy — that is, the patient's
right to self-determination. Informed consent requires the health care practi-
tioner to provide the patient with an adequate disclosure and explanation of
the treatment and the various options and consequences.
Informed consent, however, is more than a legal necessity. When conducted
properly, the process of communicating appropriate information to patients
about treatment alternatives can help establish a reciprocal relationship
between health care provider and patient that is based on good and
appropriate communication, considered advice, mutual respect, and rational
choices. The therapeutic objective of informed consent should be to replace
some of the patient's anxiety and unease with a sense of participation as a
partner in decision making. Such a sense of participation strengthens the
therapeutic alliance between provider and patient. After initial consent to
treatment has occurred, a continuing dialogue between patient and practi-
tioner, based on the patient's continuing medical needs, reinforces the original
consent. In the event of an unfavorable outcome, the enhanced relationship
will prove crucial to maintaining the patient's trust.
In the area of informed consent, as in every other area of risk management,
the best recommendation is to practice good medicine. Informed consent is
an essential part of good medical practice today and is an ethical and moral
responsibility of all health care providers.
10 Chapter 1 — Informed Consent
References
American Academy of Physician Assistants: Guidelines for Ethical
Conduct for the Physician Assistant Profession. Alexandria, Va,
American Academy of Physician Assistants, 2004.
Applebaum PS, Lidz CW, Meisel A: Informed Consent: Legal Theory and
Clinical Practice. New York, Oxford University Press, 1987.
Beauchamp TL, Childress JF: Principles of Biomedical Ethics, 5th ed.
New York, Oxford University Press, 2001.
Buchanan AE, Brock DW: Deciding for Others: The Ethics of Surrogate
Decision Making. Cambridge, England, Cambridge University Press,
1989.
Manthous CA, DeFirolamo A, Haddad C, Amoateng-Adjepong Y: Informed
consent for medical procedures: local and national practices. Chest
124:1978-1984, 2003.
Messer NG: Professional-patient relationships and informed consent.
Postgrad Med J 80:277-283, 2004.
Moskop JC: Informed consent in the emergency department. Emerg Clin
NAm 17:327-340, 1999.
Nora LM, Benvenuti RJ: Medicolegal aspects of informed consent.
Neurol Clin N Am 16:207-215, 1998.
Bibliography
Jonsen AR, Siegler M, Winslade WJ: Clinical Ethics, 4th ed. New York,
McGraw-Hill, 1998.
Mazur DJ: Medical Risk and the Right to an Informed Consent in Clinical
Care and Clinical Research. Tampa, Fla, American College of
Physician Executives, 1998.
Mazur DJ: Shared Decision Making in the Patient-Physician Relationship.
Tampa, Fla, American College of Physician Executives, 2001.
Chapter O
Standard Precautions
Kirsten Thomsen
Procedure Goals and Objectives
Goal: To use and understand the importance of standard
precautions when interacting with a patient.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
adhering to standard precautions.
• Identify and describe common problems associated with
adhering to standard precautions.
• Describe the essential infectious disease principles associated
with standard precautions.
• Identify the materials necessary for adhering to standard
precautions and their proper use.
11
12 Chapter 2 — Standard Precautions
BACKGROUND AND HISTORY
The concept of isolating patients with infectious diseases in separate facilities,
which became known as infectious disease hospitals, was introduced in a
published hospital handbook as early as 1877. Although infected and non-
infected patients were separated, nosocomial transmission continued, largely
because of the lack of minimal aseptic procedures, coupled with the fact that
infected patients were not separated from each other by disease. By 1890 to
1900, nursing textbooks discussed recommendations for practicing aseptic
procedures and designating separate floors or wards for patients with similar
diseases, thereby beginning to solve the problems of nosocomial transmission
(Lynch, 1949).
Shortly thereafter, the cubicle system of isolation changed U.S. hospital
isolation procedures as patients were placed in multiple-bed wards. "Barrier
nursing" practices, consisting of the use of aseptic solutions, hand washing
between patient contacts, disinfecting patient-contaminated objects, and
separate gown use, were developed to decrease pathogenic organism trans-
mission to other patients and personnel. These practices were used in U.S.
infectious disease hospitals. By the 1960s, the designation of specifically
designed single- or multiple-patient isolation rooms in general hospitals and
outpatient treatment for tuberculosis caused these specialized hospitals
(which since the 1950s had housed tuberculosis patients almost exclusively)
to close (Garner, 1996).
The lack of consistent infectious patient isolation policies and procedures
noted by the Centers for Disease Control (CDC) investigators in the 1960s led
to the CDC publication in 1970 of a detailed isolation precautions manual
entitled Isolation Techniques for Use in Hospitals, designed to assist large
metropolitan medical centers as well as small hospitals with limited budgets.
After revision in 1983, the manual was renamed the CDC Guidelines for
Isolation Precautions in Hospitals. These new guidelines encouraged hospital
infection control decision making with respect to developing isolation systems
specific to the hospital environment and circumstances or choosing to select
between category-specific or disease-specific isolation precautions. Decisions
regarding individual patient precautions were to be based on factors such as
patient age, mental status, or possible need to prevent sharing of contaminated
articles and were to be determined by the individual who placed the patient
on isolation status. Decisions regarding the need for decreasing exposure to
infected material by wearing masks, gloves, or gown were to be left to the
patient caregiver (Garner, 1984; Haley, 1985).
Issues of overisolation of some patients surfaced using the 1983 categories
of isolation, which included strict isolation, contact isolation, respiratory
isolation, tuberculosis (acid-fast bacilli) isolation, enteric precautions,
drainage-secretion precautions, and blood and body fluid precautions. In
using the disease-specific isolation precautions, the issue of mistakes in
applying the precautions arose if the patient carried a disease not often seen
or treated in the hospital (Garner, 1984; Haley, 1985), if the diagnosis was
delayed, or if a misdiagnosis occurred. This happened even if additional
Chapter 2 — Standard Precautions 13
training of personnel was encouraged. These factors, coupled with increased
knowledge of epidemiologic patterns of disease, led to subsequent updates
of portions of the CDC reports:
Recommendations for the management of patients with suspected
hemorrhagic fever published in 1988 (CDC, 1988)
■ Recommendations for respiratory isolation for human parvovirus B19
infection specific to patients who were immunodeficient and had chronic
human parvovirus B19 infection or were in transient aplastic crisis (CDC,
1989)
■ Recommendations for the management of tuberculosis, which stemmed
from increasing concern for multidrug-resistant tuberculosis, especially
in human immunodeficiency virus (HIV)-infected patients in care
facilities (CDC, 1990)
■ Recommendations for hantavirus infection risk reduction (CDC, 1994)
Expansion of recommendations for the prevention and control of
hepatitis C virus (HCV) infection and hepatitis C virus-related chronic
disease (CDC, 1998)
Occupational exposure recommendations and postexposure management
for hepatitis B virus (HBV), HCV, and HIV (CDC, 2001)
Recommendations for infection control of avian influenza and management
of exposure to severe acute respiratory syndrome-associated coronavirus
(SARS-CoV) in the healthcare setting (CDC, 2004; CDC, 2005)
BODY SUBSTANCE ISOLATION
An entirely different approach to isolation, called body substance isolation
(BSI), was developed in 1984 by Lynch and colleagues (1987, 1990) and
required personnel, regardless of patient infection status, to apply clean
gloves immediately before all patient contact with mucous membranes or
nonintact skin, and to wear gloves if a likelihood existed of contact with any
moist body substances. An apron or other barrier was also to be worn to
keep the provider's own clothing and skin clean. It was recommended also
that personnel be immunized if proof of immunity could not be documented
when barriers, such as masks, could not prevent transmission by airborne
routes (e.g., rubella, chickenpox). Additionally, when immunity was not
possible, as with pulmonary tuberculosis, masks were to be worn during all
patient contact. Goggles or glasses, hair covers, and shoe covers were also
used as barriers. Careful handling of all used sharps, recapping of needles
without using the hands, and the disposal of used items in rigid puncture-
resistant containers were stressed. Trash and soiled linen from all patients
were bagged and handled in the same manner. This approach sought to
protect the patient from contracting nosocomial infections and the provider
from bacterial or viral pathogens that might originate with the patient.
14 Chapter 2 — Standard Precautions
UNIVERSAL PRECAUTIONS
In response to increasing concerns by health care workers and others about
occupational exposure and the risk of transmission of human immuno-
deficiency virus, HBV, and other blood-borne pathogens during provision of
health care and first aid, the CDC, in 1987, defined a set of precautions that
considered blood and certain body fluids from all patients to be potential
sources of infection for human immunodeficiency virus, HBV, and other
blood-borne pathogens. These recommendations became known as
universal precautions (UP) and have subsequently been integrated into the
Recommendations for Isolation Precautions in Hospitals, 1996, which includes
the current standard precautions (SP) (Table 2-1).
Table 2.1 Recommendations for Isolation Precautions in
Hospitals, Hospital Infection Control Practices Advisory
Committee, 1996
STANDARD PRECAUTIONS
Use Standard Precautions, or the equivalent, for the care of all patients.
HAND WASHING
Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items,
whether or not gloves are worn. Wash hands immediately after gloves are removed, between
patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other
patients or environments. It may be necessary to wash hands between tasks and procedures
on the same patient to prevent cross-contamination of different body sites.
Use a plain (nonantimicrobial) soap for routine hand washing.
Use an antimicrobial agent or a waterless antiseptic agent for specific circumstances (e.g.,
control of outbreaks or hyperendemic infections), as denned by the infection control program.
(See "Contact Precautions" for additional recommendations on using antimicrobial and
antiseptic agents.)
GLOVES
Wear gloves (clean, nonsterile gloves are adequate) when touching blood, body fluids,
secretions, excretions, and contaminated items. Put on clean gloves just before touching
mucous membranes and nonintact skin. Change gloves between tasks and procedures on the
same patient after contact with material that may contain a high concentration of
microorganisms. Remove gloves promptly after use, before touching noncontaminated items
and environmental surfaces, and before going to another patient, and wash hands immediately
to avoid transfer of microorganisms to other patients or environments.
MASK, EYE PROTECTION, FACE SHIELD
Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes,
nose, and mouth during procedures and patient care activities that are likely to generate
splashes or sprays of blood, body fluids, secretions, and excretions.
GOWN
Wear a gown (a clean, nonsterile gown is adequate) to protect skin and to prevent soiling of
clothing during procedures and patient care activities that are likely to generate splashes or
sprays of blood, body fluids, secretions, or excretions. Select a gown that is appropriate for
the activity and amount of fluid likely to be encountered. Remove a soiled gown as promptly
as possible, and wash hands to avoid transfer of microorganisms to other patients or
environments.
PATIENT CARE EQUIPMENT
Handle used patient care equipment soiled with blood, body fluids, secretions, and excretions
in a manner that prevents skin and mucous membrane exposures, contamination of clothing,
Chapter 2 — Standard Precautions 15
Table 2.1 Recommendations for Isolation Precautions in
Hospitals, Hospital Infection Control Practices Advisory
Committee, 1996-cont'd
and transfer of microorganisms to other patients and environments. Ensure that reusable
equipment is not used for the care of another patient until it has been cleaned and
reprocessed appropriately. Ensure that single-use items are discarded properly.
ENVIRONMENTAL CONTROL
Ensure that the hospital has adequate procedures for the routine care, cleaning, and
disinfection of environmental surfaces, beds, bed rails, bedside equipment, and other
frequently touched surfaces, and ensure that these procedures are being followed.
LINEN
Handle, transport, and process used linen soiled with blood, body fluids, secretions, and
excretions in a manner that prevents skin and mucous membrane exposures and contamination
of clothing, and that avoids transfer of microorganisms to other patients and environments.
OCCUPATIONAL HEALTH AND BLOOD-BORNE PATHOGENS
Take care to prevent injuries when using needles, scalpels, and other sharp instruments or
devices; when handling sharp instruments after procedures; when cleaning used instruments;
and when disposing of used needles. Never recap used needles, or otherwise manipulate them
using both hands, or use any other technique that involves directing the point of a needle
toward any part of the body; rather, use either a one-handed "scoop" technique or a
mechanical device designed for holding the needle sheath. Do not remove used needles from
disposable syringes by hand, and do not bend, break, or otherwise manipulate used needles
by hand. Place used disposable syringes and needles, scalpel blades, and other sharp items in
appropriate puncture-resistant containers, which are located as close as is practical to the
area in which the items were used, and place reusable syringes and needles in a puncture-
resistant container for transport to the reprocessing area.
Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to
mouth-to-mouth resuscitation methods in areas where the need for resuscitation is predictable.
PATIENT PLACEMENT
Place a patient who contaminates the environment or who does not (or cannot be expected
to) assist in maintaining appropriate hygiene or environmental control in a private room. If a
private room is not available, consult with infection control professionals regarding patient
placement or other alternatives.
AIRBORNE PRECAUTIONS
In addition to standard precautions, use airborne precautions, or the equivalent, for patients
known or suspected to be infected with microorganisms transmitted by airborne droplet
nuclei (small-particle residue [5 pm or smaller in size] of evaporated droplets containing
microorganisms that remain suspended in the air and that can be dispersed widely by air
currents within a room or over a long distance).
PATIENT PLACEMENT
Place the patient in a private room that has (1) monitored negative air pressure in relation to
the surrounding area, (2) six to twelve air changes per hour, and (3) appropriate discharge of
air outdoors or monitored high-efficiency filtration of room air before the air is circulated to
other areas in the hospital. Keep the room door closed and the patient in the room. When a
private room is not available, place the patient in a room with a patient who has active
infection with the same microorganism, unless otherwise recommended, but with no other
infection. When a private room is not available and cohorting is not desirable, consultation
with infection control professionals is advised before patient placement.
RESPIRATORY PROTECTION
Wear respiratory protection when entering the room of a patient with known or suspected
infectious pulmonary tuberculosis. Susceptible persons should not enter the room of patients
known or suspected to have measles (rubeola) or varicella (chickenpox) if other, immune
caregivers are available. If susceptible persons must enter the room of a patient known or
continued
16 Chapter 2 — Standard Precautions
Table 2.1 Recommendations for Isolation Precautions in
Hospitals, Hospital Infection Control Practices Advisory
Committee, 1996-cont'd
suspected to have measles (rubeola) or varicella, they should wear respiratory protection.
Persons immune to measles (rubeola) or varicella need not wear respiratory protection.
PATIENT TRANSPORT
Limit the movement and transport of the patient from the room to essential purposes only. If
transport or movement is necessary, minimize patient dispersal of droplet nuclei by placing a
surgical mask on the patient, if possible.
ADDITIONAL PRECAUTIONS FOR PREVENTING TRANSMISSION OF TUBERCULOSIS
Consult CDC Guidelines for Preventing the Transmission of Tuberculosis in Health Care Facilities
for additional prevention strategies.
DROPLET PRECAUTIONS
In addition to standard precautions, use droplet precautions, or the equivalent, for a patient
known or suspected to be infected with microorganisms transmitted by droplets (large-particle
droplets [larger than 5 um in size] that can be generated by the patient during coughing,
sneezing, talking, or the performance of procedures).
PATIENT PLACEMENT
Place the patient in a private room. When a private room is not available, place the patient in a
room with a patient(s) who has active infection with the same microorganism but with no
other infection (cohorting). When a private room is not available and cohorting is not
achievable, maintain spatial separation of at least 3 feet between the infected patient and
other patients and visitors. Special air handling and ventilation are not necessary, and the
door may remain open.
MASK
In addition to standard precautions, wear a mask when working within 3 feet of the patient.
(Logistically, some hospitals may want to implement the wearing of a mask to enter the room.)
PATIENT TRANSPORT
Limit the movement and transport of the patient from the room to essential purposes only. If
transport or movement is necessary, minimize patient dispersal of droplets by masking the
patient, if possible.
CONTACT PRECAUTIONS
In addition to standard precautions, use contact precautions, or the equivalent, for specified
patients known or suspected to be infected or colonized with epidemiologically important
microorganisms that can be transmitted by direct contact with the patient (hand or skin-to-
skin contact that occurs when performing patient care activities that require touching the
patient's dry skin) or indirect contact (touching) with environmental surfaces or patient care
items in the patient's environment.
PATIENT PLACEMENT
Place the patient in a private room. When a private room is not available, place the patient in a
room with a patient(s) who has active infection with the same microorganism but with no
other infection (cohorting). When a private room is not available and cohorting is not
achievable, consider the epidemiology of the microorganism and the patient population when
determining patient placement. Consultation with infection control professionals is advised
before patient placement.
GLOVES AND HAND WASHING
In addition to wearing gloves as outlined under "Standard Precautions," wear gloves (clean,
nonsterile gloves are adequate) when entering the room. During the course of providing care
for a patient, change gloves after having contact with infective material that may contain high
concentrations of microorganisms (fecal material and wound drainage). Remove gloves before
leaving the patient's environment and wash hands immediately with an antimicrobial agent or
Chapter 2 — Standard Precautions 17
Table 2.1 Recommendations for Isolation Precautions in
Hospitals, Hospital Infection Control Practices Advisory
Committee, 1996-cont'd
a waterless antiseptic agent. After glove removal and hand washing, ensure that hands do not
touch potentially contaminated environmental surfaces or items in the patient's room to avoid
transfer of microorganisms to other patients or environments.
GOWN
In addition to wearing a gown as outlined under "Standard Precautions," wear a gown (a clean,
nonsterile gown is adequate) when entering the room if you anticipate that your clothing will
have substantial contact with the patient, environmental surfaces, or items in the patient's
room, or if the patient is incontinent or has diarrhea, an ileostomy, a colostomy, or wound
drainage not contained by a dressing. Remove the gown before leaving the patient's environment.
After gown removal, ensure that clothing does not contact potentially contaminated
environmental surfaces to avoid transfer of microorganisms to other patients or environments.
PATIENT TRANSPORT
Limit the movement and transport of the patient from the room to essential purposes only. If
the patient is transported out of the room, ensure that precautions are maintained to minimize
the risk of transmission of microorganisms to other patients and contamination of environmental
surfaces or equipment.
PATIENT CARE EQUIPMENT
When possible, dedicate the use of noncritical patient care equipment to a single patient (or
cohort of patients infected or colonized with the pathogen requiring precautions) to avoid
sharing between patients. If use of common equipment or items is unavoidable, adequately
clean and disinfect them before use for another patient.
ADDITIONAL PRECAUTIONS FOR PREVENTING THE SPREAD OF
VANCOMYCIN RESISTANCE
Consult the HICPAC report on preventing the spread of vancomycin resistance for additional
prevention strategies.
HICPAC, Hospital Infection Control Practices Advisory Committee.
From Centers for Disease Control and Prevention: Recommendations for Isolation Precautions in
Hospitals, 1996. Available at: http://www.cdc.gov/ncidod/hip/isolat/isopartl.htm and
www. cdc.gov. /ncidod/hip/isolat/isopart2. htm
STANDARD PRECAUTIONS
Although universal precautions were designed to address the transmission
of blood-borne infections through blood and certain body fluids, they do not
address other routes of disease transmission, which were addressed at the
time by body substance isolation guidelines. Additionally, confusion developed
as to whether one should use universal precautions and body substance
isolation guidelines, because both guidelines dealt with similar circumstances
but offered conflicting recommendations. The guideline for isolation pre-
cautions in hospitals was revised in 1996 by the CDC and the Hospital
Infection Control Practices Advisory Committee (HICPAC), which had been
established in 1991 to serve in a guiding and advisory capacity to the Secretary
of the Department of Health and Human Services (DHHS), the Assistant
Secretary of Health of the DHHS, the Director of the CDC, and the Director of
the National Center for Infectious Diseases with respect to hospital infection
18 Chapter 2 — Standard Precautions
control practices and U.S. hospital surveillance, prevention, and control
strategies for nosocomial infections. The CDC guideline revision was designed
to include the following objectives:
(1) to be epidemiologically sound; (2) to recognize the importance of all
body fluids, secretions, and excretions in the transmission of nosocomial
pathogens; (3) to contain adequate precautions for infections transmitted
by the airborne, droplet, and contact routes of transmission; (4) to be as
simple and user friendly as possible; and (5) to use new terms to avoid
confusion with existing infection control and isolation systems.
(Garner, 1996)
The new guidelines were designed to supersede universal precautions and
body substance isolation guidelines and in essence combined parts of both
these previous guidelines. This synthesis of guidelines allows patients who
were previously covered under disease-specific guidelines to now fall under
standard precautions, a single set of recommendations. For patients who
require additional precautions (defined as transmission-based precautions, for
use when additional transmission risk exists [e.g., from airborne or droplet
contamination]), additional guidelines have been developed to go above and
beyond those of standard precautions (Garner, 1996) (see Table 2-1).
GLOVES, GOWNS, MASKS, AND
OTHER PROTECTIVE BARRIERS AS
PART OF UNIVERSAL PRECAUTIONS
All health care workers should routinely use appropriate barrier precautions
to prevent skin and mucous membrane exposure during contact with any
patient's blood or body fluids that require universal precautions.
Gloves should be worn as follows:
For touching blood and body fluids requiring universal precautions,
mucous membranes, or nonintact skin of all patients
■ For handling items or surfaces soiled with blood or body fluids to which
universal precautions apply
Gloves should be changed after contact with each patient. Hands and other
skin surfaces should be washed immediately or as soon as patient safety
permits if contaminated with blood or body fluids requiring universal
precautions. Hands should be washed immediately after gloves are removed.
Gloves should reduce the incidence of blood contamination of hands during
phlebotomy, but they cannot prevent penetrating injuries caused by needles
or other sharp instruments. Institutions that judge routine gloving for all
phlebotomies as not necessary should periodically re-evaluate their policy.
Gloves should always be available to health care workers who wish to use
them for phlebotomy. In addition, the following general guidelines apply:
Use gloves for performing phlebotomy when the health care worker has
cuts, scratches, or other breaks in the skin.
Chapter 2 — Standard Precautions 19
Use gloves in situations in which the health care worker judges that
hand contamination with blood may occur; for example, when
performing phlebotomy in an uncooperative patient.
■ Use gloves for performing finger or heel sticks, or both, in infants and
children.
■ Use gloves when persons are receiving training in phlebotomy.
Masks and protective eyewear or face shields should be worn by health care
workers to prevent exposure of mucous membranes of the mouth, nose, and
eyes during procedures that are likely to generate droplets of blood or body
fluids requiring universal precautions. Gowns or aprons should be worn
during procedures that are likely to generate splashes of blood or body fluids
requiring universal precautions.
All health care workers should take precautions to prevent injuries caused
by needles, scalpels, and other sharp instruments or devices during
procedures; when cleaning used instruments; during disposal of used
needles; and when handling sharp instruments after procedures. To prevent
needlestick injuries, needles should not be recapped by hand, purposely
bent or broken by hand, removed from disposable syringes, or otherwise
manipulated by hand. After they are used, disposable syringes and needles,
scalpel blades, and other sharp items should be placed in puncture-resistant
containers for disposal. The puncture-resistant containers should be located
as close as is practical to the area of use. All reusable needles should be
placed in puncture-resistant containers for transport to the reprocessing area.
General infection control practices should further minimize the already
minute risk for salivary transmission of human immunodeficiency virus. These
infection control practices include the use of gloves for digital examination
of mucous membranes and endotracheal suctioning, hand washing after
exposure to saliva, and minimizing the need for emergency mouth-to-mouth
resuscitation by making mouthpieces and other ventilation devices available
for use in areas where the need for resuscitation is predictable.
THE APPLICATION OF STANDARD
PRECAUTIONS IN CLINICAL
PROCEDURES
Standard precautions should be followed when performing any procedure in
which exposure to, or transmission of, infectious agents is possible. These
guidelines attempt to minimize exposure to infectious body fluids. Because it
is not always possible to determine in advance whether a specific patient is
infectious, these precautions should be followed routinely for all patients.
The nature of performing clinical procedures often results in exposure to
body fluids. Consequently, as practitioners involved in performing clinical
procedures, it is imperative that we attempt to anticipate potential exposures
and implement preventive guidelines to reduce exposure risks.
20 Chapter 2 — Standard Precautions
Additionally, it is important that the practitioner assess the health status
of each patient to determine if additional precautions are warranted and, if
so, apply the necessary transmission-based precautions as described in
Table 2-1. Standard precautions are the current recommended behaviors
designed to prevent the transmission of pathogens from patient to practitioner
or practitioner to patient. It is imperative that all providers be knowledgable
about standard precautions and transmission-based precautions and how to
practice them competently and consistently.
References
Centers for Disease Control and Prevention: Interim recommendations
for infection control in health-care facilities caring for patients with
known or suspected avian influenza. May 21, 2004. Available at
http://www.cdc.gov/flu/avian/professional/infect-control.htm, accessed
7/3/06.
Centers for Disease Control and Prevention: Public health guidance for
community-level preparedness and response to severe acute
respiratory syndrome (SARS) version 2. Supplement I: Infection control
in healthcare, home, and community setting. May 3, 2005. Available at
http://www.cdc.gOv/ncidod/sars/guidance/i/, accessed 7/3/06.
Centers for Disease Control and Prevention: Updated U.S. Public Health
Service guidelines for the management of occupational exposures to
HBV, HCV, and HIV and recommendations for postexposure
prophylaxis. MMWR Morb Mortal Wkly Rep 50:1-42, 2001.
Centers for Disease Control and Prevention: Recommendations for
prevention and control of hepatitis C virus (HCV) infection and
HCV-related chronic disease. MMWR Morb Mortal Wkly Rep 47:1-39,
1998.
Centers for Disease Control and Prevention: Laboratory management of
agents associated with hantavirus pulmonary syndrome: Interim
biosafety guidelines. MMWR Morb Mortal Wkly Rep 43:1-7, 1994.
Centers for Disease Control: Guidelines for preventing the transmission
of tuberculosis in health-care settings, with special focus on
HIV-related issues. MMWR Morb Mortal Wkly Rep 39:1-29, 1990.
Centers for Disease Control: Risks associated with human parvovirus
B19 infection. MMWR Morb Mortal Wkly Rep 38:81-88, 93-97, 1989.
Centers for Disease Control: Management of patients with suspected
viral hemorrhagic fever. MMWR Morb Mortal Wkly Rep 37:1-16, 1988.
Centers for Disease Control: Update: Universal precautions for
prevention of transmission of human immunodeficiency virus,
hepatitis B virus, and other blood borne pathogens in health-care
settings. MMWR Morb Mortal Wkly Rep 37:377-388, 1988.
Garner JS: Guideline for isolation precautions in hospitals. Part I.
Evolution of isolation practices, Hospital Infection Control Practices
Advisory Committee. Am J Infect Control 24:24-31, 1996.
Garner JS: Comments on CDC guideline for isolation precautions in
hospitals, 1984. Am J Infect Control 12:163-164, 1984.
Haley RW, Garner JS, Simmons BP: A new approach to the isolation of
patients with infectious diseases: Alternative systems. J Hosp Infect
6:128-139, 1985.
Chapter 2 — Standard Precautions 21
Lynch P, Cummings MJ, Roberts PL: Implementing and evaluating a
system of generic infection precautions: Body substance isolation.
Am J Infect Control 18:1-12, 1990.
Lynch P, Jackson MM: Rethinking the role of isolation precautions in the
prevention of nosocomial infections. Ann Intern Med 107:243-246, 1987.
Lynch T: Communicable Disease Nursing. St. Louis, CV Mosby, 1949.
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borne pathogen transmission from health care workers to patients:
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seroconversion in health care workers after percutaneous exposure:
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22 Chapter 2 — Standard Precautions
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Labor, 1986.
Cha
pter O
Sterile Technique
Paul C. Hendrix
Procedure Goals and Objectives
Goal: To provide clinicians with the knowledge and skills
necessary to perform clinical procedures using accepted sterile
technique.
Objectives: The student will be able to ...
• Describe the indications and rationale for practicing sterile
technique.
• Identify and describe the history and development of the
concept of sterile technique.
List the principles of sterile technique.
Describe the essential steps performed in the surgical hand scrub.
Describe the essential steps performed in preparing and
draping a sterile field.
Describe the principles involved in the use of surgical caps,
masks, and gowns.
Describe the principles involved in the use of standard
precautions.
23
24 Chapter 3— Sterile Technique
BACKGROUND AND HISTORY
The teachings of Hippocrates (460 bc) were instrumental in turning the art of
healing away from mystical rites to an approach that everyone could
understand and practice. He stressed cleanliness to avoid infection by using
boiling water and fire to clean instruments and by irrigating dirty wounds
with wine or boiled water (Adams, 1929). Louis Pasteur (1822-1895) developed
what would come to be known as the germ theory of disease. His experiments
revealed that microbes could be found in the air and on the surface of every
object (Dubos, 1950). He discovered that the number of microbes could be
reduced on surfaces by using heat or appropriate cleansing but that they
would still remain in the air. Joseph Lister (1827-1912) is considered the
father of sterile technique (Godlee, 1917). When Lister learned of Pasteur's
work, he began to experiment with various methods of sterile technique in
surgery. He noted a significant decrease in postoperative infections after
using carbolic acid to sterilize both surgical wounds and his own hands and
by spraying the operative field. His antiseptic methods of performing surgery
were refined over the years and eventually incorporated into hospitals
worldwide.
PRINCIPLES OF STERILE TECHNIQUE
Sterile technique is the method by which contamination with microorganisms
is minimized. Adherence to protocol and strict techniques is required at all
times when caring for open wounds and performing invasive procedures. To
avoid infection, procedures should be performed within a sterile field from
which all living microbes have been excluded. Items entering the sterile field,
including instruments, sutures, and fluids, must be sterile. Although it is not
possible to sterilize the skin, it is possible to reduce significantly the number
of bacteria that is normally present on the skin. Before a procedure, personnel
must first perform a surgical hand scrub and then don sterile gloves, sterile
gown, and mask. The primary goal is to provide an environment for the
patient that promotes healing, prevents infections, and minimizes the length
of recovery time. Using the principles of sterile technique will help accomplish
that goal. The principles are as follows:
■ All items used within a sterile field must be sterile.
■ A sterile barrier that has been permeated must be considered
contaminated.
The edges of a sterile container are considered contaminated once the
package is opened.
■ Gowns are considered sterile in front from shoulder to waist level, and
the sleeves are considered sterile to 2 inches above the elbow.
Tables are sterile at table level only.
Chapter 3 — Sterile Technique 25
Sterile persons and items touch only sterile areas; unsterile persons and
items touch only unsterile areas.
■ Movement within or around a sterile field must not contaminate the field.
■ All items and areas of doubtful sterility are considered contaminated.
SURGICAL HAND SCRUB
The surgical hand scrub has its own traditions and rituals dating back to the
use of chlorinated lime by Semmelweis, who in 1846 recognized the role of
contagions on doctors' hands in the spread of puerperal fever, and the use of
carbolic acid by Lister to soak his instruments and hands (Lister, 1867). The
goal of the surgical hand scrub is to remove dirt and debris and to reduce
bacterial flora. An ideal surgical hand scrub should provide the following
antimicrobial effects:
■ Immediate reduction in the resident bacterial flora
Sustained effect to maintain a reduced bacterial count under surgical
gloves
■ Cumulative effect with each additional application of the antiseptic
Persistent effect providing progressive reduction of bacteria with
additional applications
The traditional 10-minute surgical scrub, using a stiff brush and harsh
chemicals, does not meet the criteria for satisfactory antimicrobial action
(an immediate reduction in microbial count that is sustained, cumulative,
and persistent) and is associated with a number of difficulties and problems,
chiefly a high incidence of irritation and dermatitis that can paradoxically
result in an increased microbial population on the hands (Larson, 1986).
Modifications have been made to the traditional surgical hand scrub to
increase its beneficial effects and to decrease its harmful effects.
The duration of the recommended scrub time has been decreased so that
a 2-minute scrub time is now considered by some to be optimal (Wheelock,
1997). Some authors have recommended eliminating the scrub brush, to
decrease abrasion of the hands (Gruendemann, 2001). New antiseptics,
emollients, and humectants have been developed to minimize skin dryness
and dermatitis resulting from the surgical hand scrub. New procedures and
products for hand hygiene and the surgical hand scrub have been
consolidated into a publication that was issued by the Centers for Disease
Control and Prevention (CDC) in 2002. These guidelines are comprehensive,
providing an analysis of the science of hand hygiene and specific recommen-
dations for surgical hand antisepsis (CDC, 2002):
26 Chapter 3— Sterile Technique
Surgical Hand Antisepsis
1. Remove rings, watches, and bracelets before beginning the "surgical
hand scrub" (i.e., a process to remove or destroy transient microorganisms
and reduce resident flora).
2. Remove debris from underneath fingernails using a nail cleaner under
running water.
3. "Surgical hand antisepsis" (i.e., a process for removal or destruction of
transient microorganisms) using either an antimicrobial soap or an
alcohol-based hand rub with persistent activity is recommended before
donning sterile gloves when performing surgical procedures.
4. When performing surgical hand antisepsis using an antimicrobial soap,
scrub hands and forearms for the length of time recommended by the
manufacturer, usually 2 to 6 minutes. Long scrub times (e.g., 10 minutes)
are not necessary.
5. When using an alcohol-based surgical hand scrub product with
persistent activity, follow the manufacturer's instructions. Before
applying the alcohol solution, prewash hands and forearms with a
nonantimicrobial soap and dry hands and forearms completely. After
application of the alcohol-based product as recommended, allow hands
and forearms to dry thoroughly before donning sterile gloves.
Materials Utilized for Hand Scrub
Chlorhexidine gluconate or povidone-iodine solutions are rapid-acting,
broad-spectrum antimicrobials that are effective against gram-positive
and gram-negative microorganisms. Each is prepared in combination
with a detergent to give a cleansing action along with the antimicrobial
effect.
Sterile disposable scrub brushes impregnated with chlorhexidine
gluconate, povidone-iodine, or other CDC-approved products (CDC,
2002).
Chapter 3 — Sterile Technique 27
Procedures for the Surgical Scrub: Timed (Anatomic) and Counted
Stroke Methods
Note: Two methods of surgical scrubbing are
typically used: the timed method (Fig. 3-1),
which is illustrated here, and the counted
stroke method. Both methods follow a
prescribed anatomic pattern of scrubbing
beginning with the fingernails, then moving
on to the four surfaces of each finger, the
palmar and dorsal surfaces of the hands and
wrists, and extending up the arms to the
elbows. The timed method requires a total of
5 minutes of scrub time. The counted stroke
method requires a specific number of bristle
strokes for the fingers, hands, and arms. The
scrub includes 30 strokes for the fingernails
and 20 strokes to each surface of the fingers,
hands, wrists, and arms to the elbows.
Figure 3-1.
1. Organize supplies and adjust water to a
comfortable temperature.
2. Wet hands and arms, prewash with soap
from a dispenser, rinse.
3. Remove scrub brush from package and
use nail cleaner to clean fingernails.
4. Squeeze scrub brush under water to
release soap from sponge.
5. With scrub brush perpendicular to
fingers, begin to scrub all four sides of
each finger with a back-and-forth motion.
6. Scrub dorsal and palmar surfaces of
hand and wrist with a circular motion.
7. Starting at the wrist, scrub all four sides
of the arm to the elbow.
8. Transfer scrub brush to the other hand
and repeat steps 5 to 7.
9. Discard scrub brush and rinse hands
and arms, starting with the fingertips
and working toward the elbows.
10. Allow contaminated water to drip off the
elbows by keeping hands above the waist
Materials Utilized to Prepare
the Procedure Site
Note: Preparation trays are commercially
available and typically include the listed
necessary items.
• Disposable razors to remove hair from the
procedure site
• Towels
• Antiseptic soap: There are multiple
antiseptic skin scrubs available. The most
commonly used are iodine-based soaps
and solutions.
• Gauze sponges
• Large clamp or ring forceps to hold the
preparation sponge or gauze
28 Chapter 3— Sterile Technique
Procedure for Preparing the Operative Site
1. Scrub the skin with the antiseptic solution,
beginning at the procedure site and
working outward in a circular fashion
toward the periphery of the field
(Fig. 3-2). Make sure the area prepared is
much wider than the procedure site.
Note: The scrubbing action must be vigorous,
including both mechanical and chemical
cleansing of the skin.
2. On reaching the outer boundary, discard
the first sponge and repeat the procedure
until all prepared sponges are used.
Figure 3-2.
Caution: Do not return to a previously
prepared area with a contaminated sponge.
I
Materials Utilized for Draping
a Patient and the Procedure
Site
Note: Draping the procedure site and the
patient follows preparing the skin.
• Drapes: typically green, blue, or gray to
reduce glare and eye fatigue
• Types of drapes: towels, sheets, split
sheets, fenestrated sheets, stockinette,
and plastic incision drapes
Note: Each type of drape has a specific use;
for example, fenestrated sheets have a
window that exposes the procedure site, and
stockinette is used to cover the extremities
circumferentially Drapes must be lint-free,
antistatic, fluid resistant, abrasive-free, and
made to fit contours.
Procedure for Draping
Note: Draping is the process of maintaining a
sterile field around the procedure site by
covering the surrounding areas and the
patient with a barrier.
1. Hold the drapes high enough to avoid
touching unsterile areas.
2. Always walk around the table to drape the
opposite side.
Caution: Never reach over the patient.
3. Handle drapes as little as possible and
avoid shaking out wrinkles (contaminants
are present in the air).
4. When draping, make a cuff over the
gloved hand to protect against touching
an unsterile area, and place the folded
edge toward the incision to provide a
Chapter 3 — Sterile Technique 29
uniform outline of the surgical site and to
prevent instruments or sponges from
falling between layers.
Note: Any part of the drape below waist or
table level is considered unsterile. Towel
clips fastened through the drapes have
contaminated points and should be removed
only if necessary
5. If a hole is found in a drape after it is
placed, cover it with a second drape.
6. Drapes should not be adjusted after
placement. If a drape is placed
improperly, either discard it or cover it
with another drape.
Procedure for Maintaining a Sterile Field
Note: The sterile field includes the draped
patient and any scrubbed personnel.
1. Someone outside the sterile field must
hand items needed during the procedure
into the sterile field. This is the reason a
minimum of two individuals is required to
do most procedures — one with unsterile
hands to pass instruments and supplies
into the sterile field, and one with gloved
hands working within the sterile field.
Note: Sterile supplies are uniformly packaged
in such a way to allow an unsterile person to
open and pass them safely, without
contamination, into the sterile field.
2. Contamination of supplies or personnel
within the sterile field must be addressed
immediately. This includes changing
gowns or gloves and removing from the
sterile field any instrument or supplies
that have become contaminated.
3. Unsterile personnel must avoid contact
with the sterile field by remaining at a safe
distance (at least 12 inches away) and by
always facing the field when passing to
avoid accidental contact.
4. Every individual involved with the
procedure must immediately call attention
to any observed breaks, or suspected
breaks, in sterile technique.
5. If the sterility of any item is in doubt, it
must be considered contaminated,
removed from the sterile field, and
replaced with a sterile item.
Caution: There is no compromise with
sterility. An item is either sterile or unsterile.
Procedure for Wearing Surgical Masks, Caps, and Gowns
Note: Because of the large number of
potentially harmful microbes that reside in
the respiratory tract, surgical masks are
recommended at all times when there are
open sterile items or sterile instruments
present.
1. Fit the mask snugly over both the nose
and the mouth and tie securely (Fig. 3-3).
2. When wearing a mask, keep conversation
to a minimum to prevent moisture buildup.
3. Change surgical masks routinely between
procedures or during a procedure if they
become moist or wet.
continued
30 Chapter 3— Sterile Technique
Figure 3-3.
Note: Surgical caps prevent unsterile
material from the hair entering the sterile
field. The standard unisex surgical cap is
adequate for women and men with short
hair, but a more voluminous cap is required
for long hair. Both caps and masks generally
are made of paper and are disposable.
Note: For lengthy procedures, or when it is
necessary to put the forearms into the sterile
field, a sterile surgical gown is required
(Figs. 3-4 and 3-5). Procedures for which
gloves are sufficient include joint aspiration,
suturing a minor laceration, and performing
a lumbar puncture. A gown is required for
repairing a large wound, for cardiac
catheterization, or for any procedure that
requires it by protocol. Only the front of the
gown above the waist level and the lower
portion of the sleeves are considered sterile.
Even though the entire gown is sterile
initially, brushing against an unsterile object
with the back, sides, or lower portion of the
gown is easy to do.
Figure 3-4.
Figure 3-5.
Chapter 3 — Sterile Technique 31
SPECIAL CONSIDERATIONS
Standard Precautions In 1987, the CDC
developed universal precautions, later
incorporated into standard precautions, which
were designed to protect health care personnel
from unknown exposures from the patient and
environment. The CDC (1987) stated, "Since
medical history and examination cannot
identify all patients who are potentially infected
with blood-borne pathogens, specific
precautions should be used with all patients,
thereby reducing the risk of possible exposure
to its minimum."
Therefore, all procedures and patients should
be considered to be potentially contaminated,
and strict protocols should be followed to
prevent exposure to blood and body fluids. The
CDC advised that health care workers could
reduce the risk of exposure and contamination
by adhering to the following guidelines:
1. Use appropriate barrier protection to
prevent skin and mucous membrane
exposure when contact with blood and body
fluids of any patient is anticipated. Gloves,
masks, and protective eyewear or face
shields should be worn during all surgical
procedures and when handling soiled
supplies or instruments during or after a
procedure to prevent exposure of mucous
membranes.
2. Wash hands and other skin surfaces
immediately and thoroughly if contaminated
with blood or other body fluids. Although
both sterile and unsterile personnel wear
gloves during a surgical procedure, hand
washing after the removal of gloves should
become a routine practice for all personnel
working in a procedure room.
3. Take all necessary precautions to protect
against injuries caused by needles, scalpels,
and other sharp instruments or devices
during procedures; when cleaning used
instruments; and when handling sharp
instruments after a procedure. Needles
should never be recapped or bent after use.
Suture needles and sharps should be
contained in a puncture-resistant container
and sealed for proper disposal according to
recommended practices and established
protocols. Sharp instruments should be
placed in a tray in such a way that their
points are not exposed so that injury to
persons working with the trays is avoided.
During the procedure, care must be taken
when handling suture needles to ensure that
no one receives an injury by placing the
needle on a needle holder and passing it
with the point down.
4. Health care workers who have exudative
lesions or weeping dermatitis should refrain
from all direct patient care and from
handling patient care equipment until the
condition resolves. Individuals with minor
breaks in the skin should restrict scrubbing
activities until the breaks have healed.
Sterile gloves should be worn if a skin lesion
is present, and the lesion covered when
working in a procedure room.
The Occupational Safety and Health
Administration (OSHA) has adopted these
guidelines in its efforts to maintain a safe
working environment. In addition, both OSHA
and the CDC recommend that aspirated or
drainage material never come into contact with
health care providers. Thus, the use of an
adequate suctioning system is important during
procedures, with careful disposal protocols
after the procedure is completed. For more
information on standard precautions, see
Chapter 2.
Disposal of Materials
1. Care should be taken to dispose of
contaminated supplies and materials to
avoid the transmission of infectious
organisms to others.
2. Sharp objects should be disposed in
appropriately marked containers.
3. Body fluids, human tissue, disposable
gowns, gloves, caps, and drapes should be
placed in containers marked with the
appropriate biohazard warnings.
4. All receptacles containing biohazardous
waste should be properly labeled and
identified and processed according to
institutional procedures.
32 Chapter 3— Sterile Technique
References
Adams F: The Genuine Works of Hippocrates. New York, W. Wood, 1929.
Centers for Disease Control and Prevention: Guideline for hand hygiene
in health-care settings. MMWR Recomm Rep 51(RR-16):l-45, 2002.
Centers for Disease Control and Prevention: Recommendations for
prevention of HIV transmission in health-care settings. MMWR Morb
Mortal Wkly Rep 36(suppl 2):1S-18S, 1987.
Dubos R: Louis Pasteur: Free Lance of Science. Boston, Little, Brown,
1950.
Godlee RJ: Lord Lister. London, Macmillan, 1917.
Gruendemann BJ: Is it time for brushless scrubbing with an alcohol-
based agent? AORN J 74:859-873, 2001.
Larson E: Physiologic and microbiologic changes in skin related to
frequent handwashing. Infect Control Hosp Epidemiol 7:59-63, 1986.
Lister J: On a new method of treating compound fractures, abscess, etc.
with observations on the conditions of suppuration. Lancet 1:326,
357, 507, 1867.
Wheelock SM: Effect of surgical hand scrub time on subsequent
bacterial growth. AORN J 65:1087-1098, 1997.
Chapter A
Blood Pressure Measurement
Randy Danielsen
Procedure Goals and Objectives
Goal: To accurately measure the systemic arterial blood pressure
in any patient in any setting.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing arterial blood pressure measurement.
• Describe the essential anatomy and physiology associated with
the performance of blood pressure measurement.
• Identify the necessary materials and their proper use for
performing blood pressure measurement.
• Perform the proper steps and techniques for obtaining blood
pressure measurement.
• Describe the indications for performing orthostatic blood
pressure assessment.
• Perform the proper steps and techniques for obtaining
orthostatic blood pressure measurement.
33
34 Chapter 4— Blood Pressure Measurement
BACKGROUND AND HISTORY
Various theories about circulation and blood pressure (BP) emerged about
400 bc. Hippocrates knew about arteries and veins, but he believed veins
carried air. Six hundred years later, Galen demonstrated that both arteries
and veins carried blood; however, he also thought that the heart was a
warming machine for two separate types of blood. He was convinced that
veins and arteries were not connected and that blood flowed both backward
and forward from the heart. Subsequently Galen's teachings remained
unchallenged for over 1000 years (Stevens, 1978).
It was William Harvey, in 1616, who disagreed with Galen by demonstrating
one-way circulation of blood and theorized the existence of capillaries. Thirty
years later, Marcello Malpighi was the first to view capillaries microscopically
(Stevens, 1978).
The first person to measure BP was Stephen Hales in 1733. An English
physiologist, clergyman, and amateur scientist, Hales inserted a brass pipe
into the carotid artery of a mare and then attached the pipe to a windpipe
taken from a goose. The flexible goose windpipe was then attached to a
12-foot glass tube. Although the experiment had little practical application at
the time, it did provide valuable information about BP (Wain, 1970).
Although Ritter von Basch experimented with a device that could measure
the BP of a human without breaking the skin, the prototype design of the
sphygmomanometer was devised in 1896 by Scipione Riva-Rocci (Lyons,
1987). He introduced a method for indirect measurement of BP based on
measuring the external pressure required to compress the brachial artery so
that arterial pulsations could no longer be transmitted through the artery.
The Riva-Rocci sphygmomanometer was described by Porter (1997) as "an
inflatable band that was wrapped around the upper arm; air was pumped in
until the pulse disappeared; it then was released from the band until the
pulse reappeared, and the reading was taken."
In 1905, a Russian physician named Korotkoff first discovered the
auscultatory sounds that are heard while measuring BP. While the artery is
occluded during BP measurement, transmitted pulse waves can no longer be
heard distal to the point of occlusion. As the pressure in the bladder is reduced
by opening a valve on the inflation bulb, pulsatile blood flow reappears
through the generally compressed artery, producing repetitive sounds
generated by the pulsatile flow. The sounds, named after Korotkoff, change in
quality and intensity. The five phases of these changes are characterized in
Table 4-1. Around the turn of the 20th century, BP became an accepted clinical
measurement. As data increased, physicians and other clinicians were able
to establish normal BP ranges and identify abnormalities.
Rene Laennec is credited with the invention of the stethoscope in 1816,
which became a convenience for physicians who preferred not to place their
ears directly on the chest wall of a patient. In 1905, Korotkoff tried using the
stethoscope to monitor the pulse while the sphygmomanometer was inflated.
He discovered a more accurate BP reading and that the pulse disappeared as
the cuff pressure decreased at a point in consonance with the expanding of
Chapter 4— Blood Pressure Measurement 35
Table 4.1 Korotkoff Sound'
Rights were not granted to include this table in electronic media,
Please refer to the printed publication.
From Perloff D, Grimm C, Flack J, et al: Human blood pressure determination by sphygmomanometry.
Circulation 88:2461, 1993.
the heart. Subsequently, the term Korotkoff sounds came to be used (Lyons,
1987).
According to Grim and Grim (2000):
Indirect BP measurement is one of the most frequently performed health
care procedures. Because BP measurement is a simple procedure, it is
taken for granted that all graduates from medical training programs have
the ability to record accurate, precise, and reliable BP readings. However,
research since the 1960s has shown this assumption to be false. Most
health professionals do not measure BP in a manner known to be accurate
and reliable.
The authors describe two factors that contribute to inaccurate BP measure-
ment: (1) lack of depth in the instruction of basic skills in professional
education; and (2) relying on nonmercury devices. Subsequently, every
clinician who takes BP measurements should know and understand the
principles and steps needed to obtain accurate indirect auscultatory BP
measurement. The measurement taken is an important tool in screening and
diagnosis, which is why it is considered one of the patient's "vital signs."
For the accurate indirect measurement of BP, the American Heart
Association (AHA) recommends that the cuff size be based solely on the limb
circumference. Manning, Kuchirka, and Kaminski studied prevailing cuffing
habits, compared them with AHA guidelines, and reported their findings in
Circulation in 1983. They found that "miscuffing" occurred in 65 (32%) of 200
BP determinations in 167 unselected adult outpatients, including 61 (72%) of 85
readings taken on "nonstandard-size" arms. Undercuffing large arms was the
most frequent error, accounting for 84% of the miscuffings. They concluded
that undercuffing elevates the BP readings by an average of 8.5 mm Hg
systolic and 4.6 mm Hg diastolic. It is critical, therefore, that the clinician
choose the appropriate size cuff based on the circumference of a patient's
bare upper arm. The bladder (inside the cuff) length should encircle 80% and
the width should cover 33% to 50% of an adult's upper arm. For a child
younger than 13 years of age, the bladder should encircle 100% of the child's
36 Chapter 4— Blood Pressure Measurement
upper arm. A cuff that is too narrow or too large for an arm may result in an
incorrect BP reading. Cuffs that are generally available usually have been
classified by the width of the bladder rather than by the length and are
labeled newborn, infant, child, small adult, adult, large adult, and thigh.
Over- and underestimation of BP by using an inappropriate cuff size has
been well documented in the literature. Health care settings should have
easy access to small, standard, and large cuffs (Graves, 2001).
INDICATIONS
As one of the vital signs, peripheral BP measurement is an indirect method
of determining cardiovascular function. Its use is indicated for evaluation of
both healthy and unhealthy patients to assess cardiac status. BP measure-
ment is a part of every complete physical or screening examination and is
performed to screen for hypertension or hypotension.
CONTRAINDICATIONS
There are no absolute contraindications to measuring BP. Relative contra-
indications include physical defects and therapeutic interventions, such as
indwelling intravenous catheters and renal dialysis shunts.
POTENTIAL COMPLICATIONS
Complications from measurement of BP occur as a result of improper
training of the individual performing the assessment. Overinflation or pro-
longed time of inflation may lead to tissue or vascular damage at the
measurement site. Lack of proper care of equipment or flawed equipment
may give an inaccurate reading.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
In most clinical settings, BP is measured by the indirect technique of using a
sphygmomanometer placed over the brachial artery of the upper extremity.
The brachial artery is a continuation of the axillary artery, which lies medial
to the humerus proximally and gradually moves anterior to the humerus as
it nears the antecubital crease (Fig. 4-1). Placement of the bladder and cuff of
the sphygmomanometer circumferentially over the brachial artery allows
inflation of the cuff to create adequate pressure so that the artery is fully
occluded when the pressure exceeds the systolic pressure within the
brachial artery.
Chapter 4— Blood Pressure Measurement 37
Humerus
Brachial
artery
Radial
artery
Ulnar
artery
Figure 4- 1 . Location of the
brachial artery.
Indirect measurement of the BP involves the auscultatory detection of the
initial presence and disappearance of changes and the disappearance of
Korotkoff sounds, which are audible with the aid of a stethoscope placed
over the brachial artery distal to the BP cuff near the antecubital crease.
Korotkoff sounds are low-pitched sounds (best heard with the stethoscope
bell) that originate from the turbulence created by the partial occlusion of
the artery with the inflated BP cuff.
As long as the pressure within the cuff is so little that it does not produce
even partial occlusion (or intermittent occlusion), no sound is produced
when auscultating over the brachial artery distal to the cuff. When the cuff
pressure becomes great enough to occlude the artery during at least some
portion of the arterial pressure cycle, a sound becomes audible over the
brachial artery distal to the cuff. This sound is audible with a stethoscope
and correlates with each arterial pulsation.
There are five phases of Korotkoff sounds used in determining systolic and
diastolic BP (see Table 4-1). Phase I occurs as the occluding pressure of the
cuff falls to a point that is the same as the peak systolic pressure within the
brachial artery (Fig. 4-2). The tapping sound that is produced is clear and
generally increases in intensity as the occluding pressure continues to
decrease. Phase II occurs at a point approximately 10 to 15 mm Hg lower than
at the onset of phase I, and the sounds become softer and longer with a
quality of intermittent murmur. Phase III occurs when the occluding pressure
of the cuff falls to a point that allows for large amounts of blood to cross the
38 Chapter 4— Blood Pressure Measurement
Brachial artery occluded q
by cuff, no blood flow
160
Artery intermittently ,.
compressed, blood
spurts into artery 160
Cuff deflated, artery
flows free
160
Auscultatory
sound
IV V
AAAAAAAAAAAAAAAAAAAAAaa^v— ►
Clear tapping Abrupt Silence
Silence
muffling
Figure 4-2. Phase 1 of Korotkoff sounds.
partially occluded brachial artery. The phase III sounds are again crisper and
louder than phase II sounds. Phase IV occurs when there is an abrupt
muffling and decrease in the intensity of the sounds. This occurs as the
pressure is close to that of the diastolic pressure of the brachial artery.
Phase V occurs when the blood vessel is no longer occluded by the pressure
in the cuff. At this point, the tapping sound disappears completely.
PATIENT PREPARATION
Ideally, the environment should be relaxed and peaceful. BP levels may be
affected by emotions, physical activity, or the environment. Subsequently,
the examiner should minimize any and all disturbances that may affect the
reading. The procedure should be explained to the patient.
The patient is asked to be seated or to lie down with the back supported,
making sure that the bare arm is supported horizontally at the level of the
heart. According to Mourad and Carney (2004):
Choosing the dependent arm is a behavior likely to lead to the overdiagnosis
of hypertension and inappropriate treatment of hypertension because the
dependent arm falsely elevates both systolic and diastolic blood pressure.
These results should encourage national and international organizations
to reaffirm the importance of the horizontal arm in the measurement of
blood pressure.
The clinician should avoid an arm that appears injured or has a fistula or an
IV or arterial line. If the patient has undergone breast or axilla surgery, avoid
the arm on the same side. It is important to note that rolling up the sleeves
Cloth cuff
Chapter 4— Blood Pressure Measurement 39
Inflatable rubber bladder
Mercury
manometer
— Stethoscope
Insufflation
bulb with
pressure
control
valve
Aneroid
manometer
Figure 4-3. Instruments used for recording blood pressure.
has the potential of compressing the brachial artery and may have an even
greater effect on the BP than if the shirt is left under the manometer's cuff
(Lieb, 2004) The patient should avoid smoking or ingesting caffeine for
30 minutes before the BP is recorded.
Materials Utilized for Blood Pressure
Measurement
Stethoscope
Calibrated sphygmomanometer (a mercury, aneroid, or hybrid
sphygmomanometer with a calibrated scale for measuring pressure;
inflatable rubber bladders; tubes; and valves). There continues to be
environmental concern over the use of mercury sphygmomanometers
because of the hazards of mercury spills and potential exposure (see
"Note"). As a result, more automated devices are being used
(Valler-Jones, 2005). One of the factors affecting the accuracy of BP
measurement is the equipment used. Defects or inaccuracy of aneroid
sphygmanometers may be a source of error in BP measurement.
Recording instruments (Fig. 4-3)
40 Chapter 4— Blood Pressure Measurement
■ Appropriate size cuff: A cuff that has an antimicrobial agent to help
prevent bacterial growth is recommended. It has been reported that BP
cuffs can carry significant bacterial colonization and actually can be a
source of transmission of infection (Base-Smith, 1996).
Note: Modern sphygmomanometers are less likely to spill mercury if
dropped. If a spill occurs, however, mercury is fairly simple to clean up
unless it is spilled within heated devices or is trapped in upholstery,
carpeting, or other surfaces. Unfortunately, mercury in the organic form is
extremely toxic via skin contact, inhalation, and ingestion and may require
the calling of a hazardous materials team. If mercury manometers are used,
a mercury spill kit is recommended.
Procedure for Indirect Blood Pressure Measurement
1. Check to see that the mercury level of
the sphygmomanometer is at 0 or, if an
aneroid device is used, that the needle
rests within the calibration window.
2. Palpate the brachial artery and place the
cuff so that the midline of the bladder is
over the arterial pulsation. Care should
be taken that the cuff is placed at
approximately the horizontal level of the
heart.
3. Wrap and secure the cuff snugly around
the patient's bare upper arm. The lower
edge of the cuff should be 1 inch
(approximately 2 cm) above the
antecubital crease, the point at which
the bell of the stethoscope is to be
placed (Fig. 4-4). As noted earlier, avoid
rolling up the sleeve in such a manner
that it may form a tight tourniquet
around the upper arm.
4. Place the manometer so that the center
of the mercury column or aneroid dial is
at eye level and clearly visible to the
examiner. Make sure that the tubing from
the cuff is unobstructed.
5. Inflate the cuff rapidly to 70 mm Hg and
increase by increments of 10 mm Hg
while palpating the radial pulse. Note the
Brachial
artery —
Blood pressure
cuff and bladder
Radial
artery
Figure 4-4.
Ulnar
artery
level of pressure at which the pulse
disappears and subsequently reappears
during deflation. This procedure, the
palpatory method, provides the
necessary preliminary approximation of
Chapter 4— Blood Pressure Measurement 41
the systolic pressure to ensure an
adequate level of inflation when the
actual, auscultatory measurement is
accomplished. The palpatory method is
particularly useful to avoid
underinflation of the cuff in patients with
an auscultatory gap and overinflation in
those with very low BP. The auscultatory
gap occurs at a point between the
highest systolic reading and the diastolic
reading. The Korotkoff sounds may
become absent between the peak
systolic measurement and diastole,
resulting in underestimation of the peak
systolic BP if the cuff is not initially
inflated to a high enough pressure.
6. Place the earpieces of the stethoscope
into your ear canals, angled forward to
fit snugly.
7. Switch the stethoscope head to the low-
frequency position (bell).
8. Place the bell of the stethoscope over
the brachial artery pulsation just above
and medial to the antecubital crease but
below the lower edge of the cuff
(Fig. 4-5). Hold it firmly in place, making
sure the bell makes contact with the skin
around the entire circumference.
Excessive pressure will result in
stretching the underlying skin, causing
the bell to function as a diaphragm. This
may result in the loss of low-frequency
sounds.
9. Inflate the bladder rapidly and steadily
to a pressure 20 to 30 mm Hg above the
level previously determined by palpation.
Partially unscrew the valve and deflate
the bladder at 2 mm per second while
listening for the appearance of Korotkoff
sounds.
Figure 4-5.
10. As the pressure in the bladder falls, note
the level of the pressure on the
manometer at the first appearance of
repetitive sounds, the continuation of
the sounds, and when the sounds
disappear. During the period of the
Korotkoff sounds (see Table 4-1), the
rate of deflation should be less than 2
mm per beat, thereby compensating for
both rapid and slow heart rates.
11. Record the systolic and diastolic pressure
immediately, rounded off upward to the
nearest 2 mm Hg. The name of the
patient, the date and time of
measurement, the arm or site at which
the measurement was taken, the cuff size,
and the patient's position while taking
the measurement should be noted.
12. Neither the patient nor the clinician
should talk during the measurement.
42 Chapter 4— Blood Pressure Measurement
SPECIAL CONSIDERATIONS
The Apprehensive Patient or "White
Coat" Hypertension
Ambulatory blood pressure measurement (ABPM) is increasingly being used
in clinical practice (O'Brien, 2003). ABPMs correlate better than clinical
measurements on patients with end-organ injury (Verdecchia, 2000). Twenty-
four-hour ABPM is the most efficient means for assessing white coat hyper-
tension (WCH), particularly in the absence of end-organ disease. WCH has
been defined as clinical BP greater than 140 mm Hg systolic and 90 mm Hg
diastolic (Al-Hermi, 2004). Ambulatory measurements are also valuable in
assessing patients with apparent drug resistance, low BP symptoms, and in
patients taking antihypertensive medications. There is now wider acceptance
of BP readings taken by patients in their homes. Patients should be encouraged
to monitor their BP at home with validated devices followed by appropriate
recording and reporting to their clinician.
The Obese or Large Arm
It is well known that BP measurement with a standard 12- to 13-inch (27- to
34-cm) wide cuff is inappropriate for large or obese arms. If the arm circum-
ference of the patient exceeds 13 inches (34 cm), use a thigh cuff 17 to
20 inches (18 cm) wide on the patient's upper arm. Table 4-2 gives acceptable
bladder dimensions for adult arms of different sizes. In patients with extremely
large arms, place the cuff on the patient's forearm and listen over the radial
artery. Occasionally, it may be necessary to determine the BP in the leg; this
may be required to rule out coarctation of the aorta or if an upper extremity
BP determination is contraindicated. To do this, use a wide, long thigh cuff
Table 4.2 Acceptable Bladder Dimensions for Arms of Different
Sizes*
Rights were not granted to include this table in electronic media.
Please refer to the printed publication.
From http://www.americanheart.org/presenter.jhtml?identifier=3000861; accessed May 6, 2006.
Chapter 4— Blood Pressure Measurement 43
with a bladder size of 45 to 52 cm and apply it to the mid-thigh. Center the
bladder over the posterior surface, wrap it securely, and listen over the
popliteal artery (Perloff, 1993).
According to Pickering and colleagues (2005), "wrist monitors may be useful
in very obese patients if the monitor is held at heart level. Finger monitors
are not recommended." Block and Schulte (1996) discussed ankle BP measure-
ments and found that mean BP readings obtained at the arm and at the ankle
were statistically equivalent and concluded that ankle cuff placement provided
a reliable alternative to the placement of the cuff on the arm.
Infants and Children
Measuring BP in infants and children presents special problems to the
clinician. The same measuring techniques are used as in adults. As mentioned
earlier, pediatric cuff sizes are available to ensure that the bladder
completely encircles the upper arm. Various techniques can enforce patient
compliance — using relaxation techniques for the child, having the mother
inflate the BP cuff, and/or demonstrating BP measurement on a stuffed animal.
Elderly Patients
In elderly patients, who may have significant atherosclerosis, it is likely that
the systolic pressure is overestimated by the indirect method of BP measure-
ment. BP tends to be more labile in elderly patients, so it is important to
obtain several baseline measurements before making any diagnostic or
therapeutic decisions (Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure, 2003). ABPM is very
useful in this age group.
Assessment of Orthostatic Blood
Pressure
The measurement of orthostatic BP is an essential clinical tool for the
assessment and management of patients suffering from many common
medical disorders. The most common causes are volume depletion and
autonomic dysfunction. According to Carlson (1999), orthostatic hypotension,
which is a decline in BP when standing erect, is the "result of an impaired
hemodynamic response to an upright posture or a depletion of intravascular
volume. The measurement of orthostatic blood pressure can be done at the
bedside and is therefore easily applied to several clinical disorders."
Orthostatic hypotension is detected in 10% to 20% of community-dwelling
older individuals (Mader, 1987). This condition is frequently asymptomatic,
but disabling symptoms of light-headedness, weakness, unsteadiness,
blurred vision, and syncope may occur.
44 Chapter 4— Blood Pressure Measurement
The American Academy of Neurology's consensus statement (1996) defines
orthostatic hypotension as a "reduction of systolic blood pressure of at least
20 mm Hg or diastolic blood pressure of at least 10 mm Hg within 3 minutes
of standing."
Many clinicians use a combination of a decrease in BP combined with an
increase in heart rate to determine the presence of orthostatic hypotension.
Performing these orthostatic measurements requires adequate techniques
in BP measurement, appropriate positioning of the patient, and proper timing
of the measurements.
Materials Utilized for Measuring Orthostatic Blood
Pressure
This technique requires the same equipment as previously mentioned for
measuring BP.
Procedure for Measuring Orthostatic Blood Pressure
1. Ask the patient about his or her ability to
stand.
2. Make sure the cuffed arm is positioned so
that the brachial artery is held at the level
of the heart.
3. After 5 to 10 minutes of supine rest, take a
baseline BP and pulse.
4. Have the patient sit on the side of the bed
with feet dangling for 2 to 3 minutes, then
take BP and pulse.
5. Repeat the measurements immediately
upon having the patient stand.
6. Repeat the measurements again 1 to
3 minutes after continued standing. When
recording the measurements, include the
position when you took the readings and
any signs or symptoms developed with
postural changes.
Throughout the procedure assess the
patient for dizziness, light-headedness,
pallor, sweating, or syncope. If any of these
occur, return the patient to a supine
position.
FOLLOW-UP CARE AND
INSTRUCTIONS
The results of the BP measurements dictate the follow-up actions and patient
instructions. Long-term observations have been made on the contributions
of high BP to illness and death. It is important to note that the classification
of BP has changed over the years. In 2003, the seventh report of the Joint
National Committee (JNC-VII) on prevention, detection, evaluation, and
treatment recommended the classification found in Table 4-3.
Chapter 4— Blood Pressure Measurement 45
Table 4.3 Classification of Blood Pressure (BP) for Adults
1 8 Years and Older
CLASSIFICATION
SYSTOLIC BP (mm Hg)
DIASTOLIC BP (mm Hg)
Normal
<120
and
<80
Prehypertension
120-139
or
80-89
Stage 1 hypertension
140-159
or
90-99
Stage 2 hypertension
>160
or
>100
Modified from Chobanian AV, Bakris GL, Blach HR, et al: The seventh report of the Joint National Committee
on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report. JAMA
289:2560-2572, 2003.
Table 4.4 Blood Pressure (BP) Record and Follow-up
Recommendations
Date:
BP Measurements
Sitting:
Lying:
Standing:
Recommendations
□ Return in days
□ Daily BP readings
□ Salt restriction
Name:
Right Arm
Medications
Age:
Left Arm
Home BP Readings
Clinicians should explain the meaning of their BP readings to patients and
advise them of the appropriate need for periodic follow-up care and re-
measurement. Table 4-4 demonstrates a suggested follow-up form to be given
to patients after their BP has been taken.
The measurement of orthostatic BP is a simple technique that requires the
same equipment as previously mentioned in this chapter for measuring BP.
Practical applications include the detection of intravascular volume
depletion and autonomic dysfunction and the treatment of hypertension,
congestive heart failure, and other clinical disorders.
References
Al-Hermi B, Abbas B: The role of ambulatory blood pressure
measurements in adolescence and young adults. Transplant Proc
36:1818-1819, 2004.
American Academy of Neurology: Consensus statement on the
definition of orthostatic hypotension, pure autonomic failure, and
multiple system atrophy. Neurology 46:1470, 1996.
46 Chapter 4— Blood Pressure Measurement
Base-Smith V: Nondisposable sphygmomanometer cuffs harbor
frequent bacterial colonization and significant contamination by
organic and inorganic matter. AANA 64:141-145, 1996.
Block FE, Schulte GT: Ankle blood pressure measurement: An
acceptable alternative to arm measurements. Int J Clin Monit Comput
13:167-171, 1996.
Carlson JE: Assessment of orthostatic blood pressure: Measurement,
technique, and clinical applications. South Med J 92:167-173, 1999.
Graves J: Prevalence of blood pressure cuff sizes in a referral practice
of 430 consecutive adult hypertensives. Blood Press Monit 6:17-20,
2001.
Grim CM, Grim C: Manual blood pressure measurement — Still the gold
standard: Why and how to measure blood pressure the old-fashioned
way. Hypertension Medicine October, 131-145, 2000.
Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure: The seventh report of the Joint
National Committee (JNC-VII) on Prevention, Detection, Evaluation
and Treatment of High Blood Pressure. JAMA 289:2560-2572, 2003.
Lieb M, Holzgreve H, Schultz M, et al: The effect of clothes on
sphygmomanometric and oscillometric blood pressure measurement.
Blood Press 13:279-282, 2004.
Lyons SA, Petrucelli RJ: Medicine: An Illustrated History. New York,
Abradale Press, 1987.
Mader SL, Josephson KR, Rubenstein LZ: Low prevalence of postural
hypotension among community-dwelling elderly. JAMA 258:1511-1514,
1987.
Manning DM, Kuchirka C, Kaminski J: Miscuffing: Inappropriate blood
pressure cuff application. Circulation 68:763-766, 1983.
Mourad A, Carney S: Brief communication: Arm position and blood
pressure: An audit. Intern Med J 34:290-291, 2004.
O'Brien E: Ambulatory blood pressure monitoring in the management of
hypertension. Heart 89:571-576, 2004.
Perloff D, Grim C, Flack J, et al: Human blood pressure by
sphygmomanometry. Circulation 88:2460-2470, 1993.
Pickering TG, Hall JE, Appel LJ, et al: Recommendations for blood
pressure measurement in humans: An AHA scientific statement from
the Council on High Blood Pressure Research Professional and Public
Education Subcommittee. J Clin Hypertens (Greenwich) 7:102-109,
2005.
Porter R: The Greatest Benefit to Mankind: A Medical History of
Humanity. New York, WW Norton, 1997.
Stevens G: Famous Names in Medicine. East Sussex, England, Wayland
Publishers, 1978.
Valler-Jones T, Wedgbury K: Measuring blood pressure using the
mercury sphygmomanometer. Br J Nurs 14;145-150, 2005.
Verdecchia P: Prognostic value of ambulatory blood pressure.
Hypertension 35:844-851, 2000.
Wain H: A History of Medicine. Springfield, 111, Charles C Thomas, 1970.
Cha
pter C
Venipuncture
Kenneth R. Harbert
Procedure Goals and Objectives
Goal: To obtain a venous sample of blood while observing
standard precautions and with the minimal degree of risk to the
patient.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing venipuncture.
• Identify and describe common complications associated with
venipuncture.
• Describe the essential anatomy and physiology associated with
the performance of venipuncture.
• Identify the necessary materials and their proper use for
performing venipuncture.
• Identify the important aspects of post-procedure care following
venipuncture.
47
48 Chapter 5— Venipuncture
BACKGROUND AND HISTORY
Venipuncture evolved from the practice of phlebotomy. The word phlebot-
omy is derived from two Greek words referring to "veins" and "cutting"; thus,
phlebotomy can be defined as the incision of a vein for bloodletting or
collection. Since early times, humans have appreciated the association
between blood and life itself. Many medical principles and procedures have
evolved from this belief. Hippocrates (460-377 bc) stated that disease was the
result of excess substances such as blood, phlegm, black bile, and yellow bile
within the body. It was believed that removal of the excess of these
substances would restore balance (McCall, 1998). From this belief arose the
practice of bloodletting — the first form of phlebotomy. By the 17th and 18th
centuries, phlebotomy was a major therapy for those practicing the healing
arts. Lancets were among the primary instruments used by clinicians in the
18th century.
Methods and procedures associated with phlebotomy today are
dramatically improved. Only rarely today is phlebotomy used as a thera-
peutic modality (e.g., for patients with polycythemia). Instead, the primary
purpose of phlebotomy is to obtain a sample of blood for diagnostic testing.
The development of sophisticated laboratory equipment has reduced the
need for venipuncture by requiring smaller quantities of blood for diagnostic
assessments, amounts that often can be obtained by simply puncturing
the skin without directly accessing the veins. There are many ways to
obtain a blood sample using the venipuncture method. The procedures
in this chapter describe techniques using Vacutainers, syringes, and
infusion sets.
INDICATIONS
There are as many reasons to perform venipuncture as there are different
disease entities. This procedure is indicated any time that a sample of
venous blood is necessary in quantities larger than those readily available by
finger stick methods.
CONTRAINDICATIONS
Once the decision has been made to perform the venipuncture procedure,
the next most important decision is the selection of the site from which to
draw a sample. Although many suitable sites may exist, some areas should
be avoided. Sites to avoid include the following:
Obvious areas of skin infection (e.g., cellulitis, skin rashes, newly
tattooed areas)
Skin sites that have extensive scarring from burns, surgery, injuries,
repeated venipuncture, or trauma
Chapter 5— Venipuncture 49
■ Upper extremity on the ipsilateral side of a mastectomy; use of this site
may affect the test results because of the presence of lymphedema,
which occurs after dissection and removal of the lymphatic system
■ Sites at which a hematoma is present, which might produce erroneous
results in certain types of testing; if another site is not available for
venipuncture, the sample should be drawn from the distal aspect of the
hematoma
An arm with an intravenous (IV) line for fluids or blood transfusions; it is
essential to use the opposite arm as the site of the venipuncture. If this
is not possible, satisfactory samples typically can be drawn from a site
distal to the IV site. When following this procedure, the IV line should be
turned off for at least 2 minutes, if possible. The blood should then be
drawn from a vein other than the one in which the IV is placed above the
selected site. The first 5 mL of blood should be drawn and discarded
before drawing the samples for testing. Blood specimens that are drawn
for glucose levels from the same extremity as the IV infusion may be
inaccurate, even when obtained from a point distal to the IV site.
An arm with a fistula or cannula in place without specific directions from
your supervising physician; if the extremity is edematous, another site
should be chosen
Additionally, patients with diffuse intravascular coagulation, hyperfibrinolysis,
thrombocytopenia, or qualitative platelet disorders characteristically bleed
for a long time after venipunctures.
POTENTIAL COMPLICATIONS
Several complications may occur when performing venipuncture, including
the following:
■ Infection of the skin (cellulitis)
■ Infection of the vein (phlebitis)
■ Thrombosis
■ Laceration of the vein
Hemorrhage or hematoma at the site of the puncture. The risk of
complications is increased with repeated puncture at any site. The most
common complication is hemorrhage or hematoma at the site of the
puncture, which occurs when blood leaks into the tissues after nicking
or penetrating the distal wall of the vein when inserting the needle into
the vein. Using the right angle of insertion for the needle can minimize
the likelihood of this complication. Also, slower insertion of the needle
reduces the likelihood of inserting it too deeply. A smaller gauge needle
also decreases the risk of hemorrhage or hematoma. If a hematoma does
develop, remove the tourniquet, remove the needle, and maintain
50 Chapter 5— Venipuncture
pressure on the site for at least 10 minutes. Apply pressure for an
additional 5 minutes, at least, for patients who take medications that
may have an anticoagulant effect.
Vasovagal syncope, or fainting, which can occur when performing a
venipuncture. Remove the tourniquet, remove the needle, apply pressure
to the site, and fix with tape. Carefully lay the patient down and apply
appropriate measures to wake up the patient. This potential complication
is one of the most compelling reasons why the best position for
performing a venipuncture is the supine position, especially with patients
who report previous episodes of syncope or present with overwhelming
anxiety.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
Blood constitutes 6% to 8% of the total body weight and consists of blood
cells suspended in a fluid called plasma. Serum refers to the substrate
remaining when the fibrinogen has been removed from the plasma. The three
main types of blood cells are red blood cells, called erythrocytes; white blood
cells, called leukocytes; and platelets, known as thrombocytes. The primary
function of blood is the transportation of oxygen via hemoglobin molecules
within the erythrocytes. In addition, it serves to transport nutrients, waste
products, components of the immune system, hormones, and other
specialized materials throughout the body. It also plays a critical role in the
constant regulation of body temperature, the regulation of fluids, and acid-
base equilibrium. Finally, the platelets are responsible for preventing blood
loss from hemorrhage and have their primary influence on the blood vessel
walls.
Veins serve as the structures that channel the deoxygenated blood back to
the heart and eventually to the lungs. The muscles within the vein walls
facilitate the movement of blood within the vein; one-way valves in the vein
prevent the backward flow of blood.
The cubital fossa is the triangular hollow area on the anterior aspect of the
elbow. The boundaries include an imaginary line connecting the medial and
lateral epicondyles superiorly, the pronator teres medially, and the brachio-
radialis laterally. In the cubital fossa region, the cephalic and basilic veins are
often most prominent.
Because of the prominence and accessibility of these superficial veins, the
cubital fossa is the site used most often for venipuncture. Considerable
variations can occur in the connection of the basilic and cephalic veins. The
median cubital vein crosses the bicipital aponeurosis, which separates it
from the underlying brachial artery and median nerve. The median cubital
vein often receives the median antebrachial vein and can bifurcate to form a
median cephalic vein and a median basilic vein (Fig. 5-1). These veins may be
embedded in subcutaneous tissue, making them difficult to visualize, but the
Chapter 5— Venipuncture 51
Cephalic vein
Accessory
cephalic vein
Cephalic vein
Basilic vein
Median
cubital vein
Basilic vein
Median
antebrachial
vein
Basilic vein
Metacarpal
veins
A
Figure 5-1.
and wrist.
Cephalic vein
Dorsal venous
vein
B
Superficial veins. A, Inner aspect of forearm. B, Dorsal aspect of hand
use of a tourniquet occludes the veins' return and distends them, making
them not only palpable but, in most instances, also visible.
Venipuncture is denned as the collection of a blood specimen or specimens
from a vein for the laboratory testing of the blood sample. The tests that are
performed on blood offer many important and valuable parameters for
aiding in the diagnosis of a variety of different diseases. The integrity of the
sample taken is dependent on using good technique, drawing from an
appropriate site, and avoiding hemolysis or contamination of a sample.
Standard Precautions Practitioners should use
standard precautions at all times when
interacting with patients. Determining the level
of precaution necessary requires that the
practitioner exercise clinical judgment based
on the patient's history and the potential for
exposure to body fluids or aerosol-borne
pathogens (for further discussion, see Chapter 2).
52 Chapter 5— Venipuncture
PATIENT PREPARATION
Make sure the patient has followed any preparatory instructions before
drawing blood (e.g., fasting before a blood glucose or lipid profile,
medication withheld or taken prior to procedure, use of medications that
may have an anticoagulant effect).
Discuss with the patient any previous experience with venipuncture to
identify any potential difficulties with the procedure (e.g., anxiety,
fainting, vomiting). Also ask about previous surgery (mastectomy) or
other recent procedures (venous cutdown, dialysis shunt)
Discuss the need for the procedure with the patient, as well as the
potential possibility of an initial stinging pain and possible bruising,
while continuing to stress the importance of the patient's cooperation
for a successful procedure.
Instruct the patient to remain as still as possible while the procedure is
being carried out.
Do not say, "This will be only a little uncomfortable." The patient knows
that it will hurt. Explain that you will do everything you can to minimize
the discomfort, but you will need the patient's cooperation to do so. The
practitioner might say, "I want to make this procedure as pain free as I
can for you. Follow my directions and we will work together to make that
happen."
Answer any and all questions that the patient may have before you begin
the procedure.
Materials Utilized to Perform a Venipuncture
Gloves: at least two pairs of unsterile gloves (in case one set becomes
contaminated; ask patient about latex allergy)
Needles: 18 gauge to 23 gauge, single and multidraw (Have a needle with
a rubber sheath on the part of the needle that inserts into the Vacutainer
barrel.)
Evacuated barrels: Vacutainer barrels are now available with safety
release or retract features.
Evacuated tubes: serum separator tubes, ethylenediaminetetraacetic
acid (EDTA), sodium citrate, sodium heparin, plain, and so on (Always
have spare tubes so that if the vacuum is lost or there is a tube with
insufficient vacuum you are prepared and do not have to repeat the
venipuncture procedure.^) Review color of test tube and test ordered prior
to venipuncture procedure.
Chapter 5— Venipuncture 53
Labels for evacuated tubes, ready with patient's name and pertinent
information for each tube
■ Syringes: 1, 3, 5, and 10 mL, or larger (plastic or glass)
■ IV butterfly (useful for children to prevent excessive suction on the vein)
infusion sets: 21, 23, or 25 gauge, or all three
■ Tourniquets: % inch or 1 inch for adults and l/s inch for children. These
should be clean, wide strips of latex (check for latex allergies before
beginning procedure), or an adult-child blood pressure cuff can be used.
Latex-free tourniquets are available. For elderly patients use a blood
pressure cuff (maintaining pressure greater than patient's diastolic
pressure) instead of a tourniquet, which may be helpful to prevent
excessive stress on the vein.
■ Gauze pads: 2 inch x 2 inch or 4 inch x 4 inch
Isopropyl alcohol pads, 70%
■ Povidone-iodine (used for cleansing venipuncture sites for blood cultures)
■ Adhesive strips (Band-Aids) (again, ask patient if he or she is allergic to
adhesive tape before procedure), nylon tape, and paper tape
■ Sharps disposal container
■ Biohazard waste container
Note: There are many ways to obtain a blood sample using the venipuncture
technique. The following procedures describe techniques using Vacutainers,
syringes, and infusion sets.
Procedure for Venipuncture Using Vacutainers
Note: When performing a venipuncture,
proper planning and preparation are essential
to obtaining good results and ensuring a
good outcome for your patient. Developing a
routine, sequential plan for the venipuncture
procedure helps ensure effective and efficient
results with the least amount of discomfort
for the patient.
1. Know which specific samples you will
need to collect for the laboratory studies
requested and anticipate the materials
and sequence for collecting the needed
samples.
2. For each laboratory study to be
performed, identify the additive, additive
function, volume, and specimen
considerations to be followed for each,
using the corresponding tubes with
color-coded tops. This will save the
patient undue distress and will help you
in obtaining the best outcome for each
sample of blood and corresponding
laboratory test that is to be performed.
Organize your equipment for procedure
before beginning.
continued
54 Chapter 5— Venipuncture
3. Wash hands with warm water and
bacteriostatic soap. Always observe
standard precautions for the prevention
of transmission of human
immunodeficiency virus (HIV), hepatitis
B and C, and other blood-borne
infections (Centers for Disease Control
and Prevention, 1989).
4. Check patient's identification to ensure
that the correct patient is having the
procedure.
5. Check the test ordered twice, even if
ordered by you.
6. Assemble the equipment, preparing the
tubes in the right order and placing the
appropriate needle on the Vacutainer
barrel.
Note: In some instances, the equipment
needed depends on the patient, the medical
condition, the site to be used for the
procedure, the number of samples required,
and the type of setting (hospital, outpatient,
pediatric ward, nursery, emergency room)
where the procedure will be performed.
7. Talk with the patient and explain what
you will be doing. Encourage the patient
to take slow, deep breaths as the
procedure begins. Position the patient in
a manner that is both proper for the
procedure and comfortable for the
patient. If possible, position the patient
in a supine or recumbent position. This
assists the patient in relaxing and carries
the least likelihood for injury to the
patient if he or she experiences vasovagal
syncope. If the patient is sitting up,
extend his or her arm straight down
from shoulder to waist.
8. Observe the patient for any of the
contraindications mentioned previously.
9. Inspect the patient's surface anatomy
and venous system in the chosen
venipuncture site before applying the
tourniquet. The cubital fossa is the most
common site for sampling and IV
injections. Check bilaterally, distally, and
proximally to the most common site for
venipuncture in the adult, which is the
antecubital fossa.
Note: To augment the ability to identify the
best site for venipuncture, palpation skills
and the sense of touch should be refined by
using the palmar aspects of gloved finger
pads. Do not rely totally on vision. This can
be practiced on oneself or on volunteers
until the location of a vein can be identified
confidently with eyes closed. Heavily
pigmented skin and overlying adipose tissue
can make veins difficult to visualize. In
particular, difficult venipuncture can occur
in patients who have had a number of
venipunctures, or in patients who are using
IV drugs. In these instances, selecting an
adequate site may be difficult. Patients who
are frequently subjected to venipuncture
may be able to direct you to sites with the
highest likelihood of success. A warm
compress applied lightly before the
procedure can facilitate vein dilation and
thus assist with the identification of an
adequate vein. The selection of a good site
should include a vein that is easily palpated,
is large and well anchored, and does not roll
when palpated.
Note: The best veins for venipuncture in
the right order of choice are as follows:
• Median cubital vein, which is easily
palpated, well anchored, least painful,
least likely to bruise, and usually the
largest vein in the antecubital space
• Cephalic vein, which is a large vein that
is easily palpated but poorly anchored;
venipuncture here can be painful to the
patient
• Basilic vein, which is easy to palpate,
not well anchored, and very close to the
brachial artery and the median nerve
Chapter 5— Venipuncture 55
Note: For finding difficult veins:
• Have the patient keep the extremity
below the level of the heart for a few
minutes.
• Apply a warm towel to the extremity to
promote vasodilation from the heat —
the towel should be less than 42° C
and should be left on no longer than
2 minutes.
• Use a blood pressure cuff inflated to a
point between the systolic and diastolic
pressures as a tourniquet to allow for
greater control and less discomfort to
the patient.
• Carefully rub or tap the vein over the
potential puncture site to increase the
vein's vasodilation (should be done
before the site is prepared).
10. Firmly place the tourniquet about 3 to 4
inches above the venipuncture site, not
too tight, and use a wide tube band tied
with easily removable bow ties pointing
up and away from the site (Fig. 5-2).
Note: Be sure the patient has no
contraindications against the use of a latex
Tourniquet
Figure 5-2.
tourniquet. Apply the tourniquet in a manner
in which it can be easily removed. Or use a
blood pressure cuff.
Caution: Never leave the tourniquet on for
more than 2 minutes. The vein may collapse
if the tourniquet is too close to the puncture
site.
11. After applying the tourniquet, begin
palpation of the identified site to locate a
desirable vein.
Note: The vein can also be tapped to cause
it to dilate and become more prominent.
Allow gravity to help the vein become
engorged and thus enlarged. If the vein being
palpated feels very tight and has no
flexibility, it may be a tendon or may overlie
a tendon. If it has a palpable pulse, it is an
artery. Be certain of the underlying anatomy
before performing the procedure.
12. Put on latex gloves. Make sure that all
tubes and equipment are within easy
reach in the order that they will be used.
13. Before cleansing the area, secure the site
by anchoring the vein distal to the
venipuncture site, using a finger to apply
pressure over the top of the vein (useful
with large veins) and thus serving to
hold the vein still.
14. Open several alcohol or povidone-iodine
pads. Clean the procedure area,
beginning at the vein site and circling
outward to a 2-inch diameter. Allow the
area to air dry thoroughly. This is
especially true when using povidone-
iodine.
Note: Alcohol lyses red blood cells and can
cause intense stinging. Be sure the site is
dry.
15. Visualize what you are going to do and
begin by stretching the skin downward
below the anticipated venipuncture site
with the opposite hand to anchor the
vein and limit vein movement.
continued
56 Chapter 5— Venipuncture
Bevel of needle
15 degrees
Vein
Figure 5-3.
16. Maintaining needle sterility, insert needle
into the straightest section of the vein,
puncture the skin with the bevel facing
up directly over and parallel to the vein,
and enter the vein or a point immediately
adjacent to the vein. Insert the needle
with the bevel up at about a 15- to
30-degree angle so that the needle
penetrates halfway into the vessel
(Fig. 5-3). When the needle has entered
the skin, lower the needle until it is
almost parallel with the skin.
Note: Use caution when using Vacutainers
because they can exert excessive vacuum,
causing the vein to collapse. When using a
syringe, watch for a backflow of blood. If
backflow is not present with a syringe,
carefully advance the needle slightly further
into vein.
17. Remove the protective covering from the
threaded hub and screw the needle into
the holder.
18. Place the Vacutainer tube inside the
barrel without puncturing the top of the
tube with the needle. Be sure to have
extra tubes close at hand in the right
order of draw.
Note: Determine the correct order of
drawing the samples in the tube or slide,
depending on the laboratory or the tests
required, or both. This prevents interference
by carryover of additives between tubes.
Usually the order is as follows:
1. Blood cultures, usually performed
with a syringe using only iodine as the
skin preparation
2. Red top (chemistry, immunology, and
serology panels; blood bank)
3. Gold top (chemistry, immunology, and
serology panels)
4. Light blue top (requires a full draw of
sample; uses include coagulation
tests, such as thrombin and
prothrombin times)
5. Green or lavender top (requires a full
draw and inverting slowly at least
eight times to prevent clotting and
platelet clumping; uses include
hematology, blood bank)
6. Gray top (requires a full draw to
prevent hemolysis; uses include lithium,
sodium heparin, and glucose levels)
This order changes when using a syringe for
drawing blood (see "Procedure for Syringe
Venipuncture").
Note: Inserting the needle at less than a 15-
to 30-degree angle may allow the needle to
puncture through the far wall of the vein.
19. Hold the needle steady. You may want to
prop your hand against the patient's arm,
so if he or she moves, you move, then
engage the Vacutainer tube. Avoid
rotating the needle because this may
result in excessive damage to the vessel
wall.
20. Keeping the needle very steady and still,
move the Vacutainer tube down into the
barrel so that the tube is punctured. A
drop of blood will be visible at the top of
the inside needle when it is in the vein.
Let the tube fill three-fourths full. After
blood finishes flowing into the last
Vacutainer tube, release the tourniquet
and ask the patient to relax his or her
hand.
21. When removing the filled tube and
inserting the next tube, grasp the barrel
holder securely in the nondominant
Chapter 5— Venipuncture 57
hand and anchor it by holding it against
the extremity to avoid inadvertently
removing the needle from the lumen of
the vein.
Note: The existing vacuum gently draws
blood into the tubes. Most Vacutainer tubes
are unsterile and have additives. The tube
will cease drawing blood when its vacuum is
expired (i.e., when the tube is appropriately
filled).
22. Have the next tube ready for insertion
into the Vacutainer. Remove the
Vacutainer tube from the holder before
removing the needle.
Note: Remember that multiple tubes of
blood can be drawn at this one venipuncture
site without resticking the patient.
23. If multiple tubes are drawn, carefully
invert tubes and mix as required for each
specific tube. Do not shake the tubes
vigorously because disruption of the cell
membranes may result, thus altering the
concentrations of intracellular and
extracellular components.
24. Have sterile gauze ready. Carefully
remove the needle from the skin. Cover
with alcohol pad or sterile gauze.
25. Once the needle is removed completely,
apply firm pressure for hemostasis by
holding a sterile 2 inch x 2 inch covering
over the site while the arm is outstretched
or raised. Avoid bending the arm. Apply
firm pressure to the site until the bleeding
stops, for at least 3 to 4 minutes, or for
5 minutes or more if the patient has
been taking anticoagulant medications.
26. Dress the site with gauze using
multicolored sponge tape or adhesive
D
T
Label Vacutainer
— Name
— Patient number
— Date drawn
— Time drawn
— Amount drawn
— Initials of person drawing blood
Figure 5-4.
strip (ask about allergies before applying
dressing).
Note: If the procedure was unsuccessful, do
not attempt to repeat it at the same site until
healing has occurred. After three
unsuccessful attempts, stop and ask for help.
27. Discard the needle in a puncture
resistant sharps container.
28. Clean any blood spillage with
appropriate cleaning agent.
29. Label all Vacutainer tubes according to
facility procedure (Fig. 5-4).
30. Properly dispose of all contaminated
materials in the appropriate
biohazardous waste container.
31. Talk with the patient, recheck the
venipuncture site, and assess the site
dressing.
32. Make sure the patient is feeling fine and
shows no signs of vertigo,
lightheadedness, or discomfort before
leaving.
33. Remove gloves and wash your hands.
58 Chapter 5— Venipuncture
Procedure for Syringe Venipuncture
Note: Syringes may be used for venipuncture
when the patient's veins are small or fragile
and Vacutainer tubes may cause the veins to
collapse. Using a syringe with a 20- or
21-gauge needle or butterfly allows for greater
control. The procedure for using a syringe
follows the same steps as those for using the
Vacutainer tubes except it differs in the order
of samples drawn, the aspiration of blood
into the syringe, and the transfer of blood
into the vacuum tubes. Self-capping needles
are extremely useful when using a syringe.
The order of draw is as follows:
• Blood cultures, using only iodine as a skin
preparation
• Light blue top (requires a full draw of
sample; uses include coagulation tests
such as thrombin and prothrombin times)
• Lavender top (requires a full draw and
inverting at least eight times slowly to
prevent clotting and platelet clumping;
uses include hematology, blood bank)
• Green top
• Gray top (requires a full draw to prevent
hemolysis; uses include lithium, sodium
heparin, and glucose levels).
• Red top (chemistry, immunology, and
serology panels; blood bank)
1. Wash your hands. Cleanse the area, select
the venipuncture site, and palpate the
vein in the same manner as when using a
Vacutainer system. The steps associated
with the entry into the vein are the same
as well.
2. Once the needle is in the vein, keep the
needle steady and still, and then pull back
gently on the syringe plunger while
holding the syringe securely to keep the
needle in the vein.
3. Using the syringe to brace against you,
pull back on the plunger and fill the
syringe with the desired amount of blood
(usually three quarters full) needed for
the tubes to be filled.
4. Release the tourniquet and complete the
dressing procedure using the same
technique as described for the Vacutainer
system.
5. When transferring from the syringe to the
tubes, remove the 20- or 21-gauge needle
from the syringe and replace it with an
18- or 19-gauge needle.
6. Take extreme care to puncture the tubes in
the right order and allow the tubes to fill
by using the pressure of the vacuum tube.
7. Do not use the plunger to fill the tubes.
Note: Use caution with a syringe, because
the temptation is to push the blood sample
into the vacuum tube using the syringe
plunger, which will affect the sample. Vacuum
tubes draw blood into the tubes using their
own vacuum. The Vacutainer system consists
of vacuum tubes, a needle holder (Vacutainer
barrel), and a disposable multi-sample or
single-sample needle (Fig. 5-5). New multi-
sample needles have guard sheaths.
8. Continue with the same labeling procedure
and ensure the status of the patient
before allowing him or her to leave.
(01
-Needle
— Vacutainer barrel
(hub)
□
-Vacutainer tube
v_y
Vacutainer System
Figure 5-5.
Chapter 5— Venipuncture 59
Procedure for an Infusion Set Venipuncture
Note: An IV infusion set or butterfly can be
used for venipuncture when you are drawing
from a hand or a foot or from a very small or
difficult vein. The procedure for cleansing
the area and site selection are the same as
for the syringe and Vacutainer procedures;
however, with the infusion set the hand and
the foot may be included as new sites.
1. Insert the needle at a lesser angle than for
either of the other methods.
Caution: It is important to take great care
with the needle so as not to miss the vein.
Note: Infusion sets come in different sizes of
needles, and the appropriate one for the
adult, child, or difficult vein should be
selected carefully.
2. Attach a syringe to the set and be careful
not to use excessive suction from the
syringe; the blood is drawn slowly and
carefully.
Note: The infusion set has plastic "wings"
that are attached to a short length of flexible
plastic tubing, which is then attached to
either a syringe or IV tubing.
Note: As soon as the needle is in the vein,
blood will be visible in the tubing, and this
will allow for easy access by the syringe.
3. Fill the tube with the appropriate amount
of blood, release the tourniquet, and
attach a needle. Transfer to the
appropriate tubes using the same order as
for a syringe.
4. When using a safety infusion set, slide the
safety cover over the needle and discard
the set.
5. In order to prevent an accidental restick
with the infusion set needle, hold the base
of the needle or the wings as you remove
the needle, and do not let go of the needle
base until it is being placed in the
biohazard sharps container.
SPECIAL CONSIDERATIONS
If no blood is obtained, change the position of the needle carefully. Move
it forward or backward. Watch for formation of a hematoma. If this
occurs, stop the procedure. Also consider adjusting the angle of the
needle.
If blood stops flowing into the vacuum tube, the vein may have
collapsed. Resecure the tourniquet to increase venous filling. If this is
not successful, remove the needle, take care of the puncture site, and
redraw.
Never draw from a thrombosed or scarred vein. Thrombosed veins lack
resilience, feel cordlike, and roll easily.
Never attempt venipuncture in an artery. Arteries pulsate, are very
elastic, and have a thick wall. If you see bright red blood, be cautious:
Remove the tourniquet, carefully remove the needle, and apply a firm
steady pressure for at least 10 minutes.
60 Chapter 5— Venipuncture
Never draw above an IV site. The fluid may dilute the specimen; collect
from the opposite arm. Do not use alcohol when drawing a blood alcohol
sample.
Never draw over scars or new tattoo sites. It is difficult to puncture the
scar tissue, and the needle and the tourniquet should not come in
contact with the inflamed tattoo site. Edematous extremities with
swollen tissue alter the test results.
Avoid leaving a tourniquet on for more than 2 minutes. This can cause
hemoconcentration of nonfilterable elements. The hydrostatic pressure
causes some water and filterable elements to leave the extracellular
space.
Make sure the venipuncture site is dry.
When using a syringe, avoid drawing the plunger back too forcefully.
FOLLOW-UP CARE AND
INSTRUCTIONS
■ Advise the patient that he or she may experience some minor discomfort
and discoloration at the site of the venipuncture for the following 48 to
72 hours.
■ Instruct the patient to keep the site clean and dry to reduce the
likelihood of infection.
Educate the patient about signs of infection and phlebitis and advise him
or her to call or return to the office if such signs are seen.
References
Centers for Disease Control and Prevention: Guidelines for the
prevention of transmission of human immunodeficiency virus and
hepatitis B virus to health-care and public-safety workers. MMWR
Morb Mortal Wkly Rep 38(suppl 6):l-37, 1989.
McCall RE, Tankersley CM: Phlebotomy Essentials. Philadelphia, JB
Lippincott, 1998, pp 2-4.
Bibliography
Bardes CL: Essential Skills in Clinical Medicine. Philadelphia, FA Davis,
1996, pp 104-106.
Chesnutt MS, Dewar TN, Locksley RM, Turee JH: Office and Bedside
Procedures. Norwalk, Conn, Lange, 1992, pp 27-29.
Fischbach F: A Manual of Laboratory and Diagnostic Tests, 5th ed.
Philadelphia, JB Lippincott, 1996, pp 25-27.
Chapter 5— Venipuncture 61
Greene HL, Fincher RM, Johnson WP, et al: Clinical Medicine, 2nd ed. St.
Louis, CV Mosby, 1996, pp 874-878.
Jacobs DS, DeMott WR, Grady HJ, Horvat RT: Laboratory Test
Handbook. Lexicomp, 1996, pp 197-200.
Jandl JH: Blood: Textbook of Hematology. Boston, Little, Brown, 1997,
pp 53-55.
McClatchey KD: Clinical Laboratory Medicine. Baltimore, Md, Williams
&Wilkins, 1996, pp 84-90.
Sacher RA, McPherson RA: Wildmann's Clinical Interpretation of
Laboratory Tests, 11th ed. Philadelphia, FA Davis, 2000, p 31.
Wallach J: Interpretation of Diagnostic Tests, 7th ed. Philadelphia,
Lippincott Williams & Wilkins, 2000, pp 3-17.
Cha
Pter6
Obtaining Blood Cultures
Darwin Brown
Procedure Goals and Objectives
Goal: To obtain a blood culture sample successfully while
observing standard precautions and with the minimal degree of
risk to the patient.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
obtaining a blood culture sample.
• Identify and describe common complications associated with
obtaining a blood culture sample.
• Describe the essential anatomy and physiology associated with
obtaining a blood culture sample.
• Identify the materials necessary for obtaining a blood culture
sample and their proper use.
• Identify the important aspects of patient care after a blood
culture sample is obtained.
63
64 Chapter 6 — Obtaining Blood Cultures
BACKGROUND AND HISTORY
A blood culture is performed when an infection of the blood (bacteremia
or septicemia) is suspected in the presence of fever, chills, low blood
pressure, or other symptoms. The blood culture helps identify the infection's
origin and provides a basis for determining appropriate antimicrobial
therapy.
Bacteremia is a microbial infection of the bloodstream. Identification of
pathogens within the bloodstream is accomplished primarily by blood culture.
Culturing blood is one of the most important procedures that can be
performed in individuals who are severely ill and febrile as well as those in
whom an intravascular infection is suspected. Isolation and identification of
an infectious agent from the blood have obvious diagnostic significance and
provide an invaluable guide for selecting the most appropriate antimicrobial
agent for therapy (Hoeprich, 1994).
Sources of bacteremia include focal sites of infection most often associated
with the respiratory tract, the genitourinary tract, the abdomen, and the skin
and soft tissues. The infecting organism results from organisms indigenous
to the site.
Until approximately 1985, broth culture was the most conventional blood
culture method. Conventional broth culture methods call for inoculating
blood to liquid media contained in bottles or tubes. Today there is a wide
variety of media from which to choose. The obtained cultures are incubated
either aerobically or anaerobically for 7 to 14 days at 35° C. They are then
examined visually every day for evidence of growth; in addition, blind
subcultures and smears are prepared at scheduled intervals.
INDICATIONS
Blood cultures are a useful diagnostic tool for the evaluation of patients with
a history and clinical physical examination findings that are indicative of
bacteremia or septicemia.
■ Blood cultures should be obtained only if there is reasonable suspicion
of a bloodstream infection (bacteremia). A thorough history and physical
examination can provide important information for determining the
potential of an infectious state.
■ Documentation should be made of the specific infecting organism in
bacteremia or focal infection sites.
■ Blood cultures are useful for monitoring the efficacy of pharmacologic
treatments of blood-borne infections.
■ Other specific indications for obtaining blood cultures include severely
ill and febrile patients, suspected infective endocarditis, intravascular
catheter site infection, meningitis, osteomyelitis, septic arthritis,
bacterial pneumonia, and fever of unknown origin.
Chapter 6 — Obtaining Blood Cultures 65
CONTRAINDICATIONS
There are few true contraindications to obtaining blood cultures.
Patients currently being treated with warfarin (Coumadin) should be
assessed carefully to determine if the benefit of performing the procedure
outweighs the potential risk.
■ Obtaining blood cultures should be avoided at the site of an active skin
infection because of the probability of introducing bacteria into the
blood circulation and the increased possibility of contamination of the
culture by organisms originating from the infected structures.
If multiple previous blood cultures have failed to identify an infecting
agent, the likelihood of obtaining a useful result is diminished and must
be considered in view of all the available clinical evidence.
POTENTIAL COMPLICATIONS
Complications resulting from the collection of a blood culture are limited.
The development of a hematoma at the site of the venipuncture is not
uncommon.
■ Continued bleeding from the puncture site also may occur.
■ Other possible complications include the development of a localized skin
infection or phlebitis.
■ Contaminated blood samples may result in the inappropriate use of
antibiotics, which, in turn, may enhance selection for multidrug-resistant
organisms. This may increase the rate of nosocomial infections and
antibiotic-related complications, possibly raising health care costs
(Chien, 1998).
In general, contamination should be suspected if:
■ A common component of the skin flora is recovered and the patient's
history does not warrant consideration of a "nonpathogen" as being
significant.
■ A mixture of several kinds of bacteria is recovered.
■ Growth is found in only one of several specimens from separate
venipunctures (Hoeprich, 1994).
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
It is important to know the specific anatomy of each area from which blood
cultures will be obtained. It is generally accepted that for each septic episode,
66 Chapter 6 — Obtaining Blood Cultures
Cephalic vein
Accessory
cephalic vein
Cephalic vein
Basilic vein
Median
cubital vein
Basilic vein
Median
antebrachial
vein
Basilic vein
Metacarpal
veins
Cephalic vein
Dorsal venous
vein
Superficial veins,
inner aspect of forearm
Superficial veins,
dorsal aspect of hand and wrist
Figure 6-1 . Venous anatomy of the arm and hand.
at least two sets of blood culture specimens should be collected. This results
in two separate venipunctures at different sites. The median cubital vein
usually is the easiest to locate. Other acceptable locations include the cephalic
and basilic veins and veins in the back of the hand (Fig. 6-1). For more
information regarding the anatomy and physiology of veins, see Chapter 5.
Standard Precautions Practitioners should use
standard precautions at all times when
interacting with patients. Determining the level
of precaution necessary requires the practitioner
to exercise clinical judgment based on the
patient's history and the potential for exposure
to body fluids or aerosol-borne pathogens (for
further discussion, see Chapter 2).
Chapter 6 — Obtaining Blood Cultures 67
PATIENT PREPARATION
Instruct the patient about the need for the procedure and the potential
benefits and risks associated with having the procedure performed.
■ Explain that the procedure includes skin preparation and the potential
need to use two separate venipuncture sites.
If the patient notes an allergy to iodine, use chlorhexidine or 70%
isopropyl alcohol for site cleansing.
Materials Utilized for Obtaining Blood Cultures
20-mL syringe with 21-gauge needle or vacuum tube adapter and needle
70% isopropyl alcohol swabs or wipes
1% to 2% tincture of iodine, povidone-iodine, or chlorhexidine gluconate
swabs or wipes
Alcohol swabs for cleaning blood culture bottle tops
Aerobic and anaerobic vacuum blood culture bottles with properly
identified patient labels
Tourniquet
Gloves
2-inch x 2-inch gauze pads
Bandages
Procedure for Obtaining a Blood Culture
1. Identify the patient. Ask the patient to
state his or her name and then check and
confirm other identification information.
2. Initial setup: Assemble and lay out
equipment for collecting the blood culture
specimen. Wash your hands before
putting on gloves.
3. Position the patient. Make sure patient is
in a comfortable position and that the
arm is supported appropriately.
4. Apply tourniquet 3 inches above intended
site. Locate an appropriate vein and then
release tourniquet.
5. Clean the site using sterile 70% isopropyl
alcohol wipes; starting at the intended
site, move outward in concentric circles
(Fig. 6-2). Repeat this two or three times,
being sure to use a new, clean wipe each
time.
continued
68 Chapter 6 — Obtaining Blood Cultures
Figure 6-2.
6. Next apply povidone-iodine in the same
manner two or three times and allow site
to air dry. Once dry, the site should not
be touched again. Sterile gloves must be
worn if the site is to be repalpated.
7. Replace the tourniquet and remove the
iodine with 70% isopropyl alcohol just
before venipuncture.
8. Perform the venipuncture using a syringe
or vacuum tube system.
9. Draw blood in the correct order. If
specimens for multiple laboratory tests
are to be obtained, always collect the
blood culture specimens first, and then
fill the other tubes as needed. Swab the
top of the blood culture bottle with an
alcohol wipe before blood insertion.
Inoculate anaerobic bottle, followed by
aerobic bottle.
10. Release the tourniquet after the first tube
has been filled. The tourniquet should
not be left on for more than 1 minute.
11. After the specimen has been collected,
remove the needle and apply pressure
until bleeding has stopped.
12. Immediately dispose of the needle in the
proper container. Do not attempt to
recap needles.
13. After the specimen has been collected,
label all cultures with appropriate patient
information, which should include
patient's full name, identification number,
culture site location, time, date, and
your initials.
14. Clean the patient's arm of iodine before
placing an adhesive bandage. Check to
make sure the site is not bleeding before
covering with bandage.
15. Pick up and account for all materials
before leaving the patient's room. Remove
your gloves and wash your hands. Thank
the patient for his or her cooperation.
SPECIAL CONSIDERATIONS
The issue of using indwelling central catheters for obtaining blood cultures
is somewhat controversial, and studies are conflicting (DesJardin, 1999). If a
blood sample for culture is to be obtained during the placement of a central
venous catheter, the catheter must be one that is placed in a completely
sterile manner above the chest. If an indwelling central venous or arterial
catheter is already in place, samples must be taken from both the catheter
port and peripheral venipuncture sites to rule out line sepsis (Chien, 1998).
For infants, collect 1 to 5 mL of blood per 100-mL blood culture bottle (Hall,
1995).
Chapter 6 — Obtaining Blood Cultures 69
FOLLOW-UP CARE AND
INSTRUCTIONS
■ Advise the patient that he or she may experience some minor discomfort
and discoloration at the site of the venipuncture for the following 48 to
72 hours.
■ Instruct the patient to keep the site clean and dry to reduce the
likelihood of infection.
■ Explain to the patient the signs of hematoma, infection, and phlebitis and
instruct him or her to call or return to the office or clinic if any of these
occurs.
■ Advise the patient to report any adverse events associated with the
venipuncture. These may include development of a hematoma or
continued bleeding from the venipuncture site.
References
Chien JW: Making the most of blood cultures. Postgrad Med 104:120,
1998.
DesJardin JA, Falagas ME, Ruthazer R, et al: Clinical utility of blood
cultures drawn from indwelling central venous catheters in
hospitalized patients with cancer. Ann Intern Med 131:641-647, 1999.
Hall G: Microbiology. In Tietz NW (ed): Clinical Guide to Laboratory
Tests, 3rd ed. Philadelphia, WB Saunders, 1995, p 904.
Hoeprich PD, Rinaldi MG: Diagnostic methods for bacterial, rickettsial,
mycoplasmal, and fungal infections. In Hoeprich PD, Jordan MC,
Ronald AR (eds): Infectious Diseases: A Treatise of Infectious
Processes, 5th ed. Philadelphia, JB Lippincott, 1994, pp 169-171.
Bibliography
Flynn JC: Procedures in Phlebotomy, 2nd ed. Philadelphia, WB
Saunders, 2005.
Garza D, Becan-McBride K: Phlebotomy Handbook: Blood Collection
Essentials. Upper Saddle River, NJ, Pearson Prentice Hall, 2005.
Gill VJ, Fedorko DP, Witebsky FG: The clinician and the microbiology
laboratory. In Mandell GL, Bennett JE, Dolin R (eds): Mandell,
Douglas, and Bennett's Principles and Practice of Infectious Diseases,
6th ed, vol I. Philadelphia, Elsevier/Churchill Livingstone, 2005,
pp 209-210.
Lehmann CA (ed): Saunders Manual of Clinical Laboratory Science.
Philadelphia, WB Saunders, 1998.
Inserting Intravenous Catheters
Ellen Davis-Hall
Procedure Goals and Objectives
Goal: To insert an intravenous (IV) line successfully while observing
standard precautions and with the minimal degree of risk to the
patient.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
insertion of an IV line.
• Identify and describe common complications associated with IV
line insertion.
• Describe the essential anatomy and physiology associated with
the insertion of an IV line.
• Identify the necessary materials for insertion of an IV line and
their proper use.
• Identify the important aspects of patient care after insertion of
an IV line.
Chapter *T
71
72 Chapter 7— Inserting Intravenous Catheters
BACKGROUND AND HISTORY
Once William Harvey described the circulation of blood in 1628, experi-
mentation with this system was inevitable. It was in 1656, however, that Sir
Christopher Wren used a quill and bladder to inject opium intravenously into
a dog, and IV therapy was begun (Gardner, 1982). Because of the sepsis
accompanying such endeavors, IV therapy did not come into general use
until the 1920s (Weinstein, 1997).
Little controversy exists over the value of IV therapy, and its use is wide-
spread. Performance of this activity is highly technical and demands careful
instruction and supervised experience. Various professionals and technicians
can initiate IV therapy. This is regulated by state law and may vary.
INDICATIONS
Indications for IV therapy include the following:
■ The administration of fluids (e.g., in clinical situations such as volume
depletion, burn injury, blood loss, heat illness, shock, electrolyte
imbalance)
■ The provision of rapid and efficient delivery of medications (e.g., in
various medical and surgical states and emergencies)
The administration of blood or blood products
CONTRAINDICATIONS
There are few contraindications to IV therapy.
■ Venipuncture should be avoided at the site of an active skin infection,
because of the probability of introducing bacteria into the blood
circulation.
■ IV lines should not be inserted distal to any area of preexisting
thrombophlebitis.
■ Lower extremity venipunctures should be avoided in elderly patients and
those with peripheral vascular disease and venous insufficiency. These
compromised veins will not be effective vessels for fluid or medication
administration, and the veins may suffer further injury.
POTENTIAL COMPLICATIONS
Local
■ Thrombosis or thrombophlebitis is the result of mechanical trauma to
the vein at the time of insertion and the subsequent indwelling nature of
Chapter 7— Inserting Intravenous Catheters 73
the IV cannula. To prevent or minimize these complications, avoid
trauma at time of insertion, tape the cannula securely to prevent
movement, and avoid inserting IV lines in close proximity to joints.
Infiltration of an IV line may cause the patient discomfort and increase
the risk of infection and local tissue damage. Close observation and early
detection will prevent or minimize this complication.
Local infection may also develop but can usually be avoided by adherence
to sterile technique and regular dressing changes at the puncture site.
Systemic
■ Catheter embolization is a rare occurrence that results from shearing off
of a distal portion of the catheter end by the beveled needle tip. This
may occur when either an over-the-needle or a through-the-needle
catheter is advanced into the vein and is then pulled back over or
through the needle. This serious complication is avoidable by strict
adherence to proper technique.
Septicemia can usually be avoided by adherence to sterile technique and
established institutional IV line care protocols.
Pulmonary embolism may occur when a small blood clot that may form
near the IV site dislodges and travels through the circulation until it
lodges in the small capillary bed of the lungs. Avoidance of lower
extremity veins helps prevent this occurrence.
■ Air embolism occurs when air, inadvertently left in or allowed into the IV
tubing, travels into the bloodstream. This can be avoided by careful
attention to flushing all lines before connection.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
The anatomy of the veins that are most commonly considered for IV line
placement is presented in Figure 7-1. Use of veins in the arm is recommended
because they are most accessible, most comfortable for the patient, and the
easiest to secure for long-term therapy. Often the easiest access is available
on the dorsal aspect of the hand and the lower aspects of the arm; the
metacarpal and cephalic veins are used most frequently. Valves may be
palpable as knotlike lumps in a vein. These valves, as well as bifurcations,
should be evaluated to ascertain adequate length and straightness for
threading of the IV needle and catheter.
The choice of a vein for IV line insertion is based on the prescribed
therapy, the duration of therapy, the condition of the extremity and the
patient in general, and the condition, size, and location of the veins.
74 Chapter 7— Inserting Intravenous Catheters
Cephalic vein
Accessory
cephalic vein
Cephalic vein
Basilic vein
Median
cubital vein
Basilic vein
Median
antebrachial
vein
Basilic vein
Metacarpal
veins
Cephalic vein
Dorsal venous
vein
Superficial veins,
inner aspect of forearm
Superficial veins,
dorsal aspect of hand and wrist
Figure 7- 1 . Anatomy of the veins most commonly considered for intravenous (IV)
line placement.
Standard Precautions Practitioners should use
standard precautions at all times when
interacting with patients. Determining the level
of precaution necessary requires the practitioner
to exercise clinical judgment based on the
patient's history and the potential for exposure
to body fluids or aerosol-borne pathogens (for
further discussion, see Chapter 2).
PATIENT PREPARATION
The patient should be informed of the indications for the IV line, the
benefits and risks associated with the procedure, and the steps involved
in the procedure. The patient may be anxious or afraid of the IV line
itself or the anticipated pain, and explaining the procedure may help
alleviate some of the anxiety.
Chapter 7— Inserting Intravenous Catheters 75
Inquire about iodine, latex, and tape allergies.
The patient should also be advised of the need to limit movement of the
extremity once the IV line is in place.
Occasionally, in pain-sensitive individuals, an injection of 0.5% to 1.0%
lidocaine (Xylocaine), to raise a wheal at the puncture site, may help
minimize discomfort. This can be accomplished with a needle as small as
27 gauge. This may be helpful especially when a larger gauge butterfly or
catheter is required. The patient should be warned, however, of the "bee
sting and burn" nature of the lidocaine injection. The patient must be
carefully screened for the possibility of previous allergic reactions to
lidocaine before using this technique.
Materials Utilized for Inserting Intravenous Lines
Intravenous catheter or butterfly
Note: There are a large number of catheters available for IV cannulation.
The most common choice is the over-the-needle catheter. An alternative to
this is the butterfly or winged small vein needle. The use of these two types
of infusion devices is the focus of this section. They are presented in
Figure 7-2. Beginning in 2001, IV catheters with safety mechanisms were
required. These retract the steel needle into a closed device to minimize
the chance of a needle stick. The gauge of the catheter or butterfly needle
is chosen based on the vein used and the purpose of the infusion. A plan to
administer blood, for example, demands a larger gauge, such as 16 gauge,
Butterfly
Over-the-needle catheter with safety retraction device
Figure 7-2. Butterfly and over-the-needle catheters.
76 Chapter 7— Inserting Intravenous Catheters
whereas IV fluids alone can be administered with a needle having a gauge
as small as 23. While closed infusion systems have been in use for some
time, recently this concept has also been applied to the IV catheter system.
Such a closed system combines the over-the-needle catheter, short
extension set or needleless access connector, or both. This system reduces
the chance of blood spills, and decreases the potential for contamination.
■ Gloves and eye protection
■ A topical antimicrobial to cleanse the skin
Intravenous fluid
■ Administration set (tubing with a drip chamber, a roller clamp flow
regulator, and a standard connector that fits into the hub of the cannula
or butterfly needle)
■ Tourniquet
■ ^-inch tape
■ Arm board (if necessary to prevent flexion of a joint near the IV insertion
point)
■ Scissors to trim hair (if necessary)
■ 2-inch x 2-inch or 4-inch x 4-inch gauze bandages or other occlusive
dressing
IV catheter pole
■ Biohazardous waste and needle containers
■ Antibiotic ointment (optional)
Procedure for Inserting an Intravenous Catheter
1. Apply the tourniquet above the elbow to
ensure adequate filling of the veins, first
to one arm and then to the other, to
identify the best vein for IV catheter
insertion.
Note: The most distal vein that is large
enough to accommodate the size of the
required butterfly needle or catheter should
be chosen.
2. Palpate the veins for firmness and
stability.
Note: Selection of the vein should be
determined more by how the vein feels than
by how it looks. Choose a vein that is
straight and void of palpable valves for at
least 1 inch proximal to your intended
insertion site.
3. Release the tourniquet and recheck all
supplies. Make certain that all necessary
materials are within easy reach, the
fluids are hung, and the tubing is flushed
with the IV solution.
Chapter 7— Inserting Intravenous Catheters 77
4. Reapply the tourniquet above the elbow.
Use low tourniquet pressure to avoid
damaging the vein in a geriatric patient.
A blood pressure cuff will be gentler to
sensitive tissue than a tourniquet.
5. If tourniquet pressure does not distend
the vein adequately, ask the patient to
open and close the hand several times,
tap or pat the vein lightly, apply a warm
moist towel, or have the patient place
the extremity lower than the heart to
facilitate vein dilation.
6. Apply gloves and eye protection.
7. Cleanse the puncture site with an
approved antimicrobial solution such as
chlorhexidine gluconate (O'Grady, 2002).
This particular topical should be applied
using a back and forth motion, with
friction, and allowed to dry for 30 seconds.
8. With the nondominant hand, hold the
patient's hand or arm and retract the
skin distal to the insertion site toward
the fingers.
Note: This serves to make the skin taut and
anchors the vein to help prevent it from
"rolling" (Fig. 7-3).
Over-the-needle
catheter
9. Puncture the vein using direct or indirect
entry:
Note: Direct entry (one step) is useful for
larger veins.
• Warn the patient of the "stick."
• With the dominant hand, insert the
butterfly or catheter needle (bevel up)
through the skin at a 15- to 30-degree
angle at the site of anticipated vein entry.
• As soon as the skin is punctured, and with
one continuous motion, drop the hub
down close to the skin, if needed, and
enter the vein from the top (see Fig. 7-3).
Note: Indirect entry (two steps) is useful for
smaller veins.
• Warn the patient of the "stick."
• With the dominant hand, insert the
butterfly or catheter needle (bevel up)
through the skin and tissue at a 15- to
30-degree angle slightly distal to the
anticipated point of vein entry.
• Relocate the vein and while maintaining
the distal anchor, enter the vein either
from the top or the side. A "pop" may be
felt with vein puncture.
Figure 7-3.
continued
78 Chapter 7— Inserting Intravenous Catheters
Note: If the vein is successfully entered,
there will be a flashback of blood into the
butterfly or catheter hub tubing.
10. In the case of the catheter, after the
initial appearance of the flash, advance
the device 2 to 3 mm further to help
ensure that the catheter is not
inadvertently removed from the vein
when the stylette is removed.
11. If the IV line insertion attempt is
unsuccessful (no flashback), pull the
butterfly and intact catheter back
slightly, but not out of the skin.
12. Reassess the location and anchoring of
the vein and advance the butterfly or
catheter again in the direction of the
vein. If the attempt is unsuccessful, the
tourniquet should be released and the
butterfly or catheter removed (Heckman,
1993).
13. Apply pressure for 1 minute and then
attempt insertion at a more proximal site
or in the other extremity.
14. Once removed from the skin puncture,
properly discard the butterfly or
catheter.
Over-the-needle
catheter
Caution: Never reuse a catheter.
15. Once the flashback is achieved, the vein
can be cannulated with the butterfly
needle or catheter.
Over- the- Needle Catheter
Cannulation
• Hold the needle base firmly in place with
the nondominant hand while advancing
the catheter with the dominant hand over
the needle and threading into the vein all
the way to the catheter hub (Fig. 7-4).
• Hold the catheter flange in place with the
nondominant hand.
• Apply light pressure to the vein proximal
to the indwelling catheter tip with the
little or long finger of the nondominant
hand, release the tourniquet, and activate
the needle retraction safety device
(Fig. 7-5).
• If you do not have a closed unit system,
attach the administration set and release
proximal pressure on the vein (Fig. 7-6).
The infusion may begin.
Figure 7-4.
Chapter 7— Inserting Intravenous Catheters 79
Figure 7-5.
Figure 7-6.
Caution: Once the stylette has been
separated or withdrawn from the catheter
(even partially), it should never be
reinserted. Attempting to do so can result in
the shearing off of a small portion of the
distal catheter, which then floats free in the
circulatory system. This small piece of
catheter floats until it lodges in a smaller
vessel and potentially creates a site for
embolism and infarction.
Butterfly Needle
Cannulation
• Once the flashback is noted, thread the
needle in gently up the distended vein to
its hub with the dominant hand (Fig. 7-7).
Be careful not to puncture the vein's
posterior wall.
• Hold the plastic butterfly portion of the
IV line in place against the skin with the
continued
80 Chapter 7— Inserting Intravenous Catheters
Figure 7-7.
nondominant hand and apply light
pressure to the vein proximal to the
indwelling needle tip with the little finger
of this hand.
• Release the tourniquet and, if you do not
have a closed unit system, attach the
administration set.
• Last, release the proximal pressure on the
vein and begin the infusion.
16. Inspect the site for any signs of swelling.
If swelling is observed, turn off the
infusion of fluids and remove the IV line.
Apply pressure to the site for at least
Figure 7-8.
3 to 5 minutes. Insertion of the IV line
should next be attempted at a more
proximal site or in the other
extremity.
17. Secure the butterfly or catheter with
chevron taping. Slip a 4- to 5-inch-long
piece of l^-inch tape under the base of
the IV line, adhesive side up, and then
cross over the hub to adhere it to the
skin proximal to the insertion site.
18. Tape the distal end of the administration
set tubing to the skin. Avoid taping over
the insertion site (Fig. 7-8).
Chapter 7— Inserting Intravenous Catheters 81
Note: Some institutions recommend the use
of an antibiotic ointment at the IV insertion
site.
19. Apply either a gauze bandage or an
occlusive dressing over the site.
20. Loop and secure the tubing separate
from the butterfly or catheter (Fig. 7-9).
Figure 7-9.
SPECIAL CONSIDERATIONS
• Butterfly IV line equipment is especially
useful in the pediatric population. It has also
been termed a scalp vein IV line because of
this historically useful site for infants
(Weinstein, 1997). However, scalp veins are
no longer the first choice for IV access in
babies. With small IV catheters available, the
sites currently recommended are the hand,
forearm, upper arm, foot, and antecubital
fossa. Proper securing of the IV line in
children is paramount.
• In the geriatric population, the smallest
catheter possible (based on infusion
indication) should be used. Skin care is an
important consideration, with careful
securing of the catheter onto the often
fragile skin. A tourniquet may not be
necessary. Although the site selection
process is the same as the one for adults
presented earlier, in geriatric patients, the
smaller vessels may be fragile and rupture
easily. At the other extreme, the larger,
hardened, distended veins may represent
sclerotic vessel walls, which may make
puncture and threading difficult. It is
important to avoid lower extremity IV lines in
this population.
82 Chapter 7— Inserting Intravenous Catheters
FOLLOW-UP CARE AND
INSTRUCTIONS
Instruct the patient receiving IV therapy or the caregiver to notify the IV
therapist if there is burning, stinging, redness, bleeding, or swelling at
the insertion site. These may be initial signs of infection. The IV solution
should be discontinued immediately if these symptoms occur.
The rare patient on home IV therapy will require additional education in
regard to fluid management, dressings, and possible complications. The
most common complication of any IV therapy is phlebitis, which is often
a result of movement of the needle or catheter within the vein. This vein
may appear indurated, tender, erythematous, hardened, and very warm
to the touch. The IV line should be removed immediately (Way, 1994). If
the patient experiences significant discomfort, oral analgesics and warm,
moist soaks to the area may be administered (Sager, 1980).
References
Gardner C: United States House of Representatives honors the National
Intravenous Therapy Association, Inc. J Natl Intravenous Ther Assoc
5:14, 1982.
Heckman J: Emergency Care and Transportation of the Sick and Injured.
Rosemont, 111, American Academy of Orthopaedic Surgeons, 1993.
O'Grady NP, Alexander M, Dellinger EP, et al: Guidelines for the
prevention of intervascular catheter-related infections. MMWR
Recomm Rep 51(RR-10):l-29, 2002.
Sager D, Bomar S: Intravenous Medications. Philadelphia, JB Lippincott,
1980.
Way L: Current Surgical Diagnosis and Treatment. Norwalk, Conn,
Appleton & Lange, 1994 .
Weinstein S: Plummer's Principles and Practices of Intravenous
Therapy. New York, Lippincott-Raven, 1997.
Chapter O
Arterial Puncture
Claire Babcock O'Connell
Procedure Goals and Objectives
Goal: To obtain a high-quality sample of arterial blood while
observing standard precautions and with a minimal degree of risk
to the patient.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing an arterial puncture.
• Identify and describe common complications associated with
arterial punctures.
• Describe how to perform an Allen test.
• Describe the essential anatomy and physiology associated with
the performance of an arterial puncture.
• Identify the materials necessary for performing an arterial
puncture and their proper use.
• Properly perform the actions necessary to collect an arterial
sample of blood.
• Identify the important aspects of post-procedure care after an
arterial puncture.
83
84 Chapter 8— Arterial Puncture
BACKGROUND AND HISTORY
Gaining intentional access to the circulatory system has been practiced for
centuries. As discussed in Chapter 5, at approximately 400 bc, Hippocrates
expressed the view that disease was a result of excess substances such as
blood, phlegm, black bile, and yellow bile within the body Resulting from
this view, it was believed that the removal of the excess could restore balance.
Bloodletting, which involved cutting into a vein with a sharp instrument to
release blood from the circulatory system, was commonplace.
Accessing the arterial system specifically is a relatively recent procedure.
The first recorded arterial puncture was performed in 1912, and the first
arterial sample used for blood gas analysis was obtained in 1919. However,
routine blood gas analysis was not practiced until after 1953, with the intro-
duction of technology designed to measure oxygen pressure (McCall, 1998).
INDICATIONS
Arterial puncture is indicated whenever a sample of arterial blood is
required. Unlike in venous blood, the level of dissolved gases in an arterial
sample is constant throughout the arterial system. Therefore, a sample
obtained from any arterial site represents the true level of gases dissolved in
the blood within the arterial system and provides a more accurate assessment
of ventilation and oxygenation. Arterial blood is preferred whenever an
assessment of the level of dissolved gases is needed for diagnostic or thera-
peutic purposes. The following is a list of conditions that may necessitate
arterial sampling:
■ Diagnosis of an acute dysfunction in C02/02 exchange or acid-base
balance: Conditions include severe exacerbations of asthma, suspected
pulmonary thromboembolism, coma of unknown cause, suspected drug
overdose, shock states and cardiac arrhythmias that are refractory to
medical intervention.
■ Monitoring the severity and progression of a documented disease process
in patients with a chronic condition that affects C02/02 exchange or acid-
base balance: Progressive chronic obstructive pulmonary disease (COPD)
may be monitored through changes from baseline arterial blood gas
values. Patients receiving long-term oxygen therapy should be monitored
when changes in status occur and periodically to document status.
■ After therapeutic hyperventilation therapy or cardiopulmonary
resuscitation, arterial blood gas determinations assist with the need to
quantify the patient's response to therapeutic interventions, thus
monitoring a return to baseline or the need for further intervention.
Procurement of an arterial sample may be preferred for a specific laboratory
test that offers the most accurate assessment when performed on arterial
blood. An arterial blood sample is preferable to venous blood samples when
Chapter 8— Arterial Puncture 85
Figure 8-1 . Modified Allen test. (Redrawn from Pfenninger JL, Fowler GC [eds]:
Procedures for Primary Care Physicians. St. Louis, Mosby-Year Book, 1994, p 343.)
assessing ammonia levels, carbon monoxide levels, and lactate levels. Other
laboratory tests can be performed using an arterial sample when venous
access cannot be readily obtained, such as emergency situations of severe
hypovolemia.
CONTRAINDICATIONS
Arterial puncture for blood sampling is absolutely contraindicated
whenever the arterial pulse is not palpable.
For the radial artery, negative results of a modified Allen test (collateral
circulation test) suggest an inadequate collateral blood supply to the
hand, and an alternate arterial site should be selected. To perform the
Allen test (Fig. 8-1), have the patient make a tight fist and elevate the
hand; occlude both the radial and ulnar arteries using firm pressure for
approximately 1 minute until the hand appears blanched. Lower the
hand while maintaining pressure and instruct the patient to open the fist.
Release only the ulnar compression while maintaining the radial artery
pressure. Color should return to the entire hand within 15 seconds
(positive test). Failure of color to return to normal indicates occlusion of
the collateral circulation (negative test); radial artery puncture in this
setting may result in ischemia and gangrene distal to the site and should
not be attempted.
Attempting an arterial puncture when surface landmarks are not visible
is not recommended.
Arterial puncture is inadvisable in the presence of arterial disease,
including atherosclerosis, arterial inflammatory conditions, or known or
suspected aneurysm.
The higher pressure inherent to the arterial system makes arterial
puncture a considerably higher risk in a patient with a coagulopathy,
severe thrombocytopenia, or in a patient undergoing anticoagulant
therapy; a possible future need for such therapy should also be
considered.
86 Chapter 8— Arterial Puncture
Arterial puncture should also be avoided in a patient undergoing therapy
for end-stage renal disease who has an arteriovenous shunt or may need
placement in the near future.
Local skin irritations, including infections (such as cellulitis), chronic
skin rashes, and burned areas should be avoided. If these conditions are
present in the site desired for arterial puncture, an alternative site
should be selected.
POTENTIAL COMPLICATIONS
Arterial puncture is an invasive procedure with the potential for significant
complications and must be performed with priority given to the safety of the
patient. Any break from the proper safety technique can cause injury to the
patient, which may result in loss of form and function to the body distal to
the arterial puncture site. The risk of complications is increased any time
repeated punctures are attempted at the same site.
■ The most common complication is hemorrhage or hematoma formation
at the puncture site. This occurs more often in brachial and femoral
punctures than in radial punctures. Using the smallest gauge needle
acceptable for the task helps decrease the risk of hemorrhage or
hematoma formation. Hematoma development can best be minimized by
prompt pressure placed on the puncture site continuously for 10
minutes after the procedure is complete.
Thrombosis is more common at the radial artery than at the brachial or
femoral artery. It is more likely if the arterial puncture is performed on a
vessel with occlusive disease. Thrombosis may lead to ischemia and
gangrene distal to the puncture. Thrombosis may also lead to distal
embolization of a clot or plaque with resultant arterial occlusion. The
potential for loss of function of the hand or fingers is considerable if
arterial embolism occurs and is not quickly recognized and treated. The
likelihood of thrombosis can be reduced by varying the site of repeated
puncture and by using the smallest gauge needle possible. It is
imperative to check for collateral circulation (Allen test) before a radial
puncture.
A transient arterial spasm may occur during or after arterial puncture. If
this occurs, continue to monitor and assess the collateral circulation. If
the circulation remains impaired, vascular consultation should be
obtained. If the collateral circulation is compromised, immediate surgical
intervention is warranted.
Nerve damage may result from the inadvertent direct needle
insertion into the nerve bundle or by excessive nerve compression
secondary to a large hematoma in the adjacent area. If the
patient has a coagulopathy that delays clotting, the risk is
increased.
Chapter 8— Arterial Puncture 87
■ Infection is rare when proper technique is followed. Proper sterile
technique and avoidance of broken or damaged skin when choosing the
site for arterial puncture minimizes this risk.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
Radial Artery
The radial artery is the site most frequently used for arterial puncture. It is
close to the skin surface and readily accessible. It also carries the lowest risk
of complications. The radial artery runs along the lateral aspect of the
anterior forearm and can be easily palpated between the styloid process of
the radius and the flexor carpi radialis tendon. The point of maximal
pulsation is just proximal (1 to 2 cm) to the transverse wrist crease.
Before attempting radial artery puncture, check for collateral circulation
by performing the Allen test. The distal forearm and wrist should be slightly
hyperextended and placed on a firm surface. A small, rolled towel placed
under the wrist helps achieve hyperextension. The forearm, wrist, and towel
can be secured to an arm board with tape for greater stability if necessary.
Brachial Artery
The brachial artery can be accessed if the radial artery has recently been
punctured or is otherwise not available (Fig. 8-2). It carries a greater risk of
complication, including trauma to the basilic vein or median nerve. If
occlusive complications occur, there is greater potential for tissue loss distal
to the artery because the collateral circulation is less extensive. The brachial
artery courses along the medial surface of the antecubital fossa and should
be accessed above the antecubital crease. The arm should be fully extended
and secured to a firm surface, ulnar side up.
Puncture
site
Figure 8-2. The right brachial artery, its branches,
and the anatomic site for brachial artery puncture.
(Redrawn from Pfenninger JL, Fowler GC [eds]:
Procedures for Primary Care Physicians. St. Louis,
Mosby-Year Book, 1994, p 345.)
88 Chapter 8— Arterial Puncture
Puncture
site
Figure 8-3. The right femoral artery and
branches. (Redrawn from Pfenninger JL,
Fowler GC: Procedures for Primary Care
Physicians. St. Louis, Mosby-Year Book, 1994,
p 345.)
Femoral Artery
The femoral artery should be punctured only if radial or brachial artery
access is not possible or advisable (Fig. 8-3). If the patient is severely volume
depleted or is in shock, the femoral artery may be the only pulse with enough
pressure to obtain arterial blood. The femoral artery can be located using
the mnemonic NAVEL (nerve, artery, t>ein, empty space, /ymphatics) from
lateral to medial in the inguinal crease. The patient should be supine on a
firm surface with hip extended and rotated externally.
Standard Precautions Practitioners should use
standard precautions at all times when
interacting with patients. Determining the level
of precaution necessary requires the practitioner
to exercise clinical judgment based on the
patient's history and the potential for exposure
to body fluids or aerosol-borne pathogens (for
further discussion, see Chapter 2).
PATIENT PREPARATION
The patient should be educated concerning the purpose of the test and
advised of the potential level of discomfort and complications associated
with performing the procedure.
Chapter 8— Arterial Puncture 89
If consent forms are available, consent should be obtained.
It is important that the patient remain as still as possible during the
procedure; a supine position is recommended.
If oxygen therapy is adjusted or the patient has been suctioned, wait at
least 15 minutes before sampling to allow gas levels to stabilize.
Materials Utilized for Arterial Puncture
■ 3- to 5-mL glass or special heparinized syringe made for arterial blood
gas collection.
Note: If not available, use plastic syringe and heparinize (see later).
■ 21- to 25-gauge, V2- to ^-inch needle
■ Bag or cup of ice for transport
■ Iodine-containing skin preparation pads
■ Cork board or rubber for needle safety
Rubber stopper or plug for syringe
Sterile gloves (two pairs)
■ Sterile gauze, 2 inch x 2 inch or 4 inch x 4 inch
■ Arm board
■ Tape (V2 to 1 inch)
Goggles
1:1000 lidocaine without epinephrine (1 to 2 mL)
■ Syringe and needle for local anesthesia
Procedure for Arterial Puncture
1. Secure and stabilize the site by placing
the patient's supinated arm on the arm
board and securing with tape. Prepare a
sterile field and gather all equipment.
2. Put on sterile gloves.
3. Cleanse skin with an iodine solution (e.g.,
povidone-iodine [Betadine], iodophor).
Note: Some practitioners prefer to follow
this with an alcohol cleansing. Allow the
area to air dry.
4. Coat the syringe and needle with
heparin; use a plain plastic syringe if a
preheparinized syringe is not available.
Heparinize by aspirating 0.5 mL heparin,
10,000 U/mL, and pulling the plunger to
continued
90 Chapter 8— Arterial Puncture
the end of the syringe while holding the
syringe and needle vertically Slowly
push back on the plunger to evacuate
the heparin. The syringe and needle are
now adequately coated with heparin.
Note: Heparinization of the syringe is
necessary to prevent coagulation of the
sample.
Local Anesthesia
Note: Traditionally, arterial puncture has been
performed without the use of local anesthesia.
Several studies have proved that there is a
significant decrease in pain when local
anesthesia is administered before arterial
puncture. Concerns that local anesthesia
inhibits proper placement by obliterating
landmarks have been unfounded. The use of
local anesthesia does make arterial puncture
a "two-stick" procedure rather than a "one-
stick" procedure. However, the intensity of
the pain associated with arterial puncture
may support the use of the less painful stick
required with local anesthesia.
Note: Use a small amount (1 to 2 mL) of
lidocaine without epinephrine to anesthetize
the local area. Overzealous anesthesia may
obscure landmarks or dull the pulse.
5. Anesthize the area. Advance the needle
to just above the periosteum on each side
of the artery without entering or making
direct contact with the artery. Aspiration
should be attempted before injecting the
anesthetic to ensure that the anesthetic
is injected into the surrounding tissues
and not a blood vessel.
Note: Allow several minutes for the
anesthetic to take effect before performing
the arterial puncture. (For more information
regarding local anesthesia techniques, refer
to Chapter 22.)
Figure 8-4. Needle insertion. (Redrawn from
Pfenninger JL, Fowler GC [eds]: Procedures for
Primary Care Physicians. St. Louis, Mosby-Year
Book, 1994, p 345.)
6. Palpate the artery with the nondominant
hand and locate the point of maximal
pulsation.
7. Face the patient. Hold the syringe like a
dart or a pencil with the bevel facing
proximally
8. Insert the needle at a 40- to 60-degree
angle (60- to 90-degree angle for femoral
puncture) (Fig. 8-4).
9. Advance the needle until blood is seen
entering the hub.
10. If no blood is seen, pull back until the
needle is just below the skin and redirect
the point 1 mm to either side. If the
patient complains of sharp pain
radiating up the arm withdraw slightly
and reposition. Do not exit completely.
11. Once blood enters the hub of the needle,
the arterial pressure should cause blood
to fill the syringe spontaneously.
12. In severely hypotensive patients, slight
aspiration may be required, but this is
rarely necessary.
13. Collect 3 to 5 mL of blood and then
remove the needle with a swift, smooth
motion.
Chapter 8— Arterial Puncture 91
Figure 8-5. Application of pressure. (Redrawn
from Potter P: Fundamentals of Nursing, 4th ed.
St. Louis, Mosby-Year Book, 1997.)
14. Immediately apply firm, continuous
pressure to the area for a minimum of
10 minutes, longer if the patient is
hypertensive or is receiving anticoagulant
therapy. Pressure should be applied
even if no sample is obtained (Fig. 8-5).
Apply a pressure dressing and leave
intact for the next several hours.
Note: It is not advisable to have the patient
apply the pressure; an assistant is
recommended.
15. Hold the syringe and needle upright and
allow any air bubbles to rise; tapping
gently on the side of the syringe may
help. Expel any air from the syringe.
16. Insert the needle into a cork or rubber
piece for safety; remove the needle from
the syringe, dispose of it properly, and
close the syringe with a rubber stopper.
17. Gently roll the syringe between your
palms to ensure uniform mixing of the
sample with the heparin.
18. Label the syringe and place it on ice for
immediate transport to the laboratory.
19. Check the arterial puncture site for
hematoma formation and adequate distal
perfusion.
20. Return to the patient for a repeat check
in 5 minutes and again in 15 minutes.
Monitor for any changes in color,
temperature, vascular incompetency, or
function. Inquire if the patient has
experienced any numbness, increased
pain, or coldness.
21. Record date and time of sampling,
patient temperature, and whether the
patient is on oxygen therapy at the time
of sampling.
SPECIAL CONSIDERATIONS
• Prompt analysis of the sample is imperative.
Delay in analysis or improper chilling causes
the blood to dissociate from the hemoglobin,
thus affecting oxygen levels.
• If air is trapped in the syringe, an open
system exists, which may cause 02 to be
dissolved into the sample, causing a relative
decrease in Pco2 and an increase in Po2. The
use of a Vacutainer system also allows 02 to
enter the sample. A plain plastic syringe may
lose 02 through diffusion.
• In the presence of leukocytosis
(>100,000/mm3) or thrombocytosis
(>106/mm3), consumption of 02 may be great
because of the breakdown of the excess cells.
This is accompanied by a release of C02,
causing a pseudoacidosis. A delay in analysis
or improper chilling enhances this effect. The
Pco2 rises approximately 3 to 10 mm Hg per
hour in an un-iced specimen, but it is stable
for approximately 1 to 2 hours in a properly
iced specimen.
Excess heparin in the syringe causes a
decrease in pH. This is due to the low
pH of heparin and the dilutional effects
on the bicarbonate present in the
sample.
92 Chapter 8— Arterial Puncture
FOLLOW-UP CARE AND
INSTRUCTIONS
■ Patients who have undergone this procedure must be monitored to
ensure that hemostasis has been achieved.
■ Advise the patient that a small amount of tenderness and ecchymosis
may result from the procedure.
■ Advise the patient to seek evaluation if he or she experiences increasing
pain, redness, or coolness of the extremity distal to the arterial puncture
site.
■ Patients should avoid rigorous activity for at least 24 hours.
Reference
McCall RT, Tankersley CM: Phlebotomy Essentials, 2nd ed. Philadelphia,
JB Lippincott, 1998.
Bibliography
Bhardwaj D, Norris A, Won DT: Is skin puncture beneficial prior to
arterial catheter insertion? Can J Anaesth 46:129-132, 1999.
Chestnutt MS, Dewar TN, Locksley RM, Chestnutt M: Office and Bedside
Procedures. New York, McGraw-Hill, 1996, pp 116-127.
Fowler GC: Arterial puncture. In Pfenninger JL, Fowler GC (eds):
Procedures for Primary Care Physicians. St. Louis, Mosby-Year Book,
2003, Ch 79.
Giner J, Casan P, Belda J, et al: Pain during arterial puncture. Chest
110:1443-1445, 1996.
Gomella LG: Clinician's Pocket Reference, 10th ed. New York,
McGraw-Hill, 2004, pp 249-251.
Lightowler JV, Elliot MW: Local anesthetic infiltration prior to arterial
puncture for blood gas analysis: A survey of current practice and a
randomised double blind placebo controlled trial. J R Coll Phys Lond
31:645-646, 1997.
Macklis RM, Mendelsohn ME, Mudge GH: Introduction to Clinical
Medicine, 3rd ed. Philadelphia, Lippincott-Raven, 1994, pp 123-129.
Marini JJ, Wheeler AP: Critical Care Medicine: The Essentials.
Philadelphia, Lippincott Williams & Wilkins, 1997, pp 105-107.
Okeson GC, Wulbrecht PH: The safety of brachial artery puncture for
arterial blood sampling. Chest 114:748-751, 1998.
Cha
pter Q
Injections
Conrad J. Rios
This chapter was adapted from the 1st edition chapter written by Robert J. McNellis, MPH,
PA-C. Mr. McNellis is the Director of Clinical Affairs and Education for the American
Academy of Physician Assistants in Alexandria, Virginia.
Procedure Goals and Objectives
Goal: To perform an injection successfully while observing
standard precautions and with the minimal degree of risk to the
patient.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
administering an injection.
• Identify and describe common complications associated with
administering injections.
• Describe the essential anatomy and physiology associated with
performing an injection.
• Identify the materials necessary for performing an injection and
their proper use.
• Identify the important aspects of patient care after an injection.
93
94 Chapter 9— Injections
BACKGROUND AND HISTORY
This chapter covers the most common procedures for parenteral adminis-
tration of medications. Although parenteral means any route other than
enteral (gastrointestinal), it ordinarily refers to methods of giving drugs by
injection. The most common routes of parenteral medication administration
are intradermal, subcutaneous, intramuscular, and intravenous. Intravenous
procedures are covered in Chapter 7.
Injections are part of the armamentarium of most medical disciplines. In
addition to this common ground, each specialty has its own particular appli-
cations (Brokensha, 1999).
The first experiments with intravenous injections were carried out in 1642
by a gentleman's hunting servant in eastern Germany. Similar experiments were
performed in 1656 by Christopher Wren (an astronomer, mathematician, and
architect in Oxford, England) and by a group of scientists associated with the
physicist Robert Boyle. These experiments were prompted by new knowl-
edge about blood circulation provided by William Harvey in 1628. The first
books on the applications of intravenous infusions in humans were published
in 1664 and 1667. Bladders of animals or enema syringes were used as
instruments. Because of lethal accidents, the infusions soon fell out of favor
(Feldmann, 2000).
Reinier de Graaf has been credited with the invention of the injection
syringe in the late 1660s. De Graaf studied under anatomist Johannes van
Home at the newly established University of Leyden in Holland. As a young
student, De Graaf helped Van Home prepare anatomic specimens, and he
used the injection syringe to introduce liquids and wax into the prepared
blood vessels as a coloring and preservation medium.
In 1853, Charles Pravaz, a French surgeon in Lyon, invented a small syringe,
the piston of which could be driven by a screw, allowing exact doses. A sharp
needle with a pointed trocar could be introduced into a vessel, making
dissection unnecessary. Pravaz used his syringe for obliteration of arterial
aneurysms by injection of ferric sesquichlorate. Pravaz's syringe initiated
the invention of a great number of various calibrated syringes made of glass
or metal combined with glass. The calibrated syringes were commonly used
in the treatment of syphilis by mercurialization.
Also in 1853, in a paper entitled "A New Method of Treating Neuralgia by
Direct Application of Opioids to the Painful Point," Alexander Wood introduced
his hollow needle in London, England. Within 5 years, injections of morphine
had become enormously popular; thriving practices developed in response
to what was seen as a potent, benign, and beneficial treatment. Patients were
treated with hundreds of injections. Their doctors seemed blissfully unaware
of the systemic effects of the drug they were injecting and the nature of the
demand for the new treatment.
Charles Hunter, another English physician, was discouraged from using the
new technique when his first two patients developed local abscesses. In
1858, he discovered that patients gained just as much benefit from injections
distant from the painful site. Hunter coined the term hypodermic and claimed
Chapter 9 — Injections 95
that his treatment was superior to that of Wood. Physicians debated the
merits of the two physicians' claims and decided in Hunter's favor. During
the debate, physicians continued with both treatments, apparently blind to
the addiction underlying the huge and increasingly lucrative demand
(Howard-Jones, 1971).
Since the 19th century, there have been great advances in understanding
the mechanisms of action of parenteral medications and improvements in
the technology of injections. However, the basic principles remain the same.
Today, injections can be given in any space or potential space; they can
be administered hypodermically under direct vision or guided by ultra-
sonography or radiography, as well as through the use of endoscopic
techniques. The widespread use of needleless Qet) injection systems is just
on the horizon. Delivery systems that are less invasive, such as nasal sprays,
transdermal patches, and continuous infusion devices, may make injections
less and less common.
INDICATIONS
Indications include an illness or injury that requires parenteral medication to
improve, treat, or maintain the patient's condition, as well as administration
of vaccines for disease prevention.
Caution: As with other medical therapies, the patient has the right to
refuse an invasive procedure such as an injection.
CONTRAINDICATIONS
Potential contraindications to injections include the following conditions:
Allergy to the intended medication
■ Lack of a suitable site for injection
■ Coagulopathy
■ Occlusive peripheral vascular disease
■ Shock
Impairment of peripheral absorption
POTENTIAL COMPLICATIONS
Anaphylactic or toxic reaction to the medication: Treatment is supportive
for anaphylaxis and may vary depending on the severity of the reaction.
Medication to reverse the toxic effect of the drug should be readily
available. Risk of anaphylaxis can be minimized by asking the patient
about allergies or checking medical alert bracelets before injection.
96 Chapter 9— Injections
Medication error: Errors often can be avoided by using the "five rights"
as guidelines for the administration of medication. These guidelines
ensure that the right drug is given to the right patient in the right dose
by the right route at the right time:
■ Right drug: The medication label should be checked three times: when
the drug is taken from storage, when the amount of drug is removed,
and when the container is returned to storage.
■ Right patient: Always check the patient's identification bracelet or ask
the patient to state his or her name.
■ Right dose: Errors in dose are minimized when the unit system is used
and a pharmacist prepares drugs. If a drug dose for an infant or child
must be calculated, have a second person check the arithmetic,
because even a small error can lead to a serious overdose. It is good
practice to have a second person double check doses of heparin,
insulin, and epinephrine.
■ Right route: Only give injections of substances prepared for parenteral
use; it should say "injectable" on the label. Avoid giving an inadvertent
intravenous injection by drawing back before pushing the drug.
■ Right time: It is important to know why a drug is ordered for a certain
time. Be sure to document when drugs were given.
The practitioner is responsible for the medications that are administered.
Administer only the drugs prepared personally or those that were
prepared by the pharmacist, unless there is an emergency situation.
Infection or abscess at the site: Infection typically occurs as the result of
improper aseptic technique. Sterile abscesses can occur after injecting
concentrated or irritating solutions. Rotating injection sites can minimize
this complication. Injections should be avoided at sites that are inflamed,
edematous, or irritated and at sites with moles, birthmarks, scar tissue,
or other lesions.
Lipodystrophy or atrophy of subcutaneous fat, which is caused by
repeated injections at the same site: Rotating injection sites can minimize
this complication.
Injection pain: Minimize the use of irritating solutions given
subcutaneously to reduce pain. Techniques to reduce the pain of
intramuscular injections include having the patient relax the muscle,
avoiding extrasensitive areas, waiting until the antiseptic is dry before
injecting the medication, using a new needle for injection, inserting and
withdrawing the needle rapidly, massaging the muscle after injection to
distribute the medication better and increase its absorption, and using
ice or topical spray to numb the area before injection.
Chapter 9 — Injections 97
Figure 9-1 . Sites for subcutaneous injection.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
Intradermal injections are given in the outer layers of the skin. There is little
systemic absorption of intradermally injected agents, so this type of injection
is given primarily to produce a local effect. The ventral forearm is the most
commonly used site because of its easy accessibility and lack of hair. In
extensive allergy testing, the outer aspect of the upper arms and the area of
the back between the scapulae are used.
Subcutaneous injections are given into the adipose tissue beneath the
skin. The most common sites are the outer aspects of the upper arm, anterior
thigh, loose tissue of the lower abdomen, upper buttocks, and upper back
(Fig. 9-1).
Intramuscular injections deposit medication deep into muscle tissue,
where it can be readily absorbed. The rate of drug absorption is faster than
with the subcutaneous route but slower than with the intravenous route.
Intramuscular sites (Fig. 9-2) include the following:
■ Deltoid muscle: The deltoid muscle is located on the lateral side of the
humerus. Place four fingers across the deltoid muscle, with the top
finger along the acromion process. The injection site is two to three
fingerbreadths below the acromion process (Fig. 9-3). Injecting lower or
more posterior in the muscle can result in injury to the radial and ulnar
nerves or brachial artery.
■ Dorsogluteal (gluteus medius): Locate the posterior superior iliac spine
and the greater trochanter of the femur. Draw an imaginary line between
the two landmarks. The injection site is above and lateral to the line. A
less accurate method is dividing the buttocks into quadrants. The
98 Chapter 9— Injections
Deltoid
Ventrogluteal
Vastus
lateralis
Dorsogluteal
Figure 9-2. Sites for intramuscular injection.
Acromion
process
Injection
area
Biceps
Triceps
Figure 9-3. Deltoid muscle.
Posterior superior
iliac spine
Iliac crest
Greater
trochanter
of femur
Chapter 9 — Injections 99
Figure 9-4. Inject above and
lateral to dotted line.
vertical dividing line extends from the gluteal fold up to the iliac crest.
The injecting horizontal line extends from the medial fold to the lateral
aspect of the buttock. The injection site is the upper outer quadrant,
about 2 to 3 inches below the iliac crest. The risk of injury to the sciatic
nerve can be great at this site; injury can cause paralysis of the affected
leg (Fig. 9-4).
■ Ventrogluteal (gluteus medius and gluteus minimus): Place the heel of
your hand over the greater trochanter. Point the thumb toward the groin
and fingers toward the head. Place the index finger over the
anterosuperior iliac spine and extend the middle finger along the iliac
crest. The index finger and middle finger form a V. Inject into the center
of the V. The muscles of this site are deep and away from major nerves
and blood vessels (Fig. 9-5).
■ Vastus lateralis muscle: This muscle is located at the anterolateral aspect
of the thigh and extends from a handbreadth above the knee to a
handbreadth below the greater trochanter of the femur. The middle third
of the muscle is the best site for injection. This site is a well-developed
muscle that lacks major nerves and blood vessels. The branches of the
lateral femoral cutaneous nerve are located superficially, and a few cases
of damage to these branches have been reported. It is the preferred site
for infants, children, and adults (Fig. 9-6).
Parenteral medication administration provides longer action and avoids the
first-pass metabolic effects of the liver. Each route of administration has
advantages and disadvantages:
100 Chapter 9 — Injections
Anterior superior
iliac spine
liac crest
Injection
site Greater
trochanter
of femur
Gluteus
medius
Sacrum
Gluteus Figure 9-5. Ventrogluteal site.
Biceps
femoris
Rectus
femoris
Vastus
lateralis
Injection
site
Knee
Figure 9-6. Vastus lateral site.
Intradermal injections have slow absorption, which is an advantage
when testing for allergies.
The disadvantages of intradermal injections are that only small amounts
of drug may be administered and they require an aseptic technique.
Subcutaneous injections have the advantage of faster onset of drug
action than the oral route.
Disadvantages of subcutaneous injections include the need for aseptic
technique, their greater expense when compared with oral medication,
the small volume that can be administered, and the potential to produce
anxiety; some drugs can irritate tissues and cause pain.
Chapter 9 — Injections 101
Intramuscular injections minimize pain from irritating drugs, have larger
volumes of drug that can be administered compared with the
subcutaneous route, and provide rapidly absorbed medication.
Disadvantages of intramuscular injections include the need for aseptic
technique, the possibility of blood vessel and nerve damage, and the
potential to produce anxiety
practitioner to exercise clinical judgment based
Standard Precautions Every practitioner should on the patient's history and the potential for
use standard precautions at all times when exposure to body fluids or aerosol-borne
interacting with patients, especially when pathogens (for further discussion, see
performing procedures. Determining the level Chapter 2).
of precaution necessary requires the
PATIENT PREPARATION
Explain to the patient why it is necessary to administer the injection.
■ Obtain verbal consent to give an injection.
Ask the patient if he or she is allergic to any medications and the type of
reaction that occurs.
■ Inform the patient of the benefits and risks in understandable language.
Inform the patient which site will be used for administering the injection.
■ Tell the patient that there will be a sting or pricking sensation felt when
the needle is inserted.
Warn the patient of potential side effects, and advise the patient of signs
and symptoms to watch for.
Ask again about allergies.
Materials Utilized for Administering an Injection
Appropriate medication
Syringe and needle
Materials for cleansing the skin: alcohol pad, most commonly saturated
with 70% isopropyl alcohol
Sterile or unsterile gloves
Needle disposal box
Bandage strips and gauze pads
102 Chapter 9 — Injections
Note: Medication comes in many forms:
■ Ampule containing a single drug dose
■ Vial containing single or multiple drug doses
■ Vial containing powder to which a sterile diluent or solvent must be
added with some drugs
■ Prefilled cartridge package
■ Syringe
Note: Syringes range in size from a capacity of 1 mL to 50 mL, but syringes
larger than 5 mL are rarely used for injections. A 2- or 3-mL syringe is
adequate for most subcutaneous and intramuscular injections. Most
institutions use plastic syringes, although some medications in prefilled
cartridges require cartridge syringes (e.g., Tubex).
Insulin syringes have a capacity of 1 mL and are calibrated in units. There
is a syringe designed for use with each strength of insulin. For example, a
syringe marked U 100 is coded to match the label of a vial of insulin that
contains 100 units/mL. Tuberculin syringes also have a capacity of 1 mL,
but they are long, slender, and calibrated in 0.01-mL units. This fine
calibration makes it possible to administer very small amounts of potent
drugs, such as those used for intradermal skin testing.
■ Barrel of the syringe, handle of the plunger, and hub of the needle
Note: These parts must, out of necessity, be handled during the
preparation and administration of an injection, but the inside and tip of the
barrel and the shaft of the plunger must be kept sterile, as must the entire
length of the needle (Fig. 9-7).
■ Needle
Note: Needles that are commonly used for injections vary in length from V2
to \V2 inches; they vary in diameter from 14 to 26 gauge (the larger the
gauge, the smaller the diameter). A common size for a subcutaneous
injection is 25 gauge, % inch; the needle for an intramuscular injection is
larger and longer: 18 to 22 gauge, \V2 inches. Typically, needles for
intradermal injections are 26 or 27 gauge and V2 to % inch long. Needles are
packaged individually to permit greater flexibility in selecting the right
needle for a specific patient. A syringe and needle may be packaged
Barrel
Hub
Bevel
Plunger
Figure 9-7.
Tip Needle
Parts of a syringe and needle.
Chapter 9 — Injections 103
together if the size of the needle is relatively standard, such as an insulin or
tuberculin syringe and needle.
Note: The length of the needle is determined by the size and weight of
the patient and whether the drug will be injected subcutaneously or
intramuscularly The gauge depends on the viscosity of the fluid to be
injected. A thin, watery, nonsticky solution can be injected easily through a
fine-gauge needle (25 or 26), but a thicker, sticky solution requires a larger
gauge needle (20 to 22).
Note: Many institutions are beginning to move toward needleless or
safety needle systems for injections. In these systems, medication can often
be drawn through vials without needles, and, after the injection, needles
retract into the plunger, or a sheath covers the needles. Follow the
manufacturer's instructions for proper use of these systems.
Procedure for Aspirating from an Ampule
1. Identify the patient.
2. Wash your hands and put on gloves.
3. Select and assemble the appropriately
sized needle and syringe (use filter
needle with glass ampule if the
medication requires it).
4. Remove the liquid from the neck of the
ampule by flicking it or swinging it
quickly in a downward, spiraling motion
while holding it by the top (Fig. 9-8A).
5. Tap around the neck of the ampule.
6. Protect your fingers with gauze if the
ampule is made of glass.
7. Carefully break off the top of the ampule
(for a plastic ampule twist the top) (see
Fig. 9-8B).
continued
104 Chapter 9 — Injections
8. Aspirate fluid from the ampule (see
Fig. 9-8C).
9. Remove any air from the syringe as
needed.
10. Clean up and dispose of working needle
and ampule in accordance with your
institution's policy for disposing of
contaminated materials and sharp
objects (see Chapter 2).
Procedure for Aspirating from a Vial
1. Identify the patient.
2. Wash hands and put on gloves.
3. Disinfect the top of the vial with an
alcohol pad.
4. Select a syringe with a volume twice the
required amount of drug or solution and
add the needle.
5. Draw up as much air as the amount of
solution that will be aspirated.
6. Insert the needle into the top of the vial
and turn upside down (Fig. 9-9 A).
7. Push air out of the syringe into the vial
(see Fig. 9-9B).
8. Aspirate the required amount of
solution.
Note: Make sure the tip of the needle is
below the fluid surface.
9. Pull the needle out of the vial.
10. Remove air from the syringe as needed
(see Fig. 9-9C).
11. Clean up and dispose of materials in
accordance with your institution's policy
for disposing of contaminated materials
and sharp objects (see Chapter 2).
A
Figure 9-9.
B
Chapter 9 — Injections 105
Figure 9- 1 0.
Procedure for Administering an Intradermal Injection
1. Identify the patient.
2. Wash hands and put on gloves.
3. Select a tuberculin syringe with a 26- or
27-gauge needle: V2 to % inch long is
generally used.
4. Using aseptic technique, withdraw the
appropriate amount of medication from
the vial or ampule.
5. With the patient sitting up, have him or
her extend the forearm and lay it on a
flat surface with the ventral side
exposed.
6. Cleanse the surface of the ventral
forearm about two to three
fingerbreadths distal to the antecubital
space using an alcohol pad.
Note: Be sure the test site is free of hair and
lesions. Allow the skin to dry completely
before administering the injection.
7. While holding the patient's forearm in
your hand, stretch the skin taut with
your thumb.
8. With your free hand, hold the needle at a
15-degree angle to the patient's arm,
with its bevel facing up.
9. Insert the needle about V8 inch below the
epidermis (Fig. 9-10). Stop when the
needle bevel is beneath the skin, and
inject the antigen slowly. You should feel
some resistance as you do this, and a
wheal or bleb should form as you inject
the antigen. If no wheal forms, you have
injected the antigen too deeply;
withdraw the needle and administer
Epidermis
Dermis
Subcutaneous
tissue
another test dose at least 2 inches from
the first site.
10. Withdraw the needle at the same angle
at which it was inserted.
11. Do not rub the site. This could cause
irritation of the underlying tissue and
may affect the test results.
12. Dispose of the syringe and needle
according to your institution's policy
regarding disposal of contaminated
items and sharp objects (see Chapter 2).
13. Document which agents were given,
including the lot number and expiration
date; where, how (which specific
injection method), and when they were
given; and by whom.
14. Assess the patient's response in 24 to
48 hours.
Note: In patients hypersensitive to the test
antigen, a severe anaphylactic response can
result. This requires immediate epinephrine
injection and other emergency resuscitation
procedures. Be especially alert after
giving a test dose of penicillin or tetanus
antitoxin.
106 Chapter 9 — Injections
Figure 9-11.
Procedure for Administering a Subcutaneous Injection
1. Identify the patient.
2. Wash hands and put on gloves.
3. Select a 2- to 3-mL syringe with a 24- to
26-gauge needle that is % to 1 inch long,
depending on the amount of
subcutaneous fat.
Note: A longer needle is needed for an obese
adult, a shorter needle for a thin child.
4. Using aseptic technique, withdraw the
appropriate amount of medication from
the vial or ampule.
5. Select an appropriate site.
6. Rotate sites according to a planned
schedule for patients who require
repeated injections. Use different areas
of the body unless contraindicated by
the specific drug.
7. Position and drape the patient.
8. Cleanse the injection site with a sterile
alcohol pad, beginning at the center of
the site and moving outward in a circular
motion.
Note: Allow the skin to dry so that alcohol is
not introduced into subcutaneous tissues as
the needle is inserted.
9. With the nondominant hand, pinch the
skin around the injection site.
10. Insert the needle with the bevel facing
up at a 45-degree angle (Fig. 9-11). If a fat
fold is more than 1 inch, the needle may
be injected at a 90-degree angle.
11. Release the patient's skin to avoid
injecting into compressed tissue and
irritating nerve fibers.
12. Pull back on the plunger slightly. If no
blood is aspirated, begin injecting the
Epidermis
Dermis
Subcutaneous
tissue
Muscle
drug slowly. If blood appears on
aspiration, withdraw the needle, prepare
another syringe, and repeat the
procedure.
13. After injection, remove the needle gently
but quickly at the same angle used for
insertion.
14. Cover the site with an alcohol sponge or
sterile gauze pad and massage the site
gently (unless contraindicated [e.g.,
heparin]) to distribute the drug and
facilitate absorption.
15. Remove the sponge and check the
injection site for bleeding.
16. Dispose of the syringe and needle
according to your institution's policy
regarding disposal of contaminated
items and sharp objects (see Chapter 2).
17. Document the medication given,
including the lot number and expiration
date; where, how (specific injection
method), and when it was given; and by
whom.
Chapter 9 — Injections 107
SPECIAL CONSIDERATIONS
Administering Insulin
Note: To establish more consistent blood levels, rotate insulin injection sites
within anatomic regions. Absorption varies from one region to another.
Preferred insulin injection sites are the arms, abdomen, thighs, and buttocks.
1. Make sure the type of insulin, dose, and syringe are correct.
2. When combining different types of insulin in a syringe, make sure they
are compatible. Regular insulin can be mixed with all types.
3. Before drawing up insulin suspension, gently roll and invert the bottle to
ensure even particle distribution. Do not shake the bottle, because this
can cause foam or bubbles to develop, changing the potency and
altering the dose.
Administering Heparin
Note:
The preferred site for heparin injections is the lower abdominal fat pad,
2 inches beneath the umbilicus, between the iliac crests. Injecting
heparin into this area, which is not involved in muscular activity,
reduces the risk of local capillary bleeding. Always rotate the sites from
one side to the other.
■ Do not administer any injections within 2 inches of a scar, bruise, or the
umbilicus.
■ Do not aspirate to check for blood return because this may cause
bleeding into the tissues at the site.
■ Do not rub or massage the site after the injection. Rubbing can cause
localized minute hemorrhages or bruises.
■ If the patient bruises easily, apply ice to the site for the first 5 minutes
after the injection to minimize local hemorrhage.
Procedure for Administering an Intramuscular Injection
1. Identify the patient.
2. Wash hands and put on gloves.
3. Select a 2- to 5-mL syringe with an 18- to
22-gauge needle 1 to 2 inches in length,
depending on the injection site and the
amount of muscle mass of the patient.
4. Using aseptic technique, withdraw the
appropriate amount of medication from
the vial or ampule and then draw about
0.2 mL of air into the syringe.
5. Select an appropriate intramuscular site.
6. Position and drape the patient.
continued
108 Chapter 9 — Injections
7. Cleanse the injection site with a sterile
alcohol sponge, beginning at the center
of the site and moving outward in a
circular motion. Allow the skin to dry so
that alcohol is not introduced into
subcutaneous tissues as the needle is
inserted.
8. With the thumb and index finger of your
nondominant hand, press down and
stretch the skin of the injection site.
Note: This reduces the thickness of
subcutaneous tissue that must be pierced to
reach the muscle. This is required in an
obese patient. If the patient is emaciated,
raise the underlying muscle mass by
pinching the tissue between the thumb and
index finger.
9. Position the syringe at a 90-degree angle
to the skin surface, with the needle a
couple of inches from the skin. Quickly
and firmly thrust the needle through the
skin and subcutaneous tissue deep into
the muscle (Fig. 9-12).
10. Hold the syringe with your nondominant
hand, if desired. Pull back slightly on the
plunger with your dominant hand. If no
blood is aspirated, place your thumb on
- Epidermis
Dermis
Subcutaneous
tissue
- Muscle
Air lock
Medication
Air lock
Medication
Figure 9-13.
Figure 9-12.
the plunger rod and slowly inject the
medication into the muscle.
Note: A slow, steady injection rate allows the
muscle to distend gradually and accept the
medication under minimal pressure. There
should be little or no resistance against the
force of injection. The air bubble added to
the syringe when it was prepared should
follow the medication into the injection site
to create an air block and prevent tracking of
the medication back into the subcutaneous
tissue (Fig. 9-13).
11. If blood appears in the syringe on
aspiration, the needle is in a blood
vessel. If this occurs, withdraw the
needle, prepare another injection with
new equipment, and inject another site.
Do not inject the bloody solution.
(Follow your institution's policy for
disposal of contaminated items and
sharp objects.)
12. After the injection, gently but rapidly
remove the needle at a 90-degree angle.
13. Cover the injection site immediately with
an alcohol sponge or sterile gauze pad,
apply gentle pressure and, unless
contraindicated, massage the muscle to
Chapter 9 — Injections 109
help distribute the drug and promote
absorption.
14. Remove the alcohol sponge and inspect
the injection site for signs of active
bleeding. If bleeding continues, apply
pressure to the site.
15. Dispose of the syringe and needle
according to your institution's policy
regarding disposal of contaminated
items and sharp objects, (see Chapter 2).
16. Document the medication given,
including the lot number and expiration
date; where, how (specific injection
method), and when it was given; and by
whom.
Procedure for Administering a Z-track Intramuscular Injection
Note: The Z-track method of intramuscular
injection prevents leakage of medication
back into subcutaneous tissue after the
injection is given. It is used with certain
drugs — primarily iron preparations — that
irritate or discolor subcutaneous tissue.
Lateral displacement of the skin before
injection helps seal the drug in the muscle
after the skin is released. This procedure
requires careful attention to technique,
because leakage into subcutaneous tissue can
cause patient discomfort or may permanently
stain tissue if an iron preparation is being
given. This type of injection is given only in
the outer upper quadrant of the buttocks.
1. Identify the patient.
2. Wash hands and put on gloves.
3. Select a 3- to 5-mL syringe with two
20-gauge needles at least 2 inches long.
4. Using aseptic technique, withdraw the
appropriate amount of medication from
the vial or ampule and then draw about
0.2 to 0.5 mL of air into the syringe.
Remove the first needle and attach the
second needle to prevent introduction of
medication from the outside of the first
needle into the subcutaneous tissue.
Note: For this type of injection, be sure to
provide privacy for the patient.
5. Select an appropriate site in an upper
outer buttock.
6. Position and drape the patient in the
prone or lateral position.
7. Cleanse the area with a sterile alcohol pad.
8. Displace the skin laterally by pulling it
about V2 inch away from the injection
site (Fig. 9-14A and B).
During injection
Injection tract seals
as skin is released
Skin
11— Subcutaneous
tissue
— Muscle
After release
B
Figure 9-14.
continued
110 Chapter 9 — Injections
9. Insert the needle into the muscle at a
90-degree angle.
10. Pull back on the plunger slightly. If no
blood is aspirated, inject the drug
slowly, followed by the air, which helps
clear the needle and prevents tracking of
the medication through the
subcutaneous tissue.
11. Encourage the patient to walk or move
around in bed to facilitate absorption
from the injection site.
12. Dispose of the syringe and needle
according to your institution's policy
regarding disposal of contaminated
items (see Chapter 2).
13. Document the medication given,
including the lot number and expiration
date; where, how (specific injection
method), and when it was given; and by
whom.
Caution: Never inject more than 5 mL into
a single site using the Z-track method.
Note: Alternate gluteal sites to avoid
repeated injections in the same site. If the
patient is on bed rest, encourage active
range of motion exercises or perform
passive range of motion exercises to
facilitate absorption from the injection
site.
Note: If you must inject more than 5 mL of
solution, divide the solution and inject it at
two separate sites unless the gluteal muscles
and vastus lateralis are well developed.
Intramuscular injections can traumatize local
muscle cells, causing elevated serum levels
of enzymes (creatine phosphokinase [CPK])
that can be confused with the elevated
enzyme levels resulting from damage to
cardiac muscle, as in myocardial infarction.
Oral or intravenous routes are preferred for
administration of drugs that are poorly
absorbed by muscle tissue, such as
phenytoin, digoxin, chlordiazepoxide,
diazepam, and haloperidol.
SPECIAL CONSIDERATIONS
Pediatric Patients
Subcutaneous injections are usually administered into the thigh of
infants and into the deltoid area of older children.
The preferred sites for intramuscular injections are the anterolateral
aspect of the upper thigh and the deltoid muscle of the upper arm.
Among most infants, the anterolateral thigh provides the largest muscle
mass and is therefore the recommended site.
The deltoid can also be used with the thigh when multiple injections
(such as vaccinations) are needed.
In toddlers and older children, the deltoid may be used if the muscle
mass is adequate.
Never use the gluteal muscles, which develop from walking, as the
injection site for children younger than age 3 or for those who have been
walking less than a year.
Chapter 9 — Injections 111
The buttock should not be used routinely in children because of the risk
of sciatic nerve injury (Bergeson, 1982).
FOLLOW-UP CARE AND
INSTRUCTIONS
■ Immediately dispose of needle and syringe properly in an appropriate
needle disposal (sharps) container.
Caution: Never recap needles. It is important to follow this advice
diligently to help prevent the 600,000 to 800,000 needlesticks and other
percutaneous injuries reported in the United States each year among the
8 million health care workers. (Henry 1995; EPINet, 1999).
Monitor the patient's response, especially after injections of large doses
of antibiotic. Patient should be monitored for approximately 30 minutes
for signs of anaphylaxis.
Instruct the patient to report a new onset of fever, joint pain, shortness
of breath, or rash. Also, tenderness, erythema, or ecchymosis at the
injection site should be reported to the health care provider.
References
Bergeson PS, Singer SA, Kaplan AM: Intramuscular injections in
children. Pediatrics 70:944-948, 1982.
Brokensha G: The hollow needle: Inappropriate injection in practice.
Aust Prescr 22:145-147, 1999.
EPINet: Exposure prevention information network data reports.
University of Virginia, International Health Care Worker Safety Center,
1999.
Feldmann H: History of injections. Laryngorhinootologie 79:239-246,
2000.
Henry K, Campbell S: Needlestick/sharps injuries and HIV exposures
among health care workers: national estimates based on a survey of
U.S. hospitals. Minn Med 78:1765-1768, 1995.
Howard-Jones N: The origins of the hypodermic medications. Sci Am
224:96-102, 1971.
Bibliography
American Diabetes Association: Insulin administration. Diabetes Care
23(suppl 1):S86, 2000.
Centers for Disease Control and Prevention: General recommendations
on immunization recommendations of the Advisory Committee on
Immunization Practices (ACIP). MMWR Recomm Rep 43(RR-01):l-38,
1994.
D'Angelo HH, Welsh NP (eds): Medication Administration and IV
Therapy Manual, 2nd ed. Springhouse, Pa, Springhouse, 1993.
112 Chapter 9 — Injections
De Vries PG, Henning RH, Hogerzeil HV: WHO Guide to Good
Prescribing: The Use of Injections. World Health Organization, 1995.
Available at: http:// www.med.rug.nl/pharma/ggp.htm
Elkin MK, Perry AG, Potter PA: Nursing Interventions and Clinical Skills,
2nd ed. St. Louis, CV Mosby, 1999.
Gilles FH, French JH: Postinjection sciatic nerve palsies in infants and
children. J Pediatr 58:195-204, 1961.
Newton M, Newton D, Fudin J: Reviewing the "big three" injection
routes. Nursing 22:34-42, 1992.
Smith SF, Duell DJ, Martin BC: Clinical Nursing Skills: Basic to Advanced
Skills. Upper Saddle River, NJ, Prentice Hall Health, 2000.
Cha
P'er | Q
Recording an Electrocardiogram
Richard R. Rahr and Salah Ayachi
Procedure Goals and Objectives
Goal: To perform an electrocardiogram (ECG) safely and
accurately.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing an ECG.
• Identify and describe potential complications associated with
performing an ECG.
• Describe the essential anatomy and physiology associated with
performing an ECG.
• Identify the materials necessary for performing an ECG and
their proper use.
• Identify the proper steps for performing an ECG.
113
114 Chapter 10 — Recording an Electrocardiogram
Figure 10-1. Electrocardiographic
methodology in 1911. (Redrawn from
Rawlings CA: Electrocardiography.
Redmond, Wash, SpaceLabs, 1991, p 26.)
BACKGROUND AND HISTORY
In 1790 Salvori demonstrated that stimulation of a charged glass rod
attached to a frog's leg muscle causes contraction of the muscle, as if the frog
willed it to do so. In 1855 Kollickes and Mueller dissected a frog's heart and
attached it to the leg muscle; they noted the frog's leg twitched with each
heartbeat. In 1880 Ludig and Waller developed a crude capillary electrometer
and recorded the electrical activity of the heartbeat from the skin surface. It
was not until 1901 that Einthoven developed a machine that passed light
over a moving wire and recorded the PQRSTU waveform (Fig. 10-1). He was
the first to develop the first three leads (I, II, and III) that make up the
equilateral triangle that today bears his name.
INDICATIONS
Numerous technologic advances (cardiac catheterization, echocardiography,
nuclear medicine imaging, and magnetic resonance imaging [MRI]) in the
study of heart function notwithstanding, the 12-lead ECG continues to be an
effective and inexpensive method to screen for heart disease and monitor
patients with acute and chronic heart conditions. Some of these conditions
include the following:
Chapter 10 — Recording an Electrocardiogram 115
■ Ischemic heart disease, including myocardial infarction
■ Heart block
■ Dysrhythmias (including wide ventricular tachycardia)
Electrolyte disturbances
Abnormality in chamber size or myocardial hypertrophy
The use of the 12-lead ECG is essential in the following scenarios:
At sites of accidents or emergency calls, it enables the paramedic to
identify heart disease with 62% to 90% specificity and 71% to 90%
sensitivity in the presence of chest pain (Taylor, 1998).
It gives hospital personnel warning signs of a patient's condition during
transport to the hospital for treatment with thrombolytics or for control
of advanced arrhythmias. In some instances, paramedics are allowed to
administer thrombolytics prior to arrival at the hospital.
The 12-lead ECG plays a critical role in reducing morbidity and mortality in
patients with coronary artery disease, because it enables the practitioner to
detect early danger signs and administer reperfusion medications.
CONTRAINDICATIONS
The only relative contraindications to performing an ECG are as follows:
■ Concern that the equipment may be malfunctioning
■ Hypersensitivity to the electrode adhesive
POTENTIAL COMPLICATIONS
■ The most common complication is misinterpretation of the 12-lead ECG.
A tracing can be misinterpreted as being "normal" when it is not (i.e.,
false negative), leading to acquiescence and lowering of the practitioner's
index of suspicion, thus failure to intervene, and possibly to patient
demise. The lesson is that a "normal ECG" does not preclude underlying
pathology.
Errors in interpretation could actually be due to errors in lead placement.
It is incumbent on the practitioner to repeat the ECG should unusual
waveform patterns for a set of leads appear.
Because electrodes are attached to the patient's skin, either by adhesives
or suction, skin damage may result, especially in elderly or diabetic
patients, potentially leading to infections.
Although extremely unlikely, it is possible that a patient could receive an
electrical shock if there is a short in the wiring. Electrocardiographs
today are protected by a third ground wire to prevent such events.
116 Chapter 10 — Recording an Electrocardiogram
1
1
Receiving
chambers et
/^=z>s atrium
Right if ^V /%\
/ atrium \\ / ( \> . . ^
\\ (f\\ ^\\ ventricle
Right
ventricle Pumping
chambers
1
Figure 1 0-2. Anatomy of the heart.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
A review of the anatomy and physiology of the heart is necessary for proper
understanding of the 12-lead ECG. The heart is a complex organ whose
primary function is to pump blood through the pulmonic and systemic circu-
lations. Four muscular chambers — right and left atria (collecting chambers)
and right and left ventricles (pumping chambers) — compose the heart
(Fig. 10-2). An intricate network of specialized muscle cells coordinates the
sequential contractions of the chambers to make it an effective pump.
The pulmonary artery arises from the right ventricle, whereas the aorta
originates from the left ventricle. Each of these large vessels has a valve
(pulmonic and aortic, respectively) that opens to accommodate ejection of
blood during systole and closes to prevent backward flow during diastole.
Atria and ventricles are separated by a valve — the tricuspid between the
right atrium and ventricle, and the mitral between the left atrium and ventricle.
As in the case of the pulmonic and aortic valves, the tricuspid and mitral
valves open to accommodate forward flow and close to prevent retrograde
flow. Unlike the pulmonic and aortic valves, the tricuspid and mitral valves
open during diastole and close during systole. The left main and right
coronary arteries arise from the root of the aorta. The coronary sinus drains
venous blood into the right atrium.
Chapter 10 — Recording an Electrocardiogram 117
Superior
vena cava
Pulmonary
artery
Aorta
arteries
and coronary
arteries
Figure 1 0-3. The heart box.
Poorly oxygenated blood returning from the systemic circulation, through
the superior and inferior venae cavae, to the right atrium enters the right
ventricle in large part (70%) by gravity; atrial contraction contributes only
30% to ventricular filling during diastole. The right ventricle pumps blood
into the pulmonary artery and the lungs where it is oxygenated and then
returned to the left atrium by the pulmonary veins. As in the case of the right
side of the heart, atrial contraction contributes only 30% of the blood that
enters the left ventricle during diastole.
The left ventricle pumps blood into the aorta and the systemic circulation,
including the coronary arteries, which originate from the base of the aorta
and supply the myocardium with oxygen-rich blood mostly during diastole
(Fig. 10-3). The larger and thicker walled left ventricle maintains the pressure
necessary to effect forward flow to the systemic circulation. Deoxygenated
blood from the myocardium returns to the right atrium via the coronary sinus.
The electrical pathways (or conduction system) (Fig. 10-4) are essential to
the coordinated activity of the heart. The sinoatrial (SA) node, located near
the junction of the superior vena cava and the right atrium, has an intrinsic
(spontaneous) electrical discharge of 60 to 100 cycles per minute, whereas
the atrioventricular (AV) node, located between the right atrium and the right
ventricle, spontaneously discharges at 40 to 60 cycles per minute. Adjacent
to the AV node and traveling through the ventricular septum are specialized
fibers — His bundle, bundle branches, and Purkinje fibers — that conduct
electrical impulses at a high rate of speed.
Normally, the SA node initiates the electrical impulse, which rapidly spreads
through internodal tracts and depolarizes the left and right atria, ultimately
reaching the AV node. At this node, conduction velocity slows considerably
to allow atrial activity to complete before ventricular activity begins. Following
118 Chapter 10 — Recording an Electrocardiogram
Bachman's bundle
SA node
Atrial muscle
Bundle
of His
Internodal
pathways
AV node
RBB
Ventricle muscle
Figure 1 0-4. Electrical pattern of the heart. AV, atrioventricular; LA, left atrium;
LBB, left bundle branch; LPF, left posterior fascicle; RBB, right bundle branch;
SA, sinoatrial.
this delay, the impulse moves very rapidly through the bundle of His and its
branches (the left has two fascicles) and the Purkinje fibers, resulting in the
nearly simultaneous depolarization of the right and left ventricles (Fig. 10-5).
The atria and ventricles are separated by a fibrous ring that serves to insulate
the chambers from their respective activities and permit spread of electrical
activity from atria to ventricles only through the AV node area. The system
allows the atria and ventricles to beat synchronously, resulting in effective
and efficient pumping activity.
The electrical activity of the heart can be measured on the surface of the
body using an electrocardiograph, thereby producing ECG tracings that
consist of repeating waveforms (PQRST) in which the P wave represents
depolarization of atrial tissues, the QRS complex represents depolarization
of the ventricles, and the T wave represents repolarization of the ventricles;
no waveform is noted that represents atrial repolarization (Fig. 10-6).
PATIENT PREPARATION
Patient preparation is important. Time should be taken to explain to the
patient what the procedure entails and what the patient should expect as
well as to answer any questions the patient may have. Preparing the patient's
skin helps ensure optimal conditions for recording the ECG. The following
steps should be taken to prepare the patient:
■ Introduce yourself to the patient.
Explain the 12-lead electrocardiography procedure, and proceed by
draping the patient's chest.
Chapter 10 — Recording an Electrocardiogram 119
SA node — Primary pacemaker
\
Internodal tracks
*
Atrial muscle — P wave formed
\
AV node — delay area
*
Bundle of His
/ X
Right bundle branch Left
/ \
Left bundle branch
Left Left
posterior anterior
fascicle fascicle
Purkinje cells
\
Muscle cells of ventricles
Figure 10-5. Electrical
sequence of the normal heart.
AV, atrioventricular; SA,
sinoatrial.
Figure 10-6. Electrocardiographic 12-lead tracing.
120 Chapter 10 — Recording an Electrocardiogram
Identify the six precordial leads (you may choose to mark them with a
felt-tipped pen).
If necessary, shave the areas where the electrodes are to be placed.
Use alcohol pads to cleanse the skin and, if necessary, rub with a mild
abrasive pad.
Use alcohol pads again to remove any residue.
Attach the adhesive pads and connect the electrodes.
Materials Utilized for Electrocardiography
The machine used to do routine 12-lead ECGs is a standard
electrocardiograph mounted on a cart that can be easily wheeled from
one location to another. Modern systems have a resting
electrocardiographic analysis system with quick reference readout.
Electrodes for the six precordial sites
Razor to shave hair from a male patient's chest, if necessary.
Alcohol to clean skin surface
Felt pen to mark site (optional)
Abrasive pad to remove epidermal skin layer at electrode sites; pads are
used to gently remove felt-pen marks.
Procedure for Performing the Electrocardiogram
Note: The following steps are for performing
a routine 12-lead ECG at the bedside.
yet afford adequate access to the
patient's chest for lead placement.
1. Assemble supplies (leads, alcohol,
7. Cleanse skin at the six precordial sites.
abrasive pads, etc.).
2. Verify the order on the patient's chart.
8. Attach limb and precordial leads (refer
to Figures 10-7 and 10-8 for correct lead
3. Verify the patient's identity.
4. Wash hands.
placement).
9. Confirm that all leads are connected.
5. Plug in power cord and turn on
10. Enter patient's information.
electrocardiograph.
11. Ask the patient to lie quietly for 30
6. Position the patient in a comfortable
supine position and provide a drape or
gown to maintain the patient's modesty
seconds.
12. Press the 12-lead (or the record ECG)
button to record the tracing.
Chapter 10 — Recording an Electrocardiogram 121
(ground)
V1 - Fourth intercostal space at right
border of sternum.
V2 - Fourth intercostal space at left
border of sternum.
V4 - At the mid-clavicular line and the
inter-space in which the apex is
located (the 5th intercostal space
is used if the apex is not palpable).
V3 - Midway between positions 2 and 4.
V5 - At the anterior axillary line on a
horizontal level with V4.
V6 - At the mid-axillary line on the same
horizontal level as V4 and V5.
V1 V2 V3 V4 V5 V6
(mid- (mid-
clavicular) axillary)
Spine
Chest
wall
V3
Sternum
Heart
Figure 10-7.
Figure 10-8.
continued
122 Chapter 10 — Recording an Electrocardiogram
13.
"Acquired data" message will appear;
17.
Enter your name, date, and identification
wait for "ECG acquisition complete"
number.
message to appear.
18.
Remove electrodes and adhesive pads
14.
Enter number of extra copies desired.
19.
Assist patient with cleaning up and
15.
Print report to attach to chart and for
redressing, as necessary.
cardiology reading station.
20.
Dispose of used supplies.
16.
Press "Store" and "Data in store" to store
data for comparison with future tracings.
SPECIAL CONSIDERATIONS
In case the patient is unable to remain in one position for 30 seconds because
of pain, shortness of breath, or confusion, the operator may need assistance
to complete the procedure. Similarly, assistance may be required if the patient
is a child who is anxious about or fearful of the equipment or procedure.
FOLLOW-UP CARE AND
INSTRUCTIONS
■ No follow-up care is necessary provided the skin has not been damaged
by the adhesive pads.
■ Patients should be given an estimate of the time it takes before they are
given the results and interpretation of the ECG.
Reference
Taylor RV, Key CB, Trach M: Advanced Cardiac Care in the Streets. Philadelphia, Lippincott,
1998.
Bibliography
Constant J: Essentials of Learning Electrocardiography: A Complete
Course for the Non-Cardiologist. New York, Parthenon, 1997.
Dubin D: Rapid Interpretation of EKGs. Tampa, Fla, Cover, 1996.
Goldschlager N, Goldman MJ: Electrocardiography: Essentials of
Interpretation. Los Altos, Calif, Lange Medical, 1984.
Lewis KM, Handal KA: Sensible ECG Analysis. Albany, NY, Delmar, 2000.
Lipman BC: ECG Pocket Guide. Chicago, 111, Year Book Medical, 1987.
Murphy KR, Pelton JJ: ECG Essentials. Chicago, 111, Quintessence, 1991.
Rawlings CA: Electrocardiography. Redmond, Wash, SpaceLabs, 1991.
Schamroth L: An Introduction to Electrocardiography. Oxford, England,
Blackwell Scientific, 1976.
Chapter
Exercise Stress Testing for the
Primary Care Provider
Charles S. King
Procedure Goals and Objectives
Goal: To identify appropriate candidates for exercise stress testing
and to administer the test safely
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing exercise stress testing.
• Identify and describe common complications associated with
exercise stress testing.
• Describe the essential anatomy and physiology associated with
the effective and safe performance of exercise stress testing.
• Identify the necessary materials and their proper use for
performing an exercise stress test.
• Identify the important aspects of patient care after an exercise
stress test.
123
124 Chapter 11 — Exercise Stress Testing for the Primary Care Provider
BACKGROUND AND HISTORY
Despite advances in disease prevention, coronary artery disease (CAD)
remains a major cause of death and disability in the United States. There are
considerable costs associated with treating this disease, which are
compounded by expenses related to time lost from work and lost wages.
Since the 1950s, electrocardiographic analysis during patient exercise has
been employed in the pursuit of objective evidence for the presence or
progression of CAD. More recently, and perhaps more importantly, the role of
exercise testing has taken on the goal of predicting patient outcomes. The
prognostic value of the Duke treadmill scoring system has added consider-
able dimension to cardiac stress testing. Although not perfectly applicable to
all patients under consideration for stress testing, its usefulness in estimating
prognosis in a large segment of patients has been well established. The
physiologic stress of exercise can elicit cardiovascular abnormalities not
present at rest. Although exercise testing was initially used as a diagnostic
tool, it is also a powerful predictor of subsequent cardiac events. Exercise
stress testing provides a controlled environment for observing the effects of
increased myocardial oxygen demand and can be used to determine the
adequacy of cardiac perfusion.
The exercise stress test is a valuable tool for detecting CAD and for
evaluating medical therapy, percutaneous or surgical revascularization, and
cardiac rehabilitation after myocardial infarction.
Electrocardiographic changes during exercise can provide evidence of
ischemia if significant stenosis from CAD is present. Healthy persons who are
asymptomatic may be considered candidates for exercise testing if they
intend to engage in strenuous or high-risk occupations. The American College
of Sports Medicine (ACSM) recommends an exercise test for all women
50 years of age and older and all men 40 years of age and older who plan to
engage in vigorous exercise. The ACSM does not recommend exercise testing
for asymptomatic, healthy persons who are not planning vigorous exercise,
regardless of the person's age (Pate, 1991).
In addition to the standard exercise stress test, other methods of cardio-
vascular stress testing include scintigraphy and echocardiography. Exercise
stress scintigraphy uses a radioactive tracer to enhance abnormal areas of
myocardial blood flow and can be performed with pharmacologic agents
instead of exercise if a patient's condition warrants. Echocardiography has
been used in combination with exercise or pharmacologic stress testing as
another form of noninvasive cardiac evaluation.
INDICATIONS
By exposing the cardiopulmonary system to increased metabolic demands
using standardized methods and protocols of stress, the clinician is provided
a useful tool for detecting the initial presence of cardiopulmonary pathology
and for assessing the efficacy of various therapies and rehabilitation programs.
Chapter 11 — Exercise Stress Testing for the Primary Care Provider 125
Employing electrocardiographic monitoring and patient vital signs alone or
in concert with established and developing imaging modalities, stress testing
adds a valuable adjunct to the well-thought-out history and physical
examination. Cardiac stress testing is indicated as follows:
To establish the initial diagnosis of obstructive CAD
■ To stratify risk and monitor treatment of patients with previously
diagnosed or treated CAD
■ To screen asymptomatic individuals (CAD risks or occupations that
place the public at risk)
To assess exercise capacity in patients with valvular, congenital
abnormalities or congestive heart failure (CHF)
■ To document and monitor therapy in those with exercise-related heart
dysrhythmia
As with all laboratory testing, exercise stress testing should be used to
augment an already high clinical suspicion of disease that is based on a
quality history and physical examination. Accordingly, the rationale for using
exercise stress testing in the primary care setting should be based on the
"predictive value" of the given test. Attention should be paid to the prevalence
of the disease in the patient population under consideration (i.e., the pretest
probability of detecting pathology in a given patient).
The sensitivity and specificity of exercise stress testing with electro-
cardiographic monitoring alone have been validated for its use in detecting
CAD by comparison of ST segment changes (depression or elevation) with the
gold standard of coronary angiography (Gianrossi, 1989). True positives —
that is, the percentage of patients with disease who have electrocardiographic
changes indicative of ischemia — are the measures of sensitivity in exercise
stress testing, which in the general patient population varies from 40% to
90% (Fletcher, 1992). The sensitivity of exercise stress testing in detecting
cardiac pathology other than CAD is less clear.
The occurrence of false negatives — that is, tests in which there is an
absence of diagnostic electrocardiographic changes in the presence of true
CAD — can be minimized by sound test candidate selection and practicing
good testing technique (e.g., achieving target heart rate, getting quality data).
The specificity of exercise stress testing with electrocardiographic monitoring
alone, described as the percentage of normal patients (i.e., those without
CAD) who manifest no electrocardiographic changes indicative of CAD, is
reported to be 84% (Fletcher, 1992). False-positive results — that is, tests in
which electrocardiographic changes suggest CAD that cannot be substantiated
by subsequent coronary angiography — are often associated with patient
selection (gender), electrocardiographic abnormality (left ventricular hyper-
trophy), Q waves at baseline, and associated drug therapy (digoxin).
Both sensitivity and specificity are improved when the pretest probability
of detecting the target pathology in a group of patients is high at the onset.
Prevalence tables for a variety of illnesses are published and usually broken
126 Chapter 11 — Exercise Stress Testing for the Primary Care Provider
Table 11.1 Pretest Probability of Coronary Artery Disease by
Age, Gender, and Symptoms
TYPICAL-
ATYPICAL-
DEFINITE
PROBABLE
ANGINA
ANGINA
NONANGINAL
AGE (yr)
GENDER
PECTORIS
PECTORIS
CHEST PAIN
ASYMPTOMATIC
30-39
Men
Intermediate
Intermediate
Low
Very low
Women
Intermediate
Very low
Very low
Very low
40-49
Men
High
Intermediate
Intermediate
Low
Women
Intermediate
Low
Very low
Very low
50-59
Men
High
Intermediate
Intermediate
Very low
Women
Intermediate
Intermediate
Low
Very low
60-69
Men
High
Intermediate
Intermediate
Low
Women
High
Intermediate
Intermediate
Low
High, >90%; intermediate, 10%-90%; low, <10%; very low, <5%.
Adapted from Pate RR, Blair SN, Durstine JL, et al: Guidelines for Exercise Testing and Prescription.
American College of Sports Medicine, 4th ed. Philadelphia, Lea & Febiger, 1991, p 87.
down by gender, age, and clinical presentation (Gibbons, 1997). An example
of the prevalence of CAD in Western society is detailed in Table 11-1.
Designing a strategy for determining the appropriateness of testing in a
given population is often as much an art as a science. An incremental testing
strategy for detecting CAD in individuals with a normal resting electro-
cardiogram (ECG) and those with an abnormal resting ECG is detailed in
Figure 11-1.
When considering the predictive value of exercise treadmill testing with
electrocardiographic monitoring, it may be the clinical history alone that
provides the best guidance. It has been reported that the highest predictor
of positive stress testing in either gender is the presentation of "typical"
angina pectoris as opposed to atypical or non-anginal symptoms (Weiner,
1979). Enhancement of predicted value may be appreciated with the use of
newer, more sophisticated computer analysis of exercise electrocardiographic
ST-segment changes, although many of these methods require further
validation. The appropriate addition of imaging by radionuclide or, most
recently, echocardiography can improve both specificity and sensitivity of
exercise stress testing.
Stress testing with electrocardiographic monitoring (with or without an
imaging modality) is most commonly used in patients in whom the suspicion
for cardiac ischemia is high based on clinical history and physical examination.
The American College of Cardiology guidelines for exercise stress testing
consider symptomatic adult patients with at least an intermediate pretest
probability of CAD (including those with right bundle branch block or less
than 1 mm resting ST depression, or both) candidates for exercise treadmill
testing with electrocardiographic monitoring alone (Gibbons, 1997). Patients
with suspected CAD (high pretest probability as dictated by age, symptoms,
and gender, less than 1 mm of ST depression) who have abnormal ECGs that
are at least in part attributed to glycoside therapy (digitalis), left ventricular
Chapter 11 — Exercise Stress Testing for the Primary Care Provider 127
-C Low j-
Normal Resting Electrocardiogram
(Sequential Testing)
Pre-exercise
disease probability
Exercise
electrocardiography
—C Normal V
Exercise
electrocardiography
— (AbnormalV
Abnormal Resting Electrocardiogram
(Uniform Testing)
Exercise
electrocardiography
and
Perfusion scintigraphy
Negative
Discordant ]
— C Normal V
-C Normal V
— (AbnormalV
FlGURE 11-1. Incremental testing strategy for coronary artery disease (CAD) risk using serial results of
pretest clinical risk (high, intermediate, low), exercise electrocardiography, and radionuclide perfusion
scintigraphy Top panel shows sequential testing in patients with a normal baseline electrocardiogram (ECG).
Bottom panel uses combined electrocardiographic and perfusion scintigraphy (uniform) testing in patients
with an abnormal baseline ECG. Results of these tests define low- and high-risk groups. (Negative exercise
test [<ET], <1 mm ST1, >85% maximal heart rate; discordant ET, <1 mm ST1, <85% maximal heart rate;
positive ET, >1 mm ST1, <85% maximal heart rate). (Adapted from Ladenheim ML, Kotler TS, Pollack BH, et al:
Incremental prognostic power of clinical history, exercise electrocardiography and myocardial perfusion
scintigraphy in suspected coronary artery disease. Am J Cardiol 59:270-277, 1987.)
128 Chapter 11 — Exercise Stress Testing for the Primary Care Provider
hypertrophy, left bundle branch block, or other baseline electrocardiographic
abnormalities are candidates for exercise stress testing; however, an imaging
modality also should be used to improve test sensitivity and specificity.
In addition to its purely "diagnostic" applications, exercise stress testing
may be used to assess previous therapy After infarction, patients are often
"risk-stratified" before hospital discharge through the use of exercise stress
testing in a "sub-maximal" protocol. Typically, patients without recurrence of
angina symptoms are stressed to 70% of their age-predicted maximal heart
rate while symptoms and the ECG are assessed. This testing alerts the
provider to patients who are likely to have recurrent symptoms with activities
of daily living and provides reassurance to the patient and family about the
safety of leaving the hospital.
Patients receiving antianginal agents or who have undergone or are being
considered for revascularization procedures (percutaneous transluminal
coronary angioplasty [PTCA], coronary artery bypass graft [CABG], or both),
may benefit from a functional assessment of areas of myocardium treated.
After initiation of antiarrhythmic therapy (pharmacologic or a device),
especially in patients with a history of exercise-related abnormalities, exercise
stress testing in a controlled environment can evaluate management and
provide reassurance to the patient. Functional testing using exercise is often
directed toward assessing cardiovascular capacity or response in healthy
individuals as well as a variety of those with known pathology.
Functional testing often can be offered to those who have undergone
congenital heart defect repair, valvular replacement or repair, or cardiac
transplantation in an effort to provide a baseline or document improvement
in those who were previously physically restricted. Patients who suffer from
stable but chronic heart failure, diabetes, chronic renal insufficiency, or
pulmonary pathology fall into the group that benefits from functional exercise
testing. With the exception of asymptomatic patients with multiple cardiac
risk factors and patients with occupations that place the public at risk,
exercise treadmill testing with electrocardiographic monitoring should not
be considered a screening tool. The indiscriminate use of exercise stress
testing in an effort to expose silent ischemia leads to misleading false-
positive results that are financially burdensome and lead to undue patient
worry (Sox, 1989).
CONTRAINDICATIONS
As with any testing modality, the anticipated benefits of information provided
to the clinician by a test should outweigh the potential risks associated with
obtaining the information. There are few absolute contraindications to
performing exercise treadmill testing, but the test administrator must always
weigh the anticipated benefits carefully against the perceived risks of
the test.
■ Generally, exercise stress testing is likely to worsen myocardial
ischemia in patients already suffering from myocardial infarction or
Chapter 11 — Exercise Stress Testing for the Primary Care Provider 129
unstable angina. Testing should be delayed until rest pain is absent and
the infarction has stabilized and been appropriately treated.
■ Patients with symptoms of congestive heart failure should be stabilized
to the point at which they are likely to be able to perform the planned
test protocol and are not having pulmonary edema.
■ Patients with symptomatic conduction abnormalities, such as high-degree
atrioventricular block and symptomatic supraventricular tachycardia,
and most ventricular tachycardia, and patients with demonstrated
"chronotropic incompetence" should not be stressed until an adequate
ventricular rate in response to increased metabolic demand can be
anticipated or controlled.
■ Pacemaker therapy is not a contraindication to exercise stress testing,
but reprogramming the rate and response settings may be necessary and
an imaging modality used if evidence of ischemia is being sought.
Persistent ventricular or supraventricular tachycardia should be
corrected before testing. Some antiarrhythmic agents may prevent
patients from reaching target heart rate during testing, and the addition
of an imaging modality may improve the value of the test.
■ Severe systemic arterial hypertension defined as a pretest systolic
pressure of 200 mm Hg or greater or pretest diastolic pressure of 110 mm
Hg or greater is generally considered an absolute contraindication.
Excessive myocardial wall stress imparted by this degree of hypertension
exerts a significant increase in myocardial oxygen demand at baseline.
These patients are better candidates for testing when their hypertension
is controlled.
■ Exercise stress testing in patients with severe aortic stenosis is
prohibited because the myocardial oxygen demand at baseline is already
significantly elevated. Although testing is used in determining the timing
of surgery, it is reserved for patients who have not yet manifested the
associated triad of angina, syncope, or congestive heart failure.
Other clinical conditions that should be controlled before exercise stress
testing follow:
■ Recent pulmonary embolism or infarct and severe peripheral vascular
disease (deep venous thrombosis, phlebitis, claudication)
■ Limitations to ambulation (cerebrovascular accident, orthopedic
disability, severe vertigo or dizziness)
Inability of the patient to follow instructions (mental disability, catatonia,
psychosis)
Concomitant illnesses, especially when associated with fever.
130 Chapter 11 — Exercise Stress Testing for the Primary Care Provider
Relative Contraindications
In some patients, the anticipated benefits of exercise testing outweigh the
higher than average risks or impediments. These "relative contraindications"
are usually more minor versions of the previously mentioned "absolute
contraindications" and, as such, are not prohibitive. Common examples follow:
Presence of preexisting electrocardiographic abnormalities when the
examiner is focusing on non-electrocardiographic criteria (e.g., conditions
such as new left ventricular segmental wall motion abnormality seen on
echocardiography or perfusion defects and redistribution abnormalities
in the setting of radionuclide studies)
■ The patient who cannot mount an adequate heart rate response to
exercise stress testing ((3-blocker pharmacologic therapy) has an
inability to exercise because of ambulation difficulties, or is not otherwise
willing to work physically
■ Patients using agents such as dobutamine, dipyridamole, or adenosine,
which cause pharmacologic stress and may increase myocardial oxygen
demand or myocardial perfusion during which the ECG, blood pressure,
heart rate, and imaging can be observed for changes suggesting ischemia
Potential Complications
The risks of cardiac stress testing via a treadmill, cycle ergometer (use
of a stationary bike with varying degrees of resistance), or arm exercise
testing (use of an exercise wheel analogous to the pedals of a bicycle
with varying degrees of resistance) are small when attention is paid to
appropriate patient selection. Pooled data suggest that approximately
0.5 deaths per 10,000 tests in large heterogeneous populations can be
expected (Gordon, 1993).
Most sudden death episodes during stress testing occur in middle-aged
and older individuals with advanced atherosclerotic CAD. A detailed
medical history and physical examination often identify individuals at
higher risk for complication associated with stress testing. Ironically,
these individuals are the very group for which stress testing is most
often indicated. Specifically, they are individuals with diabetes mellitus,
multiple organ system failure, ambulatory impairment associated with
orthopedic disorders, and electrolyte imbalance. Proper patient
monitoring provided by well-trained individuals who can administer
emergent care is essential to reduce known complications.
■ Complications related to the mechanics of walking on an exercise treadmill
include, but are not limited to, injury sustained from a fall; prolonged
episodes of myocardial oxygen demand in excess of supply, resulting in
prolonged myocardial ischemia or infarct, or both; hemodynamically
significant tachycardia or bradycardia; and sudden cardiac death.
Chapter 11 — Exercise Stress Testing for the Primary Care Provider 131
Aggressive efforts at screening patients for contraindications before
performing stress testing may significantly reduce the incidence of
complications. Continuous patient monitoring for rhythm disturbances,
ST segment changes, and other electrocardiographic manifestations of
myocardial ischemia, as well as disruptions in the patient's cognitive and
psychomotor function, can minimize the incidence of complications
associated with exercise stress testing.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
Dynamic or isotonic exercise (muscular contraction resulting in movement)
is preferred for testing because it puts a volume stress rather than a pressure
load on the heart. It also can be performed in increments. According to the
American Heart Association statement on exercise standards, when dynamic
exercise is begun or enhanced, oxygen uptake by the lungs quickly increases.
After the second minute, oxygen uptake usually remains relatively stable
(steady state) despite progressive levels of intensity of exercise. During steady
state, heart rate, cardiac output, blood pressure, and pulmonary ventilation
are maintained at reasonably constant levels.
Maximal oxygen consumption (Vo2max) is the highest level of oxygen
consumption a subject can achieve during maximal exercise. During exercise,
a physically fit subject progressively increases his or her oxygen consumption,
cardiac output, and pulmonary ventilation as the circulatory system provides
blood and oxygen to the exercising tissues. The definition of a unit of
metabolic equivalent (1 MET) is the total oxygen consumption measured in
milliliters of oxygen per kilogram of body weight per minute for an adult
sitting quietly at rest. 1 MET has been measured at approximately 3.5 mL/kg
per minute. MET can and should be used as a work equivalent when comparing
the level of physical work during different activities or different exercise
protocols (Cintron, 1996).
Heart rate is one of the determinants of myocardial oxygen consumption,
and thus peak heart rate is used as an indirect index of the workload imposed
on the heart during exercise. Tables and formulas have been developed that
provide the expected peak heart rate that should be attained during an
exercise test carried out to maximal effort. The maximal achieved heart rate
is usually expressed as a percentage of maximal predicted heart rate for a
given age. A test that is limited by noncardiac factors at an attained heart
rate less than 85% of maximal heart rate (MHR) may not have challenged the
circulatory cardiac reserve enough to attain predictive validity. The percent
of MHR at which symptoms or electrocardiographic evidence of myocardial
ischemia occurs is an indicator of severity of the cardiac impairment, the
individual's disability, and a rough index of prognosis. Studies suggest that
attained METs may represent a better unit of measure of stress in quantifying
exercise.
132 Chapter 11 — Exercise Stress Testing for the Primary Care Provider
During graduated exercise performed by normal subjects, heart rate and
systolic blood pressure increase progressively The product of the achieved
MHR and blood pressure is called the double product or rate-pressure product
and also serves as an index of myocardial oxygen consumption. At rest, for
example, the heart rate may be 70 and the systolic blood pressure 120 mm Hg,
giving a double product of 8400. During exercise, the double product may
exceed 30,000. When subjects cannot achieve a double product of 18,000
without signs or symptoms of cardiac disease, cardiac reserve is severely
impaired, indicating a poor prognosis (Cintron, 1996; Fletcher, 1992).
A normal or negative test is one in which the end points are achieved
without the appearance of symptoms, signs, or electrocardiographic findings
that suggest the presence of cardiac disease. A negative test usually indicates
a low statistical probability for the presence of clinically important cardiac
disease.
The normal physiologic response to exercise may be altered by a number
of cardiac diseases. Coronary atherosclerosis is the most common and limits
the dilatory capacity of the coronary arteries. This restricts the amount of
blood available to the myocardial tissues. Heart rate, blood pressure,
myocardial contractility, and left ventricular chamber diameter and wall
thickness all determine myocardial oxygen demand. The increase in heart
rate, systolic blood pressure, and myocardial contractility induced by exercise
is balanced by an increase in myocardial blood flow. Since myocardial oxygen
extraction is almost maximal, even at rest, an imbalance between oxygen
demand and blood supply quickly leads to myocardial ischemia and its
clinical counterparts — angina, electrocardiographic changes, transient
myocardial mechanical dysfunction, and, occasionally, cardiac rhythm dis-
orders. The most common objective finding in patients with physiologically
limiting coronary atherosclerosis who are subjected to exercise testing
is electrocardiographic ST segment depression, with or without anginal
symptoms (Fig. 11-2).
PATIENT PREPARATION
■ Explain the indications for and benefits and inherent risks of the test to
the patient and assess for understanding.
■ The patient should have been given a physical examination and had a
medical history taken that focused on cardiopulmonary and orthopedic
systems before scheduling the test. Attention to the use of (3-blocker
therapy, cardiac glycosides, and medicines altering the patient's state of
consciousness should be considered before testing. With the use of an
imaging modality, it is not always necessary for the patient to discontinue
(3-blocker or digitalis therapy, although these medicines can alter the
quality of the study by modifying the patient's MHR response or cause
an abnormal baseline ECG. The physical examination should be directed
toward eliciting signs or symptoms of orthopedic disease, peripheral
Chapter 11 — Exercise Stress Testing for the Primary Care Provider 133
Phase name Stage name
Time in Speed Grade }
i/Vorkload
Heart rate BP
RPP
VE count
Stage mph %
METS
bpm
mm Hg bpm*mm Hg
ves/min
PRETEST SUPINE
0:00 1.0 0.0
1.7
74
142/78
14500
0
EXERCISE STAGE 1
3:00 1.7 10.0
4.6
102
158/74
17100
0
STAGE 2
3:00 2.5 12.0
7.0
106
166/72
22700
0
STAGE 3
3:00 3.4 14.0
10.1
137
0
STAGE 4
3:00 4.2 16.0
13.4
162
0
RECOVERY
6:06 0.0 0.0
1.0
103
0
■
40 yr White
Male BRUCE
Total exercise time: 12:00
Wt: Ht:
MaxHR: 162
bpm 90% of Max Predicted 180
bpm
25 mm/sec
Med:
MaxBP: 166/72
Maximum workload: 13.7 METS 10 mm/mV
100 Hz
Reason for termination:
Max HR attained
Comments:
BASELINE
MAX ST
Lead
Lead
EXERCISE STAGE 1 74 bprr
l ST@10mm/mV ST
EXERCISE STAGE 4 161 bpm ST @ 10 mm/mV ST
00:00 1.7METS
80 msec post-J . slope
11:37
13.7 METS
80 msec
post-J slope
I
— ~H^H V -fcfh
— *ja
I
0.1
J J r
-^\
.
^1 f
r1^ avffT~
0.0 0.31
0.0 -0.2
YT
aflJ-Kv
V4 V
-2.1
aVR
1.3 '
vi r
0.2
-0.3, 0.0
1
0.2 -1.3
-«rV — «^ —
0.0 ' -0.2
0.3
■ J
-2.8
-0.6
,Jl1
1.9
— -vi. r^
0.5
AlJ .
^Vlk^ ^J~J
V
II Y|r ^vtT
-0.7 0.3
a^P
1.6 '
0.2 y
-2.0
-1.6 -0.1
•-villi 1 _ /U ll 1 ^v
0.1 -1.4
-vT^— vT^
0.6
■ J
0.3
__A , —
1.7
0.8
J
■
ur1^ — wp^ —
v/
aVFV
^ir~
veAr
-0.7 -0.7
-0.2 -0.2
-3.0
-2.9
-1.3
-1.3
-1.8 -1.8
-0.8 -1.4
-0.4
0.1
1.2
1.3
Figure 1 1 -2. Examples of electrocardiographic changes indicative of a positive exercise stress test.
Compare baseline ST segments (Bruce protocol — stage 1 — 1.7 METs) with exercise ST segments at 11:37
(Bruce protocol — stage 4 — 13.7 METs) in this 40-year-old man with a positive exercise stress test.
ST segments are measured 0.08 seconds after the J point. Note significant ST segment depression of 0.2 mm
in leads II, III, aVF, and V2-V6. BP, blood pressure; bpm, beats per minute; HR, heart rate; MAX ST, maximal ST;
METS, metabolic equivalent; RPP, rate-pressure product.
vascular disease (claudication), or neurologic abnormalities that would
limit the patient's ability to perform ergometry.
In an attempt to minimize patient anxiety and maximize performance in
this patient-dependent test, written instructions that outline the patient's
responsibilities and address common concerns and questions should be
offered. A detailed description of the test procedure should occur before
patient preparation, and questions should be solicited and addressed.
In preparation for the test, the patient should be told to abstain from
smoking and to wear comfortable clothing and sturdy footwear.
134 Chapter 11 — Exercise Stress Testing for the Primary Care Provider
Much information is gained when the examiner "walks the patient" back to
the testing area. Information regarding gait, balance, respiratory reserve,
and overall physical ability identifies individuals for whom treadmill testing
is prohibitive and in whom pharmacologic stress might be considered.
Materials Utilized for Performing Exercise Stress
Testing
General Environment
Note: Treadmill testing is usually conducted in a laboratory environment;
however, family practitioners and internists often use any extra available
space for this type of procedure. The space should be adequate for the
testing team who must attend the patient during the testing. This typically
involves the test proctor and one or more technicians.
■ Temperature control and adequate ventilation essential to maximize
patient performance
Note: Generally, temperatures between 22° and 26° C (72° to 79° F) are
comfortable for exercise, especially if adequate air movement is present. In
geographic locations where environmental humidity is greater than 50%,
the testing environment temperature must be adjusted down to
accommodate this. Often, a portable fan improves exercise performance.
Adequate lighting for patient assessment and patient comfort and safety
Note: In the setting of diagnostic imaging modalities, adjustable lighting,
usually in the form of a dimmer switch, can be a useful feature.
Room for readily available emergency equipment
■ Crash cart
Portable defibrillator
Supplemental oxygen supply
Curtains to ensure patient privacy as well as provide enough separation
between patients to allow for normal conversation and promote patient
comfort and performance
A sink, supply of towels, and wash cloths for the patient to use after
exercise
Testing Equipment
■ Treadmill
Note: Treadmill weight capacity should equal or exceed a patient weight of
350 pounds. The system should have a variable range of speeds and degree
of incline (1 to 8 miles per hour and 0 to 20 degrees) and should optimally
be electronically controlled by and in synchrony with the testing clock.
Chapter 11 — Exercise Stress Testing for the Primary Care Provider 135
A dedicated electrical source should be used for the treadmill and
electrocardiograph system to avoid interruption during studies. A standard
treadmill platform should be equal to or exceed 50 inches in length and 16
inches in width (Pina, 1995). Padded handrails and emergency stop
switches, which are readily visible and accessible to both patient and staff,
afford added safety. The area directly behind the treadmill (often referred
to as the run-out area) should be kept clear of obstruction and afford the
patient safe egress from the treadmill at any time. Typically, a reclining
chair or bed should be stationed proximal to the treadmill to afford the
patient recumbence in the recovery period.
Imaging equipment
Echocardiogram
Radionuclide camera
■ Continuous oscilloscopic monitoring of a minimum of three leads, and
preferably 12 leads, in the Mason-Likar configuration
■ ST segment templates, baseline correction software, and automatic
dysrhythmia alerts are helpful but not essential to the safe conduct of
testing
Machine-patient interface, specifically the electrocardiographic electrode
placement
Note: Commercially available silver-silver chloride electrodes with adhesive
attachment offer excellent electrocardiographic signal transmission.
■ The addition of a "tube shirt," using elasticized medical mesh material,
adds stability to electrodes
The cable array should arise from a central module, which should be
attached by a belt worn about the patient's waist
Note: Attention paid to confirming quality signals before testing will serve
the examiner in ensuring good data for interpretation.
Blood pressure monitoring equipment, which consists of a variety of
available devices, ranging from automated systems that use oscillatory
signaling to a standard manual mercurial sphygmomanometer and
stethoscope
Note: In high-volume, experienced laboratories, manual cuff measurement
is still the standard, offering reliable blood pressure monitoring but
requiring specially trained personnel. Attention should be paid to using
appropriately sized blood pressure cuffs in the variety of patients seen in a
laboratory, as well as routine maintenance and calibration of manometers.
Attention to basic details, such as placing the manometer at the level of the
patient's heart, as well as routine cleaning and calibration, ensures accurate
and reliable blood pressure monitoring.
Note: Laboratories using stationary bicycle ergometers for individuals
with specific orthopedic, peripheral vascular, or neurologic limitations to
136 Chapter 11 — Exercise Stress Testing for the Primary Care Provider
weight bearing on a treadmill test should have similar automated resistance
control features. Commercially available stationary bicycles use either
mechanically braked or electronically braked flywheels for this purpose.
Often, software that interfaces with the ECG and bicycle ergometer will
"ramp" the degree of stress on a preprogrammed basis. As with treadmill
testing, the cycle ergometer area must be free of other equipment and
afford rapid egress from the bicycle for the recovery period. Attention to
seat height and handlebar adjustments can improve the chances of
maximal exercise performance and data quality. Numerous tables have
been computed to project METs for cycle ergometry, but generally speaking,
maximal oxygen uptake is lower on cycle ergometry than on treadmill
testing.
An arm ergometer uses not only dynamic arm exercise but also the
musculature of the chest, back, buttocks, and legs for body stabilization.
Individuals with lower extremity impairment, such as those with
orthopedic or vascular disease, can often be stressed safely with this
equipment; however, difficulty often arises with electrocardiographic signal
quality because of electrical or mechanical interference with upper body
musculature activity. Close attention to detail in skin preparation for
electrode placement can often overcome this technical limitation.
Imaging Equipment
In an effort to increase the sensitivity and specificity of exercise stress
testing, an imaging modality is useful. Its typical application is in the
patient with an abnormal baseline ECG for whom stress-related changes
might not be quantifiable. Examples of this are left bundle branch block;
prior myocardial infarction with Q waves; ST-T abnormalities of any cause,
including digitalis effect; or individuals taking (3-blockers in whom failure to
achieve target heart rate may occur. Pacemaker-dependent patients may
benefit from adjunctive cardiac imaging. Equipment ranges from
scintigraphy cameras for radionuclide imaging to two-dimensional cardiac
ultrasonography. Although beyond the scope of this discussion, cardiac
ultrasonography or radionuclide imaging can be applied in patients
undergoing ergometry or in those who are stressed with pharmacologic
agents such as dobutamine, dipyridamole, or adenosine. In the application
of stress echocardiography, an echocardiographic bed with a "cutaway" in
the mattress — affording the sonographer apical access with the patient in
the left lateral decubitus position (before and after exercise or during
pharmacologic stress) — markedly improves image quality. A variety of
commercially available systems afford continuous loop (rest and stress)
imaging, as well as comparative (before and after) formatting.
Emergency Equipment
Exercise testing is a common and safe procedure, even in the outpatient
setting, but still presents some risk. Accordingly, basic emergency
Chapter 11 — Exercise Stress Testing for the Primary Care Provider 137
Table 1 1 .2 Emergency Equipment for Exercise Stress Testing
Nasal cannula, non-rebreathing oxygen mask, airways (oral), oxygen tank (portable for
transport)
Defibrillator (portable)
Bag-valve-mask hand respirator (Ambu bag)
Syringes and needles
Intravenous tubing, solutions, and stand
Suction apparatus and supplies (e.g., gloves, tubing)
Adhesive tape
Table 1 1 .3 Emergency Medications and Solutions
MEDICATIONS
INTRAVENOUS FLUIDS
Atropine
Epinephrine
Isoproterenol
Procainamide
Verapamil
Bretylium
Lidocaine
Dobutamine
Adenosine
Sublingual nitroglycerin
Dopamine
Normal saline (0.9%)
D5W
Adapted from Pina IL, Balady GJ, Hanson P: Guidelines for clinical exercise testing laboratories: A statement
for healthcare professionals from the Committee on Exercise and Cardiac Rehabilitation, American Heart
Association. Circulation 91:912-921, 1995.
equipment should be readily available to the testing team. Most diagnostic
exercise stress tests are performed on a population with at least a
moderate pretest probability of CAD. Thus, the testing facility must have
appropriate emergency equipment, pharmaceuticals, and personnel trained
in their use.
A written protocol that clearly outlines the responsibilities of each
testing team member should be composed and periodically reviewed. Mock
emergency drills should be carefully planned, executed, and critiqued, using
a variety of scenarios on a regular basis in an effort to remain prepared for
the inevitable medical emergency that affects all laboratories. At a minimum,
the emergency equipment listed in Table 1 1-2 should be close to the testing
area and considered "ready" on a regular basis.
When generating emergency protocols, the testing team must decide the
limits of its response. In the outpatient setting, basic cardiac life support
and early Emergency Medical Service (EMS) activation are the mainstays of
the emergency response, whereas stress testing facilities within the confines
of hospitals or medical centers may offer advanced cardiac life support
procedures (endotracheal intubation), highly specialized personnel, and
equipment. Emergency medications and solutions should also be available
in these settings (Table 11-3).
138 Chapter 11 — Exercise Stress Testing for the Primary Care Provider
Personnel
The exercise stress team often consists of nurses, physicians, physician
assistants, an exercise physiologist or specialist, a physical therapist, and
electrocardiography and nuclear medicine technicians. Members of the
team should have appropriate training and periodic proficiency evaluation
in the duties they perform routinely All staff members should receive
training in basic cardiac life support, with at least one member of the team
being versed in advanced cardiac life support. Stress testing in the outpatient
environment is usually conducted under the supervision of a clinic
physician who should be available in the immediate area during the conduct
of stress testing. A laboratory policy and procedure manual should be
established in keeping with the policies of the health care facility and any
state or local restrictions. An individual identified as the Medical Director
of the testing facility should be active in the formulation of policies and
procedures as well as proficiency evaluations of the staff members.
Documentation of this duty should be ongoing and available for review.
Requirements for physician competency in the exercise stress testing of
patients with known or suspected cardiac pathology are well outlined in
the American College of Physicians/American College of Cardiology/
American Heart Association statement on clinical competence (Schlant, 1990).
Procedure for Exercise Stress Testing
Applying Electrodes and
Obtaining Resting
Electrocardiographic
Tracings
1. Remove hair in the testing region of
the electrode placement with
battery-operated shaving equipment.
2. Remove lotions and skin oil from the
area of electrode application with
alcohol-saturated gauze. Allow the skin
to dry.
3. Place commercially available electrodes
in the proper location.
Note: In many laboratories, an abrasive (fine
sandpaper or commercially available pads)
is used to abrade the superficial layer of
skin, thus decreasing skin resistance to
5000 Q or less.
4. Attach lightweight ECG cables to the
electrode array and secure the central
module to the patient, usually with a
holster-and-belt device around the waist.
5. Apply a flexible tube vest over the
patient's trunk to help in decreasing
electrical or mechanical interference
associated with lead bouncing.
6. Perform a baseline ECG in the standard
12-lead configuration.
7. Perform a standard 12-lead ECG with the
patient in the supine and standing
positions and after 30 seconds of
hyperventilation.
Note: ST segment depression occurring with
hyperventilation, although uncommon,
should be taken into account before
initiation of the exercise test itself.
8. Evaluate the tracing for baseline ST-T
abnormality or other rhythm
Chapter 11 — Exercise Stress Testing for the Primary Care Provider 139
disturbances that would prohibit the
performance of stress testing.
Note: When using an imaging modality, the
baseline ECG is performed at this time. To
afford adequate acoustical windows, often
leads V4, V5, or V6 must be altered to
accommodate ultrasonographic transducer
placement.
Data Collection
Note: Average individuals exercise between
8 and 12 minutes when tested on the
appropriate exercise treadmill protocol.
There is a variety of protocols available,
each with its proponents. Most can be
programmed with a typical
electrocardiographic-treadmill system. The
Bruce protocol is used most commonly,
beginning with a low level of stress and
increasing in speed and incline every
3 minutes (Bruce, 1977).
9. Demonstrate the proper technique for
mounting the treadmill, handgrip
placement, and body positioning for
performing the exercise protocol.
10. Advise the patient that the protocols
start the patient at a slow walking pace
with a minor or no incline and then ramp
up to the next level of work (speed and
incline) at predetermined time intervals.
11. Have monitoring personnel or yourself
obtain a 12-lead ECG at least every
minute (depending on the patient's
symptoms) and a blood pressure check
just before advancement to the next
stage.
Note: Because of the inaccuracy of data
generated by automated systems, manual
blood pressure measurement, using a
mercury manometer, stethoscope, and
Modified Borg Scale
Original Borg Scale
0
Nothing at all
6
0.5
Very, very weak
7
Very, very light
1
Very weak
8
2
Weak
9
Very light
3
Moderate
10
4
Somewhat strong
11
Fairly light
5
Strong
12
6
Somewhat hard
13
7
Very strong
14
8
15
Hard
9
16
10
Very, very strong
17
Very hard
(almost maximum)
18
19
Very, very hard
Maximum
20
Figure 1 1 -3. Borg scales. (Adapted from
Pollock ML, Wilmord JH: Exercise in Health and
Disease: Evaluation and Prescription for
Prevention and Rehabilitation, 2nd ed.
Philadelphia, WB Saunders, 1990, p 290.)
trained personnel, remains the preferred
technique of monitoring (Froelicher, 1993).
12. Instruct the patient to communicate to
the monitoring team his or her
perception of exertion.
Note: Often, a hand-held card or sign (in
large print), with various descriptions of
perceived exertion (Borg scales [Borg,
1982]), is held before the patient by the
monitoring team in preparing for test
termination (Fig. 11-3).
Note: Symptoms of general fatigue,
dyspnea, leg fatigue, and pain are often
difficult to quantify, and a system of
quantifying perceived exertion can aid in
stopping at an appropriate end point.
13. Counsel patients not to exit the treadmill
while it is going; instead, the patient
should signal to the testing team their
impending exhaustion so that the test
may be terminated in a safe manner.
continued
140 Chapter 11 — Exercise Stress Testing for the Primary Care Provider
Note: The test should be stopped as
indicated. End points for stress testing
include, but are not limited to, the following:
• Progressive angina
• Persistent ventricular tachycardia
• Significant blood pressure blunting or
decrease below baseline
• Significant and progressive ST-T
depression or any ST-T elevation
• Progressive heart block
• Excessive blood pressure response
greater than 250 mm Hg systolic and
greater than 120 mm Hg diastolic
• Lightheadedness
• Confusion
• Ataxia
• Cyanosis or evidence of cerebral or
peripheral circulatory collapse
• Sincere patient requests to stop the
test
• Failure of critical monitoring equipment
14. On completion of the test, assist the
patient into a supine position while
serial ECGs and blood pressure data are
collected every 1 to 2 minutes or until
the patient's heart rate approximates
baseline by 10%.
Note: Exercise stress testing using imaging
requires special patient positioning, such as
a left side lying position (stress ECG), thus
resulting in a short delay in vital sign
monitoring.
15. Record blood pressure, heart rate, and
electrocardiographic data recording
continually until patient is asymptomatic
and near-baseline vital signs are present.
16. Observe any patient who manifests signs
or symptoms of cardiac disease during
or after testing (angina, hypertension,
hypotension, ventricular
tachyarrhythmias, or other clinical
indications for continued monitoring)
until those conditions stabilize.
Note: A typical monitoring period after
exercise recovery is between 6 and
12 minutes.
17. While the patient is preparing for exit,
review electrocardiographic,
hemodynamic, and applicable imaging
data before the patient's discharge from
the testing facility.
18. Although a final report may require a
more detailed analysis, in the interest of
patient safety, make a preliminary
evaluation of the collected data and
inform the patient of these preliminary
findings and, if appropriate, the referring
provider.
SPECIAL CONSIDERATIONS
It is imperative that the test administrator monitor vital signs (blood
pressure, heart rate, respiratory rate, and tissue perfusion) throughout the
exercise protocol, which includes pre-exercise evaluation and continuous
monitoring throughout the exercise test itself and throughout an appropriate
recovery period. Symptom evaluation using the Borg scale serves as an
important aid in the assessment of functional capacity, as well as dictating
Chapter 11 — Exercise Stress Testing for the Primary Care Provider 141
appropriateness of test termination. The testing team, directed by the test
administrator, must be continuously vigilant for signs of cardiovascular
compromise or deteriorating ambulatory ability Scenarios in which test
termination must occur abruptly should be practiced frequently by the
testing team, with provisions for acute intervention in the setting of hemo-
dynamic collapse. Most patients experiencing an abrupt inability to continue
provide adequate warning to the testing team and afford them the opportunity
to terminate the test and come to the aid of the patient without resultant
injury.
■ In the setting of abnormal cardiac rhythm, rapid intravenous cannulation
and supplemental oxygen are essential to the patient's positive outcome.
In patients in whom rhythm abnormality or hemodynamic deterioration
is highly suspected, intravenous placement before testing affords the
testing team a route for rapid drug administration.
In the setting of ventricular tachyarrhythmias, immediate termination of
the testing protocol and placement of the patient in a supine position
with supplemental oxygen and establishment of intravenous access are
important.
Individuals who continue to manifest ventricular or atrial tachycardia, or
both, benefit from antiarrhythmic therapy, typically lidocaine or
adenosine, but may require elective or even emergent DC cardioversion.
■ Individuals manifesting lightheadedness, confusion, pallor, cyanosis, or
diaphoresis in the setting of profound ST-T abnormalities may be
demonstrating acute ischemia and may benefit from oxygen therapy and
nitroglycerin.
Chronotropic impairment (i.e., relative bradycardia in the setting of
increasing metabolic demands) is treated most successfully with
termination of cardiac stress and rest.
Patients manifesting severe bradycardia may benefit from instructions to
cough until sinus node function returns.
■ Patients demonstrating progressive angina on termination of stress
testing are best treated with immediate supplemental oxygen therapy,
nitroglycerin, and rest.
Individuals who do not respond to the preceding measures in the setting
of significant ST-T abnormality are likely to have multi-vessel CAD and
should be considered unstable angina patients and managed accordingly.
FOLLOW-UP CARE
■ Advise patients on discharge from the testing facility that it is not
unusual to feel fatigued for the remainder of the day and counsel against
activities that would compound this symptom.
142 Chapter 11 — Exercise Stress Testing for the Primary Care Provider
In individuals with findings suggestive of tachydysrhythmia or ischemia,
the referring provider should be involved in making any further
recommendations and in initiation of therapy
Provide printed literature that addresses findings as well as instructions
on activity modifications, monitoring for and response to changes in
symptoms, and contacts for further information or evaluation.
Individuals demonstrating unstable responses to stress testing should be
hospitalized (unstable angina; early, marked positive
electrocardiographic changes; and hemodynamically unstable rhythms).
References
Borg G: Psycho-physical bases of perceived exertion. Med Sci Sports
Exerc 2:100-119, 1982.
Bruce RA: Exercise testing for ventricular function. N Engl J Med
296:671-675, 1977.
Cintron GB: Clinical exercise testing. In Chizner MA (ed): Classic
Teachings in Clinical Cardiology, vol 1. Cedar Grove, N.J., Laennec,
1996, pp 378-392.
Fletcher GF, Blair SN, Blumenthal J, et al: Statement on exercise:
Benefits and recommendations for physical activity programs for all
Americans: A statement for health professionals by the Committee on
Exercise and Cardiac Rehabilitation of the Council on Clinical
Cardiology, American Heart Association. Circulation 86:340-344, 1992.
Froelicher VF: Exercise and the Heart, 3rd ed. St. Louis, CV Mosby, 1993.
Gianrossi R, Detrano R, Mulvihill D, et al: Exercise-induced ST
depression in the diagnosis of coronary artery disease: A
meta-analysis. Circulation 14:87-98, 1989.
Gibbons RJ, Balady GJ, Beasley JW, et al: ACC/AHA guidelines for
exercise testing: A report of the American College of Cardiology/
American Heart Association Task Force on the Practice Guidelines
(Committee on Exercise Testing). J Am Coll Cardiol 30:260-311, 1997.
Gordon NF, Kohl HW: Exercise testing and sudden cardiac death.
J Cardiopulmon Rehabil 13:381-386, 1993.
Pate RR, Blair SN, Durstine JL, et al: Guidelines for Exercise Testing and
Prescription: American College of Sports Medicine, 4th ed.
Philadelphia, Lea & Febiger, 1991.
Pina IL, Balady GJ, Hanson P, et al: Guidelines for clinical exercise
testing laboratories: A statement for healthcare professionals from
the Committee on Exercise and Cardiac Rehabilitation, American
Heart Association. Circulation 91:912-921, 1995.
Schlant RC, Friesinger GC, Leonard JJ: Clinical competence in exercise
testing: A statement for physicians from the ACP/ACC/AHA taskforce
on clinical privileges in cardiology. J Am Coll Cardiol 16:1061-1065, 1990.
Sox HC, Littenberg B, Garber AM: The role of exercise testing in
screening for coronary disease [see comment]. Ann Intern Med
110:456-469, 1989.
Weiner DA, Ryan TJ, McCabe CH, et al: Exercise stress testing:
Correlations among history of angina, ST-segment response and
prevalence of coronary artery disease in the Coronary Artery Surgery
Study (CASS). N Engl J Med 301:230-235, 1979.
Chapter 11 — Exercise Stress Testing for the Primary Care Provider 143
Bibliography
Darrow MD: Ordering and understanding the exercise stress test. Am
Fam Phys 59:401-410, 1999.
Ladenheim ML, Kotler TS, Pollock BH, et al: Incremental prognostic
power of clinical history, exercise electrocardiography and
myocardial perfusion scintigraphy in suspected coronary artery
disease. Am J Cardiol 59:270-277, 1987.
Pina IL, Chahine RA: Lead systems: Sensitivity and specificity Cardiol
Clin 2:329-335, 1984.
Vogel JA, Jones BH, Rock PB: Environmental consideration in exercise
testing and training. In Resource Manual for Guidelines for Exercise
Testing and Prescription. Philadelphia, Lea & Febiger, 1991, p 119.
Cha
pter 1 O
Endotracheal Intubation
Shepard B. Stone
Procedure Goals and Objectives
Goal: To successfully insert an endotracheal tube while observing
standard precautions and with a minimal degree of risk to the
patient.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing endotracheal intubation.
• Identify and describe common complications associated with
endotracheal intubation.
• Describe the essential anatomy and physiology associated with
the performance of endotracheal intubation.
• Identify the materials necessary for performing endotracheal
intubation and their proper use.
• Identify the important aspects of patient care after endotracheal
intubation.
145
146 Chapter 12 — Endotracheal Intubation
BACKGROUND AND HISTORY
Endotracheal intubation is the process by which a tube is inserted into the
trachea. This may be accomplished through the larynx or through the skin of
the neck. Cricothyroidotomy and tracheostomy are the terms for the latter
approach. This chapter limits discussion to the former approach and refers
to the translaryngeal intubation of the trachea simply as intubation.
Intubation is a procedure that is performed daily in many locations around
the world — electively in the operating room and urgently in emergency
rooms, in clinics, and in the field. Practitioners should be familiar with this
lifesaving skill. Proficiency at intubation is a requirement for practitioners
whose practices put them in an environment in which advanced cardiac life
support, pediatric/neonatal advanced life support, and advanced trauma life
support skills are used on a regular basis and in which advanced backup (an
anesthesia care provider) is not rapidly accessible.
The technique has been performed since the 18th century (Roberts, 1983);
however, its use as we know it today became more common in the 1940s. The
value of intubation is well established. The ability to place an unobstructed
conduit into a patient's airway to assist with ventilation and to protect the
airway is potentially a lifesaving skill. Conversely, if performed improperly,
endotracheal intubation can be life threatening. Providing the necessary
knowledge and skills to master this technique successfully is the goal of this
chapter.
INDICATIONS
Intubation, which provides a secure means of maintaining a patent air passage,
should be used for the following situations:
For a patient who has lost the ability to maintain a patent airway if other
methods are ineffective or unreliable
■ If a patient is at risk of losing the ability to ventilate adequately (e.g.,
airway edema, decreasing levels of consciousness, respiratory failure)
■ For bypassing anatomic obstructions to clear airflow and provide a
means to suction the lower airways of secretions and foreign materials;
positive-pressure ventilation with a self-inflating reservoir bag (e.g.,
Ambu) is facilitated, as is the use of mechanical ventilators
CONTRAINDICATIONS
The only contraindication to translaryngeal intubation is laryngeal disruption
itself. Airway compromise must never be tolerated, but intubation through
the traumatized larynx may not succeed, may waste precious time, and may
exacerbate the injury. In this situation, creation of a surgical airway (e.g.,
cricothyroidotomy) may be the more prudent choice.
Chapter 12 — Endotracheal Intubation 147
POTENTIAL COMPLICATIONS
Complications of intubation may be anatomic, physiologic, or psychological.
Anatomic complications, which may result from the intubation itself or from
the presence of the tracheal tube, are as follows:
Nasal intubation may traumatize the nasal turbinates, the nasal mucosa,
or the adenoids or may dissect into the retropharyngeal tissues.
■ Oral intubation may cause damage to the lips, teeth, tongue, tonsillar
pillars, tonsils, or a combination of these structures. All intubations may
damage the epiglottis, the laryngeal cartilages and mucosa, and the
vocal cords.
■ Esophageal and tracheal perforations have occurred during intubation
attempts.
■ Cervical spine injuries and ocular injuries have also been reported.
■ As in any instrumentation, bleeding may occur.
■ Late complications of intubation include vocal cord paralysis and a
subsequent increased risk of aspiration and dysphonia, tracheal
stenosis, and tracheomalacia.
The "anatomic" problems of tracheal tube malposition or kinking can
also occur.
Physiologic complications of intubation include the following:
■ Hypoxia
Hypercarbia
Cardiac dysrhythmias (including cardiac arrest)
■ Hypertension
Hypotension
Intraocular hypertension
■ Intracranial hypertension
Vomiting and aspiration
■ Bronchospasm
■ Laryngospasm
Late complications include
■ Pain
■ Sore throat
Speech problems
■ Difficulty swallowing and breathing
Sinusitis
■ Pneumonia
148 Chapter 12 — Endotracheal Intubation
Tongue
Oral cavity
Nares
Oral
pharynx
Hyoid bone
Uvula
Esophagus
Laryngeal
opening
Cricoid
cartilage
Vallecula
Thyroid cartilage
Tongue
Epiglottis
Vallecula
Arytenoid
cartilage
Route to
trachea
Visualization of cords
via pharynx
Cutaway side view of head and neck
Figure 12-1. Anatomy of the oropharynx, nasopharynx, and larynx. (Redrawn
from Pfenninger JL, Fowler GC: Procedures for Primary Care Physicians. St. Louis,
Mosby-Year Book, 1994, p 456.)
Psychological complications include
Posttraumatic stress disorder that may result from intubation of patients
who have not been adequately prepared psychologically for the
intubation procedure or have not been sufficiently anesthetized or
sedated during or after the intubation, or both.
Prevention of all complications in all patients is not possible. However, proper
preparations (physical, psychological, and pharmacologic) and gentle ma-
nipulations result in both the highest success and the lowest complication
rates.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
The successful performance of any procedure is enhanced by adequate
knowledge of the relevant anatomy. Review of the structures of the
oropharynx, nasopharynx, and larynx is essential (Fig. 12-1).
The nasotracheal tube traverses the nostrils, passing between the nasal
septum and the nasal turbinates and bending around the posterior naso-
pharynx to arrive in the hypopharynx. The nasal mucosa is both friable and
sensitive. Efforts must be made to reduce the likelihood of epistaxis before
tube insertion.
Orotracheal intubation involves manipulation of the tongue to elevate the
epiglottis, exposing the larynx. The lips and teeth are structures to avoid
Chapter 12 — Endotracheal Intubation 149
when manipulating the laryngoscope, as are all other tissues. Epiglottic
manipulation is carried out either directly with the laryngoscope blade or
indirectly by placing the laryngoscope blade in the vallecula. The vallecula is
the point at which the epiglottis attaches to the tongue. Elevation of the
tongue at this point causes the epiglottis to rotate anteriorly and expose
the larynx.
When the epiglottis is elevated, the larynx is visualized. Note that in
pediatric patients (younger than 3 years of age), the epiglottis is relatively
long and floppy, and it must be manipulated directly for laryngeal exposure.
The key landmark is the glottis, the opening into the larynx itself. The glottis
is bordered laterally by the vocal cords, which are whitish structures
originating at the 12 o'clock position and attaching at 5 and 7 o'clock (when
the patient is supine). The arytenoid cartilages are the paired posterior
laryngeal landmarks from the 3 to 9 o'clock positions. The vocal cords are
located in the narrowest portion of the adult larynx. Deep to the larynx
(which is formed anteriorly by the thyroid cartilage) is the cricoid cartilage.
This is a complete cartilaginous ring attached to the thyroid cartilage via the
cricothyroid membrane. This is important to remember when it is desirable
to manipulate the larynx during intubation attempts or to occlude the
esophagus. Also, the cricoid cartilage is the narrowest part of the pediatric
airway. Distal to the cricoid is the trachea itself. The tracheal bifurcation
results in the left main stem bronchus taking a more acute deviation to the
left than the right main stem bronchus takes to the right. Overly enthusiastic
tracheal tube insertion usually results in a right main stem bronchial
intubation. The esophagus lies posterior to the airway structures.
The nasopharynx, oropharynx, and larynx are richly innervated by the
sphenopalatine ganglion, anterior ethmoidal nerve, glossopharyngeal nerve,
superior laryngeal nerve, and the recurrent laryngeal nerve (Sanchez , 1996).
This must be considered when intubating a patient who is conscious. The
placement of a tracheal tube or a laryngoscope, or both, in this circumstance
will result in discomfort and autonomic nervous system stimulation. This is
the cause of many of the physiologic complications mentioned earlier.
There are certain features assessable on physical examination that may
predict difficulties in intubation. Narrow nostrils make nasal intubation
difficult, as do narrow nasal passages. This can be ascertained by occluding
one nostril and having the patient breathe in rapidly and deeply through the
nonoccluded nostril. If there is occlusion, this is readily noted by the patient.
Limited mouth opening may make laryngoscopy difficult. Limited intraoral
visualization (often caused by a large tongue) is a risk factor for difficult
laryngoscopy. Limited neck movement, especially extension, may be a
predictor of intubation difficulty. A significant overbite or micrognathia may
make intubation challenging. Another predictor of possible difficulty is if the
distance from the chin to the larynx is less than three fingerbreadths (patient's),
or 6 cm. None of these physical examination findings is completely reliable for
accurately predicting difficult intubation. Their presence should not be ignored,
however, and the presence of multiple risk factors must be considered as an
increasing likelihood of difficult intubation (Mallampati, 1996).
150 Chapter 12 — Endotracheal Intubation
to exercise clinical judgment based on the
Standard Precautions Practitioners should use patient's history and the potential for exposure
standard precautions at all times when to body fluids or aerosol-borne pathogens (for
interacting with patients. Determining the level further discussion, see Chapter 2).
of precaution necessary requires the practitioner
PATIENT PREPARATION
Having a cooperative patient markedly facilitates intubation.
■ In the patient who is capable of responding to the environment but requires
intubation, it is important to explain why he or she needs to be intubated
and what the procedure will entail, both during and after the procedure.
As always, it is important to consider historical information, including the
patient's past medical history.
■ If possible, query the patient or the patient's family about any prior
difficulties with intubation.
■ If time permits and previous medical records are available, look for an
anesthesia record.
■ If it is found that general anesthesia was administered, intubation may
have taken place. If intubation was difficult, the anesthesia care provider
should have noted it.
Pharmacology
Pharmacologic support can be useful. If intubation with the patient awake is
desired, the process can be facilitated with the use of topical anesthetics; in
fact, intubation may be performed using topical anesthetics alone. Intubation
can also be performed without any pharmacologic support; if time is critical,
this may be the only option. Providing adequate topical anesthesia requires
approximately 10 to 20 minutes of preparation. The anesthetization itself
takes no more than 10 minutes, but the drying of the airways that enhances
absorption of the local anesthetics takes about 10 minutes after intravenous
administration or 20 minutes after intramuscular administration. Glyco-
pyrrolate, 0.2 mg intravenously in adults, is an adequate dose. The advantage
of glycopyrrolate over atropine is that it does not cross the blood-brain
barrier, decreasing the potential for causing confusion, which can be a major
problem when patient cooperation is desired.
Local Anesthetics
Commonly used topical anesthetics include cocaine, benzocaine, tetracaine,
lidocaine, or combinations thereof. These drugs are applied to the surfaces
that are to be in contact with the laryngoscope and endotracheal tube, but
they are not necessary for airway anesthesia. One nerve that must not be
Chapter 12 — Endotracheal Intubation 151
blocked is the recurrent laryngeal nerve, because sensory blockade
anesthetizes the larynx and part of the epiglottis, and motor blockade results
in vocal cord paralysis. A unilateral block causes hoarseness, dysphonia, and
possible aspiration; a bilateral block causes complete airway obstruction.
One may attain sensory blockade only by topical application of local
anesthetics to the larynx and trachea (this may be carried out from above the
larynx or by injecting through the cricothyroid membrane). If the patient is
at risk for pulmonary aspiration of oral or gastric secretions, anesthesia
should not be provided, some argue, so that the patient can sense the
presence of aspirated material and be able to clear it by coughing.
Cocaine
Cocaine offers the unique advantage of also providing topical vasocon-
striction. This is useful for reducing epistaxis when performing intubations
via the nasal route. If used, no more than 3 mg/kg of body weight of a 4% or
10% solution should be used to avoid toxicity. It should also be avoided when
tachycardia and hypertension are a concern. If vasoconstriction is desired,
phenylephrine (Neo-Synephrine) or oxymetazoline (Afrin) may be used in
conjunction with other local anesthetics.
Benzocoine
Benzocaine has a rapid onset and brief duration of action. The dose limit of
4 mg/kg is readily exceeded, because it comes in high concentrations of 10%,
15%, and 20%. Overdosage can result in methemoglobinemia.
Tetracaine
Tetracaine has a longer duration of action than benzocaine. It is available in
dilute concentrations of 0.5%, 1%, and 2%, and the dose limit is 0.5 mg/kg.
Cetacaine
Cetacaine is a commercially available aerosolized mixture of 14% benzocaine
and 2% tetracaine that has a rapid onset and reasonable duration. Be aware that
the toxic effects of local anesthetics are additive, thus it is recommended to
limit administration to no more than two one-second sprays. Cocaine,
benzocaine, and tetracaine are all members of the amino ester group of local
anesthetics. This group has a higher associated incidence of allergic reactions.
Lidocaine
Lidocaine is the most readily available local anesthetic. It is of the amino
amide group, and allergic reactions to lidocaine itself are rare. It is available
in 0.5%, 1%, 2%, and 4% solutions; 2% viscous solution; 2% jelly; 2.5% and 5%
ointments; and a 10% aerosol spray. The dose limit is 5 mg/kg.
Sedatives
The intubation of the patient who is not obtunded (by pathologic or iatrogenic
processes) is made easier by sedation. Drugs that have a rapid onset and
152 Chapter 12 — Endotracheal Intubation
brief duration of action are best for this purpose. Surprisingly small amounts
are necessary in the presence of a well-anesthetized airway; in fact, the
anesthetization itself may be facilitated with judicious sedation. The most
commonly used drugs are fentanyl and midazolam. These drugs also have
the advantage of having an antagonist available — naloxone (Narcan) and
flumazenil (Romazicon), respectively. Titrated to effect, they are not likely to
produce adverse hemodynamics. Be aware that synergism may result from
polypharmacy and undesired responses such as airway obstruction and
respiratory depression may result. Any drug can be used as long as the
desired effects are achieved, that is, a patient who breathes and is calm and
cooperative. The advantage of intubation performed in a conscious patient
is that the patient maintains airway patency, spontaneous ventilation, the
ability to protect the airway, and the ability to verify neurologic function
during and after intubation. This is particularly important with cervical spine
injuries (Sanchez, 1996). It should always be considered in patients who are
known to be difficult to intubate, those who are anticipated to be difficult to
intubate, those who have airway or neck trauma, or those who are
hemodynamically unstable (Sanchez, 1996).
Other Methods of Anesthesia
If performing intubation while the patient is awake is not required,
performing intubation while the patient is unconscious is usually faster and
easier for both the patient and the practitioner. Psychological stress is
reduced, and the intubating conditions may be improved by general
anesthesia. The risk of anesthized intubation is that it removes the patient's
ability to maintain the airway and ventilate spontaneously. There is also the
chance that the intubation will not succeed. If the patient cannot be ventilated
by face mask or other device and cannot be intubated and the anesthetizing
drugs cannot be cleared, the only recourse to save the patient's life is to create
a surgical airway, which is not without risk. In the process of performing
intubation, it is important to remember to "do no harm."
The practitioner can use the sedatives mentioned earlier in larger doses to
obtain unconsciousness, or other drugs can be used. The intravenous agents
that are used most commonly to induce rapid unconsciousness are thiopental,
propofol, etomidate, and ketamine. All work within seconds. Thiopental and
propofol may cause hypotension. Propofol and etomidate cause local pain on
injection and sometimes cause myoclonic movements. Etomidate has a high
incidence of nausea associated with its use. Ketamine is associated with
auditory and visual hallucinations during the recovery phase that may be
attenuated by benzodiazepines. It also causes bronchodilation, making it
especially useful as an induction agent in status asthmaticus. Both etomidate
and ketamine tend to maintain blood pressure and are the preferred induction
agents in hemodynamically unstable patients in whom anesthetized intubation
is desired. It should be noted that ketamine might cause hypotension in
patients who are catecholamine-depleted (associated with long-term physio-
logic stress). Note that ketamine and etomidate may cause increases in
Chapter 12 — Endotracheal Intubation 153
cerebral metabolic rate and are not the agents of choice if cerebral ischemia
is of greater concern than the ability to intubate the anesthetized patient.
Usual induction doses are thiopental, 3 to 5 mg/kg; propofol, 2 to 2.5 mg/kg;
etomidate, 0.3 to 0.5 mg/kg; and ketamine, 1 to 2 mg/kg. Doses should be
decreased in elderly, hypovolemic, and hemodynamically unstable patients.
There are no reversal agents for these drugs.
Neuromuscular Blocking Drugs
Rendering the patient unconscious may be helpful; providing neuromuscular
blockade (NMB) or paralysis may be helpful or may result in death. By
causing all the skeletal muscles to relax, the patient cannot cough or offer
any physical resistance to intubation. The jaw muscles are lax, enabling
easier mouth opening and facilitating laryngoscopy. The lack of coughing
prevents spontaneous movement of an unstable cervical spine. Lack of
coughing also prevents increases in intrathoracic pressure that can increase
central venous pressure, which can result in increased intracranial pressure.
The life-threatening complication of neuromuscular blockade is cessation of
any spontaneous ventilatory efforts. If the patient cannot be intubated
and/or ventilated and surgical access to the airway is not attained rapidly,
the patient may die.
The other consideration when using neuromuscular blocking drugs is that
they paralyze skeletal muscles only. They do nothing to suppress conscious-
ness, pain, or the reception and interpretation of any sensory stimulus. When
NMB agents are administered alone, the patient remains as awake as you are,
with the ability to feel, hear, smell, taste, and see (if you open the patient's
eyelids). The only way that the patient can protest is autonomically by
becoming hypertensive, developing arrhythmias, becoming bronchospastic, or
increasing intracranial pressure. Subtle clues are pupillary dilation, tearing, and
diaphoresis. Administering sufficient amounts of sedating and anesthetizing
drugs can prevent these undesirable effects. If this cannot be carried out
because of hemodynamic status, the patient should be informed. Let the
patient know that he or she will feel and hear everything that goes on.
The desirable characteristics of NMB agents to facilitate intubation include
the rapidity of onset and brevity of duration; therefore, if intubation fails,
breathing may return sooner. The absence of unwanted hemodynamic and
other side effects is also desirable. The NMB agents are of two classes:
depolarizers and nondepolarizers. The one depolarizer, succinylcholine,
causes muscular depolarization at the neuromuscular junction. This is just
like acetylcholine. Unlike acetylcholine, however, it takes minutes rather
than seconds to be cleared from the muscle receptor. The depolarizers (all
other NMB agents) are competitive inhibitors of acetylcholine, preventing
depolarization by occupying the muscle receptor site where acetylcholine
normally triggers the depolarization. Termination of effect takes minutes to
hours, depending on the drug and the dose; a greater dose results in a longer
duration of action. Anticholinesterases (e.g., neostigmine, pyridostigmine,
and edrophonium) can be used to reverse nondepolarizing neuromuscular
154 Chapter 12 — Endotracheal Intubation
blockade when indicated. Note that this reversal may be neither rapid nor
complete depending upon the intensity of the neuromuscular block.
Succinylcholine
Succinylcholine is effective at a dose of 1 mg/kg (in children 1 to 2 mg/kg). Its
onset is within 60 seconds, and the duration of action is about 5 to 10 minutes.
Increasing the dose increases the duration of action. Its mode of action,
skeletal muscle membrane depolarization, results in a transient hyperkalemia
of about 0.5 to 1 mEq/L. Patients who are paretic, those who have been burned,
those who have sustained crush injuries, or those who are hyperkalemic for
any reason may sustain a hyperkalemic increase of 5 to 10 mEq/L, resulting in
cardiac arrest. Succinylcholine may also trigger malignant hyperthermia. It
may also cause transient increases in intraocular and intracranial pressures,
so it should be used with caution if the patient has an open globe injury and
closed head injury unless the risk of a failed intubation is greater than the
risk of increased intracranial pressure. Succinylcholine may cause bradycardia;
therefore, its use in pediatric patients should be preceded by anticholinergic
administration. Myalgias sometimes follow succinylcholine use; administering
a small dose of a nondepolarizing agent prior to the succinylcholine may
reduce the incidence of myalgias. If a nondepolarizing NMB agent is used
to mitigate myalgias, the dose of succinylcholine should be increased to
1.5 mg/kg.
Nondepolarizing Neuromuscular Blockade
Agents
The nondepolarizing NMB class includes curare, metocurine, pancuronium,
vecuronium, atracurium, c/s-atracurium, doxacurium, pipecuronium,
mivacurium, and rocuronium. Rocuronium offers the fastest onset (within
1 minute and maximal effect within 3 minutes, with a duration of 30 minutes)
at a dose of 1.2 mg/kg. The others have a slower onset. Increasing the dose
enhances the onset of all these drugs, increasing their duration of action.
Increasing the dose also increases the likelihood of unwanted side effects.
Some of the drugs listed release histamine when given rapidly or in a large
dose, which may cause flushing, hypotension, and bronchospasm.
Physical Preparation
Patient positioning is critical.
Intubation is easiest if the patient is supine with the head as close to the
practitioner as possible and at the level of the practitioner's xiphoid
cartilage.
■ The patient's head should be in the "sniffing" position: cervical flexion
with C1-C2 extension.
■ If cervical spine injury is a possibility, the patient should either be
maintained in an appropriate cervical immobilization system or should
Chapter 12 — Endotracheal Intubation 155
Figure 1 2-2. Axes in line with "sniffing"
position. (Redrawn from Pfenninger JL,
Fowler GC: Procedures for Primary Care
Physicians. St. Louis, Mosby-Year Book,
1994, p 456.)
have axial stabilization maintained by an individual who does nothing
else during the intubation sequence.
In normal adults, the sniffing position is readily attained by placing a
support under the head while displacing the occiput toward the patient's
feet.
■ In children and the obese, a more optimal position may be attained by
placing support under the shoulders and neck.
Caution: The importance of this maneuver cannot be overstressed. The
sniffing position aligns the axes of the oropharynx (mouth), hypopharynx
(throat), and larynx, making the shortest distance from the "outside world"
to the trachea (Fig. 12-2).
Materials Utilized to Perform Endotracheal
Intubation (Fig. 12-3)
Adjuncts
■ Emergency support equipment (More frequently than not, tracheal
intubation is an urgent, if not an emergent, procedure.)
An adequate source of suction to reduce the likelihood of pulmonary
aspiration and to enhance laryngeal visualization
■ Airway adjuncts such as oropharyngeal and nasopharyngeal airways
An appropriately sized face mask, self-inflating reservoir bag, and oxygen
source
For patients in whom mask ventilation and intubation is unsuccessful, a
laryngeal mask airway, which may be a lifesaving aid
156 Chapter 12 — Endotracheal Intubation
Straight blades
r
Stylet
Laryngoscope
Oxygen setup
Batteries
Endotracheal
tubes
Tape
Suction setup
Scissors
Anesthesia and
bag valve masks
Figure 1 2-3. Endotracheal intubation equipment. (Redrawn from Pfenninger JL,
Fowler GC: Procedures for Primary Care Physicians. St. Louis, Mosby-Year Book,
1994, p 454.)
Intravenous access and resuscitative medications as well as specific
adjunctive medications (see later)
Monitors for pulse oximetry, electrocardiography, and blood pressure
If neuromuscular blocking drugs are to be used, a peripheral nerve
stimulator to monitor the onset and duration of action of those drugs
Laryngoscopes
■ The laryngoscope is a lighted tongue elevator (rather than depressor)
and is a necessity for most oral intubations and some nasal intubations.
Note: The intubator should confirm that the laryngoscope is functioning. If
the batteries are exhausted or the bulb is burned out, the intubation
process will be significantly impeded. Other common causes of malfunction
are loose bulbs and impurities between the contacts of the blade and the
handle. Fiberoptic laryngoscopes are more reliable and often brighter than
conventional devices.
■ Appropriately sized blades for the patient: for adults, Macintosh No. 3
and No. 4 (curved blades) and Miller No. 2 and No. 3 (straight blades)
Chapter 12 — Endotracheal Intubation 157
H
r\
Curved blade
r\
Straight blade
Figure 1 2-4. Curved and
straight laryngoscope blades.
15-mm adaptor
Pilot
balloon
10-mL
syringe
Murphy
eye
Figure 12-5. An endotracheal
tube.
(Fig. 12-4); for pediatric patients, straight blades in order to directly
manipulate the relatively large and floppy epiglottis
Available backup equipment, such as additional handles, batteries, and
blades
Tracheal Tubes
Tracheal tubes (or endotracheal tubes), constructed of a plastic that has
been implant tested to prove it is not harmful to biologic tissues, are
needed. They are for single-patient use. The tubes are described by their
size, which is determined from the internal diameter in millimeters.
Common sizes are from 2.5 to 10 mm. Sizes frequently used for orotracheal
intubation in adults are 7 to 8 mm in women and 7.5 to 8.5 mm in men
(Fig. 12-5). Tube size for nasotracheal intubation is limited by the size of
the nasal passages; small nares or enlarged nasal turbinates may markedly
limit the size of the tracheal tube that can pass.
Note: An often-used formula for calculating tube size in children is
18 + age in years/4; this is a rule of thumb, and adjustments are made as
required (see below). Tracheal tubes of the expected size, as well as those
158 Chapter 12 — Endotracheal Intubation
a size larger and a size smaller, should be immediately available. The tubes
have centimeter markings along the distal length.
Note: Tracheal tubes should be kept in the sterile wrapper until ready for
insertion. Preparation of the tube includes confirming that the 15-mm
external diameter adapter is securely in place — it is usually loosely in place
in the unopened package. If the adapter is lost, conventional ventilation
equipment will not be able to "mate" with the tracheal tube, and only
"mouth-to-tube" ventilation or spontaneous ventilation will be possible.
Note: Other preparation includes confirming that the tube's inflatable cuff
and its inflation valve are functional. First injecting a volume of air
sufficient to distend the cuff into the inflation valve and then detaching the
inflation syringe from the inflation valve accomplishes this. The cuff should
be observed to maintain its inflated state. If it does, both the cuff and
inflation valve are functional. If the syringe is not removed, the competence
of the inflation valve has not been confirmed. It is more common to have a
defective inflation valve than a defective cuff on a new tracheal tube.
Note: Tracheal tubes for children younger than 6 years of age are usually
not cuffed (cuffed tubes are manufactured but are not commonly used).
This is because of concerns of postextubation airway narrowing. The
inflammation after intubation of the narrow pediatric airway can result in
obstruction to airflow. Adult airways also develop inflammation, but
because they are of much greater diameter, the effect of the inflammation
usually is not clinically significant.
■ Lubrication for tracheal tubes
Note: This may be helpful in the presence of dry oral mucosa (oral
intubation). Lubrication is essential for nasal intubation to reduce nasal
trauma, bleeding, and pain. Water-soluble lubricants (sterile) or local
anesthetics (e.g., lidocaine, 2% jelly) are useful. Use of tubes lubricated
with local anesthetics is associated with an increased incidence of sore
throat, although the cause is unknown.
Stylets
The final step in tube preparation is preparing a lubricated stylet for the
tracheal tube.
■ Stylets are made of a malleable metal, often coated with polymeric
silicone (Silastic). They serve to provide a means of modifying the tube's
innate mild curve to the shape desired by the intubator.
Stylets should be lubricated before insertion into the tracheal tube. The
lubricant must not be harmful if inhaled into the lungs. A sterile, water-
soluble jelly is used most often. Care should be taken to avoid getting
the lubricant on the outside of the 15-mm adapter because it can
interfere with mating to self-inflating bag-valve units, ventilator tubing, or
anesthesia circuits.
■ Stylet should be placed for all oral intubations. During intubation,
removing an unneeded stylet is easier than placing a needed one.
Chapter 12 — Endotracheal Intubation 159
Magill's Forceps
Magill's forceps are used to help pass nasotracheal tubes when
laryngoscopes are used to facilitate nasal intubation.
Confirming Tube Placement
■ Tools for confirming correct placement of tracheal tubes must be
immediately available.
■ A stethoscope to confirm breath sounds and a carbon dioxide detector
(a capnograph is ideal; colorimetric is acceptable) to confirm placement
in a perfused, ventilated airway
Note: Other devices are advocated but are not yet in common use.
Medications
■ See "Patient Preparation."
Other Equipment
Note: The equipment described is sufficient for most intubations. If it is
insufficient, specialized assistance should be sought. If this assistance is
unavailable, transcricothyroid jet ventilation or cricothyroidotomy should
be considered. Tracheostomy specifically is not recommended.
A failed intubation is likely due to anatomic abnormalities such as a short,
thick neck; airway edema and bleeding; and cervical immobilization.
Emergently "cutting down" into this anatomy to search for the trachea while
striving to avoid the carotid arteries, the jugular veins, and the thyroid gland
while the patient is becoming increasingly distressed is not recommended.
Many patients have died in such a circumstance. The specialist consultant
may have more experience, "tricks of the trade," and special equipment.
Examples of this equipment include (but are not limited to) fiberoptic
laryngoscopes, fiberoptic bronchoscopes, specialized laryngoscope blades,
antegrade and retrograde intubating stylets, and intubating laryngeal mask
airways.
Procedure for Oral Endotracheal Intubation
Reliable intravenous access should be in
place before beginning the procedure.
Cardiac and respiratory monitors should
be applied (electrocardiogram, pulse
oximetry, and blood pressure, at a
minimum). The patient must be
breathing 100% oxygen, and suction and
intubating equipment must be
immediately available in close proximity.
On completion of the preceding
preparations, open the patient's mouth
as wide as possible, with the right thumb
displacing the mandible toward the
patient's feet and the right index finger
pushing against the patient's maxillary
teeth (thumb being anterior to index
finger).
continued
160 Chapter 12 — Endotracheal Intubation
Note: This is best accomplished at the level
of the molar teeth, which are flat and will not
injure the fingers as incisors might.
Additionally, molars are closer to the
temporomandibular joint, so displacement
there will yield greater mouth opening, and
by having a hand off to the patient's right,
there will be ample room to place the
laryngoscope in the mouth.
3. Hold the laryngoscope in the left hand
and place it in the right side of the open
mouth. Slide along the tongue, displacing
the tongue anteriorly and to the left.
4. Keep the tongue from falling over the
right side of the blade, which will obscure
visualization.
5. Keep an eye on the tip of the blade as it
is being manipulated.
Note: As the blade is advanced, the epiglottis
comes into view.
6. When a fair amount of the epiglottis is
visualized (curved blade; Fig. 12-6),
apply force along the axis of the
laryngoscope's handle. This lifts the
tongue and rotates the epiglottis,
exposing the larynx (Fig. 12-7).
Note: When using a straight blade (Fig. 12-8),
the epiglottis is directly elevated with the tip
of the blade, again exposing the larynx.
Note: A common mistake is inserting the
blade too far. This can be disorienting, as the
ensuing esophageal visualization is
unanticipated. Another common error is not
applying the force vector along the
laryngoscope handle's axis but "levering"
the laryngoscope. This tends to cause it to
pivot on the patient's upper incisor teeth,
sometimes breaking them. More importantly
(in a lifesaving situation), it makes laryngeal
visualization more difficult because it tends
Base of
tongue
Epiglottis
Vocal cords
Trachea
Figure 12-7.
Figure 12-6.
Figure 12-8.
Chapter 12 — Endotracheal Intubation 161
to lift the larynx anteriorly out of the view of
the intubator. The goal is to raise the
structures above the larynx, leaving the
larynx in the field of vision. Assistance may
be obtained by displacing the cricoid
cartilage posteriorly; this displaces the
larynx for a better view. A cephalad and
rightward displacement may also be
helpful — backward, i/pward, rightward,
posteriorly (BURP) describes this
combination maneuver (Knill, 1993).
7. Take the tracheal tube in the right hand,
held as one would hold a writing
instrument, and pass it from the right
side of the mouth into the laryngeal
inlet, medial to the vocal cords and
anteromedially to the arytenoid cartilages.
8. If the patient is breathing spontaneously,
the vocal cords will be moving. Time the
tube insertion to correspond to the end
of inspiration. This is when the vocal
cords are farthest apart.
Note: Be aware that at the moment of tube
insertion, the view into the larynx is lost. If
the tube is not properly aligned with the
larynx, it is possible for it to be deflected
into the esophagus. The key to this potential
problem is to keep one's eye on the larynx
during and after the tube insertion. If the
tube is visualized between the vocal cords
and anterior to the arytenoids after tube
insertion, the tube is in the correct position.
If it is visualized posteriorly in the esophagus,
it is not in the correct position and should
be removed and placed properly.
9. Pass the tube so that the cuff just passes
the vocal cords; more is neither
necessary nor better.
Note: There is a great tendency among
practitioners who intubate infrequently to
advance the tube much too far. In most
adults, the depth of insertion is in the range
of 18 to 24 cm at the level of the upper
incisor teeth; the depth is less in shorter
patients and more in taller patients. As long
as the cuff is just beyond the vocal cords,
tube placement is adequate.
10. Pass the uncuffed pediatric tube so that
the heavy black marker line just passes
the vocal cords.
11. At this point, remove the laryngoscope
from the patient's mouth, holding the
tube securely while the stylet is removed.
12. Inflate the cuff at this time with just
enough air to cause a seal within the
trachea.
Note: The volume of air depends on the size
of the tube relative to the size of the trachea:
large tube, small trachea, small volume;
small tube, large trachea, large volume. It is
usually in the range of 5 to 10 mL. More is
not better, because excessive pressure is
exerted on the tracheal mucosa. This causes
ischemia that may predispose to tracheal
scarring and stenosis or tracheomalacia.
Just enough air should be administered so
that during positive-pressure ventilation one
does not hear air leaking around the tube
out of the patient's mouth.
Note: In children, a leak should be heard
at 20 cm of water pressure. If there is no leak
at this level of positive pressure, replace the
tube with a smaller one. If, conversely, the
leak is so large that one cannot effectively
ventilate the child, replace the tube with a
larger one.
Note: A recommended technique to change
the tube is to repeat the laryngoscopy and,
under direct vision, withdraw the wrong-sized
tube and replace it with another.
13. Confirm tube placement by auscultating
breath sounds bilaterally at the lung
apices (either in the axillae or
supraclavicular^) — first the right, then
the left. If tube placement is in question,
radiographic confirmation may be helpful.
Note: Auscultating the right side first
confirms placement in the airway; if there
continued
162 Chapter 12 — Endotracheal Intubation
are sounds, there is either a tracheal or right
main stem bronchial intubation. No sounds
indicate esophageal intubation. If there are
sounds on the left, it confirms tracheal
intubation. This sequence verifies correct
placement. Another approach is to disprove
incorrect placement. One auscultates over
the stomach first, then the right hemithorax,
and finally the left hemithorax.
14. Assess if the expiratory gas contains the
appropriate amount of carbon dioxide.
Note: This is highly desirable, especially if a
capnographic waveform is available for
analysis. This enables one to rule out a false-
positive determination, as is seen when a
patient has recently consumed carbonated
beverages. False-negative determinations
occur when there is a total absence of blood
flow to the lungs, as happens during either
cardiac arrest or massive pulmonary embolus.
15. Also inspect for symmetrical chest
expansion, fogging of the tube with
airway moisture, and absence of gastric
distention. If the tube is seen in the
larynx after tube placement, it is in place
(unless it gets displaced afterward). The
tube must now be secured.
16. Degrease the patient's skin and
prepare the skin with tincture of
benzoin or other skin adherent/
protector. Use of some commercially
available tube holders makes this step
unnecessary.
Note: The tube can be secured by
circumferentially wrapping the tape around
the patient's neck and then the tracheal
tube. If performed properly, it is almost
impossible for the tube to "fall out." The tube
can also be secured circumferentially with
cloth umbilical tapes or commercial tube
holders.
Procedure for Nasal Endotracheal Intubation
Note: Nasal intubation is most easily
performed in the spontaneously breathing
patient who is placed in a sitting position.
Topical vasoconstrictors are essential to
reduce the chance of epistaxis. If both
nostrils are equally patent, the right nostril
is preferred, as the bevel of the tube is less
likely to "scoop" the nasal turbinates as it
passes them.
1. Lubricate the tube; an easy way is to
place water-soluble jelly or anesthetic
jelly in the nostril, and the tube will "pick
up" the jelly as it is inserted.
2. Exert firm, steady pressure along the axis
of the nasopharyngeal floor (just as one
would do during insertion of a nasogastric
tube).
3. As the tube reaches the posterior
nasopharynx, some resistance is felt;
continue the steady pressure, and the
resistance decreases as the tube "turns
the corner."
4. As the tube is advanced further, breath
sounds are audible. It may be helpful to
occlude the other nostril and the
patient's mouth so that all ventilation is
via the tube.
5. Advance the tube during inspiration.
Note: If the tube is aligned with the larynx,
it will pass into the trachea. This is often
marked with a cough and, if the patient
is conscious, the loss of the ability to
phonate.
Chapter 12 — Endotracheal Intubation 163
6. If alignment is off in the midline, flex the
patient's neck and advance the tube. This
may attain success.
7. If the tube is misaligned laterally (the tube
causes a bulge laterally), rotate it to
remedy the situation.
Note: Because of the resistance of the tube
in the nose, a much greater rotation is
necessary than would be expected. It might
be necessary to rotate the tube 180 degrees
to get 30 degrees of rotation at the tube's tip.
8. If these maneuvers are ineffective, place
the patient supine as for oral intubation
and perform laryngoscopy and advance
the tube under direct vision.
Note: The Magill's forceps is often helpful at
manipulating the tube into the larynx.
Caution: Do not grab the tube's cuff with the
forceps, as it may tear. An assistant should
advance the tube as the intubator guides it.
9. Once in place, confirmation should be
obtained and the tube secured.
FOLLOW-UP CARE AND
INSTRUCTIONS
Having succeeded in this therapeutic maneuver, the patient must be
protected both physically and psychologically.
Physical Protection
■ Provide an adequate amount of humidified oxygen.
■ Prevent the tube from kinking and becoming dislodged.
Psychological Protection
Administer sedation and analgesia. If drugs are used to facilitate
intubation, the patient will experience pain and anxiety after their effects
have dissipated. It is both cruel and dangerous not to treat these
symptoms. It is dangerous because self-extubation is likely, and
hypertension, tachycardia, arrhythmias, and increased intracranial
pressure may occur. NMB agents are an inappropriate means of keeping
the tube in place in the absence of sedatives and analgesics.
There are infrequent circumstances when the patient's hemodynamic
status is so precarious that administration of sedatives and analgesics is
inadvisable, and the patient must be pharmacologically paralyzed to
prevent him or her from self-harm or harming others, to facilitate evaluation
and treatment, or to allow mechanical ventilation at safe airway pressures.
When these circumstances exist, all personnel must remember that the
patient is awake and sensate and must be treated appropriately. Speech
must be appropriate, and comfort and explanations offered to the
patient. It is my opinion that NMB agents are overused both inside and
outside the operating room.
164 Chapter 12 — Endotracheal Intubation
References
Knill RL: Difficult laryngoscopy made easy with a "BURP." Can J Anesth
40:279-282, 1993.
Mallampati SR: Recognition of the difficult airway. In Benumof JL (ed):
Airway Management: Principles and Practice. St. Louis, CV Mosby,
1996.
Roberts JT: Overview in Fundamentals of Tracheal Intubation. New
York, Grune & Stratton, 1983, p 4.
Sanchez A, Trivedi NS, Morrison DE: Preparation of the patient for
awake intubation. In Benumof JL (ed): Airway Management:
Principles and Practice. St. Louis, CV Mosby, 1996.
Bibliography
Applebaum EL, Bruce DL: A short history of tracheal intubation. In
Tracheal Intubation. Philadelphia, WB Saunders, 1976.
Benumof JL (ed): Airway Management: Principles and Practice.
St. Louis, CV Mosby, 1996.
Mallampati SR: Airway management. In Barash PG, Cullen BF,
Stoelting RK (eds): Clinical Anesthesia, 3rd ed. Philadelphia,
Lippincott-Raven, 1997, pp 573-594.
Cha
pter 1 O
Office Pulmonary Function
Testing
Gary R. Sharp, Daniel L. O'Donoghue, Roger A. Elliott, and
Daniel L. McNeill
Procedure Goals and Objectives
Goal: To perform office pulmonary function testing (PFT) on a
patient successfully
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing office PFT.
• Identify and describe common complications associated with
office PFT.
• Describe the essential anatomy and physiology associated with
the performance of office PFT.
• Identify the materials necessary for performing office PFT and
their proper use.
• Identify the important aspects of patient care after office PFT.
165
166 Chapter 13 — Office Pulmonary Function Testing
BACKGROUND AND HISTORY
The first explanation of the working of the body in mechanical terms dates
back more than 300 years, and PFT has been used for more than 150 years.
Thackrah, in 1832, was the first to present data on lung function in human
subjects. He was investigating the effects of occupation on lung size. His
initial study revealed that workers who stooped at work tended to have
smaller lungs than those who did not. Hutchinson's work, in 1844, is typically
identified as the founding work in spirometry and includes the first accurate
description of the use of spirometry to measure vital capacity. The first
measurement of dynamic lung function was proposed in 1933 by Hermannsen,
who recorded maximal voluntary ventilation. Tiffeneau and Pinelli first pro-
posed the measurement of a timed forced expiratory volume (forced expiratory
volume in 1 second [FEVJ) in 1947 (Miller, 1998).
Objective measurements of pulmonary function were developed initially in
the 1940s with the advent of spirometry. Improvements in spirometric
design, along with the development of complex procedures such as body
plethysmography and gas dilution techniques, continue to provide valuable
physiologic data on lung function. Because of the complexity of performing
and interpreting the techniques, PFT remained within the domain of hospital-
based laboratories (Ferguson, 1998). Currently, advances in spirometer design
have enabled the primary care provider to conduct PFT testing in the office
setting. Office-based spirometry has been made even more reachable by the
adoption of standards for testing and interpreting results (American Thoracic
Society, 1991, 1995).
When adding PFT to a practice, the provider must determine if it will be
used simply to manage or assess disease or if it will be used to quantify
pulmonary function for impairment ratings or for meeting Occupational Safety
and Health Administration (OSHA) requirements. For impairment or OSHA
uses, the examiner must undergo certification training through a National
Institute of Occupational Safety and Health (NIOSH)-approved course and
must adhere to stringent requirements for testing. Because of the governmental
regulations that apply to the use of spirometry in occupational medicine, this
chapter focuses on using the technique in a primary care setting. The terms
PFT and spirometry are used interchangeably.
INDICATIONS
Spirometry alone does not establish the diagnosis of a specific disease.
Spirometry aids in differentiating pulmonary dysfunction as having an
obstructive, restrictive, or a mixed cause (Bosse, 1993). The provider must
take into account the patient's complaints, a medical history, and physical
examination before making a diagnosis. PFT provides objective measures of
respiratory function that along with the clinical presentation aid the provider
in establishing a diagnosis, which leads to proper disease management and
prognosis (Bosse, 1993). Common indications for the use of office-based
spirometry include the following:
Chapter 13 — Office Pulmonary Function Testing 167
■ Evaluating patients with pulmonary complaints such as wheezing and
dyspnea
Determining the degree and reversibility of impairment in airflow
■ Assessing preoperative pulmonary risk
Establishing the impact of related risks on lung function, such as
smoking or occupational exposures
Assessing abnormalities of chest wall motion
As a component of periodic physical examination testing for individuals
requiring certification in respirator use — for example, emergency
personnel, carpenters, and many industrial workers (OSHA, NIOSH)
■ As a component of a Social Security disability examination (Social
Security Administration, 2005)
Bronchodilator and medication use just prior to testing needs to be evaluated.
Withholding short- and long-acting bronchodilators and steroids may be
necessary to establish baseline lung function. If the goal is to determine
bronchodilator response, simply discontinuing short-acting agents may be
needed. Lastly, there is no need to discontinue drug therapies if the goal is to
establish a new baseline for patients with long-standing pulmonary disease.
If patients are to withhold medication, explaining the risk of encountering
bronchospasm during the test is a prerequisite.
CONTRAINDICATIONS
Accurate spirometry is physically and mentally challenging, yet there are no
absolute contraindications for performing the procedure. Despite the absence
of absolute contraindications, the examiner should exercise common sense
and not perform spirometry on a patient unable to tolerate the physical
demands of the procedure. The American Association for Respiratory Care
(1996) defined the following as relative contraindications:
■ Hemoptysis of unknown origin
■ Pneumothorax
■ Unstable cardiovascular status
■ Thoracic, abdominal, or cerebral aneurysm
Recent eye surgery
Recent surgery involving the thorax or abdomen
ECONOMICS
Given the number of patients who are encountered routinely with indications
for spirometry, each clinic must determine the economic prudence of adding
168 Chapter 13 — Office Pulmonary Function Testing
spirometry to the practice or continuing the referral of patients to a PFT
laboratory. To aid in this decision, one must realize that the cost of a reliable
and completely computerized and automated spirometer starts at about
$1500, with replacement mouthpieces and supplies costing about $1.75 per
test. Generating a spirogram takes approximately 10 minutes. Using Medicare
and the author's home state of Oklahoma as examples, reimbursement under
Part B for performing spirometry (CPT 94010) is approximately $28.72, and
reimbursement for the technical component (e.g., interpretation, CPT
94010TC) is approximately $20.59. Thus, one could anticipate a total reimburse-
ment from Medicare of about $49 per spirometry examination (U.S. Department
of Health and Human Services, 2004). CPT code 94060, Bronchodilation
responsiveness, spirometry as in 94010, pre- and post-bronchodilator adminis-
tration, is reimbursed at approximately $79. Reimbursements vary by state
and insurance carrier.
POTENTIAL COMPLICATIONS
Common complications of spirometry usually are related to the physical
condition of the patient.
Individuals with cardiopulmonary disease — for example, asthma,
emphysema, chronic obstructive pulmonary disease (COPD), or unstable
angina — may suffer an exacerbation of symptoms related to their disease
when spirometry is performed.
■ Paroxysmal coughing, bronchospasm, and chest pain have been
reported after spirometry, even in a "normal patient."
A more commonly occurring untoward effect of the procedure is
lightheadedness or, on rare occasions, syncope brought on by the
momentary change in intrathoracic pressure.
■ Patient fatigue or lack of understanding of the test may compromise the
results of the procedure.
For optimal results, the patient must be well motivated and understand that
spirometry is a patient effort-dependent procedure. Consequently, providing
patient education and instructions before the procedure begins is important.
This is particularly useful in avoiding patient fatigue resulting from an
incomplete understanding of instructions regarding performing the test.
Finally, a well-trained staff is essential for maximizing the quality of the
procedure and reliability of the data.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
From a practical viewpoint, the lungs may be divided into the following:
■ Large airways consisting of the trachea and bronchi
Chapter 13 — Office Pulmonary Function Testing 169
Table 13.1 Pulmonary Disorders That Commonly Yield an
Abnormal Spirogram
DISORDERS RESULTING IN OBSTRUCTIVE
DYSFUNCTION
DISORDERS RESULTING IN RESTRICTIVE
DYSFUNCTION
Asthma
Emphysema
Chronic bronchitis
Neoplasm
Foreign body
Tracheal stenosis or malacia
Vocal cord paralysis
Fibrosis
Pneumonitis
Pneumoconiosis
Granulomatosis
Pulmonary edema
Neoplasm
Atelectasis
Pleural effusion or fibrosis
Kyphoscoliosis
Neuromuscular disease
Obesity
Abdominal distention
Small airways, which include bronchi and bronchioles down to less than
2 mm in diameter
■ The respiratory component consisting of the alveoli
Although the diameter of the airways becomes progressively smaller over
the 23 or so generations of divisions, the total cross-sectional area of the
small airways actually increases (Brooks, 1981). Thus, resistance to airflow
decreases as one proceeds from the lung hilum to the parenchyma. Because
small airways contribute only about 15% to total airway resistance, significant
disease must be present before evidence of small airway dysfunction is
measurable by spirometry.
Obstructive Disease
Disorders that present with an obstructive pattern by spirometry are noted
in Table 13-1. Congenital or mechanical impediments to airflow in the large
airways obviously result in an obstructive dysfunction. However, in the smaller
airways, the cause of obstructive dysfunction may be due to a decrease in
the elastic recoil of the lung or an increase in airway resistance, or both. For
example, a decrease in recoil is observed in emphysema, in which break-
down of alveoli and loss of lung stroma contribute to a decrease in elasticity.
The increase in airway resistance observed in chronic bronchitis and asthma
is produced by a decrease in small airway diameter secondary to mucosal
edema, hypersecretion, spasm, or a combination (Brooks, 1981).
Obstructive diseases reduce the ability of the lungs to move air, whereas
lung volumes and capacities remain normal or increase. Abnormalities in air
movement become most obvious by spirometry during forced expiration
(Fig. 13-1). As such, obstructive diseases result in a decrease in the volume
of air a patient is able to move during the first second (FEVj) and in midphase
(FEV250/.750/) of forced expiration (Table 13-2).
170 Chapter 13 — Office Pulmonary Function Testing
^^^— Normal pattern
....... Obstructive pattern
/ *x
/•— l.\
L* •«. x.
/ -^
i
\
\
\
\
— — — Restrictive pattern
o
CD
_l
o
LL
%x
•X
%x.
%x
%x
Volume (L)
2
CD
E
f,.
Time (sec)
Figure 13-1. Normal and
abnormal spirographs
patterns.
Table 13.2 Volumes and Flows in Obstructive and Restrictive
Disease
FORCED VITAL
FEVt/FVC
TOTAL LUNG
INTERPRETATION
FEVt
CAPACITY*
RATIO
VITAL CAPACITY
CAPACITY1
Normal
NL
NL
NL
NL
NL
Obstruction
Low
NL/low
Low
NL/low
High
Restriction
NL
Low
NL/high
Low
Low
Mixed
Low
Low
NL/low
Low
Low
FEVb forced expiratory volume, the volume of air forcefully exhaled in 1 second; FVC, forced vital capacity,
the volume of air that can be exhaled forcefully after full inspiration; NL, normal.
*Vital capacity is the maximal volume of air exhaled from the point of maximal inspiration.
tTotal lung capacity is vital capacity plus the total volume of inspired air.
Restrictive Disease
The pathologic presence of fibrotic tissue in the lungs underlies the basic
cause of restrictive diseases. As a result of pulmonary fibrosis, the lungs are
stiffened. This increases the elastic recoil pressure with a reciprocal
Chapter 13 — Office Pulmonary Function Testing 171
decrease in compliance. The net effect is that restrictive disease prevents the
lungs from expanding fully. See Table 13-1 for disorders that result in a
restrictive lung dysfunction pattern.
In pure restrictive disease, there is no obstruction to airflow. Therefore,
FEVi and other parameters of flow remain relatively normal (see Fig. 13-1 and
Table 13-2). Conversely, spirogram tracings from patients with restrictive
disease reveal a decrease in lung volumes that may be identified by the
forced vital capacity (FVC) (see Fig. 13-1 and Table 13-2).
Mixed Disease
A mixed pattern of obstructive and restrictive disease is typical in patients
presenting with more than one disease — for example, asthma and pulmonary
edema. More commonly, a mixed pattern is observed in smokers with some
degree of COPD. Therefore, caution must be exercised when attempting to
make a diagnosis of restrictive disease if the comorbid obstructive disease is
severe (Brooks, 1981). The reason for caution is that in severe obstructive
disease, the FVC may be decreased because of hyperinflation and air trapping
from the obstructive process. If severe obstructive disease is suspected, the
examiner may rely on other parameters of lung volume, such as vital capacity
without forced effort and total lung capacity (vital capacity plus total volume
of inspired air; Milhorn, 1981). In mixed diseases, FEVb FVC, vital capacity,
and total lung capacity are all decreased (see Table 13-2).
practitioner to exercise clinical judgment based
Standard Precautions Every practitioner should on the patient's history and the potential for
use standard precautions at all times when exposure to body fluids or aerosol-borne
interacting with patients, especially when pathogens (for further discussion, see
performing procedures. Determining the level Chapter 2)
of precaution necessary requires the
PATIENT PREPARATION
■ Patient education regarding the procedure is the primary preparation
required for spirometry.
Because the procedure requires the ability to follow instructions and
give maximal effort, children younger than 5 years of age are not good
candidates.
Although a common cold usually does not affect the outcome of the test,
individuals with acute bronchitis or pneumonia should wait 3 weeks for
recovery in order to perform at their optimal level (Horvath, 1981b).
■ Advise the patient to wear loose-fitting clothing and not to eat a meal
within 1 hour of testing.
172 Chapter 13 — Office Pulmonary Function Testing
Table 13 3 Suggested Times Medications Should Be Withheld
Based on Drug Half-life
AGENT
WITHHOLDING TIME
Short-acting inhaled bronchodilators (e.g., albuterol)
Long-acting inhaled bronchodilators (e.g., salmeterol)
Anticholinergic inhalers (e.g., ipratropium)
Long-acting anticholinergics (e.g., tiotropium)
Mast cell stabilizers (e.g., cromolyn sodium)
Leukotriene modifiers (e.g., montelukast)
Corticosteroids, inhaled or oral (e.g., fluticasone)
6-8 hr
48 hr
24 hr
<1 wk
48 hr
24 hr
Unknown,
long
If the patient is a smoker, instruct him or her not to smoke for at least
1 hour before spirometry.
Advise the patient on which medications should be withheld prior
to the procedure. Note that withholding long-acting medications may
cause acute bronchospasm during the test and that the purpose of the
test should guide the practitioner in determining which medications
to instruct the patient to withhold. Table 13-3 offers a guide for
withholding medications based on drug half-life (American Thoracic
Society, 2000).
At the time of the examination, ask the patient to loosen any tight
clothing and remove dentures, if worn.
The use of a nose clip during the procedure is optional.
The patient may be seated or standing for the procedure. If the patient
chooses to stand for the test, a chair should be placed behind the
patient should lightheadedness ensue during the procedure.
Materials Utilized for Performing Pulmonary Function
Testing
Spirometers on the market today fall into two main groups. There are those
that measure volume, such as a rolling seal or bellows type, and those that
measure flow directly, such as a rotating vane, hot wire anemometer, or
pneumotachograph. Most instruments today are computerized for data
collection and analysis. The spirometer of choice should be one that meets
American Thoracic Society standards. The type of instrument should be
selected based on the need to store patient data and load computerized
measurements into databases, ability to transmit data, cost per procedure,
and maintenance requirements.
Chapter 13 — Office Pulmonary Function Testing 173
Procedure for Pulmonary Function Testing
Note: It is important to read the instructions
specific for the operation of each machine,
because operation may vary from model to
model.
Calibration
1. The rationale for calibration is to provide
data to the spirometer that corrects for
fluctuations in ambient atmospheric
pressure. Therefore, before performing
PFT, the machine should be calibrated
daily or every 4 hours, or both, if
multiple tests are administered in a day.
Note: Calibration involves using a 3-L syringe
to blow air through a mouthpiece. The
syringe usually is provided with the machine.
In addition, results from each patient must
be corrected to BTPS (body temperature,
ambient pressure, saturation with water).
The BTPS correction factor is necessary
because volumes change when warm expired
air rapidly cools to the lower ambient
temperature. Modern machines, fortunately,
provide the BTPS correction automatically.
2. To complete the calibration, the altitude
above sea level and the temperature
must be entered into the machine.
3. For each test, enter the patient's height
(without shoes), weight, age, gender, and
race.
4. Many modern instruments are
programmed to input other patient
information (e.g., smoking history,
presence of chronic cough). Although
not critical in terms of calculating the
results, recording the patient's history
may be informative when interpreting
the spirogram.
Patient Instructions
Note: Providing patients with instructions
and active coaching during the test are
critical in obtaining an acceptable spirogram.
5. Instructing the patient "I want to see how
hard and how fast you can breathe or
exhale your air" is usually sufficient.
Explain the maneuver by stating "Take
in a deep breath, close your mouth
around the mouthpiece, and then blow
the air from your lungs into the
mouthpiece as hard and as fast as you
can" (Fig. 13-2).
6. The preferred patient posture for
performing spirometry is standing. A
sitting position is acceptable if the
patient is unable to stand or if the risk
of syncope is a concern.
Figure 1 3-2. (Redrawn from Pfenninger JL,
Fowler GC: Procedures for Primary Care
Physicians. St. Louis, Mosby-Year Book, 1994,
p 489.)
continued
174 Chapter 13 — Office Pulmonary Function Testing
7. During the maneuver, it is important to
provide active coaching. As the patient
begins to exhale, enthusiastically say
"Blow, blow, blow!" When it appears that
the patient is nearing the end of
expiration, say "Keep blowing!"
Note: Most machines have a signal that
identifies when the patient has reached a
plateau (a change of 25 mL or less in
2 seconds) or meets the length requirement
(between 6 and 15 seconds), or both. A
plateau signifies the end of an acceptable
maneuver.
Note: The maneuver may also be ended
when the patient cannot or should not
continue.
Obtaining a Meaningful
Spirogram
Note: An acceptable maneuver is free from
coughs, early termination, hesitant starts, or
variable effort. Coughs typically show up as
spiked notches on the volume-time curve.
• Early termination is defined as an inability
of the patient to plateau or have a change
of 25 mL or less within 2 seconds.
• A hesitant start is determined by back
extrapolation from the volume-time curve.
• Variable effort is an inconsistent curve
and is often a sign of poor compliance
with the procedure.
• Many computerized instruments have a
built-in algorithm program that looks for
and reports any of the preceding flaws in
technique.
• If possible, it is best to save each
maneuver, even if flawed.
• An acceptable spirometry test is
composed of at least three acceptable
maneuvers, with the two best curves for
FVC and FEVj being within 5% of each
other.
• No more than eight maneuvers should be
performed at any one session, because
fatigue can become a factor in the quality
of expiratory effort. Most instruments let
the examiner know when an acceptable
spirometry test has been accomplished.
• Individuals with disease may not fulfill all
criteria for an acceptable test. In such
circumstances, information gained from at
least an attempt may be useful in the
management of their disease.
8. Documenting the patient's effort in
complying with the procedure aids in
interpreting the spirogram and is useful
when comparisons are made with
subsequent tests as part of monitoring
the progression of disease.
9. It is common for errors in technique to
occur during spirometry. Frequently, the
patient may give up too soon, resulting
in a spirogram tracing lacking a plateau.
Properly encourage the patient toward
the end of the maneuver to correct this.
10. Air leakage around the mouthpiece can
give erroneous readings. Have the
patient wet his or her lips to obtain a
better seal.
11. Look for pursed lips and obstruction
with the tongue, which are errors readily
correctable by proper technique.
12. At the conclusion of the test,
computerized instruments allow you to
print the results of the test (Fig. 13-3).
Chapter 13 — Office Pulmonary Function Testing 175
SPIROMETRY REPORT
PBIOOSWRev: J-J
Patient Name
Patient ID:
University Occupational Health
Clinic, OUHSC, OKC, OK, 271-3100
TEST DATE:
TIME:
08:47
PreMed Time: 08:48
Age: 42 Height (in): 72 Weight (lbs): 200 Sex: Male Race Correction: No Smoker: No
Barometric Pressure (mmHg): 730 Temp (deg F): 76 BTPS Correction: 1.093 Sensor: FS200 Insp Code: None
Last Cal Date: 03/08/00
FVC TEST DATA - Clinical Format
BEST TEST SUMMARY
Measurement
FVC
FEV1
%FEV1
FEF25%-75%
PEF
FEV3
FET
(L)
(L)
(%)
(US)
(US)
(L)
(S)
PreMed
5.16
4.29
83.13
4.82
13.55
4.84
14.04
Pred
5.40
4.42
81.58
4.55
9.73
4.97
%Pred
96
97
102
106
139
97
PostMed
Knudson 83 Adult Predicted Normals
%Pred %Change
Variability : PreMed: FVC = 0.2%(10 ml_) FEV1 = 0.2%(10 mL) PEF = 2.6%
PREMED
TRIAL 3
TRIAL 2
TRIAL 1
Flow (L/sec)
0.25 CM/L/sec
n — i — i — i — r^n — i — i — i — i
1 23456789 10
VOLUME (L) 0.5 CM/L
PREMED
TRIAL 3
TRIAL 2
TRIAL 1
□ = PRED POINT
Volume (L)
0.5 CM/L
1 2
TIME (sec)
Interpretations:
PREMED: Testing indicates normal spirometry.
Comments:
Figure 13-3.
continued
176 Chapter 13 — Office Pulmonary Function Testing
Comparison of Results with
Standards
13. Interpreting spirometry involves
comparing the patient's actual results
with predicted results from an accepted
standard.
Note: Many spirometers allow the examiner
to choose which standard to be applied. The
two standards used predominantly are those
of Morris (also referred to as the ATS
Standard) (Morris, 1971) and Knudson
(Knudson, 1976). The standard of Knudson is
used when performing spirometry to satisfy
OSHA requirements. At present, the standard
of Morris is applied in all other circumstances.
Another standard, termed National Health
and Nutrition Examination Survey III
(NHANES III), developed in 1999 from a
broad-based study, will probably become a
more suitable standard for primary care
practice (Hankinson, 1999). However, the
NHANES III standard is not yet available on
all computerized spirometers.
14. Report the highest values obtained from
any of the three maneuvers as the
results for the test.
Note: Using the highest values is consistent
with the Morris standard. In fact, a principal
difference between the two standards is that
Morris uses the best of the three maneuvers,
whereas the Knudson standard is an average
of the three spirogram results. Predicted
values for children are not consistently
accepted. Most office-based spirometers
extrapolate from the adult Morris standards.
Postbronchodilator Test
Note: A major use of spirometry in the office
setting is in determining a patient's response
to an inhaled bronchodilator, thus aiding in
the diagnosis of asthma.
15. To test for reversibility of pulmonary
dysfunction, ask the patient to perform
prebronchodilator spirometry.
16. After collecting the results, give the
patient two puffs of albuterol by metered
dose inhaler.
17. Fifteen minutes after administration of
the albuterol, perform postbronchodilator
spirometry.
Note: The general agreement is that a 12% to
15% increase in FEVj and FVC after
bronchodilator use is diagnostic of asthma
or reversible airway disease. Additional PFT
testing in asthma is not usually performed.
Instead, patients should be instructed on
monitoring peak expiratory flow through
personal testing (National Asthma Education
and Prevention Program, 1997, 2002).
SPECIAL CONSIDERATIONS
Patient Variability
Normal values for spirometric results vary with body habitus and gender.
Height and age are of particular concern and must be considered with all
spirometry examinations. Interestingly, airflow in liters per minute increases
linearly with increased height. However, age has an opposite effect on
airflow, with a decline of approximately 4% to 5% in FEVi and FVC occurring
Chapter 13 — Office Pulmonary Function Testing 177
every 5 years after age 25 (Knudson, 1983). Gender also must be taken into
consideration, with FEVl and FVC being approximately 10% less in women
than in men of comparable height and age (Horvath, 1981a).
Another patient-related variable is race. Specifically, FEVl and FVC are
observed to be consistently 15% less in nonwhites. Differences in thoracic
configuration and diaphragm position are speculative explanations for the
race-related decreases in flow and volume (Horvath, 1981a).
Finally, children are extremely variable due to the puberty growth spurt
and a larger effect of race on predicted values.
Understanding What Is Normal
The actual, predicted, and percent of predicted values are presented in
Figure 13-3. Regardless of which standard is applied, there is great variability
in the normal values. For example, a patient's FEVi and FVC can fall between
80% and 120% of predicted and still be considered normal. This range
represents two standard deviations from the mean. Other values frequently
reported have an even larger range. One example is the FEV25%.75%, which has
an individual daily variability of 20% versus a 3% daily change in FEVi or FVC.
Despite the variability, a workable guideline for identifying the degree of
pulmonary dysfunction (American Medical Association, 1993) is described in
Table 13-4. Note that when following disease progression by spirometry, it is
more prudent to document changes in the patient's actual values than to
compare them with predicted values.
FOLLOW-UP CARE AND
INSTRUCTIONS
In the management of pulmonary disease in the outpatient setting, it is crucial
to be able to stabilize the airway using various pharmacologic approaches
and to have rescue medications available in the event that stabilizing
modalities fail.
Table 13.4 American Medical Association Guidelines for
Determining the Degree of Pulmonary Dysfunction
CHARACTERIZATION
FEVt, FVC, OR BOTH (PERCENT OF PREDICTED VALUES)
Normal
80%
Mild disease
60-79%
Moderate disease
41-59%
Severe disease
40%
FEVb forced expiratory volume, the volume of air forcefully exhaled in 1 second; FVC, forced vital capacity,
the volume of air that can be exhaled forcefully after full inspiration.
From American Medical Association: Guides to the Evaluation of Permanent Impairment, 4th ed. Chicago,
American Medical Association, 1993, pp 153-167.
178 Chapter 13 — Office Pulmonary Function Testing
■ Provide patients with instruction on the mechanism of action for each
medication, monitoring the progress of therapy, and follow-up care.
■ Encourage patients to call if they are confused or if they have questions
concerning medications. For patients with multiple medications, a simple
outline may alleviate confusion and prevent exacerbations due to
noncompliance.
■ For patients who smoke, an unambiguous statement of the continued
health risks of smoking should be emphasized at every visit.
The success of treating pulmonary disease depends largely on patient
compliance with regimens. Providing patients with a peak flowmeter is a useful
means of helping them to monitor their lung function at home. Cardio-
pulmonary exercise testing is useful in trying to identify how pulmonary or
cardiac factors are contributing to a patient's shortness of breath. For such
advanced testing, an electrocardiographic stress test is performed with
pulmonary function measurements including Vo2max. Referral for single
breath-hold carbon monoxide diffusing capacity (DLCO) may also be useful
in pulmonary fibrosis and Social Security disability determinations. Patients
will be more compliant if they understand the different treatment modalities
and the central role of monitoring pulmonary function.
References
American Association for Respiratory Care: Clinical Practice Guideline:
Spirometry. Respir Care 41:629-636, 1996.
American Medical Association: Guides to the Evaluation of Permanent
Impairment, 4th ed. Chicago, American Medical Association, 1993,
pp 153-167.
American Thoracic Society: Standardization of spirometry: 1994 update.
Am J Respir Crit Care Med 152:1107-1136, 1995.
American Thoracic Society: Lung function testing: Selection of reference
values and interpretative strategies. Am Rev Respir Dis 144:1202-1218,
1991.
America Thoracic Society: Guideline for methacholine and exercise
challenge testing— 1999, Am J Respir Crit Care Med 161:309-329,
2000.
Bosse CG, Criner GJ: Using spirometry in the primary care office:
A guide to technique and interpretation of results. Postgrad Med
93:122-148, 1993.
Brooks SM: Pulmonary anatomy and physiology. In Horvath EP (ed):
Manual of Spirometry in Occupational Medicine. Washington, DC, U.S.
Department of Health and Human Services, 1981, pp 3-11.
Ferguson GT: Screening and early intervention for COPD. Hosp Pract
33:67-84, 1998.
Hankinson JL, Odencrantz JR, Fedan KB: Spirometric reference values
from a sample of the general U.S. population. Am J Respir Crit Care
Med 159:179-187, 1999.
Horvath EP Jr: Calculations. In Horvath EP (ed): Manual of Spirometry
in Occupational Medicine. Washington DC, U.S. Department of Health
and Human Services, 1981a, pp 17-33.
Chapter 13— Office Pulmonary Function Testing 179
Horvath EP Jr: Technique. In Horvath EP (ed): Manual of Spirometry in
Occupational Medicine. Washington, DC, U.S. Department of Health
and Human Services, 1981b, pp 13-16.
Knudson RJ, Lebowitz M, Holberg CJ, et al: Changes in the normal
maximal respiratory flow-volume curve with aging. Am Rev Respir Dis
127:725-734, 1983.
Knudson RJ, Slatin RC, Lebowitz MD, et al: The maximal expiratory
flow-volume curve: Normal standards, variability, and effects of age.
Am Rev Respir Dis 113:587-600, 1976.
Milhorn HT Jr: Understanding pulmonary function tests. Am Fam Phys
24:139-145, 1981.
Miller MR: Chronic obstructive pulmonary disease and 150 years of
blowing. Hosp Med 59:719-722, 1998.
Morris JF, Koski A, Johnson LC: Spirometric standards for healthy
nonsmoking adults. Am Rev Respir Dis 103:57-67, 1971.
National Asthma Education and Prevention Program, Expert Panel
Report 2. Guidelines for the Diagnosis and Management of Asthma.
National Institutes of Health, National Heart, Lung and Blood
Institute. NIH Publication No. 97-4051. Washington, DC: U.S.
Government Printing Office, 1997.
National Asthma Education and Prevention Program, Expert Panel
Report. Guidelines for the Diagnosis and Management of Asthma:
Update on Selected Topics 2003. National Institutes of Health,
National Heart, Lung and Blood Institute. NIH Publication No. 02-5075.
Washington, DC: U.S. Government Printing Office, 2002.
Social Security Administration, 2005. Available at:
http://www.ssa.gov/disability/professionals/bluebook/
3.00-Respiratory-Adult.htm#content
U.S. Department of Health and Human Services: Medicare Part B,
Participation Program for Physicians. Oklahoma City, Okla, Health
Care Financing Administration, 2004.
Bibliography
Eaton T, Withy S, Garrett JE, et al: Spirometry in primary care practice:
The importance of quality assurance and the impact of spirometry
workshops. Chest 116:416-423, 1999.
King D: Asthma diagnosis by spirometry: Sensitive or specific? Aust
Fam Phys 27:183-185, 1998.
Thiadens HA, de Bock GH, Dekker FW, et al: Identifying asthma and
chronic obstructive pulmonary disease in patients with persistent
cough presenting to general practitioners: Descriptive study. BMJ
316:1286-1290, 1998.
Cha
pter 1^
Nasogastric Tube Placement
Dan Vetrosky
Procedure Goals and Objectives
Goal: To perform nasogastric (NG) tube placement in a patient
safely and accurately.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing NG tube placement.
• Identify and describe common complications associated with
performing NG tube placement.
• Describe the essential anatomy and physiology associated with
the performance of NG tube placement.
• Identify the materials necessary for performing NG tube
placement and their proper use.
• Describe the steps for correctly inserting an NG tube.
• Discuss aspects of post-NG tube placement care and follow-up.
181
182 Chapter 14 — Nasogastric Tube Placement
BACKGROUND AND HISTORY
The first recorded use of a tube placed into the esophagus for feeding was
reported by His to have been by Capivacceus in 1598 when he introduced
nutrient substances into the esophagus using a hollow tube with a bladder
attached to one end. In 1617, Fabricius ab Aquapendente reported using a
silver tube passed through the nostril into the nasopharynx for feeding a
patient with tetanus. In 1867, Kussmaul introduced a flexible orogastric tube
for gastric decompression, and Ewald and Oser introduced the soft rubber
tube for gastric intubation in 1874 (Randall, 1990).
The passage of a hollow tube into the stomach has been used for research
and medical-surgical purposes for many years. Sampling the gastric contents,
decompressing a distended stomach, preventing aspiration during surgery,
and performing gastric lavage are just a few of the current and past uses for
the NG tube. This chapter covers the indications, rationale, and complications
of NG tube placement as well as types of NG tubes and insertion techniques.
INDICATIONS
Indications for the insertion of an NG tube are many and range from severe
diverticular disease to unrelenting vomiting. NG tubes are indicated as
follows:
■ Sampling gastric contents
Removing air, blood, ingested substances, and gastric contents
■ Providing nutritional support for patients who cannot eat but have a
functional gastrointestinal (GI) tract
Table 14-1 outlines some of the indications and rationale for the insertion of
the NG tube.
CONTRAINDICATIONS
NG tube placement is contraindicated when the intended path of the tube is
obstructed or any of the structures the NG tube would traverse are damaged,
as well as in the following situations or conditions:
■ Choanal atresia
Significant facial trauma or basilar skull fracture
■ Esophageal stricture or atresia
Esophageal burn
■ Zenker's diverticulum
■ Recent surgery on the esophagus or stomach
■ History of gastrectomy or bariatric surgery
Chapter 14 — Nasogastric Tube Placement 183
Table 14.1
Insertion
INDICATIONS
Indications and Rationale for Nasogastric Tube
RATIONALE
Diverticulitis (usually severe)
Gastric outlet obstruction
Gastrointestinal bleeding
Intestinal obstruction
Near drowning
Vomiting
Surgery (stomach, abdominal)
Severe burns
Nutritional support
Gastrointestinal lavage-aspiration
To rest the gastrointestinal tract, especially if bowel
obstructive symptoms exist; relieves abdominal distention
and vomiting if present
As above, and can be diagnostic if >200 mL foul-smelling
fluid obtained in the presence of obstructive symptoms
Diagnostic if bright red blood or "coffee grounds" material
is aspirated; can intermittently suction to assess presence
of active bleeding (should not perform lavage in these
patients because it may increase the chance of aspiration)
To relieve abdominal distention and vomiting
To empty swallowed water and to prevent aspiration
To prevent aspiration and in intestinal obstruction, if
present
Decompresses stomach and may help lessen the chance
for aspiration; can monitor postoperative bowel function
return
Patients in the immediate postburn period are prone to
develop ileus; nasogastric intubation helps empty the
gastric contents and lessen the chance of aspiration
Used in patients who cannot take in adequate amounts of
nutrition orally; must be used only in patients who are
able to sit up in bed and can protect the airway; aspiration
is a concern
Used in patients with suspected or known overdose to
lavage and evacuate any residual medication or ingested
agents
POTENTIAL COMPLICATIONS
Trauma to the turbinates or nasopharynx, or both, during passage of the
tube: Bleeding from the nares and spitting of blood from the mouth are
signs of trauma to the nasopharyngeal region caused by NG tube
placement. Proper insertion techniques, gentle pressure during the
tube's passage, and ensuring patient cooperation will help to prevent
these problems.
■ Erroneously assuming that the tube is in the stomach: Irrigation of an NG
tube that is in the lungs can cause serious complications, such as
pneumonia.
■ Placement of the NG tube into the trachea and lung: This can result in
pneumothorax if the tube is advanced forcefully into the lung tissue.
The best way to avoid complications associated with NG tubes placed in
anatomic locations other than the stomach is to obtain radiographic
confirmation. If radiography is not available, placing the NG tube in a glass of
water once it has been passed can confirm poor placement. If the tube is
placed in the lung, submerging the end of the tube in water reveals bubbles
184 Chapter 14 — Nasogastric Tube Placement
during exhalation. When this occurs, the tube must be removed completely
and another NG tube inserted.
Other potential complications are as follows:
Gastric erosion with hemorrhage
■ Erosion or necrosis of the nasal mucosa
■ Aspiration pneumonia
Sinusitis
■ An NG tube passed in a patient with significant head, neck, thoracic, or
abdominal trauma: In this setting, the NG tube may traverse a break in
the nasopharynx, larynx, esophagus, or stomach. Advancement of the
tube in this setting may result in severe damage to the brain, lungs, or
peritoneal cavity.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
Insertion of the NG tube involves passing it through one of the nares into the
nasopharynx. It is then passed into the posterior oropharynx and further
inferiorly until it reaches the level of the larynx. At the level of the larynx, the
tube may pass either anteriorly into the trachea or posteriorly into the
esophagus (Fig. 14-1). Having the patient swallow greatly facilitates the passage
of the NG tube into the esophagus. With swallowing, the vocal cords of the
Figure 14-1. Passage of the
nasogastric tube. (Adapted
from Rosen P, Bankin RM,
Sternback GL: Essentials of
Emergency Medicine. St. Louis,
CVMosby, 1991, p 615.)
Chapter 14 — Nasogastric Tube Placement 185
larynx are strongly approximated and the epiglottis swings backward,
covering the opening of the larynx. These factors help prevent the passage
of food (or in this case, the NG tube) into the trachea.
During swallowing, the entire larynx is pulled upward and forward by the
muscles that are attached to the hyoid bone. This movement causes the
opening of the esophagus to stretch. Simultaneously, the upper portion of the
esophagus (upper 3 to 4 cm) relaxes and thus food moves more easily into
the upper esophagus.
The esophagus is a muscular tube that begins at the level of the cricoid
cartilage and is an average of 20 cm long and 3 cm in diameter in most adults.
It courses through the posterior mediastinum, behind the heart and aorta,
and penetrates the esophageal hiatus of the diaphragm. It then joins the
cardia portion of the stomach just below the level of the diaphragm. Once
the NG tube reaches the upper esophagus, rapid peristaltic waves are initiated,
which assist in passing it down the length of the esophagus and facilitating
its advancement into the stomach. The esophagus has two sphincters, one
at each end, which serve to physically isolate the remainder of the GI system
from the outside environment. The esophagus, like other organs in the
thoracic cavity, undergoes negative pressure during inspiration, and without
sphincters, gastric contents would be sucked into the esophagus with each
breath.
Anterior flexion of the cervical spine during NG tube insertion also
facilitates passage into the esophagus. This occurs by causing the tube to
rest or press against the posterior portion of the oropharynx as the NG tube
is advanced. Consequently, it is better aligned to pass into the esophagus
when it reaches the level of the larynx.
to exercise clinical judgment based on the
Standard Precautions Practitioners should use patient's history and the potential for exposure
standard precautions at all times when to body fluids or aerosol-borne pathogens (for
interacting with patients. Determining the level further discussion, see Chapter 2).
of precaution necessary requires the practitioner
PATIENT PREPARATION
The patient should be alert and able to cooperate with the procedure.
■ Informed consent typically is not required.
■ Before beginning, explain and discuss the procedure to help facilitate
patient cooperation.
■ Explain to the patient the importance of keeping the neck flexed until the
tube is in the esophagus. This is essential to avoid placement of the tube
in the trachea.
■ Patients should be informed that the introduction of the tube normally
produces some degree of gagging.
186 Chapter 14 — Nasogastric Tube Placement
Ask the patient to take small sips of water through a straw and swallow
to facilitate placement of the tube into the esophagus.
Materials Utilized to Perform Nasogastric Tube
Placement
Note: Typical equipment needed for placement of an NG tube can include
the following (equipment may vary slightly from setting to setting):
■ Nonsterile procedure gloves, goggles, and gown
■ Portable or wall suction equipment and connection availability
■ Hypoallergenic tape, an occlusive seal dressing, or a premanufactured
NG tube holder (some hospitals keep them available)
■ Tincture of benzoin
Emesis basin
Cup of water and a straw
■ Stethoscope
■ 20- to 60-mL irrigation syringe (an irrigation-tip Toomey syringe, not a
Luer syringe)
■ 100 mL of water (tap or sterile) for irrigation
■ Towels to protect patient gown and bed linen in case of emesis
Malleable stylet if small feeding tube is used
Appropriate size and type of NG (Levin) tube
Note: The most common type of NG tube used today is the Levin tube.
These tubes range in size from 3 to 18 French (Fr). Tubes larger than 18 Fr
should not be passed nasally because of the increased risk of trauma.
Larger tubes, placed through the oral cavity, are reserved for extreme
emergency procedures, and can be as large as 26 to 32 Fr.
The size of the NG tube used depends on the patient's age and size,
purpose of the NG intubation, length of time the tube will be required, the
viscosity of the fluids being instilled or evacuated, and disease processes
present, if any. Neonates, infants, and patients with sinus or esophageal
problems may require very small sizes (3 to 8 Fr), whereas typical,
otherwise healthy adult patients require NG tubes from 10 to 18 Fr. Patients
who require gastric lavage for medicine overdosage, ingestion of certain
toxic substances, or evacuation of blood clots require larger bore NG tubes
or may require oral gastric intubation.
Specialized NG tubes, such as those with weighted ends, are used to
facilitate passage into the duodenum and small intestine. Double-lumen NG
tubes that have one opening at the distal end (for feeding or instillation of
Chapter 14 — Nasogastric Tube Placement 187
fluids) and other openings along the distal sides of the tube allow for
gastric decompression as well as jejunal feeding. NG tubes with multiple
openings along the distal length, known as sump tubes, are used when it is
necessary to irrigate or evacuate large amounts of fluids from the stomach.
Procedure for Performing Nasogastric Tube Insertion
1. Make sure the patient is sitting in a
45-degree angle or greater.
2. Ensure that all necessary materials and
personnel are readily available before
beginning the procedure.
3. Wash hands and don gloves, goggles,
and gown.
4. Place protective sheet in place over
patient's chest and abdomen.
5. Check for nasal patency and examine
each nasal passageway. Choose the
appropriate, most patent nostril for tube
placement.
6. Using the tube to be inserted, measure
from the tip of the nose to the ear lobe,
and from the ear lobe to the patient's
xiphoid to determine the appropriate
tube insertion length and distance
(Fig. 14-2).
Note: Either count the premade markings on
the tube or place a small piece of tape at the
measured insertion length. If the tube is to
be placed below the stomach, add an
additional 15 to 25 cm to the premeasured
mark.
7. Lubricate the first 2 to 3 inches of the
tube with lidocaine jelly lubricant.
8. Before inserting the tube, make sure the
beveled opening or side of the tube is
positioned toward the nasal septum to
avoid trauma to the turbinates.
9. Have the patient flex the neck forward,
bringing his or her chin toward the chest.
Figure 1 4-2. Measuring tube insertion length
and distance. (Adapted from Potter PA, Perry AG:
Fundamentals of Nursing: Concepts, Process,
and Practice, 4th ed. St. Louis, CV Mosby, 1997,
p 1407.)
10. Slowly and gently begin inserting the
tube into the nostril straight back at a
90-degree angle to the long axis of the
head.
11. Have the patient begin taking small sips
of water through a straw and swallow as
you gently advance the tube. Timing the
advancement of the tube in conjunction
with the patient swallowing greatly
facilitates the passage of the NG tube
into the stomach.
continued
188 Chapter 14 — Nasogastric Tube Placement
Caution: If any obstruction is encountered,
do not force the tube, because you may
cause damage to the turbinates.
Note: If resistance is met, withdraw the
tube slightly and try placing the tube again.
If continued resistance is met, try the other
nostril.
12. If the tube advances without resistance,
continue having the patient swallow
while gently inserting the tube until the
premeasured mark or tape is reached.
13. Have the patient slowly begin raising the
chin from the chest as the tube passes,
because this helps facilitate the tube's
passage.
14. If the patient begins to gag, pause and
have the patient take some deep breaths
until the gagging has stopped or calmed
down, and then continue with the
insertion as already described.
15. If the tube curls up in the posterior
pharynx, which typically causes the
patient to gag, gently pull back on the
tube until it uncurls.
Caution: Do not pull the tube out
completely. Wait until the patient has
stopped gagging or has calmed down.
16. Make sure the patient takes sips of water
and swallows while gently advancing the
tube again.
17. Check the position of the tube by:
• Making sure the tube is inserted the
measured or calculated distance
• Injecting approximately 10 mL of air
through the tube while listening over
the left upper quadrant of the abdomen
with the stethoscope for the "rush
of air"
• Aspirating gastric contents and checking
the pH: If the pH reading is less than 3,
the tube is in the stomach.
• Obtaining radiographs: Because there
is a radiopaque strip in all Levin tubes,
radiography is the gold standard for
determining placement of feeding tubes
or NG tubes when there is a question of
appropriate placement. When
radiography is readily available and
not contraindicated, all NG tube
placements should be confirmed
radiographically as soon as conveniently
possible.
18. Tape the tube in place; this is important
for ensuring maintenance of proper tube
placement.
19. Use tincture of benzoin to facilitate the
adherence of the tape, premanufactured
NG tube holder, or occlusive seal
dressing.
Caution: Taping the tube so that no torsion
or pressure is placed on the nares while
the tube remains in place is paramount
(Fig. 14-3).
Figure 14-3. Proper taping technique.
(Adapted from Rosen P, Bankin RM, Sternback GL:
Essentials of Emergency Medicine. St. Louis,
CVMosby, 1991, p 615.)
Chapter 14 — Nasogastric Tube Placement 189
SPECIAL CONSIDERATIONS
Patients with impaired mentation or who are comatose and cannot assist
with important aspects of the procedure may present technical challenges.
In this instance, placing the NG tube in an ice bath before insertion may help
by causing the tube to become temporarily somewhat more rigid and less
likely to kink. Also it may be necessary to pass the tube to the level of the
oropharynx and then pass the tube into the esophagus using a Magill
forceps.
Insertion of an NG tube in patients with endotracheal tubes can be
challenging. In some instances, deflating the cuff on the endotracheal tube is
necessary to pass the NG tube into the esophagus.
FOLLOW-UP CARE AND
INSTRUCTIONS
Ensure that the NG tube is functioning properly.
■ The tubes are ineffective when they are not patent. To ensure the
patency, disconnect the tube from the suction device.
■ Using a large syringe, inject 20 to 30 mL of air through the NG tube. Free
flow of air through the tube indicates that the tube is functioning
properly.
It is important to assess the nares and nasopharynx periodically to
ensure that no pressure ulcer or tissue necrosis is occurring from
irritation or pressure from the NG tube.
Remove the NG tube as soon as it is no longer needed or indicated.
References
Randall HT: The history of enteral nutrition. In Rombeau JI, Caldwell
MD (eds): Clinical Nutrition. Philadelphia, WB Saunders, 1990.
Bibliography
Feldman M, Scharschmidt BF, Sleisenger MH (eds): Sleisenger &
Fordtran's Gastrointestinal and Liver Disease: Pathophysiology,
Diagnosis, and Management, 6th ed, vol 1. Philadelphia,
WB Saunders, 1998.
Chapter I C
Lumbar Puncture
Virginia F. Schneider
Procedure Goals and Objectives
Goal: To obtain a high-quality sample of cerebrospinal fluid (CSF)
while observing standard precautions and with the minimal degree
of risk for the patient.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing a lumbar puncture.
• Identify and describe common complications associated with a
lumbar puncture.
• Describe the essential anatomy and physiology associated with
the performance of a lumbar puncture.
• Identify the necessary materials and their proper use in
performing a lumbar puncture.
• Properly perform the actions necessary to collect a CSF sample.
• Identify the important aspects of post-procedure care following
a lumbar puncture.
191
192 Chapter 15 — Lumbar Puncture
BACKGROUND AND HISTORY
The first lumbar puncture is attributed to Heinrich Quincke, who performed
it in December 1890 on a 21-month-old boy with fever, stiff neck, coma, and
pneumonia. It was adopted and widely used within a few years as a diag-
nostic and therapeutic procedure. By 1900, Quincke had also reported the
technique of spinal anesthesia, using the same procedure with cocaine as a
local anesthetic (Evans, 1998). Complications of the procedure quickly became
apparent and ranged from self-limited post-procedure headache to tonsillar
herniation in the presence of increased intracranial pressure. Recognition of
complication risk factors and the development of new equipment and
techniques have resulted in a procedure that is relatively simple, safe, and
commonly used in the diagnosis of a variety of conditions today.
INDICATIONS
■ Lumbar puncture is performed in adults, children, and infants to obtain
CSF for cell count, glucose, protein, culture, and other specialized
analyses.
■ It is frequently used in the evaluation of infection of the meninges,
subarachnoid hemorrhage, and demyelinating diseases.
CSF analysis results may also be helpful, although nonspecific, in
diagnosing systemic lupus erythematosus with central nervous system
involvement, central nervous system malignancy, and subdural or
epidural hematoma (Evans, 1998; Martin, 1986).
■ In infants and children, the procedure may be used serially as a way to
relieve increased intraventricular pressure from hydrocephalus while the
patient is awaiting a more definitive procedure (Hood, 1996).
■ Lumbar puncture may serve as a route of administration for various
pharmacologic agents, including antibiotics and chemotherapeutic
agents for the treatment of disease (Martin, 1986).
■ Evaluation for bacterial meningitis is the most common reason for
lumbar puncture, and characteristically it is suggested by a CSF sample
with an elevated white blood cell count, elevated polymorphonuclear
cell count, and a low glucose level.
■ Organisms may also be tentatively identified by Gram staining the CSF
specimen.
■ Patients with viral meningitis typically have CSF mononuclear
pleocytosis, a normal glucose level, an elevated protein level, and a
negative Gram stain result.
■ Neurosyphilis is a difficult clinical and laboratory diagnosis and is most
commonly manifested by a CSF pleocytosis, elevated protein level, and
positive treponemal-specific antibody test.
Chapter 15 — Lumbar Puncture 193
Fungal meningitis should be suspected in immunocompromised or
hospitalized patients on long-term, broad-spectrum antibiotics. In these
patients, CSF analysis is usually somewhat abnormal but nonspecific.
Central nervous system tuberculosis may have similar findings.
Identification depends on a high index of suspicion and specific
microscopic, serologic, or culture testing for tuberculosis (Martin, 1986).
Subarachnoid hemorrhage is generally characterized by CSF with a
xanthochromic color at the time of the lumbar puncture and an elevated
erythrocyte count in the fluid. In contrast, a traumatic lumbar puncture
is usually characterized by initially red CSF with subsequent clearing of
the fluid as collection progresses (Martin, 1986).
In the evaluation of demyelinating diseases, lumbar puncture is primarily
used in the diagnosis of multiple sclerosis and Guillain-Barre syndrome.
In multiple sclerosis, analysis of the proteins by electrophoresis and
the identification of specific band patterns is useful as a diagnostic
measure. The CSF of patients with Guillain-Barre syndrome has an
isolated, very high protein concentration (generally greater than
200 mg/dL), which is specific enough to this condition to be nearly
diagnostic (Martin, 1986).
CONTRAINDICATIONS
■ The primary contraindication for lumbar puncture is increased
intracranial pressure. Signs and symptoms of increased intracranial
pressure include progressive headache, focal neurologic signs or
symptoms, progressive deterioration of mental status over hours to
weeks, and papilledema on funduscopic examination. Lumbar puncture
and the associated removal of CSF fluid results in a corresponding area
of decreased pressure in the spinal column. In patients with increased
intracranial pressure, creation of this area of lower pressure may result
in herniation of the brain through the foramen magnum. Any patient
suspected of having increased intracranial pressure should be evaluated
by computed tomography before a lumbar puncture is attempted.
■ Lumbar puncture is also contraindicated in the presence of suspected or
known coagulation disorders. This may include hemophilia, leukemia,
liver disease, or a patient receiving anticoagulant therapy. It is only a
relative contraindication in the event of suspected meningitis in a patient
with a coagulopathy, because the benefits of the procedure may
outweigh its risks.
■ Local infection overlying the site of the lumbar puncture risks direct
inoculation of organisms into the CSF.
■ Abnormalities such as nevi, hair tufts, sinuses, or palpable bony
abnormalities may be associated with spinal column structural
abnormalities.
194 Chapter 15 — Lumbar Puncture
■ Lumbar puncture is contraindicated in any patient who is severely ill or
medically unstable.
POTENTIAL COMPLICATIONS
Several potential complications exist for the lumbar puncture procedure:
■ Postdural puncture headache (PDPH) is the most common complication
of lumbar puncture and may occur in as many as 30% to 50% of patients.
The headache is always bilateral but varies in location and is usually
described as "throbbing" or "pressure." Intensity is increased in the
upright position and by movement, coughing, straining, or sneezing. It is
relieved by lying supine. Patients may also have neck stiffness, nausea,
vomiting, dizziness, or visual symptoms (Evans, 1998). Management of this
complication is discussed later (see "Follow-Up Care and Instructions").
■ Herniation into the foramen magnum may occur when lumbar puncture
is performed in the presence of increased intracranial pressure. In the
presence of tumors or hematoma, herniation is relatively uncommon. It
can be difficult to determine if the lumbar puncture or the underlying
pathologic condition is ultimately responsible for subsequent neurologic
deterioration or death. The absence of papilledema and focal neurologic
symptoms does not guarantee normal intracranial pressure. The patient's
presentation and differential diagnosis should guide the need for computed
tomography or magnetic resonance imaging before lumbar puncture.
Nerve damage occurs when the needle inadvertently moves laterally,
contacting the dura and penetrating a segmental nerve in the extradural
space, causing pain, electric shocks, and dysesthesias. Transient cranial
nerve dysfunctions have been reported, including cranial nerves III, IV, V,
VI, VII, and VIII. Up to one third of patients complain of back pain and
discomfort for several days after lumbar puncture because of local
trauma. Disk herniation or infection is a rare complication but has been
reported.
Bleeding (e.g., hematoma of the spine and subdural, epidural, or
subarachnoid space) is rare and occurs almost exclusively in patients
with blood dyscrasias or those receiving anticoagulant therapy. In infants,
inquire about a family history of blood dyscrasias, routine vitamin K
administration, or signs and symptoms of disorders predisposing to
thrombocytopenia, such as cytomegalovirus infection.
■ Intraspinal epidermoid tumors are rare but may be induced by lumbar
punctures in which epidermal fragments are carried in by the needle and
implanted into the spinal canal. Use of a stylet minimizes this risk.
Symptoms, occurring months later, consist of pain at the site or neurologic
symptoms in the lower extremities.
■ Infection may be introduced by improperly preparing the skin,
contaminating the needle, performing the procedure through an area of
local infection, or introducing blood into the subarachnoid space in the
Chapter 15 — Lumbar Puncture 195
presence of bacteremia. Consequences may range from local cellulitis to
meningitis and empyemas of the epidural or subdural space. Sterile
technique and selection of an infection-free puncture site significantly
reduce the risk of infection.
■ Needle breakage is an unusual event. If the needle breaks and the fragment
is beneath the skin surface, leave the stylet in place, if possible, and use
it as a guide to perform a small incision. Once the end is found, it can be
removed with a hemostat. If this is not quickly and easily accomplished,
a neurosurgeon should be consulted.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
CSF is produced almost exclusively in the choroid plexus. Fluid formed in the
lateral ventricles flows through the interventricular foramen of Monro and
mixes with the fluid produced in the third ventricle. It passes through the
aqueduct of Sylvius to the fourth ventricle, where another choroid plexus
adds its component, and it flows into the cisterna magna. From there, the
fluid is directed anteriorly under the base of the brain and then up over the
sulci between the cortical convolutions.
Although the cisterns at the base of the brain communicate freely with the
spinal subarachnoid space, the main circulation continues in the cerebral
subarachnoid space. The CSF is transferred back into the blood stream by
filtration and osmosis chiefly through arachnoid villi and granulations in the
supratentorial region.
The spinal cord terminates at the LI level in an adult (Fig. 15-1). Lumbar
puncture is performed usually at the L4-L5 or L3-L4 interspace by inserting a
Vertebral body
Posterior
longitudinal
ligament
Disk
Dura
Epidural space
with veins and
arteries
Spinal cord
Skin
Interspinous ligament
Supraspinous ligament
Cauda equina
Ligamentum flavum
Vertebral spine
Needle
Nerve root
Subarachnoid space
Figure 15-1. Anatomic orientation for performing lumbar puncture. (Redrawn
from Taft JM: How to perform a lumbar puncture. JAAPA 3:473-476, 1990.)
196 Chapter 15 — Lumbar Puncture
needle into the subarachnoid space via percutaneous puncture. In the absence
of spinal abnormalities, there is little danger of injuring the spinal cord. In
infants, however, the spinal cord terminates at the L3 level. More care should
be used to ensure appropriate interspace identification, and use of those
above L3-L4 should never be attempted.
to exercise clinical judgment based on the
Standard Precautions Practitioners should use patient's history and the potential for exposure
standard precautions at all times when to body fluids or aerosol-borne pathogens (for
interacting with patients. Determining the level further discussion, see Chapter 2).
of precaution necessary requires the practitioner
PATIENT PREPARATION
■ Because this procedure involves placing a relatively large-appearing
needle into the spinal column, it can be very anxiety-producing for
patients and parents. Frequently, patients and families have heard
negative anecdotal experiences about the procedure from acquaintances,
friends, or family members. Therefore, it is important to establish a good
rapport by thoroughly explaining the procedure, answering questions,
and addressing any concerns of the patient and family before beginning.
■ Explain the steps of the procedure and include the use of drawings to
illustrate the anatomy of the spine to emphasize the low risk of spinal
cord damage associated with the procedure when properly performed.
■ It is important to emphasize that although complications are possible
and can be serious, this is a commonly performed procedure. The risk of
complication is low in contrast to the benefit to be gained from the
information received from the CSF sample.
■ When the procedure is performed on an outpatient basis, the patient is
typically retained for observation and monitoring for at least 1 to 2 hours
after the procedure has been performed.
Materials Utilized to Perform a Lumbar Puncture in
Adults, Children, and Infants
The standard lumbar puncture tray contains the following:
■ Three sterile skin swabs or sponges
1% lidocaine solution
■ 20- and 25-gauge skin infiltration needles
■ 3-mL syringe
■ Four sample collection vials, numbered and capped
Chapter 15 — Lumbar Puncture 197
tO:
Stylet (obturator) ^^^^T* Needle
Figure 1 5-2. Spinal needle with stylet.
Sterile bandage or dressing
■ Sterile gauze pads
■ Pressure manometer with three-way stopcock
■ 20-gauge (adult) or 22-gauge (child) spinal needle with stylet (Fig. 15-2)
■ Spare spinal needle with stylet
Povidone-iodine solution
Sterile gloves
■ Fenestrated sterile drapes
An assistant is also required (O'Brien, 1999).
Procedure for Lumbar Puncture in Adults
1. Have an assistant present.
2. Position the patient.
• Position the patient in the lateral recumbent
position with the knees flexed toward the
chest and the chin touching the knees.
Note: It is helpful if an assistant gently holds
the patient at the upper back and behind the
knees in a flexed position. The assistant can
help the patient avoid sudden movements
during the lumbar puncture. The patient's
back should be just at the edge of the table,
with the vertical plane of the back
perpendicular to the table surface.
• For an alternative position, place the
patient in an upright sitting position with
the legs hanging over the side of the bed
and the trunk flexed forward over a pillow
or bed table. The head is flexed toward
the chest, and the arms are brought
forward for support. One cannot assess
opening CSF pressure with the patient in
this position.
Note: Again, it is helpful if the assistant
holds the patient in this position during the
procedure.
3. Put on sterile gloves.
4. Open the lumbar puncture tray using
sterile technique.
5. Pour povidone-iodine solution into the
well of the tray or over the skin
preparation sponges.
6. Set up the four collection tubes and
unscrew the tops. Preassemble the
manometer and attach the three-way
stopcock.
7. Partially remove the stylet from the
spinal needle to check for smooth
continued
198 Chapter 15 — Lumbar Puncture
function and then return it to its fully
inserted position.
8. Check to make sure all necessary
equipment is in the tray before
beginning the procedure.
9. Using two sterile drapes, place one
under the patient and the second on the
table.
10. Clean the patient's back with povidone-
iodine solution. Start at approximately
the L3 level and work in a circular
fashion outward three times, cleansing
upward to the lower thoracic spine,
downward over the buttocks and
sacroiliac area, and sideways over the
iliac crests. Repeat this procedure a total
of three times.
11. Place the fenestrated, sterile drape over
the patient's back, with the circular
opening centered over the L3-L4 area.
Note: The second drape allows you to touch
the area around the immediate field while
maintaining sterile technique.
12. Identify the level of L4, which is usually
lying on an imaginary line created by
joining the iliac crests with a straight
line. This imaginary line crosses the
spine at the level of L4. Anesthetize the
skin with 1% lidocaine solution in this
area.
13. Once local surface anesthesia has been
achieved at the L4 level, slowly insert
the spinal needle (see Figure 15-2) with
the stylet into the L3-L4 intervertebral
space. The needle should be precisely in
the midline and directed toward the
patient's umbilicus (Fig. 15-3). Advance
the needle slowly.
Note: Removal and replacement of the stylet
allows you to determine if the subarachnoid
space has been reached. There is usually a
"popping" sensation appreciated when the
Figure 1 5-3. Needle placement. (Redrawn from
Pfenninger JL, Fowler GC: Procedures for Primary
Care Physicians. St. Louis, Mosby-Year Book,
1994, p 1112.)
needle passes through the ligamentum
flavum. When this occurs, remove the stylet
and CSF should flow.
14. Attach the manometer as soon as fluid
appears in the hub of the needle and
measure the opening pressure. Have the
patient gently relax the legs and breathe
slowly.
15. Collect approximately 1 mL in each of
the four collection bottles provided,
using them in numerical order.
16. When sufficient fluid is collected, replace
the stylet and, with a quick, smooth
motion, remove the needle from the
spine. Use sterile gauze to apply
pressure to the site, holding the
pressure for several minutes at a
minimum. When no bleeding or fluid
leakage can be detected at the lumbar
puncture site, cleanse the area, removing
the povidone-iodine, and place a sterile
bandage over the site (O'Brien, 1999).
Chapter 15 — Lumbar Puncture 199
SPECIAL CONSIDERATIONS
Traumatic lumbar punctures are extremely common and are estimated
to occur in up to 40% of lumbar puncture attempts. If vessels are
punctured during needle insertion with a return of bloody fluid, several
maneuvers can be attempted. First, rotate the needle 45 degrees from
the original orientation. This may move the needle bore away from the
site of bleeding and allow clearing of the fluid. Second, be patient and
allow a few minutes with the stylet in place to see if the bleeding site
seals over and allows clearing of the fluid. Finally, if these maneuvers are
unsuccessful, you may attempt to repeat the lumbar puncture at the next
higher interspace if that is an appropriate site within usual guidelines for
the patient's age.
Nerve root pain may occur during insertion if the needle disrupts small
nerve fibers in the area. This is usually described by the patient as
paresthesias or the sensation of mild shooting pains locally or with
radiation down the leg, or both. Repositioning the needle slightly often
eliminates the symptoms.
Occasionally, no fluid is obtained at lumbar puncture — a "dry tap."
The most common reason for this is that the epidural space was not
pierced, and repositioning of the needle is indicated. Other things to
consider are dehydration, blockage to fluid circulation, and congenital
anomalies.
Procedure for Lumbar Puncture in Children
1. The same precautions and positioning
description outlined for adults apply to
children (Fig. 15-4). A 22-gauge spinal
needle is commonly used for infants and
children.
2. The most important component in
performing a successful lumbar puncture
in a child is to take the necessary steps to
ensure adequate restraint of the patient.
With the child in the lateral recumbent
position, have an assistant hold the child
securely at the knees and shoulders.
3. Depending on the child's clinical state, a
mild, short-acting sedative may be
administered (Hughes, 1996; Rowe, 1994).
Iliac crest
Iliac crest
Figure 1 5-4. Patient positioning. (Redrawn
from Hughes WT, Buescher ES: Pediatric
Procedures, 2nd ed. Philadelphia, WB Saunders,
1980, p 180.)
200 Chapter 15 — Lumbar Puncture
Procedure for Lumbar Puncture in Infants
Note: Maintenance of body temperature,
positioning, and an open airway must be
taken into account when performing a
lumbar puncture in an infant.
1. Bring the baby to an infant treatment
warmer. Attach a skin temperature probe
and set the warmer to maintain the baby
at normal body temperature during the
procedure.
2. Position the infant on the warmer. Two
positions can be used. The infant may be
placed in the sitting position, with the
holder flexing the thighs on the abdomen,
allowing him or her to grasp the right
knee and elbow with the right hand and
the left knee and elbow with the left hand.
3. Gently flex the spine, using care not to
cause excessive abdominal pressure or to
overflex the neck and occlude the infant's
airway (Fig. 15-5). Alternatively, the
assistant may place the infant on his or
her side, using one hand to flex the thighs
to the abdomen and secure the
extremities while the other hand flexes
the neck and spine (Fig. 15-6). The second
position is useful with small premature
and term infants who may not be well
enough to tolerate the sitting position.
Note: An infant with a distended abdomen
may have difficulty breathing when flexed
into a lumbar puncture position and become
bradycardic and apneic, requiring cardio-
pulmonary resuscitation. When performing a
lumbar puncture on any ill or premature
infant, electronically monitor the heart and
respiratory rate during the procedure. Also,
be sure an assistant observes the baby during
the lumbar puncture for respiratory
movements and the development of cyanosis.
Figure 1 5-6. Flexing of the thighs to the
abdomen and flexing of the neck and spine.
(Redrawn from Hughes WT, Buescher ES: Pediatric
Procedures, 2nd ed. Philadelphia, WB Saunders,
1980, p 181.)
Figure 1 5-5. Flexing of the
spine. (Redrawn from Hughes
WT, Buescher ES: Pediatric
Procedures, 2nd ed.
Philadelphia, WB Saunders,
1980, p 181.)
Chapter 15 — Lumbar Puncture 201
FOLLOW-UP CARE AND
INSTRUCTIONS
Contrary to conventional wisdom, study data indicate that bed rest and
hydration do not reduce the risk of postdural headache, the most common
complication of lumbar puncture (Evans, 1998). Follow-up care and
instructions should include the following:
■ Observation of the patient to ensure that the lumbar puncture site has
sealed over, and no leakage of CSF persists.
■ Recommendations for treatment of postdural headache:
For initial or mild headache
Bed rest
■ Over-the-counter analgesia
■ Caffeine, 300 mg orally every 6 to 8 hours or
■ Theophylline, 300 mg orally every 8 hours
For moderate to severe headache that is present more than 24 hours
■ Return to the clinic for evaluation
■ Although bed rest does not prevent PDPH, it is a recommended
treatment once it has developed. Methylxanthines may relieve PDPH
through their action as an intercerebral vasoconstrictor, resulting in
decreased cerebral blood flow and intracranial pressure. If the PDPH
persists beyond 24 hours, an epidural blood patch is the most
effective treatment. This is accomplished by drawing 10 to 20 mL of
the patient's blood and then slowly injecting it into the lumbar
epidural space near the prior puncture site. The patient should remain
in the decubitus position for 1 to 2 hours after the procedure for
maximal benefit. The epidural blood patch works by exerting a mass
effect and compressing the dural sac, sealing any continued CSF leak
(Evans, 1998).
References
Evans RW: Complications of lumbar puncture. Neurol Clin N Am 16:105,
1998.
Hood BR: Lumbar Puncture in Procedures in Infants and Children.
Philadelphia, WB Saunders, 1996, pp 202-205.
Hughes WT, Buescher ES: Central Nervous System: Pediatric
Procedures. Philadelphia, WB Saunders, 1996, pp 178-185.
Martin KI, Gean AD: The spinal tap: A new look at an old test. Ann
Intern Med 104:840-848, 1986.
O'Brien J: Lumbar Puncture in Primary Care Practice Procedures.
Philadelphia, WB Saunders, 1999, pp 1109-1114.
Rowe PC: Pediatric Procedures in Principles and Practice of Pediatrics.
Philadelphia, JB Lippincott, 1994, pp 2206-2207.
Chapter I ft
Urinary Bladder Catheterization
Dan Vetrosky
Procedure Goals and Objectives
Goal: To perform urinary bladder catheterization on a patient
safely and accurately
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing urinary bladder catheterization.
• Identify and describe common complications associated with
performing urinary bladder catheterization.
• Describe the essential anatomy and physiology associated with
the performance of urinary bladder catheterization.
• Identify the materials necessary for performing urinary bladder
catheterization and their proper use.
• Discuss aspects of post-urinary catheter placement care and
follow-up.
203
204 Chapter 16 — Urinary Bladder Catheterization
BACKGROUND AND HISTORY
Disease processes that require urinary bladder catheterization have existed
since ancient times. Urethral strictures, bladder stones, and prostatism are
among the first diseases that necessitated urinary bladder decompression
by catheterization. The approach to urinary catheterization remains the same
today as it was in ancient times. It is the technique of passing a hollow tube
through the urethra into the urinary bladder for purposes of circumventing
an obstructed urinary bladder or obtaining a sample of urine for analysis,
or both.
The first known urologic instruments would be considered somewhat
barbaric by today's standards. Ancient and medieval "urologists-lithotomists"
used perineal incision and metal and glass tubes to circumvent urinary
obstruction. Today's approach often uses a local anesthetic and urethral
catheters made of rubber, latex, polytetrafluoroethylene (Teflon), or silicone
polymers. Urethral catheterization is used currently for relief of bladder
outlet obstruction or when measurement of urinary output must be precise
(e.g., in multiple trauma, surgery, intensive care, renal failure).
INDICATIONS
Reasons for passing a catheter into the urinary bladder are many. The most
common uses of bladder catheterization are as follows:
To obtain a sterile urine sample, especially in the female patient
To monitor urinary output closely in critically ill patients
To facilitate urinary drainage in patients who are incapacitated (e.g., due
to stroke, advanced Alzheimer's disease, spinal transection)
To bypass obstructive processes in the urethra, prostate, or bladder
neck caused by disease or trauma until surgical repair can be
performed
■ To hold urethral skin grafts in place after urethral stricture repair
■ To act as a traction device for the purpose of controlling bleeding after
prostate surgery
Specialized three-way Foley catheters are used after bladder or prostate
surgery to allow for continuous bladder irrigation. Continuous irrigation
as well as drainage helps prevent the formation of blood clots, which can
occlude a catheter and cause bladder obstruction. Three-way Foley
catheters also allow for easier evacuation of formed blood clots
(Fig. 16-1).
The main reasons for using the "one time," "straight," or Robinson catheter
are as follows:
■ To obtain a sterile urine sample or to decompress a distended bladder
caused by an acute obstructive process
Chapter 16 — Urinary Bladder Catheterization 205
Drainage
eyelet Balloon
<^— /
Irrigation eyelet
A Three-way irrigation Foley
Drainage eyelet
B Robinson "straight"
^
Notch indicating
Coude tip curved side
*V
Drainage eyelet
Coude
Balloon inflated
Left tip port for balloon
inflation-deflation
^
Drainage eyelet
3:
Balloon deflated
D Foley
Figure 16-1. A, Three-way Foley irrigation catheter. B, Robinson catheter.
C, Coude catheter. D, Foley catheter.
As a protocol of intermittent catheterization in persons with neurogenic
bladders: Catheter izing patients with neurogenic bladders at regular
intervals with the Robinson catheter facilitates complete bladder
emptying, routine urine sampling, and "bladder training." Some of these
patients may be able to decrease the frequency of their catheterization
or may regain complete bladder control, or both, after a time.
■ To deliver topical antineoplastic medication to the bladder in patients
who have bladder cancer or to deliver other topical medication to
patients who suffer from interstitial cystitis
■ To assess post-void residual urine in circumstances where ultrasound
equipment is unavailable.
CONTRAINDICATIONS
The only contraindication to inserting a catheter (either Robinson or Foley)
is the appearance of blood at the urethral meatus in a patient who has
206 Chapter 16 — Urinary Bladder Catheterization
sustained pelvic trauma. This finding can be an indication that the urethra
has been partially or totally transected. Attempting to pass a catheter in this
situation could cause a partial urethral transection to become total. It is
advised that a urologist be consulted when blood at the urethral meatus
is present in a patient with pelvic trauma. Allergy to materials used in
the procedure, such as latex, rubber, tape, and lubricants, is also a
contraindication.
POTENTIAL COMPLICATIONS
Most of the complications with catheterization are seen in the male patient.
Female patients rarely have urethral stricture, and because the female urethra
is comparatively short, false passages are rarely created. Complications can
include the following:
■ Urethral dilation due to placement of a long-term indwelling Foley
catheter in women. Leaking can occur because of bladder spasm. Instead
of treating the spasm, progressively larger diameter catheters are placed
causing urethral dilation and continuation of leaking.
■ Urinary structural trauma
■ Urinary tract infection
■ Inflammation of the urinary tract secondary to the procedure
■ Catheterizing a male patient with urethral stricture disease, bladder neck
contracture, or an enlarged prostate; this may present some technical
difficulties for the unsuspecting health care provider
Passage of a Robinson or Foley catheter in a patient with urethral stricture
disease or an enlarged prostate: This increases the danger of creating
false passages in the urethra if excessive force is applied when resistance
is met during the catheterization. The mechanism of injury occurs when
the obstructive process deflects the catheter into the side wall of the
urethra. If the clinician meets these types of obstructive processes and
continues to apply excessive pressure in an attempt to bypass the
blockage, the catheter can act like a drill and undermine the lining of the
urethra, thus creating a "false passage." The worst scenario in this
situation would be pushing the catheter completely through the urethra
into the surrounding tissue. This results in copious bleeding from the
urethra and creates the possibility of urine and blood extravasating into
the surrounding tissues.
■ Having the catheter "double back" or make a "U-turn" at the site of
obstruction: It is not uncommon to have the catheter tip reappear at the
urethral meatus when there is a significant obstruction or bladder neck
spasm.
■ Improper securing/taping of the Foley catheter.
Chapter 16 — Urinary Bladder Catheterization 207
Figure 1 6-2. Anatomy of the female (left) and male (right) lower urinary tracts
with catheters in place. (Redrawn from Potter PA, Perry AG: Fundamentals of
Nursing, 4th ed. St. Louis, Mosby-Year Book, 1997, p 1324.)
Patient caused trauma: patients who are confused can pull out a fully
inflated Foley catheter.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
Urine is produced by the kidneys and transported to the bladder by the
ureters, where it is stored for transport through the urethra during urination.
Bladder catheterization involves the passage of a mechanical device into the
bladder through the urethra. To accomplish this without damage requires an
understanding of the anatomy of the lower urinary tract. Figure 16-2 illustrates
the anatomy in relation to the location at which a urinary catheter would be
placed for females and males.
In females, the distance from the distal end of the urethra to the bladder is
relatively short (1.5 to 2 inches) and the course through the urethra is
relatively unobstructed. Because of this, bladder catheterization in the female
patient is typically accomplished faster and with less discomfort than it is in
the male patient.
In males, the distance from the distal tip of the urethra to the bladder is
longer (typically 6 to 7 inches; however, it can vary considerably) and is more
circuitous than in females, thus making catheter insertion potentially more
difficult. In males, the path to the bladder typically includes curves that may
be encountered while traversing the penis as well as a sharp bend through
208 Chapter 16 — Urinary Bladder Catheterization
the prostate. Occasionally, prostatic hypertrophy can make catheter insertion
difficult because the pressure of the hypertrophic prostate can add a
curvature to the urethra as well as produce urethral obstruction.
to exercise clinical judgment based on the
Standard Precautions Practitioners should use patient's history and the potential for exposure
standard precautions at all times when to body fluids or aerosol-borne pathogens (for
interacting with patients. Determining the level further discussion, see Chapter 2).
of precaution necessary requires the practitioner
PATIENT PREPARATION
■ Inform the patient before the procedure how the catheterization will be
performed and what he or she might expect to feel during the procedure.
This will help secure the patient's trust and cooperation. Do not tell the
patient that he or she will not feel anything, because this would be
untruthful and counterproductive during the procedure. Inform the
patient that the passage of the catheter may feel as though he or she
must urinate and that it will be slightly uncomfortable.
■ Patient comfort must be a primary consideration if a sterile, atraumatic
catheterization is to be accomplished.
■ Explain to the patient the importance of being reasonably still and not
touching your gloved hands or sterile implements.
Typically, the patient is positioned in the supine position. Drapes should
be placed to cover all but the genitalia. The female patient will need to
abduct the legs laterally to allow easy access to the urethra.
Materials Utilized to Perform a Urinary Bladder
Catheterization
Sterile tray or working area
Vessel for collecting urine (sometimes included with tray)
Sterile gloves
Sterile lubricant or anesthetic jelly lubricant
Antiseptic cleansing solution (typically povidone-iodine [Betadine])
Sterile gauze or cotton balls for cleansing the external exit of the urethra
and the surrounding skin
Sterile forceps
Syringe filled with sterile water for catheter balloon, 5 mL to 30 mL
depending on the balloon capacity of the catheter selected
Chapter 16 — Urinary Bladder Catheterization 209
Urine collection tubing, bags, hardware, and specimen collection
containers
Sterile drapes to protect the sterile field and nonsterile drapes to
maintain patient modesty
Catheter (see "Types of Catheters")
Catheterization kits containing the following:
■ Sterile lubricant
■ Sterile drapes
Sterile gloves
■ Sterile cotton swabs
Povidone-iodine
■ Forceps to grasp the cotton swabs
Sterile specimen container for urinalysis and culture
Container to catch the urine
Robinson or Foley catheter, 14, 16, or 18 French: If a Foley catheter is
used, the kit will also contain a prefilled 10-mL Luer-tipped syringe to
inflate the Foley balloon and can contain a preattached drainage bag
(attached to the Foley catheter). The advantage of a preattached
drainage bag is that once in place, the Foley catheter and the drainage
bag are considered a sterile "closed system." The disadvantage is the
inability to obtain a specimen or irrigate the bladder without "breaking
the seal" and making what was once a sterile closed system a
"contaminated" open system.
TYPES OF CATHETERS
Urinary catheters (Robinson, coude, and Foley types) are made of various
materials and are soft and flexible (see Fig. 16-1). The most common catheter,
Robinson or "straight" type, is made of rubber. Catheters can be made of
pure rubber, rubber with synthetic coatings such as latex, or pure latex. Pure
silicone and silicone-coated catheters are also manufactured, although they
are much more expensive than rubber or latex catheters. These coated
catheters are more commonly seen in indwelling or Foley catheter lines. The
coatings are touted to resist encrustation when left in the bladder for
prolonged periods. Patients with latex allergies should not be catheterized
with rubber or latex catheters. In such cases, catheters made of pure silicone
are an acceptable alternative.
210 Chapter 16 — Urinary Bladder Catheterization
Robinson Catheter
The Robinson catheter is also known as the "straight" catheter and is sterile
if the package seal is not broken. It has a soft, rounded tip and one or two
drainage eyelets on the tip side walls. The catheter is hollow, and the distal
end is flared to facilitate urinary drainage. These catheters are designed for
one-time use, hence the term in-and-out catheter (see Fig. 16-1).
Coude Catheter
Coude catheters have a bend at the distal tip that causes the catheter to
follow the anterior surface of the male urethra. This bent tip facilitates the
insertion of the catheter in patients with false passages, which typically
occur on the posterior surface of the urethra.
Foley Catheter
The Foley catheter is designed to remain in place in the bladder. It too is
sterile, and its appearance is similar to the Robinson catheter, with a few
exceptions. At the tip, behind the drainage eyelets, is an inflatable balloon.
The balloon is inflated after the catheter is properly placed in the bladder to
help keep the catheter seated in the bladder. The flared end of the catheter
is located at the distal end, and it can be attached to a drainage bag. Also at
the distal end is an elbow with a Luer-Lok cap attached. This elbow is the end
of an extremely small lumen, which traverses the length of the catheter
and ends in the balloon at the tip. The Luer-Lok cap allows the balloon to be
inflated once the catheter is in place and deflated once the catheter needs to
be removed. The balloon is typically inflated with sterile water. Use of saline
is discouraged because of the possibility of crystal formation along the
balloon's lumen. Should this occur, the balloon might not deflate when the
catheter needs to be removed.
There are two sizes of Foley catheter balloons: a 5-mL balloon and a 30-mL
balloon. The most common balloon size used is 5 mL, and it is typically
inflated with 10 mL of sterile water, which accounts for the lumen volume and
the balloon volume; 30-mL balloons are used to ensure that the Foley catheter
does not migrate into the prostatic fossa or out of the urinary bladder
altogether. In addition, the 30-mL balloon can be inflated with 50 mL of sterile
water and used as a traction stent after certain urologic procedures (e.g.,
radical prostatectomy, transurethral prostatectomy).
CATHETER SIZE REQUIREMENTS
Urinary catheters come in various sizes and are measured according to the
Charriere French scale (0.33 mm equals 1 French [Fr]). A 3-Fr catheter is
Chapter 16 — Urinary Bladder Catheterization 211
1 mm in diameter, whereas a 30-Fr catheter is 10 mm in diameter. The French
size of the catheter depends on the patient and the catheter's purpose. As an
example, pediatric boys need a French size between 5 and 12 Fr. Adult men
should be catheterized with a 16- or 18-Fr catheter. These sizes are slightly
stiffer and will follow the anatomic curvature of the male urethra easier and
better than the smaller French catheters (14 Fr or smaller). Smaller French
catheters have a tendency to "turn around" in the male urethra if the slightest
resistance is met (especially at the bladder neck). The adult woman should
also be catheterized with 16- or 18-Fr catheters, although a 14 Fr should be
used most of the time to facilitate comfort. Larger French catheters (20 to
30 Fr) are used to evacuate blood clots in postoperative prostate surgery
patients or in patients who are bleeding from the kidney or bladder.
Procedure for Performing a Urinary Bladder Catheterization on a Male
Patient
Note: Male patients are more prone to
sustaining damage to the urethra during the
catheterization procedure. Improper
lubrication and excessive force used to
"overcome" an obstruction are the most
common offending factors causing urethral
trauma. The steps outlined here will help
reduce the chances of inflicting excessive
pain, causing urethral damage, or
introducing infection.
1. Obtain the Robinson or Foley catheter
that is sized commensurate with the
procedure or purpose. Make sure it is
sterile (packaging must be intact).
2. Obtain the appropriate catheterization
kit or supplies.
3. Follow aseptic techniques and standard
precautions by washing hands and
putting on sterile gloves.
4. Open the kit in a sterile manner.
5. Prepare the patient by draping him in
sterile drapes (found in the kit) and
exposing the genital area, making sure to
allow for the patient's privacy and
comfort.
6. Open the catheter, if not contained in the
kit, and place on the sterile drape using
sterile technique.
7. Even if a package of sterile lubricant is
contained in the kit, obtain a sterile
15- to 20-mL syringe and place it on the
sterile drape.
8. Once the operator is gloved, an assistant
is needed to squirt some lubricant into
the syringe. Water-soluble lubricant can
be substituted for sterile anesthetic jelly
(lidocaine [Xylocaine] jelly, not
ointment, or Anestacon [a prepackaged
anesthetic jelly]).
Note: If there is a prefilled sterile syringe
with water-soluble lubricant in the kit, this
step can be omitted.
9. Open the package of povidone-iodine
and pour onto the cotton swabs.
10. Inform the patient that you are going to
hold his penis and clean it with the
povidone-iodine. Assure him that it will
not stain the skin permanently. Swab the
head of the penis, making sure to clean
the meatal opening first and wiping out
continued
212 Chapter 16 — Urinary Bladder Catheterization
to the glans with the povidone-iodine
soaked cotton swabs. (Use your
nondominant hand to hold the penis.)
Use all the cotton swabs.
Note: If the patient is uncircumcised, the
foreskin needs to be drawn back before
beginning the cleansing and catheter
insertion process.
11. Once the penis is clean, do not let go
and position the penis at a 90-degree
angle from the abdomen and instill the
lubricant or anesthetic agent into the
urethra. Gently occlude the urethra so
that the lubricant or anesthetic agent
does not come back out the urethra. If
using anesthetic jelly, wait for
approximately 1 minute before proceeding
so that the anesthetic jelly has time to
work.
12. Position the urine container near the
patient's leg or between the patient's
legs, as appropriate.
13. Grasp the catheter with your dominant
hand about three quarters of the way
toward the catheter tip. Inform the
patient that you are now going to insert
the catheter. Gently begin inserting the
catheter into the urethral meatus and
continue the insertion without stopping
(Fig. 16-3). When the sphincter is
encountered, you will feel slight
resistance. Ask the patient to take a deep
breath, which might assist in relaxing
him somewhat, but continue to insert
the catheter, applying gentle pressure if
necessary.
Note: When a stricture or obstruction is
encountered during catheterization, the
clinician has some techniques and tools that
may facilitate atraumatic bladder
catheterization. The first technique is to
make sure the urethra is well lubricated by
instilling sterile, water-soluble lubricating
jelly or topical anesthetic jelly into the
Figure 1 6-3. Catheter insertion in a male
patient. (Adapted from Potter PA, Perry AG:
Fundamentals of Nursing, 4th ed. St. Louis
Mosby-Year Book, 1997.p 1323.)
urethra. Once this is accomplished, a 16- or
18- Fr coude-tipped catheter (see Fig. 16-1)
can be used to facilitate bypassing false
passages or bladder neck obstruction. The
coude tip is fashioned to follow the normal
curve of the urethra and should be passed
with the tip facing the anterior portion of the
patient's urethra. If the clinician continues to
meet obstruction and is unsuccessful using
the coude catheter and the techniques
outlined, a urologist should be called. The
urologist will most likely try using a filiform
bougie and followers in order to bypass and
dilate urethral structures or bladder neck
contractures. If these techniques or tools are
not successful, a flexible cystoscope or
suprapubic catheterization may be used.
14. Once the sphincter is passed, continue
to pass the catheter until almost to the
hub of the catheter. Urine should begin
to flow, although it may take some time
for the lubricant, which will be in the
Chapter 16 — Urinary Bladder Catheterization 213
catheter after you pass it into the
bladder, to "melt." Place the end of the
catheter into the urine container and
empty the bladder.
15. Obtain a specimen at this point if needed.
16. Once the bladder is empty, remove the
catheter in one continuous motion,
making sure to pinch off the distal end
so that the column of urine left in the
catheter does not pour onto the patient.
17. Make sure to measure the amount of
urine obtained and record it.
Note: This is important in any situation, but
especially when trying to measure a post-
void residual. Having the patient void
immediately before catheterizing him allows
for the measurement of residual urine in the
bladder. The amount voided must be
measured, and then the post-void residual
left in the bladder can be measured
following catheterization. In many practices,
ultrasound measurement of post-void
residual urine in the bladder is replacing the
in-and-out catheterization.
18. If this is a Foley catheter placement,
once the catheter is in the bladder and
urine begins to flow, get the prefilled
syringe (with sterile water) and inflate
the Foley balloon.
19. Make sure the Foley catheter is inserted
almost to the hub.
Note: This ensures that the balloon is not
blown up in the prostate, bladder neck, or
urethra.
20. Once the balloon is blown up, pull the
Foley catheter out gently until it stops.
The Foley catheter is now in the proper
position.
21. Attach the drainage bag if it is not
already in place.
22. Tape the Foley catheter to the abdomen.
Caution: Taping the Foley catheter is an
important step. The penis should be
pointing toward the umbilicus and the
catheter taped just below the hub.
Note: Taping the Foley catheter in this
manner prevents it from eroding through
the urethra by eliminating the first curve of
the "S" formed by the male urethra.
Maintenance of the Foley catheter includes
daily cleaning, retaping in the proper
position when necessary, and appropriate
meatal care.
23. Apply bacitracin ointment to the
urethral meatus one to three times a day
as needed. This helps keep the catheter
from irritating the meatus excessively
and prevents infection.
Note: If the patient is uncircumcised, the
foreskin needs to be placed back into its
original position.
Procedure for Performing a Urinary Bladder Catheterization on a
Female Patient
Note: Female patients can be difficult to
catheterize because of the placement of the
urethral meatus. If the female patient has a
normal anatomy and is not excessively
obese, the urethral meatus should be
superior to the vaginal introitus and inferior
to the clitoris. Some women's urethral
meatus is located just inside the superior
aspect of the vaginal introitus. This can
make catheterization difficult, as
identification of the urethral orifice can be
obscured by vaginal tissue.
continued
214 Chapter 16 — Urinary Bladder Catheterization
1. Obtain a Robinson or Foley catheter in a
size commensurate with the procedure
or purpose, making sure that it is sterile
(the packaging must be intact).
2. Obtain the appropriate catheterization
kit or supplies.
3. Wash your hands.
4. Open the kit in a sterile manner.
5. Put on sterile gloves.
6. Prepare the patient by draping her in
sterile drapes (found in the kit) and
exposing the genital area, making sure
to allow for the patient's privacy and
comfort.
7. Open the catheter, if not contained in the
kit, and place on the sterile drape using
sterile technique.
8. Instead of instilling lubricant into the
female urethra, lubricate the catheter
well, about one third of the way from the
tip of the catheter up.
9. Open the package of povidone-iodine
and pour onto the cotton swabs.
10. Inform the patient that you are going to
swab the urethral opening with
povidone-iodine once you separate the
labia majora and labia minora. Using the
nondominant hand, spread the patient's
labia. Wipe the urethral opening with the
cotton swabs from an anterior to a
posterior direction. If the urethral
opening is at or in the vaginal opening,
the vaginal opening must be swabbed as
well.
11. At this point, you can anesthetize the
urethra if desired. To do this, apply
lidocaine jelly or aqueous cocaine to a
cotton-tipped swab and gently insert it
into the urethra. Leave it in place for
approximately 1 to 2 minutes before
placing the catheter.
Figure 1 6-4. Catheter insertion in a female
patient. (Redrawn from Potter PA, Perry AG:
Fundamentals of Nursing, 4th ed. St. Louis,
Mosby-Year Book, 1997, p 1323.)
12. Place the urine container between the
patient's legs.
13. Grasp the catheter with your dominant
hand, making sure that the catheter is
still well lubricated, and gently insert the
tip of the catheter into the urethral
opening until urine starts to flow or
approximately one third of the catheter
has been inserted into the bladder (Fig.
16-4).
Note: If you have missed the urethral
opening or inserted the catheter into the
vagina, you must obtain a new catheter and
try again. (A helpful technique is to leave the
catheter you missed with temporarily in
place. This helps you identify where not to
place the new catheter.)
14. Once the bladder is empty (and you
have obtained your specimen), remove
the catheter in one continuous motion,
making sure to pinch off the distal end of
the catheter so that the column of urine
left in it does not pour onto the patient.
Chapter 16 — Urinary Bladder Catheterization 215
15. If this is a Foley catheter placement,
once the catheter is in the bladder and
urine begins to flow, get the prefilled
syringe (with sterile water) and inflate
the Foley balloon.
16. Make sure the Foley catheter is inserted
at least one third of the way into the
bladder.
Note: This ensures that you do not blow the
balloon up in the bladder neck or urethra.
17. Once the balloon is blown up, pull the
Foley catheter out gently until it stops.
The catheter is now in the proper
position.
18. Attach the drainage bag if it is not
already in place.
Caution: Taping the Foley catheter is an
important step.
19. Tape the Foley catheter to the inner
thigh. Leave some slack so that it
is not taut and pulling against the
bladder neck. This can cause
bladder spasms. Tape just below
the hub.
Note: Maintenance of the Foley catheter
includes daily cleaning, retaping in the
proper position when necessary, and
appropriate meatal care. Typically,
povidone-iodine ointment is applied to the
urethral meatus one to three times daily as
needed. This helps keep the catheter from
irritating the meatus excessively and helps
prevent infection.
FOLLOW-UP CARE AND
INSTRUCTIONS
Short-Term or In-and-Out
Catheterization
■ Complications are unlikely.
The most common complications include irritation of the urinary tract
and infection.
Patients will most likely "burn" the first few times they urinate following
catheterization. Reassurance is usually all that is needed.
Instruct the patient to monitor urination for continuous dysuria, urinary
frequency, hematuria, and pyuria, as well as for systemic signs of urinary
tract infection such as fever or back pain.
Indwelling Catheterization
The two major risks associated with an indwelling urinary catheter are
trauma and infection. After successful catheter placement, trauma is
typically a result of not protecting the catheter properly.
Instruct the patient that the catheter should be secured with tape at all
times and that care should be taken not to snag the tubing on clothing or
furniture in a way that would pull on the catheter.
216 Chapter 16 — Urinary Bladder Catheterization
Infection prevention measures include the following:
■ Advise the patient always to position the drainage bag below the bladder
to prevent urine from flowing back into the bladder.
Instruct the patient to be careful to avoid kinks in the tubing system.
■ Instruct the patient to monitor the bag often to make sure that it is
emptied before it becomes completely full.
■ Caution the patient to be careful when emptying the bag or manipulating
the drainage system, to avoid introducing contaminants.
■ Instruct the patient to wash hands frequently and to use latex gloves (if
not allergic; if allergic to latex, indicate which type of gloves to obtain).
■ Instruct the patient to be careful not to have the drainage system come
into contact with contaminated objects such as toilet bowls.
Caution the patient to be aware of signs of infection, such as changes in
the appearance of the urine or symptoms of a urinary tract infection,
and to call the office.
Bibliography
Potter PA, Perry AG: Fundamentals of Nursing, 4th ed. St. Louis,
Mosby-Year Book, 1997.
Tanagho EM, McAninch JW (eds): Smith's General Urology, 14th ed.
Norwalk, Conn, Appleton & Lange, 1995.
Cha
pter I *T
Clinical Breast Examination
Patricia Kelly
Procedure Goals and Objectives
Goal: To perform a thorough breast examination on a female
patient in a manner that preserves the patient's modesty while
maximizing the likelihood of identifying abnormal findings.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing a breast examination.
• Describe the essential anatomy and physiology associated with
the performance of the breast examination.
• Describe the logical order of the steps used to perform the
breast examination.
• Describe normal and abnormal findings associated with the
breast examination.
217
218 Chapter 17 — Clinical Breast Examination
BACKGROUND AND HISTORY
The clinical breast examination (CBE) is a universally taught ambulatory care
skill. As part of a physical examination, CBE complements but does not replace
mammography The CBE is both a screening and diagnostic procedure. As a
screening procedure, its purpose is to detect cancer in asymptomatic women.
As a diagnostic procedure, it is part of a comprehensive evaluation for
patients with symptoms related to the breasts.
Breast cancer is diagnosed in more than 170,000 women annually in the
United States. Established risks for breast cancer include age older than
50 years, family history of breast cancer in first- and second-degree relatives,
a younger age at menarche (<12 years), older age at menopause (>55 years),
older age at first birth (>30 years) or nulliparity, some types of benign breast
disease (particularly atypical hyperplasia), and hormone replacement
therapy. Societal, demographic, and medical trends have markedly increased
the number of women at risk.
Before the introduction of cancer screening as an integral part of
generalized preventive medical services, most breast cancer was discovered
by women themselves or as an incidental finding during the evaluation of
other complaints. Frequently, breast cancer was advanced at the time of
diagnosis. Specific techniques to increase the sensitivity of the examination,
therefore, were not generally thought to be important. In its later stages, the
alterations caused by breast cancer were evident on physical examination.
Historically, breast cancer has been a fearful entity. Before 1970, the
diagnosis of breast cancer called for "automatic" radical mastectomy, a
disfiguring procedure with substantial postoperative morbidity. Because
many newly diagnosed women had advanced disease, the prognosis was
considered poor. Breast cancer also carried with it a social stigma; therefore,
it was not widely discussed. Women were frequently not told of female
relatives who had succumbed to the disease. Risk factors for the disease had
not been clearly described. Most patients, and many physicians, had
incomplete or erroneous knowledge concerning the disease. Adjuvant
chemotherapy and hormonal therapy were unavailable until the latter half of
the 20th century, and breast cancer generally carried with it an aura of hope-
lessness. Many women died in excruciating agony. The concepts of palliative
therapies or hospice care were not well explored until recent decades.
More recently, societal change and medical progress have correctly imbued
us with the notion that breast cancer is a relatively common — and treatable —
malignancy. Unfortunately and concomitantly, longevity, decreased rates of
childbearing, and younger age at menarche have raised the incidence of this
illness. Increased public awareness, however, along with growing emphasis
on screening techniques such as CBE and mammography, have improved
detection efforts.
Although breast cancer is still frequently a systemic disease at the time of
diagnosis, therapeutic advances and earlier detection have rendered it, in
many or most cases, a "curable" entity. More than 60% of breast cancer victims
now survive and succumb to other diseases. Less radical surgical inter-
Chapter 17— Clinical Breast Examination 219
ventions, increased consumer knowledge and empowerment, and "gender
shift" in the ranks of clinicians have all undoubtedly played an important role
in subduing this disease.
INDICATIONS
The value of CBE is not universally supported. The American Cancer Society
recommends CBE every 3 years in women of reproductive age until 40 years
of age and annually after that. The U.S. Preventive Services Task Force (2002)
states that there is insufficient evidence to recommend for or against the
examination. The National Cancer Institute recommends annual screening
examinations in women age 40 years or older. Recent studies indicate that
screening CBEs discover a small number of cancers that are missed by routine
mammography (Elmore, 2005). The effect on disease end-outcome, however,
is uncertain.
The following guidelines seem reasonable:
CBE is performed on an annual basis for women who are age 40 years or
older.
Women who have a strong family history of early breast cancer should
undergo annual examination at a younger age. Although traditionally
performed in all women of reproductive age, whether annual CBE for
women younger than age 40 who are at normal risk confers any survival
advantage is unclear. The positive predictive value (the chance that an
abnormality discovered on examination is malignant) increases with age
and with the presence of other risk factors for breast cancer. Barton and
coworkers (1999) estimate the specificity and sensitivity of CBE at 54%
and 94%, respectively.
■ The current legal standard of care strongly suggests that CBE be combined
with screening mammography in women age 40 years or older. Neither
procedure alone is sufficient. Masses apparent on physical examination
require further evaluation even in the face of negative or normal
mammographic findings. Informed consent regarding the potential
benefits and limitations of various screening modalities, including CBE,
should always be documented in the patient record.
The CBE, when used as a screening procedure, has legal as well as medical
importance. Failure to diagnose breast cancer is a leading source of mal-
practice litigation. Providers who fail to perform or document adequate
examinations are at high risk for adverse legal consequences.
CONTRAINDICATIONS
There are no medical contraindications to the performance of this
procedure.
220 Chapter 17 — Clinical Breast Examination
POTENTIAL COMPLICATIONS
There are no reported medical complications associated with the perform-
ance of this procedure. Legal or practical complications may arise when the
examination is omitted or improperly documented, or if adequate informed
consent regarding the benefits and limitations of the procedure is not
obtained. Since this is a sensitive examination, many providers may wish to
have the procedure chaperoned or assisted by another clinician or office
staff person. Patient education regarding the breast self-examination, necessity
of the examination by a clinician, and the presence of any assistants should
be documented in the medical record.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
The average female breast is somewhat "lumpy" to palpation and contains
glandular tissue, fibrous tissue, supporting ligaments, and fat. Glandular
tissue, intended to produce breast milk, radiates centrally from the nipple.
Each glandular lobe terminates in a milk sinus and an excretory duct in the
nipple area. The nipple is slightly inferior and lateral to the center of each
breast. The skin of the nipple generally extends outward to form the areola.
Small sebaceous glands also terminate in the areola. These serve to secrete
a protective substance during nursing. Smooth muscles in the subcutaneous
tissue under the areola control the erection of the nipple. Small super-
numerary nipples, often mistaken for moles, can sometimes be found along
the embryological milk lines. These are of no clinical consequence.
Fibrous tissue provides support to the breast, which is connected to the
underlying muscle by fascial suspensory structures called Cooper's ligaments.
The breasts overlie the pectoral muscles of the chest. Nerves, blood vessels,
and lymphatic structures are also contained within the breast. Fatty tissue
intermingles with breast tissue in the breast itself. Lymphatic drainage of the
breast provides the primary pathway for cancer spread (Fig. 17-1).
The area requiring visual inspection and manual palpation extends
inferiorly (vertically) from the clavicle, or second rib, to the seventh rib and
laterally from the sternal border to the midaxillary line. The "tail" of the
breast extends well into the axilla and must not be omitted during exami-
nation. The upper outer quadrant of the breast has the greatest amount of
breast tissue and is frequently the site of malignant processes. Peripheral
and superficial breast structures are predominantly fatty; deep, central areas
contain the greatest percentage of glandular and fibrous tissue. The breasts
are usually slightly unequal in size; the left is frequently larger.
The breasts change during maturation and pregnancy and in a cyclic
fashion dependent on the menstrual cycle. The glandular breast tissue
typically increases in size and tenderness in a pattern conforming to normal
hormonal fluctuations. Increased tenderness and engorgement coincide with
Chapter 17— Clinical Breast Examination 221
Supraclavicular nodes
Interpectoral
(Rotter) nodes
Midaxillary
nodes
Lateral
axillary
(brachial)
nodes
Subclavicular
nodes
Internal mammary
nodes
Cross-mammary
pathways to
opposite breast
Figure 17-1. Lymphatic drainage of the breast. (Redrawn from Seidel HM:
Mosby's Guide to Physical Examination, 4th ed. St. Louis, Mosby-Year Book, 1999.)
Subscapular
nodes
Anterior axillary
(pectoral) nodes
Pathways to
subdiaphragmatic
nodes and liver —
the immediate premenstrual period and with pregnancy. The premenstrual
period, therefore, is not the optimal time for screening CBE.
Women in their reproductive years have "denser" and "lumpier" breasts
than postmenopausal women. The latter frequently have some diminution of
breast tissue that increases with age. Women who are obese have excess
adipose tissue and, hence, larger breasts.
Lactation, or milk production, is influenced by prolactin, which is present
secondary to parturition, drug effect, or abnormalities of the pituitary. During
nursing, the breasts become markedly engorged.
Abnormalities that are commonly present in the breast may be of the
breast tissue itself or of overlying skin. Edema of the skin, characterized by
unusually prominent pores (sometimes called peau d'orange because of its
orange peel appearance), is an important sign of carcinoma of the breast.
Inflammatory breast carcinoma can appear as an eczematous eruption.
Erythema can also signify malignancy, although it is more often indicative of
infection. Scars may mark the presence of previous biopsies. Retraction or
dimpling of skin, although not truly a superficial phenomenon, signifies
underlying fibrotic tissue changes that are frequently due to cancer.
Many findings on breast examination are the consequence of stimulating
hormones on breast tissue. Both estrogen and progesterone affect breast
tissue; progesterone causes more cell division than does estrogen. As
previously stated, breast tissue therefore "swells and shrinks" in a relatively
predictable fashion during the menstrual cycle. However, sometimes this
effect can cause discrete, although benign, abnormalities. Fibroadenomas —
characterized by firm, rubbery, nontender, freely movable but solid masses —
can be caused by hormonal influences on one component of breast tissue,
222 Chapter 17 — Clinical Breast Examination
the stroma. Breast cysts, which are fluid-filled, tender, benign entities, are
also largely due to hormonal fluctuations. As such, they are rare (as initial
presentations) in postmenopausal women, who are the group at most risk for
breast cancer. Although both these benign entities are fairly characteristic
on physical examination, further studies, including ultrasonography,
mammography, and tissue cytologic studies, are almost always indicated.
The diagnostic evaluation of a breast mass is beyond the scope of this chapter.
Other solitary, nontender breast masses that may be mistaken for carcinoma
are chronic abscesses and fat necrosis. These, too, generally must be
subjected to biopsy for definitive diagnosis.
Inflammatory breast changes (tender, red) can represent acute mastitis,
which generally occurs during lactation or pregnancy. If the cause is not
evident (i.e., if this occurs in a 65-year-old, nonlactating woman), inflam-
matory carcinoma must be ruled out. If not promptly treated, mastitis can
lead to an acute abscess, which can present as a localized, fluctuant, exquisitely
tender mass.
The classic presentation of breast cancer is a hard, irregular, fixed mass.
Evidence of metastatic disease is denoted by enlarged, fixed, hard lymph
nodes (pectoral, subscapular, or central groups) in the axilla. If the suspending
ligaments are involved, dimpling or retraction may occur. Bloody or clear
discharge indicates invasion of the milk ducts. Lymphatic obstruction, as
previously stated, can produce skin edema.
to exercise clinical judgment based on the
Standard Precautions Practitioners should use patient's history and the potential for exposure
standard precautions at all times when to body fluids or aerosol-borne pathogens (for
interacting with patients. Determining the level further discussion, see Chapter 2).
of precaution necessary requires the practitioner
PATIENT PREPARATION
As discussed later, the duration of CBE is important. It is likely that many
patients have never received an adequate examination and might be
surprised by the length of time required to perform the examination and its
thoroughness.
■ The examination should be conducted in a room that is climate
controlled and ensures privacy. Cold examination rooms deter clinicians
and patients; hot rooms cause patients and providers to perspire,
inhibiting optimal technique.
The patient must be relaxed for an adequate examination, and cloth
gowns enhance comfort. Pillows provide comfort while improving
positioning.
Chapter 17— Clinical Breast Examination 223
Materials Utilized to Perform a Breast
Examination
Note: The CBE can be considered a low-cost examination in that it uses
only the time and expertise of the clinician to screen for disease. Basic
equipment is as follows:
■ Powder
■ Lotion
■ Gloves
■ Sufficient light
■ Pillow
Procedure for Performing a Breast Examination
Note: Recommendations for performance of
the CBE are derived predominantly from
Barton and colleagues (1999). These
researchers thoroughly reviewed the
literature and specified components of the
examination that have been validated in
independent investigations.
Note: Some clinicians prefer that a female
assistant be present for this sensitive
examination.
Inspection
Note: Inspection has been traditionally advised
but has not been demonstrated to add
additional specificity or sensitivity to an
examination with palpatory components alone.
1. Inspect the breasts with the patient
sitting, hands by her side (Fig. 17-2).
2. Note the condition of the skin: any
eczematous changes, "enlarged pores"
(peau d'orange), or erythema.
Note: Tangential light may aid this portion of
the examination.
Figure 1 7-2. (Redrawn from Seidel HM:
Mosby's Guide to Physical Examination, 4th ed.
St. Louis, Mosby-Year Book, 1999.)
Look for retraction, dimpling,
displacement, nipple inversion, or
obvious mass defect. Also note scars from
previous biopsies.
continued
224 Chapter 17 — Clinical Breast Examination
Note: Since retraction and dimpling are
phenomena that result from underlying
tissue compression or displacement, the
patient may be examined in several different
postures. Pressing the hands against the
hips contracts the pectoralis muscles
(Fig. 17-3); bending at the waist to let the
breasts hang free can also be useful
(Fig. 17-4). *
Figure 1 7-3. (Redrawn from Seidel HM:
Mosby's Guide to Physical Examination, 4th ed.
St. Louis, Mosby-Year Book, 1999.)
Palpation in the Axillary
Area
4. Palpate the axillae for enlarged nodes (see
Fig. 17-1).
Note: Many clinicians conduct this portion
of the examination with the patient in a
supine position; others support the sitting
patient's arm with one hand and examine the
axilla with the other. However, palpating the
axillae with the patient lying down facilitates
a smooth segue into the remainder of the
supine breast examination.
Note: Since the axillary areas are
frequently damp, the clinician may want to
don gloves for this procedure. After the
axillary examination, the gloves should be
removed, leaving a powder residue on the
hands. This substance, or lotion, may
enhance the ease of the palpatory breast
examination.
Palpation of the Breast
Figure 1 7-4. (Redrawn from Seidel HM:
Mosby's Guide to Physical Examination, 4th ed.
St. Louis, Mosby-Year Book, 1999.)
Note: Palpation is emphasized because
inspection, although traditionally included,
has not been demonstrated to substantially
increase diagnostic yield.
Note: Most authorities advise that
palpation is optimally performed on women
who are supine. Some classic references on
physical examination technique recommend
conducting the examination with the patient
sitting and supine. This has not proved to
increase sensitivity or yield and would be
very time consuming if done with sufficient
thoroughness.
Note: Women, especially those with larger
breasts, can improve examination efficacy by
flattening the breast (e.g., by raising the
ipsilateral hand, rotating the shoulder
externally, placing a pillow behind the back).
Chapter 17— Clinical Breast Examination 225
Technique
5. With the patient supine, and the hands
behind the head, use the finger pads of
the middle three fingers of the dominant
hand to palpate breast tissue. These
fingers are held together; the hand may
flex slightly at the knuckles.
Note: If the proximal interphalangeal joints
are flexed, the clinician will examine the
patient with the fingertips instead of the
fingerpads; this is incorrect and must be
avoided. The proximal interphalangeal joints
and the distal interphalangeal joints should
be held in hyperextension for this delicate
maneuver (Fig. 17-5).
6. For optimal palpation, "rock" the fingers
back and forth in the horizontal and
vertical planes, producing an almost
circular "rotatory" movement from a
central axis located at the fingerpad of the
third digit.
Figure 17-5. (Redrawn from Seidel HM:
Mosby's Guide to Physical Examination, 4th ed.
St. Louis, Mosby-Year Book, 1999.)
Note: The diameter of this rotation, as
measured from each fingertip, should be no
greater than 1.5 cm. Light, medium, and
deep palpation are used sequentially.
7. Never lift the fingerpads completely from
the skin, but advance very slightly
(<1 cm) by sliding along the skin, still
exerting traction, after each area is
thoroughly palpated. Again, maintain
palpatory pressure at all times.
Note: In order for this maneuver to be
successful, the fingerpads and breast tissue
must be either powder "dry" or moistened
with lotion. Otherwise, the fingerpads stick
to the skin surface and cannot be rotated or
advanced smoothly.
Note: "Walking" fingertips are to be
avoided.
Pattern of Palpation
8. Begin palpation laterally at the midaxillary
line and extend inferiorly in a straight line
until approximately the level of the
seventh rib, where the breast tissue stops.
9. Shift the finger pads medially and
continue palpation superiorly, again in a
straight line, back to the midaxilla or
clavicle, depending on how far medially
the examination has progressed.
Note: Some examiners palpate the area
around the nipple in exactly this same
manner; some, however, also traditionally
"squeeze" the nipple to check for fluid. The
validity of this technique in cancer detection
is uncertain.
Note: This technique, called the vertical
strip pattern, is analogous to "lawn mowing."
Much as in cutting grass, rows need to
overlap to avoid skipping areas. The vertical
strip pattern has been found to be more
thorough and reproducible than the
continued
226 Chapter 17 — Clinical Breast Examination
traditional concentric circumferential
technique or the radial spoke method
(Fig. 17-6). However, it is certain that any
uniformly practiced, sequential technique is
better than "random" palpation, which,
unfortunately, is the method used by many
busy clinicians.
Examination of the breast
Vertical stripping Concentric circles Radial spokes
Figure 17-6.
SPECIAL CONSIDERATIONS
Training and practice enhance diagnostic capability. Silicone breast models,
demonstrating common benign and malignant abnormalities as well as the
consistency of "normal" breast tissue, have demonstrated efficacy when used
with lay and professional populations. Although experience with previous
abnormalities does enhance the diagnostic efficacy of a provider, the single
most important determinant of examination sensitivity is duration of the
procedure. The other vital component is a sequential palpation plan with well-
defined landmarks, ensuring that no area of breast tissue is inadvertently
overlooked. The attention, thoroughness, and diligence of the examiner are
more predictive of screening sensitivity than the examiner's specific
professional role (physician assistant, nurse, physician), level of training, or
previous experience.
FOLLOW-UP CARE AND
INSTRUCTIONS
A breast examination not recorded is a breast examination not
performed. The clinician should clearly document the performance and
findings of the CBE and the plan of action.
If referral for further diagnostic or screening studies is warranted or
recommended, "tickler" files or computer reminders to ensure and
document patient compliance and the results obtained are essential.
Written documentation of all patient contacts regarding referral or
recommended further diagnostic or screening studies is vital. Patients
who do not keep referral appointments should be contacted by
telephone and certified mail.
Patient education concerning the CBE should include information on the
sensitivity and specificity of the examination and information about why
the duration of the examination is important.
Chapter 17— Clinical Breast Examination 227
Education must also include accurate information concerning breast
cancer prevalence.
■ Information concerning current recommendations for other breast
cancer screening modalities, such as mammography and breast
self-examination, should be provided as well.
■ The patient education provided must be accurately documented in the
medical record.
■ Most clinicians include information and education concerning the
breast self-examination during the annual CBE. The effect of breast self-
examination on breast cancer mortality is uncertain. Self-reported
frequency of breast self-examination has never been correlated with
improved outcome. Appropriate teaching of technique, however, has
been shown to improve the efficacy of breast self-examination in the
discovery of smaller, and hence more treatable, masses. Many studies of
this practice have provided contradictory results; the evidence is not
considered strong enough to make a clear recommendation for or
against breast self-examination by many governmental health authorities.
Private organizations, however, including the American Cancer Society,
recommend this procedure. As a result, women should be instructed
in appropriate technique, frequency, and duration of breast
self-examination. These examinations, however, should not substitute
for CBE.
Many clinicians traditionally included information and education concerning
the breast self-examination during the annual CBE. However, breast self-
examination has not been demonstrated to decrease breast cancer deaths; it
does increase the number of negative invasive diagnostic procedures without
providing a corresponding survival benefit. Although some prominent
organizations continue to recommend the procedure and it is widely
publicized, its risks and lack of demonstrated positive outcomes should be
discussed with each patient thoroughly.
References
Barton MB, Harris R, Fletcher SW: Does this patient have breast cancer?
The screening clinical breast examination: Should it be done? How?
JAMA 282:1270-1280, 1999.
Elmore JG, Armstrong K, Lehman CD, Fletcher SW: Screening for breast
cancer. JAMA 293:1245-1256, 2005.
U.S. Preventive Services Task Force: Guide to Clinical Preventive
Services: Breast Cancer Screening. Rockville, Md., Agency for
Healthcare Research and Quality, 2002.
228 Chapter 17 — Clinical Breast Examination
Bibliography
Armstrong K, Eisen A, Weber B: Primary care: Assessing the risk of
breast cancer. N Engl J Med 342:564-571, 2000.
DeGowin RL, Brown DD: DeGowin's Diagnostic Examination, 7th ed.
New York, McGraw-Hill, 2000.
Elmore JG, Reisch LM, Barton MB, et al: Efficacy of breast cancer
screening in the community according to risk level. J Natl Cancer Inst
97:1035-1042, 2005.
Fletcher SW, Black W, Harris R, et al: Report of the international
workshop on screening for breast cancer. J Natl Cancer Inst
85:1644-1656, 1993.
Hortobagyi GN: Drug therapy: Treatment of breast cancer. N Engl J Med
339:974-984, 1998.
National Cancer Institute and American Cancer Society: Joint statement
on breast cancer screening for women in their 40s. Press release of
March 27, 1997.
Physician Insurers Association of America Breast Cancer Study.
Washington, DC, Physician Insurers of America, 1995.
Roy JA, Swaka CA, Prichard KI: Hormone replacement therapy in
women with breast cancer: Do the risks outweigh the benefits? J Clin
Oncol 14:997-1006, 1996.
Schwartz MH: Textbook of Physical Examination, 3rd ed. Philadelphia,
WB Saunders, 1998.
Chapter I O
The Pelvic Examination and
Obtaining a Routine
Papanicolaou Smear
L. Gail Curtis
Procedure Goals and Objectives
Goal: To perform a thorough pelvic examination (PVE) in a female
patient in a manner that preserves the patient's comfort while
maximizing the likelihood of identifying abnormal findings and
obtaining a sample for a Papanicolaou (Pap) smear.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing a PVE.
• Describe the essential anatomy and physiology associated with
the performance of a PVE.
• Describe the logical order of the steps used to perform a PVE.
• Describe normal and abnormal findings associated with a PVE.
229
230 Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear
BACKGROUND AND HISTORY
Many women dislike having a PVE performed. The lithotomy position makes
some women feel vulnerable. This examination may invoke feelings of anxiety
or embarrassment. It is the examiner's responsibility to put the patient at ease
while conveying the importance of the examination. The challenge is to make
this experience educational, comfortable, and not to be feared in the future.
The PVE is an extension of the abdominal examination in the female
patient. The Pap smear is one aspect of the PVE and was developed in the
1920s by Dr. George Nicolas Papanicolaou, an anatomist and cytologist in
the United States. Dr. Papanicolaou identified characteristic cellular changes
associated with cervical cancer. The original technology allowed for cytologic
evaluation of cervical cells exfoliated from the female genital tract. Approxi-
mately 20 years elapsed before the technique named for him, the Papanicolaou
smear, was accepted as a cancer screening procedure. The Pap smear was
initially used to detect asymptomatic invasive cervical cancer; as time passed,
the importance of preinvasive disease was recognized. The Pap smear remains
a screening test. It does not provide a diagnosis. Current standard of care
requires further workup of any abnormality found on a Pap smear. This work-
up typically includes a screening for human papilloma virus (HPV), a
colposcopy, and biopsy of cervical samples.
INDICATIONS
Pap smear screening has been documented to decrease the incidence and
mortality rate of cervical cancer. In the United States there are approximately
20,000 new cases of cervical cancer per year, with an annual mortality rate of
roughly 7600. American women have a 0.83% chance of developing cervical
cancer in their lifetime, and death from the disease is estimated at 0.27%.
Debate exists on recommended standards for obtaining a Pap smear, such as
age to begin screening, how frequently to screen, and at what age to cease
screening.
The American Cancer Society (ACS) updated their recommendations in
2002 and the U.S. Preventive Services Task Force (USPSTF) guidelines were
updated in 2003. These are summarized and contrasted in Table 18-1.
Factors thought to increase the risk for an abnormal Pap smear can be
divided into two broad categories: those related to coitus and those related
to nonsexual factors. Coitus-related factors include a young age at first inter-
course, multiple sexual partners, sexually transmitted disease, and HPV. Non-
sexual factors include tobacco smoking, illicit drug use, diet, oral contra-
ceptive use, a prior history of abnormal Pap smears, poor personal hygiene,
and an uncircumcised partner. Though all these factors may play a part, the
presence of or exposure to HPV is now accepted as the leading risk factor for
an abnormal smear and development of cervical cancer. HPV types 16 and 18
seem to be the most oncogenic. The natural history of how HPV infection
progresses to cancer is still poorly understood.
Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear 231
Table 18.1 Comparison of USPSTF and ACS Guidelines on
Screening for Cervical Cancer
CRITERIA
USPSTF GUIDELINE
ACS 2002 GUIDELINE
Age to initiate
screening
Screening frequency
Screening after
hysterectomy
Discontinuation
Routine screening
for HPV infection
Optimum age unknown; within
3 years of onset of sexual
activity or age 2 1
At least every 3 years
No cytologic testing after total
hysterectomy for benign
condition
After age 65 (see below)
Insufficient evidence
Three years after the onset of sexual
activity; no later than age 21
Annually with conventional cytology
or every 2 years with liquid-based
cytology. After age 30, women with
three consecutive normal tests
may be screened every 2 to
years. 3
No cytologic testing after total
hysterectomy for benign condition
After age 70 (see below)
Not yet FDA approved. If approved,
conventional or liquid-based
cytology combined with test for
DNA from high-risk HPV subtypes
should be performed not more
often than every 3 years
ACS, American Cancer Society; FDA, U.S. Food and Drug Administration; HPV, human papillomavirus;
USPSTF, U.S. Preventive Services Task Force.
From U.S. Preventive Services Task Force: Screening for cervical cancer: Recommendations and rationale.
AHRQ Publication No. 03-5 15A. Rockville, Md, Agency for Healthcare Research and Quality, 2003; and
Saslow D, Runowicz CD, Solomon D, et al: American Cancer Society guideline for the early detection of
cervical neoplasia and cancer. CA Cancer J Clin 52:342-362, 2002.
CONTRAINDICATIONS
There are no absolute contraindications to performing a routine PVE.
Permission to perform the examination should be obtained.
POTENTIAL COMPLICATIONS
False-negative Pap smear results do occur. Common causes of a smear being
interpreted as normal when the cervical epithelium is abnormal include the
following:
■ Sampling error: due to poor sampling technique or small, peripherally
located lesions missed on sampling
■ Lesions that do not shed cells well
■ Interpretation error
The most common cause is sampling error. The error that is most publicized
is misinterpretation. Using the proper technique to obtain the Pap smear can
significantly decrease the incidence of false-negative results due to sampling
error. New technologies have been developed to decrease the false-negative
rate from errors in interpretation. Other sources of Pap smear screening
232 Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear
Mons pubis CNtoris
Labia majora
Skene's gland
Hymen
Perineum
Anus
Urethral orifice
Labia minora
Vestibule
Vagina
Opening of
greater vestibular
(Bartholin's) gland
Figure 18-1. External anatomy of the vulva.
errors are failure of the clinician to understand or respond appropriately
to Pap smear results or failure of the patient to follow the clinician's
recommendations.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
External Anatomy (Fig. 18-1)
The vulva consists of the mons pubis, the labia majora, the labia minora, the
clitoris, and the glandular structures that open into the vagina. The shape,
size, and color of the various structures vary among individual women and
racial groups. Normal hair distribution is in the shape of an inverted triangle
centered over the mons pubis.
The labia majora are two mound-shaped structures composed primarily of
adipose tissue originating at the mons pubis and terminating in the
perineum. They form the lateral boundaries of the vulva. Underlying the skin
is a poorly developed muscle layer: the tunica dartos labialis. There are also
numerous sweat glands in the labia majora. The internal and external
pudendal arteries and a branch of the perineal artery provide the arterial
blood supply to the labia majora. The venous drainage is extensive and
provided primarily by the perineal, posterior labial, external pudendal, and
saphenous veins. Lymphatic drainage occurs through two systems: one
superficial and one deep within the subcutaneous tissue primarily draining
into the inguinal nodes.
The labia minora are two skin folds medial to the labia majora that begin
at the base of the clitoris and extend posteriorly to the introitus. The arterial
supply is from the superficial perineal artery. The venous drainage is to the
perineal and vaginal veins. Lymphatics pass to the superficial and deep
subinguinal nodes. The innervation is supplied from branches of the pudendal
nerve, which originates from the perineal nerve.
Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear 233
Normal
Annular
Imperforate
Cribriform
Septate
Ruptured hymen
(parous)
Figure 1 8-2. Types of hymens.
The clitoris is the homologue of the dorsal aspect of the penis. Blood
supply is rich, with the dorsal and pudendal arteries supplying arterial blood.
Venous drainage consists of a rich plexus draining into the pudendal vein.
The lymphatics coincide primarily with those of the labia minora. Innervation
to the clitoris is from the terminal branch of the pudendal nerve. Nerve
endings in the clitoris vary, from woman to woman, from total absence to a
rich supply.
The vestibule is the space bordered by the labia minora and includes the
entrance to the vaginal canal or the introitus. The vaginal opening can be
obscured by the hymenal ring or hymen. The hymen is a membrane that
partially or wholly occludes the introitus. The shape and opening of the
hymen can vary greatly (Fig. 18-2), but only a completely imperforate hymen
is pathologic. The arterial supply to the vestibule and hymen is from an
extensive capillary plexus from the perineal artery. The venous drainage is also
extensive and involves the same areas as the arterial network. The lymphatic
drainage terminates in the superficial inguinal nodes and the external iliac
chain. The urethra is positioned between the clitoris and the vaginal opening
and is not difficult to visualize.
Skene's glands are posterior to the urethral orifice and are often difficult to
locate. Bartholin's glands lie inferior and lateral to the posterior vestibule, are
less superficial, and are usually not visible. The arterial supply and venous
drainage is along the pudendal vessels. The lymphatics drain directly via the
perineum into the inguinal area. The innervation of Bartholin's glands is a
small branch of the perineal nerve.
234 Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear
Fallopian
tube
Introitus
Rectum
Vaginal
canal
Perineum
Side view
Figure 18-3. Female
internal anatomy.
Internal Anatomy (Fig. 18-3)
The vagina is a muscular canal that is lined with mucosa or rugae and is
approximately 7 cm long, extending from the uterus to the vestibule. It meets
the cervix of the uterus at an angle of 45 to 90 degrees. The cervix projects
into the upper portion of the anterior vaginal wall, thereby making the anterior
vaginal wall slightly shorter than the posterior vaginal wall. The vaginal
arterial supply is from the vaginal branch of the uterine artery, and the veins
follow the course of the arteries. The lymphatics drain into the external iliac
and inguinal nodes. Both sympathetic and parasympathetic nerves innervate
the vagina. The perineum is the tissue between the vaginal opening and
the anus.
The uterus is a pear-shaped, thick-walled muscular organ about 7 to 8 cm
in length and 4 to 5 cm at its widest in the nonpregnant adult woman. It
consists of three parts: the fundus, the body, and the cervix (Fig. 18-4). The
uterine cavity opens into the vagina below and into the fallopian tubes above.
It is supported by ligamentous attachments to various pelvic structures,
including the vagina. The cervix is the portion of the uterus that can be
visualized during the PVE and is the structure sampled to obtain the Pap
smear. When viewed during the PVE, the cervix appears as a round bagel-like
mound with a circular or slit-type opening that varies with parity (Fig. 18-5)
and leads to the endocervical canal.
The fallopian tubes extend from the lateral portions of the uterine fundus
and terminate in a fringed, cone-shaped conduit that arches toward the
ovaries (Fig. 18-6). The ovaries are oval organs measuring about 2.5 to 5 cm
in length, 1.5 to 3 cm in breadth, and 0.7 to 1.5 cm in width. The fimbriated
ends of the fallopian tubes overhang the upper part of each ovary. The
Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear 235
Fundus ■
Body ■
Cervix -
Internal
cervical os
Fallopian
tube
Cervical canal
External
cervical os
Figure 1 8-4. The uterus
consists of three parts: the
fundus, body, and cervix.
Speculum
Cervix
Figure 18-5. The cervix as viewed
during pelvic examination.
236 Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear
Fallopian tubes
Figure 18-6. The fallopian
tubes.
ovarian artery is the chief source of blood for the ovary, and the ovarian
veins follow the course of the arteries. Lymphatic channels drain retro-
peritoneally to the lumbar lymph nodes. The lymphatic channels in the
ovaries are extensive and may provide additional fluid to the ovary during
periods of preovulatory swelling. The ovaries produce ova and hormones,
including estrogen and progesterone.
All the pelvic organs are supported within the lower abdominal cavity by
a system of muscles, ligaments, and fascia.
to exercise clinical judgment based on the
Standard Precautions Practitioners should use patient's history and the potential for exposure
standard precautions at all times when to body fluids or aerosol-borne pathogens (for
interacting with patients. Determining the level further discussion, see Chapter 2).
of precaution necessary requires the practitioner
PATIENT PREPARATION
As noted previously, some women may be reluctant to have a PVE performed.
If a patient has had several previous examinations, she knows what to
expect. If this is her first, she has most likely heard about it from others. Your
responsibility as the examiner is to explain what is ahead and provide
education in order to decrease anxiety.
First Pelvic Examination Experience
This examination will set the tone for all that follow.
■ Schedule enough time to allow a complete explanation of the PVE from
beginning to completion.
■ It is helpful to have a diagram or model of the female anatomy to aid the
explanation.
Have the actual equipment to be used on hand to show your patient.
Explain all aspects of the PVE and the Pap smear.
Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear 237
Cytobrush
Speculum
Figure 1 8-7. Top, Closed
fist, simulating the cervix.
Bottom, Closed fist simulating
the vaginal opening for
speculum insertion in tensed
position (teft) and relaxed
position (right).
Show your patient, using your closed fist to simulate the cervix, how you
will sample her cervical cells (Fig. 18-7). Explain that relaxing her pelvic
muscles eases the insertion of the speculum (again, demonstrate with
your fist; see Fig. 18-7).
Allow and encourage your patient to ask questions.
Explain terms she may have heard and been fearful about such as:
"blades," "scraping," and "stirrups."
Educate her about the lithotomy position: why it is necessary, including
how it allows visualization of the cervix.
Offer opportunities that empower the patient, such as the semi-sitting
position and a hand-held mirror if she desires to observe the examination
and visualize her own anatomy while the examination is in progress.
Assure your patient that this examination is indicated and that the PVE
should not be painful. Tell her you will be gentle and that if she wants
you to stop at any time during the examination, you will.
The Returning Patient
Always ask the patient if she has any particular concerns about this
examination.
238 Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear
Plastic
Graves
Pedersen
Figure 18-8.
speculums.
Types of vaginal
Reassure her that you will be gentle and that there should be no pain
associated with the PVE.
Assure her that she can ask questions at any time during the
examination.
Tell her that if she should experience any discomfort to alert you
immediately and you will stop and redirect your attempt.
Explain every step of the examination as it unfolds.
Chaperone in Attendance for All
Patients
Having a chaperone in attendance is important for this examination. This is
advised even if the provider is female. In addition to providing assistance
with the examination, the presence of another member of the staff helps
reduce the likelihood of a patient filing an unfounded accusation regarding
inappropriate conduct of the clinician during the examination. Explain that
the chaperone is in attendance to assist with any needs during the examination.
Avoid statements such as "he (or she) is here to watch and observe."
I
Materials Utilized for Performing the Pelvic
Examination and Obtaining Cells for a Routine
Pap Smear
The Vaginal Speculum (Fig. 18-8)
Several types of speculums are available:
■ Pedersen speculum, metal and reusable: This type of speculum comes in
short and long sizes. It should be used if at all possible because it has a
narrow blade and is more comfortable for most women.
Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear 239
Graves speculum, metal and reusable: This speculum also comes in
short and long sizes. The Graves has a "duckbill-shaped" blade and is a
better choice for viewing the cervix if the patient is significantly
overweight, has a lot of redundant skin surrounding the introitus, or has
a severely retro verted uterus.
■ Disposable speculum: This type of speculum is made of hard, clear
plastic, usually has the Graves-type blades, and makes a loud click when
locked into place. Warn patients about the upcoming click, and use great
care not to pinch the patient's surrounding skin on insertion.
■ Pediatric speculum: This speculum is useful for children and virginal or
geriatric women. This speculum is also preferable when explaining a first
PVE to a patient. Its small size reduces undue anxiety and fear of pain
about the pending examination.
Note: It is all right to switch speculums during the examination if there is
trouble viewing the cervix. Avoid comments such as "I have to get a bigger
speculum." Women may feel sensitive to implications that their anatomy is
too large. Rather state, "I am having difficulty visualizing your cervix and I
don't want you to experience any discomfort, so I am going to change
speculums to make this examination more comfortable for you."
Whichever speculum is chosen, be sure that you understand how to
open it, insert it, and lock it into place before you begin.
Other equipment needed to complete the examination may include the
following:
Cytobrush (Fig. 18-9)
■ Wooden spatula (see Fig. 18-9)
Plastic broom (see Fig. 18-9)
■ Pap smear slide or vial of preservative solution
■ Good light source
■ Water-soluble lubricating jelly
■ Latex gloves
Note: The choice of a wooden spatula, a cytobrush, or a plastic broom to
collect samples is dictated by the sampling system that is available. The
spatula or cytobrush is typically used with fixation of the specimen on a
slide. The plastic broom is preferred for liquid-based preparation of the
specimen.
240 Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear
KJ
Cytobrush Wooden spatulas Plastic broom
Figure 1 8-9. Instruments used for gathering cervical cells.
Procedure for the Pelvic Examination and Obtaining Cervical Cells
Note: The examination itself is divided into
three parts: inspection of the external
genitalia; the internal examination, which
includes obtaining the Pap smear; and the
bimanual examination.
1. Before beginning the examination, have
all your equipment ready and your
chaperone in the room.
2. Extend the foot stirrups. Keep in mind
the stirrups are often cold and
uncomfortable. If possible, have the
stirrups covered with a soft, warm
material or allow the patient to keep her
socks on. When prepared, ask the
patient to lie back in the lithotomy
position (hips flexed and abducted, feet
in stirrups and buttocks slightly beyond
the edge of the examining table). Place a
sheet as a drape over her. Most women
will indicate if they prefer to be fully
draped with the sheet to their knees
blocking their view of the examination or
if they prefer to be able to see you
throughout the examination.
Note: Although most examiners have patients
lay flat on the examining table, some women
prefer to be in a semi-sitting position
(Fig. 18-10). The semi-sitting position works
just as well for the examiner and makes
some women feel more comfortable.
Be prepared to explain each step to the
patient as it is being performed. Encourage
her to ask any questions she may have.
Continue to talk to her, and monitor her
status throughout the examination. If she
Figure 18-10.
Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear 241
tenses her abdomen or buttocks, ask her to
relax them. Once the patient is as comfortable
as possible, the examination of the external
genitalia should begin.
External Examination
3. Put on gloves and be seated comfortably
on a rolling stool at the table end, adjust
the light source, and begin inspecting
the external genitalia.
4. First examine the mons pubis, labia, and
perineum. Note the pubic hair for its
pattern, for any lice or nits, infected hair
follicles, or any other abnormality, and
then inspect for any lesions, erythema,
swelling, nodules, or discharge on the
skin.
5. Expose the clitoris, urethral orifice, and
the vaginal opening by gently retracting
the labia minora. Inspect for any cysts or
other lesions. Inspect the area of
Bartholin's glands. Normal Bartholin's
glands cannot be seen or felt.
6. If enlargement or redness is noted, or if
indicated by symptoms, examine
Bartholin's glands by inserting your
index finger into the vagina and your
thumb outside (Fig. 18-11), and palpate
the tissue between the internal and
external fingers. Check for any discharge
from the duct. If discharge is noted, a
culture should be obtained using the
appropriate medium.
7. Next, ask your patient to perform the
Valsalva maneuver or bear down while
you check for cystocele, rectocele, or
uterine prolapse.
Note: Take care during the external
examination to avoid unnecessary contact
with the clitoris.
Internal Examination
Figure 18-11.
8. Warm the previously selected vaginal
speculum under running water. Water
warms the instrument and acts as a
lubricant to ease insertion. Other
lubricants cannot be used because
they may interfere with the cytologic
studies.
9. A digital examination performed by
inserting a finger into the vaginal canal
helps locate the cervix (it has a
consistency similar to the end of the
nose). Insertion of the speculum can
then be directed toward the cervix for
easy visualization and comfort of the
patient. This technique eliminates the
need to "search" for the cervix with the
speculum, a maneuver which can be
uncomfortable for the patient.
10. To insert the speculum, withdraw
your internal finger while applying
gentle pressure to the perineum in a
downward motion. Ask the patient to
relax this muscle as you press
downward. Insert the speculum over
your withdrawing finger with the blades
closed and at a 45-degree angle
(Fig. 18-12A).
continued
242 Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear
A Entry angle of speculum
B Angle once rotated
Urinary
bladder
Speculum in place,
blades not open
Uterus
Cervix
Speculum in place, blades open.
Ready for Pap smear
Figure 18-12.
11. Once the blades are fully inserted, rotate
the speculum to the appropriate angle
and open blades to allow visualization of
the cervix (see Fig. 18-12B). Avoid
pressure on the more sensitive anterior
wall, urethral orifice, or clitoris.
12. If there is still a problem locating the
cervix, withdraw the speculum and
reposition it (usually more posteriorly).
Apply gentle pressure to the posterior
vaginal wall and try again.
13. Avoid excessive movements of the
speculum while searching for the cervix,
as this can be uncomfortable.
14. Once the cervix is visualized, lock the
speculum in place. Your hands are now
free to obtain the Pap smear sample and
any other needed cultures or samples.
15. Collecting the Pap smear sample —
spatula: A wooden spatula can be used
to obtain cells from the cervix and the
vaginal wall (Fig. 18-13).
• Use the pointed or longer end of the
spatula and insert it into the external
cervical os.
• Apply mild pressure while turning the
spatula 360 degrees to obtain cells
from the squamous-columnar junction
or the transformation zone.
• Use the opposite, rounded end of the
spatula to sample cells from the
vaginal wall.
• Apply the obtained cells to a slide by
gently dragging the spatula with the
Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear 243
Cervix as it
appears on PVE
Cervix
Spatula
/
Area to sample
with wooden spatula
Fundus
Uterus
Cervix
Cytobrush in
cervical os
Plastic broom
in cervical os
Cervix
Figure 18-13.
samples from the external cervix and
the vaginal wall down the slide.
16. Collecting the Pap smear sample —
cytobrush: The cytobrush (see
Fig. 18-13) is used to obtain cells from
the endocervical canal.
• Insert this brush into the cervical os
until the bristles are no longer seen
and turn two full revolutions.
Note: Always warn the patient that this may
induce uterine cramping and mild bleeding.
• Immediately place obtained cells on a
slide by rotating the brush
counterclockwise while moving the
brush from left to right on the slide
(Fig. 18-14).
17. Collecting the Pap smear sample —
plastic broom:
continued
244 Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear
CD
E
Cfl
~~2 >
c
c
CD
£
Side 1
Side 2
Figure 18-14.
• Insert the long central bristles into
the os until the lateral bristles bend
against the ectocervix. Rotate the
broom three to five times in both
directions.
• Transfer the material onto a slide with
a stroke of both sides of the broom
placing the second stroke exactly over
the first.
• Or if using a vial of preservative
solution, place the entire broom tip
into the solution and stir vigorously to
transfer material. Then remove tip
and discard broom, or leave in
solution based on lab preference.
18. Transfer cells collected from the Pap
smear quickly to the appropriate
transport medium:
• The object is to quickly but evenly
spread the cellular material in a
monolayer on the slide or into the vial
of preservative solution.
• When using a slide, thin out large
clumps of material as much as
possible, while avoiding excessive
manipulation, which can damage
cells.
• Transfer material from both sampling
instruments to the slide within a few
seconds.
• Immediately fix the specimen by
either immersing the slide in 95%
ethanol or coating the slide with a
surface fixative.
• Label the Pap smear slide or vial of
preservative solution with the
patient's name.
Be sure to obtain an adequate sample to
avoid having to repeat the examination and
to reduce the false-negative rate. In a woman
with a uterus, endocervical cells must be
obtained. If the cytologic report comes back
stating "no endocervical cells seen,"
inadequate sampling is indicated, and the
patient will need to have the examination
repeated in order to obtain the adequate
sample. Therefore, it is important to sample
adequately the first time.
Note: If a wet mount or cultures are to be
obtained, do so only after the Pap smear
cells have been obtained.
19. After collecting the sample or samples,
unlock the speculum and slowly
withdraw the instrument while
inspecting the vaginal wall for any
abnormalities. Allow the speculum
blades to close naturally as they are
withdrawn.
20. Once the speculum is removed and the
samples are preserved, proceed to the
bimanual examination.
Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear 245
Bimanual Examination
21. Inform the patient that you are going to
examine her uterus and ovaries. Tell her
this includes a digital rectal examination.
Note: Lubricating jelly can be used during
this portion of the examination, as the
cytologic samples have been procured. This
lubricant makes this portion of the PVE
more comfortable for your patient.
22. Insert two lubricated fingers into the
vagina while applying pressure to the
abdomen in a sweeping motion toward
the mons pubis.
23. Push upward on the cervix with your
internal fingers while pushing downward
on the uterine area of the abdomen with
the external hand. Palpate the uterine
fundus as it rises toward your external
fingers.
24. Then palpate the ovaries by moving the
internal fingers to the right and left of
the cervix while sweeping down on
either side of the uterus with the
external hand.
Note: Ovaries should be palpable in women
until menopause. A palpable ovary in a
postmenopausal woman needs further
workup. Most women can tell when you
palpate their ovaries and can offer
feedback.
25. The rectovaginal examination is the final
step in the PVE. Insert your index finger
in the vagina and your middle finger in
the rectum and repeat the maneuvers of
the bimanual examination.
Note: This approach allows assessment of
the retroverted uterus and the region behind
the cervix.
26. The examination is complete. Remind
your patient to push back on the table
before trying to sit up. Provide your
patient with a towelette to remove any
excess lubricant used during the
examination.
SPECIAL CONSIDERATIONS
Pediatric genital examinations, when necessary, often can be performed
using the "frog leg" position (Fig. 18-15). Special attention must be given to
semantics and patient education when examining children. Keep in mind
that most children have been taught not to allow anyone to touch their
genitals.
In the geriatric population, frequency of PVE can often be decreased. Any
posthysterectomy patient can receive less frequent examinations, varying
from every 3 to 5 years. Some practitioners cease doing examinations
altogether unless circumstance dictates. If the ovaries are still present,
bimanual examination can still be important. Postmenopausal women often
have dryer atrophic vaginas. This can make the PVE uncomfortable or painful.
Care should be taken to use the smallest possible speculum and not tear the
thin tissue.
246 Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear
Figure 18-15. Pediatric "frog
leg" position.
FOLLOW-UP CARE AND
INSTRUCTIONS
■ Inform the patient of the results of the examination, taking care not to
imply that everything is completely normal until all test results are
received.
Educate her about when to return for her next screening examination. If
anything was noted on examination, explain the possibilities and what
follow-up may be necessary.
■ Let her know what correspondence to expect from your office and the
time period within which to expect it. Specifically tell her how she will
receive her Pap smear results (e.g., letter, phone call, report).
■ Ask her to call the office requesting her results if she has not heard
anything within the specified period.
Patient education handouts explaining Pap smear results are helpful and
should be sent home with the patient. These handouts may increase the
patient's understanding of Pap smears and increase compliance with the
recommendations made based on the Pap smear results.
The PVE and the Pap smear are important parts of providing comprehensive
well-woman care. Patient education and examiner sensitivity and competence
increase compliance of the female patient in regard to this life-saving
examination. For all examiners, competence and sensitivity toward the patient
help make this examination repeatable for the patient and the next provider.
Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear 247
INTERPRETATION OF THE PAP
SMEAR
Prior to the development of the Bethesda system, pap smears were divided
and reported in 5 classes (see Table 18-2). The utilization of pap smear classes
is now antiquated because:
■ Do not reflect current understanding of pathology
■ Classes not transferable to histology terms
■ No classes for non-cancerous entities
■ No longer uniform
Years of experience have demonstrated a lack of reproducibility
The Bethesda system developed in 2001 incorporates important changes
over older systems:
Pap smear analysis considered a medical consult
Pathologist responsible for diagnosis
Referring physician provides history
■ Must have a statement of adequacy
Recommendations regarding follow-up should be made by a pathologist.
The Bethesda system is now used to interpret Pap smear findings. This
system includes information on the following:
■ Whether the Pap smear is an adequate sample
■ Incidental findings such as evidence of infection
■ Evidence of lesions: low-grade squamous intraepithelial lesion (SIL),
high-grade SIL, or cancer
Providers performing the PVE and obtaining Pap smears must understand
how to interpret the results to avoid errors in interpretation from failure of
Table 18.2 Previous Systems and the Bethesda System
PAP CLASS
DESCRIPTION
BETHESDA 2001
I
Normal
Normal and variants
II
Reactive changes
Reactive changes
Atypia
ASC, ASG
Koilocytosis
Low-grade SIL
III CIN I
Mild dysplasia
Low-grade SIL
III CIN II
Moderate dysplasia
High-grade SIL
III CIN III
Severe dysplasia
High-grade SIL
IV
Carcinoma in situ, suspicious
High-grade SIL
V
Invasive
Microinvasion (<3mm)
Frankly invasive (>3mm)
ASC, atypical squamous cells; ASG, atypical glandular cells; CIN, cervical intraepithelial neoplasia; SIL,
squamous intraepithelial lesion.
248 Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear
Table 18.3 New Bethesda System Classification Terms
LOW-GRADE SQUAMOUS INTRAEPITHELIAL LESION
Cellular change associated with HPV
Mild (slight) dysplasia/CIN I
HIGH-GRADE SQUAMOUS INTRAEPITHELIAL LESION (HSIL)
Moderate dysplasia/CIN II
Severe dysplasia/CIN III
Carcinoma in situ/CIN III
ATYPICAL SQUAMOUS CELLS (ASQ
Unspecified (ASC-US) — includes unspecified and favor benign/inflammation
Cannot exclude HSIL (ASC-H)
ATYPICAL GLANDULAR CELLS OF UNCERTAIN SIGNIFICANCE (AGC-US)
AGC is broken down into favoring endocervical, endometrial, or not otherwise specified origin
or endocervical adenocarcinoma in situ
Unspecified (AGC-US) (ASC-US)
Atypical glandular cells, favor neoplastic (AGC-H)
CIN, cervical intraepithelial neoplasia.
the clinician to understand or respond appropriately to Pap smear results
(Tables 18-2 and 18-3). In October of 2005, the Institute for Clinical Systems
Improvement provided a summary of changes for management of the
abnormal pap smear. Algorithms delineate proper management for abnormal
results and include management for benign endomatrial cells (BEC), ASC-US,
and new LSIL management in special populations. These may be reviewed at
the National Guidelines Clearing house web site (www.guideline.gov/
summary/summary.ASPX?doc_ID=8327; Accessed 7/17/06).
References
Saslow D, Runowicz CD, Solomon D, et al: American Cancer Society
guidelines for the early detection of cervical neoplasia and cancer.
CA Cancer J Clin 52:342-362, 2002.
U.S. Preventive Services Task Force: Screening for cervical cancer:
Recommendations and rationale. AHRQ Publication No 03-5 15A.
Rockville, Md, Agency for Healthcare Research and Quality, 2003.
Bibliography
Agency for Health Care Policy and Research: Evidence
Report/Technology Assessment. Rockville, Md, U.S. Department of
Health and Human Services, Agency for Health Care Policy and
Research, Jan 1, 1999.
Anderson JE: Grant's Atlas of Anatomy, 7th ed. Baltimore, Md, Williams
&Wilkins, 1978.
Curtis P, Skinner B, Varenholt JJ, et al: Papanicolaou smear quality
assurance: Providing feedback to physicians. J Fam Pract 36:309,
1993.
Chapter 18— The Pelvic Examination and Obtaining a Routine Papanicolaou Smear 249
Eddy DM: Screening for cervical cancer. Ann Intern Med 113:214, 1990.
Goroll AH: Primary Care Medicine, 3rd ed. Philadelphia,
Lippincott-Raven, 1995.
Lundber GD: The 1988 Bethesda system for reporting cervical/vaginal
cytological diagnoses. JAMA 262:931, 1989.
Optimizing the Papanicolaou Smear; accessed August 28, 2005.
Available at: http://www.sh.lsuhsc.edu/fammed/OutpatientManual/
PapSmear.htm
National Guideline Clearing house: Management of initial abnormal pap
smear; accessed July 17, 2006. Available at: http://www.guideline.gov/
summary/summary,aspx?doc_id=8327
Pfenninger JL, Fowler GC: Procedures for Primary Care Physicians.
St. Louis, Mosby-Year Book, 1994.
Richart RM, Wright TC Jr: Controversies in the management of
low-grade cervical intraepithelial neoplasia. Cancer 71:1413, 1993.
Ryan KJ, Berkowitz RS: Kistner's Gynecology and Women's Health,
7th ed. St. Louis, CV Mosby, 1999.
Wingo PA, Tong T, Bolden S: Cancer statistics, 1995. CA Cancer J Clin
45:8, 1995.
Chapter I Q
Examination of the Male
Genitalia
Richard Dehn
Procedure Goals and Objectives
Goal: To perform a thorough examination of the male genitalia in
a manner that preserves the patient's modesty while maximizing
the likelihood of identifying abnormal findings.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing an examination of the male genitalia.
• Describe the essential anatomy and physiology associated with
the performance of the examination of the male genitalia.
• Describe the logical order of the steps used to perform the
examination of the male genitalia.
• Describe normal and abnormal findings associated with the
examination of the male genitalia.
251
252 Chapter 19 — Examination of the Male Genitalia
BACKGROUND AND HISTORY
Examination of the male genitalia is taught to practitioners as part of the
physical examination and should be performed on all patients for whom
information derived from the examination would be helpful. Although this
examination has long been performed for diagnostic purposes, it has gained
increasing importance as a screening examination for testicular cancer,
prostatic cancer, and colon cancer.
The examination of the male genitalia typically is understood to include
the physical examination of the external genitalia, which includes the perineum,
penis, and scrotum, as well as a rectal examination in which the prostate is
palpated. In addition, the examination often includes an assessment of the
presence of an inguinal hernia.
The examination of the penis and scrotum also can have value for early
disease detection, particularly if performed by the patient regularly as a self-
examination regimen. Self-examination of the penis and urethra can be useful
for the early detection of sexually transmitted diseases, and testicular self-
examination can lead to early detection of testicular tumors. In young men,
testicular tumors are often malignant and aggressive; thus, early detection is
a significant factor in increasing survival rates, because testicular cancer is
the most common malignancy in men 20 to 40 years of age (Kelly, 1998).
The rectal examination and associated prostate examination have also been
used for screening directed at the early detection of cancer. A sample of stool
is easily obtained during the rectal examination, and the presence of occult
blood is correlated with colon cancers. Screening for stool occult blood has
been demonstrated to reduce colon cancer mortality, especially in individuals
older than 50 years of age, at which time the incidence of colon cancer greatly
increases (Walsh, 2003). The incidence of prostate cancer also increases
beginning at age 50. Prostate cancer is often discovered by digital rectal
examination, although the value of digital rectal examination for detecting
cancer before it has spread beyond the prostatic capsule is questionable
(Woolf, 1995). Additionally, most examiners can palpate only part of the
posterior prostatic surface when performing digital rectal examination; thus,
this process does not detect all prostatic lesions.
INDICATIONS
The examination of the male genitalia is indicated in the following
circumstances:
■ For routine preventive screening for testicular cancer
For routine preventive screening for prostate cancer
■ For routine preventive screening for colon cancer
■ To derive information concerning the male genital system
To derive information concerning the male reproductive system
Chapter 19— Examination of the Male Genitalia 253
CONTRAINDICATIONS
There is no contraindication to performing an examination of the external
genitalia. Palpation of the prostate is relatively contraindicated in patients
suspected of having acute bacterial prostatitis, because this maneuver can
result in septicemia (Dehn, 2001).
POTENTIAL COMPLICATIONS
Complications of the male genital examination include the following:
■ Temporary discomfort from palpation of the penis and contents of the
scrotum
Rectal abrasions and fissures from the following:
■ Inadequate digit lubrication
■ Failure to allow the anal sphincter to relax adequately
Rectal masses or strictures
Septicemia from prostatic manipulation if the patient has acute bacterial
prostatitis
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
Examination of the male genitalia involves structures of the male reproductive
system, the lower urinary tract, and the lower gastrointestinal tract (Fig. 19-1).
Pubic symphysis
Corpus
cavernosum
Urethra
Penis
Corpus
spongiosum
Seminal vesicle
Prostate gland
Vas deferens
Epididymis
External meatus
Scrotum
Figure 19-1 . Anatomy of the male genitalia. (Redrawn from Swartz MS: Male
genitalia and hernias. In Swartz MS: Textbook of Physical Diagnosis, 3rd ed.
Philadelphia, WB Saunders, 1998, p 391.)
254 Chapter 19 — Examination of the Male Genitalia
The structures that are accessible by examination include the penis and
internal penile structures, the scrotum, and the contents of the scrotal sac.
The posterior surface of the prostate is palpable during a digital rectal
examination. The anatomy of the rectum is illustrated in Figure 30-1.
The penis includes structures of both the reproductive system and the
lower urinary system. The distal opening of the urethra is located at the glans
penis. The urethra travels the corpus spongiosum the length of the penis,
passing through the prostate gland to the bladder. The urethra serves as
the conduit for both urination and ejaculation from the junction with the
ejaculatory duct in the prostate distally The two corpus cavernosa are
located on the dorsum and sides of the penis and expand to produce penile
erections when engorged with blood. The skin of the penis is thin and loose
to accommodate the changes in size.
The scrotal sac contains the testicles, the epididymis, and the vas
deferens. The testicles produce testosterone. Spermatozoa, also produced
by the testicles, are transported by the vas deferens to the seminal vesicle
at the point where it forms the ejaculatory duct, which then traverses
the prostate. The vas deferens, testicular arteries, testicular veins, and
associated nerves form the spermatic cord, which traverses the inguinal
canal.
Examination of the male genitalia also identifies the presence of inguinal
hernias. The inguinal canal, the remnants of where the scrotal sac contents
passed through the abdominal wall at about the twelfth week of gestation,
can present a point of weakness in the abdominal wall. Points of weakness of
the abdominal wall include the internal and external rings of the inguinal
canal. Occasionally, abdominal contents enter the inguinal canal and can
present a strangulation risk. An indirect hernia traverses the inguinal canal
from the internal ring to the external ring, sometimes resulting in abdominal
contents in the scrotum. A direct hernia traverses the abdominal wall directly
through the external ring.
PATIENT PREPARATION
■ Because the examination of the male genitalia can be embarrassing to
the patient, be sure to have the examination take place in an
environment where privacy is established and maintained.
■ Plan so that enough time can be taken not to rush the
examination.
■ Take the time to explain carefully to the patient what the examination
involves and make sure the patient understands.
Ask the patient to remove all clothing, at least from the waist
down.
■ Provide a hospital gown to ensure protection of the patient's
modesty.
Chapter 19— Examination of the Male Genitalia 255
Materials Utilized for Performing an Examination of
the Male Genitalia
The following materials should be assembled before initiating an examination
of the male genitalia:
Draping sheet and hospital gown (as noted in "Patient Preparation")
An examination table for the patient to support himself during the rectal
examination
Unsterile gloves
Water-soluble lubricant
■ Sample collection apparatus and Hemoccult (diagnostic aid for occult
blood) collection cards if needed
A flashlight or penlight for transillumination
Facial tissues
Note: Depending on the patient's presenting symptoms and clinical
circumstances, samples may be needed for laboratory analysis. The
urethra may be sampled with a urethral brush, and the skin and rectal
mucosa may be swabbed with cotton applicators. Prostatic secretions may
be collected on a microscope slide for cell analysis or collected for culture.
Materials for appropriately collecting and transporting the necessary
samples should be assembled before starting the examination, if possible.
Performing the Procedure of Examining the Male Genitalia
Examination of the External
Genitalia
1. Ask the patient to stand. If support is
necessary, have the patient stand next to
the examining table and use it for
support.
2. Sit on an examination stool in front of
the patient at approximate eye level with
the patient's genitalia.
Note: If the patient is unable to stand,
the examination can be performed
with the patient in the supine
position.
3. Put on unsterile examination gloves.
4. Expose the patient's genitalia fully.
5. Inspect the external genitalia, including
the surrounding skin, penis, and
scrotum. Note the hair distribution, the
quality of the skin, the structures of the
penis, and the structures of the scrotum.
Also note any urethral discharge, lesions
of the skin and hair, and structural
deviations of the penis and scrotum,
which should be investigated.
Note: If the patient is uncircumcised, the
foreskin should be carefully pulled back for
inspection and then returned to its original
position when inspection is completed.
continued
256 Chapter 19 — Examination of the Male Genitalia
Examination of the Rectum
and Prostate
Figure 1 9-2. Palpation of the internal
structures of the scrotal sac. (Redrawn from
Seidel HM, Benedict GW, Ball JW, et al: Male
genitalia. In Mosby's Guide to Physical
Examination, 4th ed. St. Louis, Mosby, 1999,
p 654.)
Some patients prefer to do the foreskin
manipulation themselves.
6. Palpate the meatus, penile shaft, and
scrotum for abnormal structures and
tenderness.
7. Palpate the internal structures of each
side of the scrotal sac for masses and
tenderness (Fig. 19-2).
8. Palpate symmetrical structures such as
the testicles, epididymis, and vas
deferens.
9. Insert the index finger into each external
inguinal ring, then ask the patient to turn
his head to the side and cough (turning
the head avoids coughing on the
examiner). If a hernia is present, it
should be felt at this time.
10. Cover the patient's external genitalia
area with the gown or drape.
1. Ask the patient to flex forward at the
waist, supporting his upper body with the
examination table. Instruct the patient to
spread his legs shoulder width apart and
to place most of his weight on his upper
extremities, which are supported by
leaning on the examination table.
2. Sit on a stool facing the patient's rectal
area.
Note: If the patient is unable to stand, the
examination can be performed in the knee-
to-chest position or the left lateral decubitus
position with the hips and knees flexed.
3. Put on unsterile examination gloves if
the gloves that were used for the first
part of the examination were removed.
4. Inspect the area of the anus and
surrounding structures. Note hair
distribution and skin characteristics in the
perineum and perianal region, and any
lesions and areas of abnormal coloration.
5. Inspect the anus for lesions, fissures,
hemorrhoids, and deviations from normal
structure. Spread the patient's buttocks
apart to facilitate the inspection process.
Note: Clock numbers define the geography
of the anus, with the sacral surface located
at 12 o'clock. Findings from the examination
should use this convention in descriptions
and documentation.
6. Liberally lubricate the gloved index finger
of the dominant hand.
7. Gently press the lubricated gloved index
finger into the anal opening.
8. Instruct the patient to bear down in a
manner similar to having a bowel
movement to facilitate the relaxation of
the rectal sphincter.
Chapter 19— Examination of the Male Genitalia 257
9. When the anal sphincter feels relaxed,
gently advance your index finger into the
anal canal.
10. Ask the patient to tighten the sphincter
around the index finger; the muscle tone
should be evaluated in this manner.
11. Rotate your finger using 360-degree
motions, and use the pad of the distal
finger to palpate for defects in the
mucosa. Palpate the entire surface of the
anal canal in this fashion by repeating
the rotation at progressively deeper
finger depths.
12. Advance the examining digit as far as is
comfortably possible and palpate the
anterior rectum to examine the posterior
surface of the prostate (Fig. 19-3).
Note: Firm but gentle palpation should allow
determination of the size, shape,
Figure 1 9-3. Palpation of the
anterior rectum and examination of
the surface of the prostate. (Redrawn
from Seidel HM, Benedict GW, Ball JW,
et al: Anus, rectum, and prostate.
In Mosby's Guide to Physical
Examination, 4th ed. St. Louis,
CV Mosby, 1999, p 678.)
consistency, mobility, and tenderness of the
prostate.
Note: Palpation of the prostate may cause
prostatic secretions to exit the urethra. If
clinically indicated, these should be
collected for laboratory analysis.
13. Slowly and carefully withdraw your
finger.
14. Transfer residual stool on the
examination glove to testing medium for
occult blood if indicated.
15. Wipe the external anal area clean of
lubricating jelly.
16. Provide the patient with toilet paper or
tissue to clean the lubricating jelly from
his anal area, redrape the patient, and
give him privacy to clean up and get
dressed.
SPECIAL CONSIDERATIONS
Patients presenting with anatomy that deviates from normal because of
past trauma, congenital defects, or past disease may be difficult to
examine.
258 Chapter 19 — Examination of the Male Genitalia
■ Examination of young children requires patience and gentle technique.
Rectal examinations and hernia examinations in children should be
performed with the examiner's smallest digit.
FOLLOW-UP CARE AND
INSTRUCTIONS
■ Inform the patient before and during the examination that self-
examination of the scrotal sac is useful for the early detection of
testicular cancer.
■ Instruct the patient in the technique for self-examination during the
examination in a way that the patient would be able to perform self-
examination in the future. The patient should be encouraged to establish
a self-examination routine on a monthly basis.
■ It is uncommon for the examination of the male genitalia to cause
adverse effects. However, after the examination, instruct the patient to
report any rectal tenderness, rectal bleeding, back pain, scrotal masses
or tenderness, dysuria, pyuria, hematuria, hematospermia, fever, penile
discomfort, or penile lesions.
References
Dehn R: Prostatitis. In Moser RL (ed): Primary Care for Physician
Assistants, 2nd ed. New York, McGraw-Hill, 2001, pp 712-713.
Kelly P: Testicular cancer. In Moser RL (ed): Primary Care for Physician
Assistants, 2nd ed. New York, McGraw-Hill, 2001, pp 523-525.
Walsh JM, Terdiman JP: Colorectal cancer screening: Scientific review.
JAMA 289:1288-1296, 2003.
Woolf SH: Screening for prostatic cancer with prostate-specific antigen.
N Engl J Med 333:1401-1405, 1995.
Bibliography
Seidel HM, Ball JW, Dains JE, Benedict GW: Male genitalia; Anus, rectum,
and prostate. In Mosby's Guide to Physical Examination, 5th ed.
St. Louis, Mosby, 2003, pp 648-693.
Swartz MS: Male genitalia and hernias. In Swartz MS: Textbook of
Physical Diagnosis: History and Examination, 5th ed. Philadelphia,
WB Saunders, 2006, pp 520-556.
Cha
p|er 20
Joint and Bursal Aspiration
M F. Winegardner
Procedure Goals and Objectives
Goal: The goal of this procedure is to aspirate a knee joint or
olecranon bursa successfully while observing standard precautions
and with the minimal degree of risk to the patient.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing knee joint or olecranon bursa aspiration.
• Identify and describe common complications associated with
knee joint or olecranon bursa aspiration.
• Describe the essential anatomy and physiology associated with
the performance of a knee joint or olecranon bursa aspiration.
• Identify the materials necessary for performing a knee joint or
olecranon bursa aspiration and their proper use.
• Identify the important aspects of post-procedure care after a
knee joint or olecranon bursa aspiration.
259
260 Chapter 20— Joint and Bursal Aspiration
BACKGROUND AND HISTORY
Joint aspiration offers both diagnostic and therapeutic benefits when
managing joint effusion or inflammation. Diagnostically, the procedure permits
acquisition of synovial fluid for analysis. Therapeutically, joint aspiration in
the face of painful effusion relieves the patient's discomfort and may facilitate
a more accurate joint examination. The same technique can be used for the
administration of intra-articular medications. Aspiration of bursal distention
relieves discomfort and restriction of motion and decreases the risk of
chronicity, spontaneous drainage, or infection within the stagnant bursal
fluid (Greene, 2001).
Despite the benefits, joint aspiration is an invasive procedure with the
potential for grave injury if not carried out under strict sterile conditions.
The procedure always necessitates careful, sterile preparation and sterile
technique.
Each joint has specific anatomic landmarks by which the joint space is
outlined and the needle can be placed for aspiration. In addition to reliance
on anatomic landmarks, musculoskeletal ultrasound increasingly is used to
guide needle placement (Grassi, 2004). The general steps in a joint aspiration
procedure are the same, regardless of the joint. For the purposes of this
chapter, knee joint aspiration is described.
Both traumatic and rheumatic processes affect the knee joint, although
relatively more aspirations are performed at the knee for traumatic effusion
than at other joints, where inflammation and effusion are more likely to be
rheumatic in nature. A significant volume of joint effusion can collect within
the knee joint. When assembling equipment for a therapeutic knee tap, it is
important to recognize that there may be a significant volume of fluid to be
aspirated and to plan accordingly.
INDICATIONS
Joint aspiration is indicated in the following situations:
When there is a painful effusion of a joint, a monoarticular inflammation
of a joint, or suspicion of a systemic rheumatic disorder of uncertain
cause. In the mature patient, trauma can result in painful joint effusion,
which can be remedied easily by joint aspiration.
■ In the case of articular inflammation of unknown cause, the synovial fluid
analysis — including viscosity, crystal examination, cell count, bacterial
culture, Gram stain, and polymerase chain reaction studies — may be the
most accurate diagnostic tool (Schumacher, 2001).
Bursal aspiration is indicated in the following situations:
When painful bursal swelling persists despite conservative treatment or
when questions arise about cause.
When olecranon bursitis is perpetually aggravated by normal activities.
Chapter 20— Joint and Bursal Aspiration 261
Like joint aspiration, strict sterile technique is indicated for bursal
aspiration.
CONTRAINDICATIONS
■ Joint aspiration is contraindicated whenever circumstances exist by
which entering the joint facilitates the seeding of bacteria into the joint.
Introduction of a needle into the joint space through burns, infected
skin, or infected subcutaneous tissue is contraindicated. Aspiration
increases the risk of introducing bacteria into the joint when there is
concern for overlying soft tissue cellulitis or impetigo, and joint
aspiration should not be performed in this situation.
■ Aspiration of a bursa is likewise contraindicated when risks for
introducing bacteria outweigh the benefits of aspiration.
■ Joint aspiration by the generalist is contraindicated after total joint
arthroplasty except under the supervision of an orthopedic specialist.
Should effusion or inflammation occur any time after joint replacement,
the patient must be returned to the care of an orthopedist.
■ In the rare circumstance in which aspiration of a hemarthrosis is
undertaken in a hemophiliac patient, the hemarthrosis will reaccumulate
if bleeding has not been controlled before the procedure. Similarly,
aspiration is relatively contraindicated in the patient who has undergone
anticoagulation and has a significantly prolonged bleeding time.
POTENTIAL COMPLICATIONS
Joint Aspiration
■ The most common complications of joint aspiration include bleeding,
infection, pain, intra-articular injury, and reaccumulation of fluid. When
providing patients with adequate information for informed consent,
these complications should be outlined.
Inadvertent injury to vascular or neural structures near joint spaces can
occur, as can a scoring injury of the intra-articular joint surface from the
needle. Awareness of the proximity of nerves, arteries, or veins is
necessary, as is caution when introducing a needle or infiltrating
medications. As with any injection procedure, drawing back on the
syringe plunger before administering medication is recommended to
confirm that the needle is not within the lumen of a blood vessel.
■ Careful history taking concerning topical and systemic allergic reactions,
with specific focus on iodine and anesthetic drug sensitivities, further
minimizes complications associated with the procedure. With any
parenterally administered medication, there must be prompt access to
262 Chapter 20— Joint and Bursal Aspiration
epinephrine 1:1000 for subcutaneous administration, and resuscitation
equipment must be available in the event of a severe adverse reaction.
Using a minimal volume of anesthetic is reasonable, and some authors
recommend injecting no more than 5 mL of anesthetic solution within
30 minutes (Steinberg, 1999). When adequately anesthetizing the needle
track for a joint aspiration, it is not difficult to exceed 5 mL of
administered anesthetic. By respecting the landmarks and anatomy
unique to each joint, one can minimize complications associated with an
aspiration procedure.
Bursal Aspiration
The most common complications of bursal aspiration are infection, pain,
chronic recurrence, chronic drainage via a sinus tract, and acute
recurrent swelling. For bursal aspirations, keep in mind that some bursae
communicate directly with the joint space.
■ Baker's cysts, or popliteal bursae, are actually herniations of the joint
capsule.
■ Communication between the olecranon bursa and elbow joint may
develop in rheumatoid arthritis. When aspirating the olecranon bursa, a
lateral aspiration approach is recommended to prevent subsequent
development of a chronic sinus tract that can result from introducing a
needle directly into the tip of the elbow bursa (Steinberg, 1999). Despite
the best technique, recurrence of olecranon bursitis with chronic painful
inflammatory changes may necessitate definitive orthopedic resection of
the bursa (Greene, 2001).
REVIEW OF ESSENTIAL ANATOMY
AND PATHOPHYSIOLOGY: JOINT
ASPIRATION
Pathophysiology
The knee is representative of diarthrodial joints, with a synovial lining
containing secretory cells and a fine capillary system from which synovial
fluid is derived. Plasma transudation and mucin production within the joint
combine to give synovial fluid its viscous, lubricating quality that reduces
joint surface friction. Synovial fluid diffusion is an important factor in providing
nutrition to the intra-articular structures (Weiner, 2004). Noninfectious
effusions do not generally develop in fibrocartilaginous joints, such as the
sacroiliac joint, because of the absence of synovial lining, but effusions do
develop within bursae, which are cavities lined with secretory cells that
function much like synovial cells (Sledge, 2001).
Chapter 20— Joint and Bursal Aspiration 263
When trauma, inflammation, or infection occurs within the joint, the synovial
fluid is characteristically altered, and sampling of the synovial fluid can be
diagnostic. In the case of inflammatory reaction, the synovium produces
increased synovial volume as a response to mechanical trauma or crystalline
precipitants within the joint. Traumatically induced bleeding within the
synovial fluid directly damages the synovial cartilage through the release of
destructive proteolytic enzymes from blood cells. Hemarthrosis management
should include aspiration to eliminate biochemical injury to the joint in
addition to decreasing discomfort from mechanical distention.
Aspiration of a bloody synovial effusion is best attempted within the first
couple of days after swelling develops. The clotting process makes aspiration
nearly impossible between 3 and 7 days after injury, but aspiration becomes
possible again 7 days after injury because of the breakdown of intra-articular
clot. However, some cartilaginous damage is likely to have occurred by the
time there is liquefaction of the intra-articular clot.
The synovial surface can also be transformed by chronic inflammatory
changes that lead to proliferative changes on the synovial surface (Steinberg,
1999). This tissue proliferation can make aspiration techniques difficult or
ineffective when the proliferative tissues obstruct the intra-articular needle
and prevent aspiration of the joint fluid. Proper placement of the needle can
reduce the likelihood of obstruction by avoiding areas commonly affected by
synovial proliferation (Fig. 20-1).
Anatomy and Pathomechanics
The knee joint is formed between the distal femur and proximal tibia, with
the synovium covering the femur in a saddle configuration and reflecting
anteriorly and superiorly on the femur behind the patella and draping inferiorly
and posteriorly on the caudad surface of the femur, medially and inferiorly
Lateral anterior oblique
Posterior
Figure 20- 1 .
knee joint.
Synovial surfaces of the
264 Chapter 20— Joint and Bursal Aspiration
Quadriceps
Suprapatellar fat
Femur
Infrapatellar fat pad
Space narrowing
with flexion
Figure 20-2. Anatomy of the knee joint.
over the lateral surfaces of the cruciate ligaments, and down to the tibial
articular surfaces. A small synovial draping also occurs over the proximal
fibula. The pommel of the synovial saddle lies on the anterior distal femur
behind the patella, reflecting at the upper margin anteriorly toward the patella.
The space medially between the femoral condyles and behind the patella
generally permits better synovial aspiration because the probability of
encountering synovial proliferation or abutting a bony surface is less,
particularly when the knee is extended (Fig. 20-2).
Chapter 20— Joint and Bursal Aspiration 265
PATIENT PREPARATION: JOINT
ASPIRATION
Informed consent is appropriate for any invasive procedure. Whether
using a formal written consent form or simply documenting the risks and
benefits discussed, patients should be apprised of the risks for infection,
bleeding, adverse reactions to anesthesia, joint surface injury, ongoing
pain, and reaccumulation of fluid.
For some patients whose effusion has stabilized the knee, the removal of
the fluid may uncover previously unnoticed knee instability. It is helpful
to prepare patients for this by discussing the possibility before tapping
the joint.
Let patients know that additional management after aspiration may
include immobilization of the joint, antibiotic or anti-inflammatory
therapy, hospitalization, or referral to a specialist, depending on the
findings on aspiration.
Inform the patient that the procedure takes about 5 to 10 minutes after a
10-minute scrub of the joint area to ensure asepsis.
Patients must be reminded that once the preparation has begun, it is
essential that the patient refrain from touching, pointing, or reaching
over the area being prepared. Patients do well with this when told not to
touch anywhere within the "covered area," when drapes are used, or
where the "soap" was applied until the procedure is completed.
Patients should be prepared for a brief episode of stinging discomfort
when the lidocaine anesthetic is administered subcutaneously The "bee-
sting" sensation lasts less than 30 seconds for most patients.
Considering overall safety for the patient as well as the position for
optimal access of the effusion, it is preferable to have the patient in a
supine position with the knee extended as much as the effusion permits.
Knee flexion allows the patella to ride more closely to the femur,
narrowing the retropatellar space. The widest patellofemoral space is
afforded by placing the knee at the fullest extension allowable. Because
the tension on the anterior cruciate ligament is greatest when the knee is
in full extension or deep flexion, the patient may prefer to maintain a
30- to 70-degree flexion to maintain laxity of the anterior cruciate
ligament and allow for comfort. Likewise, effusive distention of the joint
may prevent full extension.
266 Chapter 20— Joint and Bursal Aspiration
Table 20.1 Synovial Fluid Testing
TEST
Crystals
RA latex
Total protein
Glucose
Mucin clot
Cell count
Routine culture
Gram stain
TB culture
Fungal culture
COLLECTION TUBE/
CONTAINER
AMOUNT OF
FLUID NEEDED
SPECIAL CONSIDERATIONS*
Red- or green-top
tube (sodium
heparin)
Red-top tube
Red-top tube
Red- or gray-top*
(sodium heparin)
Red-top tube
Purple-top tube
(EDTA)
Sterile syringe*
Yellow top (ACD)*
Sterile syringe*
Yellow top (ACD)*
Sterile syringe*
Yellow top (ACD)*
Sterile syringe*
Yellow top (ACD)*
0.5 mL
0.5 mL min
0.5 mL min
0.5 mL min
0.5 mL min
1.0 mL min
0.5 mL min
0.5 mL min
0.5 mL min
0.5 mL min
Caution with other tubes
containing EDTA — may be
mistaken for joint fluid crystals
Send to laboratory in syringe
Send to laboratory in syringe
Send to laboratory in syringe
Send to laboratory in syringe
individual microbiology and chemistry laboratories may have specific criteria for tests; confirm the
laboratory's preference for the tests you are running.
ACD, anticoagulant citrate dextrose; EDTA, ethylenediaminetetra-acetic acid; min, minimum;
RA, rheumatoid arthritis; TB, tuberculosis.
Materials Utilized for Performing Joint and Bursal
Aspiration
Tray table
Sterile drapes
Sterile gloves
Povidone-iodine solution (or other topical antiseptic if iodine allergic)
1% lidocaine (unless contraindicated by allergy)
Sterile 1-inch, 25-gauge needles; sterile l^-inch, 19-gauge needles
Three sterile 20- or 30-mL syringes, sterile 5- or 10-mL syringe
Sterile hemostat
Green-top sodium heparin tube or other Vacutainer tubes as indicated
(Table 20-1).
Chapter 20— Joint and Bursal Aspiration 267
Procedure for Performing Joint Aspiration
1. Determine the position that will allow
the patient to be most comfortable and
the effusion to be most easily accessed.
2. Perform a 10-minute scrub of the knee
with povidone-iodine solution. The
preparation must encircle the knee and
extend 2 to 3 inches above and below
the knee.
3. Draping of the knee is not essential but it
reduces the risk of infection. If
performed, the draping should allow
adequate visualization of the joint space
for the ballottement of fluid and
determination of landmarks.
4. Prepare a sterile field on which to
assemble all needed sterile equipment
including syringes, needles, hemostat,
and sterile cup.
5. Once prepared, don sterile gloves, drape
if desired, and define the superior pole
of the patella. Identify the joint spaces
lateral to the patella by ballottement of
fluid beneath the patella (Fig. 20-3).
6. Draw up 1% lidocaine in a 5- or 10-mL
syringe.
7. Identify the landmarks to determine the
location for needle placement.
Note: The needle may be introduced into the
joint space either anteromedially or
anterolateral^.
8. Draw a visual line along either lateral
margin of the patella to intersect with
the line of the superior patellar margin
and, entering the skin at that point or
slightly more laterally and superiorly,
administer a small amount of the
anesthetic subcutaneously Angle
45 degrees off the sagittal plane and
30 degrees off the frontal plane, directing
the needle caudally
9. Advance the needle as deep as
anesthesia is desired, aspirating for
blood.
Note: When advancing to the joint capsule,
resistance is encountered at the level of the
joint capsule.
10. While withdrawing the needle,
administer the anesthetic along the track
from the joint capsule out to the skin
(Fig. 20-4).
11. Remove the smaller gauge needle and
syringe and assemble the 18-gauge
needle on a 20- or 30-mL syringe.
Hold the needle-syringe like a pencil
and align to advance medially and
caudally into the joint space behind
the patella.
12. Introduce the 18-gauge needle into the
anesthetized track angled 45 degrees
laterally and directed 30 degrees
caudally. Place gentle pressure on the
syringe plunger while advancing and
aspirate the synovial fluid on entering
the joint space as the needle is directed
medially and downward behind the
patella (Fig. 20-5).
Note: Entering the joint space is painful
briefly for the patient.
13. When the syringe is full, place the
hemostat on the needle hub, remove the
syringe, and replace it with an empty
syringe or discharge the synovial fluid
into a sterile cup. Repeat this step until
the knee joint is no longer visibly
distended or fluid can no longer be
aspirated.
Note: Pressure applied above the knee joint
can "milk" additional fluid centrally for
aspiration. Caution must be exercised not to
compromise sterile conditions.
continued
268 Chapter 20— Joint and Bursal Aspiration
/
Patella
Femur
B
Figure 20-3.
Tibia
14. Intra-articular medication can be
administered after the aspiration if
indicated.
15. Withdraw the needle from the joint
space and apply direct pressure with
sterile dressing over the puncture site
for several minutes.
16. Confirm that the wound site is dry and
active bleeding has stopped and then
dress with sterile adhesive dressing.
Patella
Normal visible
patellar contour
Patellar contours
camouflaged by fluid
within joint
17. Maintaining sterile conditions, observe
the synovial fluid for evidence of a
cloudy appearance and obtain Gram
stain, cell counts, and cultures if there is
suspicion of infection.
Note: Gram stain and cultures are usually
collected in sterile syringes and transported
promptly to the laboratory. Rapid transport
and inoculation on special medium are
essential for growth of fastidious bacteria
Chapter 20— Joint and Bursal Aspiration 269
Lateral point
of insertion
Medial point
of insertion
:--iK-
ri
A'
Superior
patellar margin
such as Neisseria gonorrhoeae. Specimens
sent for crystal analysis should not be
drawn into an ethylenediaminetetra-acetic
acid (EDTA) tube because the EDTA crystals
can be confused with intra-articular crystals.
See Table 20-1 for guidelines on acquiring
samples for the laboratory
Lateral patellar ■
margin
Medial patellar
margin
Figure 20-4. Landmarks for needle placement.
Angle 30 degrees
down in AP
plane
Angle 45 degrees
off sagittal plane
directing needle
medially
45 degrees
30 degrees
Figure 20-5. Positioning the needle for joint aspiration.
270 Chapter 20— Joint and Bursal Aspiration
FOLLOW-UP CARE AND
INSTRUCTIONS: JOINT ASPIRATION
■ Advise patients to avoid use of the joint for at least 1 day. If traumatic
injury preceded the effusion, longer immobilization or avoidance of
weight bearing may be indicated. When aspiration eliminates internal
splinting, the instability of the joint may become apparent and should be
managed as would otherwise be indicated.
■ Instruct the patient to call the office in the event of sudden
reaccumulation of fluid, increased heat at the joint, fever, chills, or a
severe increase in pain, which would necessitate the patient's prompt
return for further evaluation.
■ Evidence or strong suspicion of infection at the time of tapping
necessitates an immediate referral to an orthopedist.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY: BURSAL
ASPIRATION
Numerous bursae are found around the joints, many of which may accu-
mulate excessive fluid as part of an inflammatory process. The olecranon
bursa is one that can become visibly distended because of inflammation.
This easily accessible bursa may swell slowly over time or accumulate
suddenly from trauma or infection. Because of the relatively exposed and
superficial anatomy of the bursa, external mechanical irritation plays a
significant role in the initiation and perpetuation of olecranon bursitis. Other
differential considerations include ulnar fracture, gout, acute rheumatoid
arthritis, or a synovial cyst of the elbow joint (Greene, 2001).
Intrabursal scar tissue, which feels like small nodules within the bursa, can
develop rather early as a sequela to olecranon bursitis. These "nodules" may
result in chronic pain and tenderness when the elbow is mechanically
aggravated.
The general approach to aspirating an olecranon bursitis can be applied to
other bursae. Few others have such easily accessible anatomy. Some, such
as the trochanteric bursae, are difficult to isolate anatomically because of
overlying structures (Fig. 20-6). Others, such as the prepatellar bursae, are
nearly as accessible as the olecranon bursae (Fig. 20-7).
PATIENT PREPARATION: BURSAL
ASPIRATION
■ Apprise the patient of the risks of infection, bleeding, adverse reactions
to anesthesia, ongoing pain, and reaccumulation of fluid.
Chapter 20— Joint and Bursal Aspiration 271
Trochanteric bursa
Figure 20-6. Trochanteric bursae are difficult
to isolate because of overlying structures.
Quadriceps
Suprapatellar
bursa
Prepatellar
bursa
Patella
Deep
infrapatellar \^ y^
bursa
Superficial
infrapatellar
bursa
Femur
Popliteal bursa
(joint capsule
herniated)
Tibia
Pes anserinus
bursa
Figure 20-7. Knee bursae.
272 Chapter 20— Joint and Bursal Aspiration
Let the patient know that additional management after aspiration includes
resting and protecting the elbow, antibiotic or anti-inflammatory therapy
if indicated, or hospitalization or referral to a specialist, depending on
the findings.
Inform the patient that the procedure takes about 5 to 10 minutes after a
10-minute scrub of the joint area to ensure asepsis. Patients must be
reminded that once the preparation has begun, it is essential that the
patient refrain from touching, pointing, or reaching over the area being
prepared.
Warn the patient to be prepared for a brief episode of stinging discomfort
when the lidocaine is administered subcutaneously The "bee-sting"
sensation lasts less than 30 seconds for most patients.
Procedure for Performing Bursal Aspiration
1. Have the patient sit well supported or
lying down prone for the procedure. If
sitting, the arm must be supported on a
Mayo stand flexed at the elbow to
90 degrees. If lying down prone, have the
patient rest the arm on the examination
table with elbow flexed and shoulder
comfortably abducted to allow access to
the lateral olecranon bursa.
2. Prepare a sterile field on which to
assemble all needed sterile equipment,
including syringes, needles, hemostat, and
sterile cup.
3. Perform a 10-minute scrub with povidone-
iodine solution. Cover the entire olecranon
process as well as the lateral elbow surface.
4. Once the patient is prepared, don sterile
gloves and drape the area so that the
bursa is easily accessible but sterility is
maintained.
5. Draw up 1 mL of 1% lidocaine in a syringe.
Identify the landmarks to determine the
location for needle placement.
Note: The olecranon bursa is usually readily
visible and distended beyond the typical
elbow contour. Anesthesia to the skin and
subcutaneous tissues may be administered
as desired using a 25- to 27-gauge needle.
6. Administer the anesthetic under the skin
of the elbow, centering the needle over
the lateral surface of the distended bursa
(Fig. 20-8).
Enter olecranon bursa
from the side at 90 degrees
Posterior
Figure 20-8. Positioning the needle for bursal
aspiration.
Chapter 20— Joint and Bursal Aspiration 273
7. With the elbow flexed to 90 degrees and
resting comfortably, switch to an 18-gauge
needle and syringe. Enter into the
distended olecranon bursa at 90 degrees
to the plane of the arm. Aspirate the fluid
slowly until the bursal sac is flat.
8. Apply direct pressure over the puncture
site. Dress with an adhesive bandage and
wrap the elbow with an elastic
compression bandage to retard the
reaccumulation of fluid.
9. Observe the synovial fluid for evidence of
a cloudy appearance and obtain a Gram
stain, cell counts, and cultures if there is
suspicion of infection. Tests for crystals
or other rheumatoid parameters should
proceed as was described in the joint
aspiration section (see Table 20-1).
FOLLOW-UP CARE AND
INSTRUCTIONS: BURSAL
ASPIRATION
■ Advise the patient to avoid general use of the joint for at least 2 days.
Recurrence of bursal effusion is more likely with persistent mechanical
irritation of the bursa. Avoiding resting the elbow on tables, automobile
arm rests, and chair arms decreases irritation. For some patients, these
activities are so habitual that the elbow is inevitably chronically irritated
and an elbow protector may be indicated. Another option is the
placement of a posterior plaster splint after aspiration to limit elbow
motion for the first week after the procedure. For those who go on to
develop chronic bursitis, surgical excision may become necessary.
Instruct the patient to call the office in the event of the development of a
warm elbow, fever, chills, or severe increase in pain, which would
necessitate prompt return for further evaluation (Greene, 2001).
Recurrence of olecranon bursitis more than three times probably
indicates a need for surgical bursal excision, as does the development of
a draining sinus tract.
References
Grassi W, Filipucci E, Busilacchi P: Musculoskeletal ultrasound. Best
Pract Res Clin Rheumatol 18::813-826, 2004.
Greene WB (ed): Essentials of Musculoskeletal Care. Rosemont, 111,
American Academy of Orthopaedic Surgeons, 2001.
Schumacher HR: Synovial fluid analysis and synovial biopsy. In Ruddy
S, Harris ED, Sledge CB (eds): Kelley's Textbook of Rheumatology,
6th ed. Philadelphia, WB Saunders, 2001, pp 605-617.
Sledge CB, Reddi AH, Walsh DA, Blake DR: Biology of the normal joint.
In Ruddy S, Harris ED, Sledge CB (eds): Kelley's Textbook of
Rheumatology, 6th ed. Philadelphia, WB Saunders, 2001,
pp 1-25.
Steinberg G, Akins C, Baran D (eds): Orthopaedics in Primary Care, 3rd
ed. Philadelphia, Lippincott Williams & Wilkins, 1999.
274 Chapter 20— Joint and Bursal Aspiration
Weiner DS (ed): Pediatric Orthopedics for Primary Care, 2nd ed.
Cambridge, UK, Cambridge University Press, 2004.
Bibliography
Carr AJ, Hamilton W (eds): Orthopedics in Primary Care, 2nd ed.
Edinburgh, Elsevier/Butterworth-Heinemann, 2005.
McMahon PJ, Skinner HB: Sports medicine. In Skinner H (ed): Current
Diagnosis and Treatment in Orthopedics. Norwalk, Conn, Lange
Medical Books/McGraw-Hill, 2003.
Owens DS: Aspiration and injection of joints and soft tissues. In Ruddy
S, Harris ED, Sledge CB (eds): Kelley's Textbook of Rheumatology, 6th
ed. Philadelphia, WB Saunders, 2001, pp 583-603.
Ruddy S, Harris ED, Sledge CB (eds): Kelley's Textbook of
Rheumatology, 6th ed. Philadelphia, WB Saunders, 2001.
Schumacher HR: Aspiration and injection therapies for joints. Arthritis
Rheum 49:413-420, 2003.
Cha
pter O 1
Casting and Splinting
Donald Frosch and Patrick Knott
Procedure Goals and Objectives
Goal: To apply comfortable and well-fitting casts and splints that
effectively immobilize an injured extremity in the appropriate
position and minimize potential complications to the patient.
Objectives: The student will be able to ...
• Compare and contrast the indications and contraindications of
utilizing plaster and fiberglass materials for casts and splints.
• Distinguish the various types of splints and casts used to
immobilize upper and lower extremity injuries.
• Describe the proper procedure for selecting and applying a
short-arm cast, short-leg cast, short-arm gutter splint, short-leg
posterior mold, and lower-leg sugar tong splint.
• Identify and describe potential complications associated with
casting and splinting extremities.
• Describe how to perform a proper post-cast or post-splint
assessment to determine if the device fits well, properly
immobilizes the injured extremity, and is comfortable.
• Identify the important aspects of patient education and cast care
following a casting and splinting application.
• Explain how to properly utilize an oscillating cast saw to
remove a cast without causing injury to the patient.
275
276 Chapter 21— Casting and Splinting
Figure 21-1. Short-arm cast.
BACKGROUND AND HISTORY
Immobilization of the extremities in casts and splints is a practice that dates
back to nearly 3000 bc, when tree bark was used to splint injured forearms.
In the 1920s, plaster of Paris was commercially introduced to medicine as a
powder that was impregnated into rolls of cloth. Since the 1970s, synthetic
materials like fiberglass and plastic have been used to make casts and splints,
but the principles of immobilization have remained remarkably constant
throughout time.
There are numerous types of casts and splints used to treat an even
greater number of specific fractures and soft tissue injuries. Some devices
immobilize only the distal half of an extremity ("short-arm" or "short-leg"
casts or splints), whereas others immobilize the entire extremity ("long-arm"
or "long-leg" casts or splints) or only the upper arm. Describing the many
special types of immobilization is beyond the scope of this chapter, and
the use of many of these specialized types of casts and splints may be
inappropriate in the primary care setting. What follows is an explanation of
the basic principles of casting and splinting, and instructions for constructing
several commonly used casts and splints.
A cast is an immobilization device that completely encases the circum-
ference of an extremity. It consists of a rigid material (usually plaster or fiber-
glass), placed over several layers of padding and a cloth stockinette that
together cover and protect the skin. Because a cast is circumferential, it must
not be employed until the acute swelling phase of the injury has subsided.
Two types of casts are discussed in this chapter, the short-arm cast (Fig. 21-1)
and the short-leg cast (Fig. 21-2).
A splint is similar to a cast except that its rigid material encases only part
of an extremity's circumference and must therefore be secured with a self-
adherent and elastic wrap, such as an ACE bandage or Coban wrap. Although
a splint provides less mechanical support and protection than a circum-
ferential cast, its main advantage is that it allows for soft tissue swelling
Chapter 21 — Casting and Splinting 277
Figure 2 1 -2. Short-leg cast.
Figure 2 1 -3. Gutter splint.
during the acute phase of an injury. It is typically employed as a temporary
immobilization measure and is replaced with a cast after the acute swelling
subsides. The stockinette is excluded from splint constructions because it is
potentially constricting in the setting of acute swelling. A splint can be easily
constructed from strips of fiberglass or plaster that are sandwiched between
an upper and lower row of cast padding. Prefabricated splints, however, are
commercially available in a variety of precut sizes or in cut-to-size rolls, and
typically consist of an outer paper shell overlying fiberglass strips with foam
padding on one side. Three general types of splints are discussed in this
chapter: the "gutter," the "posterior mold," and the "sugar tong." The gutter
splint (Fig. 21-3) is appropriately named for its gutter-like shape in supporting
the extremity. The forearm gutter splint is an example of this type. The
278 Chapter 21— Casting and Splinting
Figure 21-4. Posterior mold
splint.
Figure 21-5. Sugar tong
splint for the lower leg.
posterior mold splint (Fig. 21-4) is so named because it is molded to the
posterior aspect of the splinted extremity. Posterior mold splints of the
short-leg, short-arm, or long-arm variety are commonly employed. The sugar
tong splint (Figs. 21-5 and 21-6) forms a U-shaped strap around an extremity,
resembling the kitchen accessory after which it is named. The sugar tong
splint can be used to initially immobilize the lower leg, lower arm, or upper arm.
Plaster and fiberglass are the two primary materials used to make casts
and splints today, although several other synthetic materials are gaining in
popularity. Each material has inherent benefits and drawbacks that deter-
mine which is the best choice for the situation. Plaster is easier to mold to
an extremity than is fiberglass, giving it an advantage when a snug and form-
fitting cast is needed on an area with challenging contours, such as the
chubby, cone-shaped arm or legs of a toddler. Despite this significant
advantage, plaster has a number of drawbacks. It is much heavier than fiber-
glass, yet not as durable. It is also messy to apply and it emits quite a bit of
heat as it cures. Because of the exothermic reaction generated, it is sometimes
uncomfortable for the acutely injured patient and poses a potential burn risk
in patients with sensory deficits. Fiberglass is an extremely popular casting
material because of its strength, light weight, ease of application, and excellent
durability. Unlike plaster, fiberglass cures rapidly and is water-resistant
Chapter 21 — Casting and Splinting 279
Figure 2 1 -6. Sugar tong splint for the lower arm.
(although the underlying padding must still be kept dry). For these reasons,
fiberglass is clearly the material of choice for the majority of cast and splint
applications, and especially for weight bearing ("walking") casts. The draw-
back to fiberglass is that it is several times more expensive than plaster. Its
higher initial cost can be justified because it lasts longer and requires fewer
repairs and replacements during the period of immobilization.
INDICATIONS
Casts and splints are used in the primary care setting as follows:
To treat simple, acute, nondisplaced fractures
■ To immobilize a dislocation after it has been reduced
To treat soft tissue injuries, such as severe ligament sprains and muscle
strains
Immobilization is necessary for comfort and healing after a bone fracture,
and it is also beneficial in the short term following a soft tissue injury.
Because long periods of immobilization cause disuse atrophy and stiffness in
the affected limb, the benefits of immobilization must be weighed against
these predictable side effects when deciding upon the optimal duration of
immobilization.
280 Chapter 21— Casting and Splinting
CONTRAINDICATIONS
Cast (circumferential) immobilization should be avoided in the following
situations:
During the acute injury phase (usually 3 to 4 days), when immediate
swelling of the extremity is expected
■ When the cast would cover or conceal a known skin or soft tissue
infection
When the cast would cover or conceal an open wound, where infection
may occur
In these situations, a splint (noncircumferential) is much safer than a cast,
because it allows the extremity to expand with swelling and provides access
to the skin so that it can be periodically checked for wound healing and signs
of infection.
POTENTIAL COMPLICATIONS
A circumferential cast on an injured extremity can be a potentially dangerous
form of treatment, and the primary care provider must be vigilant to signs
and symptoms of potential complications. These include compartment
syndrome, cast dermatitis, pressure sores, nerve injuries, and deep venous
thrombosis.
Compartment Syndrome
The most serious complication after the application of a cast is the develop-
ment of a compartment syndrome. This refers to a buildup of pressure within
the soft tissues that can impede or cut off the blood supply to an injured
extremity, causing permanent damage to muscles and nerves. A compartment
syndrome typically follows an injury to a large bone in an area where there
is a closed compartment formed by fascial layers (e.g., the forearm or lower
leg). It is also more likely after a crush injury or arterial laceration. However,
a compartment syndrome can occur without any of these predisposing factors.
The classic example of a compartment syndrome in an upper extremity is
Volkmann's ischemic contracture, a complication that results in muscle
necrosis and loss of function of the affected arm and hand. The most
predictive symptom of a compartment syndrome is pain that increases over
time and is out of proportion to the severity of the injury. The pain is much
worse with passive motion of the distal extremity and usually prevents active
motion altogether. Less reliable signs and symptoms in the involved limb
include paresthesias, decreased two-point discrimination, decreased capillary
Chapter 21 — Casting and Splinting 281
refill, pallor, and, ultimately, pulselessness. Normal soft tissue compartment
resting pressures are in the range of 5 to 10 mm Hg. As these pressures rise
above 30 mm Hg and begin to approach diastolic pressures, irreversible
damage to the soft tissues can result. If suspected, one should look for
compartment syndrome by directly measuring compartment pressure, rather
than waiting for the later signs of decreased capillary refill or changes in the
arterial pulse amplitude. Today, compartment pressure is most commonly
measured with a special electronic hand-held device, although it can also be
measured using a needle, three-way stopcock, intravenous tubing, and a
mercury manometer (Whiteside's technique), or with a specially prepared
catheter and pressure transducer (wick catheter technique). Treatment for a
suspected compartment syndrome requires immediate loosening of the cast.
This is accomplished by cutting and splitting the cast, padding, and stockinette
down both sides of the extremity, and then separating the two halves to
relieve pressure. Adequate relief of pressure may not be achieved unless the
underlying padding and stockinette layers are cut all the way down to
the skin. If symptoms do not resolve within a few minutes of this "bivalving"
procedure, compartment pressures should be measured and surgical
decompression undertaken, if necessary.
Cast Dermatitis
Cast dermatitis is a complication that occurs when air circulation is insufficient
to clear residual moisture and ongoing limb perspiration from inside the
cast. Patients often try to relieve the associated pruritus by scratching with
coat hangers, pencils, or other long objects that they are able to insert into
their cast. Such objects may cause skin abrasions or lacerations that become
secondarily infected.
Cast Pressure Sores
Cast pressure sores result from inadequate cast padding over bony
prominences or from finger indentations in the cast that result from poor
technique during cast application. If not detected early, pressure sores may
progress to pressure ulcers, and may require surgical debridement and skin
grafting.
Nerve Injuries
Pressure over superficial nerves, especially the ulnar nerve at the elbow and
the common fibular (common peroneal) nerve at the fibular head, can cause
a temporary nerve palsy or permanent paralysis if left untreated. The causes
are the same as for cast pressure sores.
282 Chapter 21 — Casting and Splinting
Deep Venous Thrombosis
In addition to lack of ambulation, long periods of immobilization of the lower
extremities can lead to formation of deep venous thrombi or pulmonary
emboli.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
A rule of thumb when casting an injured extremity is that the immobilization
should include the joints proximal and distal to the injured area. This rule is
frequently broken, however, if the length of the limb proximal to the injury is
sufficient to allow for proper immobilization and fixation of the fracture. For
example, for a wrist fracture, the cast may not have to include the elbow if the
length of cast along the forearm allows for adequate wrist joint immobilization.
One should recognize that a short-arm cast never completely immobilizes
the wrist joint because it does not prevent forearm pronation and supination.
When uncertain about the length of cast required, an orthopedic specialist
should be consulted.
practitioner to exercise clinical judgment based
Standard Precautions Practitioners should use on the patient's history and the potential for
standard precautions at all times when exposure to body fluids or aerosol-borne
interacting with patients. Determining the pathogens (for further discussion, see Chapter 2).
appropriate level of precaution requires the
PATIENT PREPARATION
■ Inform the patient about the procedure and answer any questions.
■ Place the extremity in the position of function:
■ For a short-arm cast, short-arm ulnar gutter splint, or short-arm sugar
tong splint: The elbow should be flexed to 90 degrees and the forearm
maintained in neutral pronation-supination (with the thumb pointing
upward). The wrist should be held in slight extension, with the fingers
slightly curled as if holding a can of soda.
■ For a short-leg cast, short-leg posterior mold splint, or short-leg sugar
tong splint: The ankle must be strictly maintained at 90 degrees of
flexion. Allowing an ankle to drift into plantar flexion during cast
application will result in a cast that is difficult to walk on. If
uncorrected, a plantar-flexed cast will result in contraction of the
Achilles tendon and stiffening of the calf and hamstring musculature.
It is easiest to maintain proper ankle position during casting or
splinting by applying the cast with the patient lying prone with the
knee flexed to 90 degrees. If applying the cast with the patient sitting,
it is helpful to have an assistant hold the patient by the toes to maintain
Chapter 21 — Casting and Splinting 283
proper ankle position. Whether performed in the prone or sitting
position, casting the leg with the knee bent helps avoid the mistake of
casting too high into the knee area and restricting knee flexion.
Materials Utilized for Applying Casts
■ Stockinette
Note: Stockinette is a stretchable socklike material that is available in 2-,
2V2-, 3-, 4-, 5-, and 6-inch widths. It comes on a large roll that is cut to the
desired length. The most appropriate width is selected based upon the limb
involved, the size of the patient, and the degree of swelling of the limb.
Stockinette serves two purposes. First, it acts as a barrier between the skin
and the sometimes itchy cast padding. Second, after the cast padding and
first layer of fiberglass are placed, the stockinette and cast padding are
pulled over the rough edges of the cast to provide comfortable cast borders.
■ Cast padding
Note: Cast padding is available in 2-, 3-, 4-, and 5-inch widths and is
packaged in individual small rolls. Depending on the size of the injured
extremity, 2- or 3-inch padding is usually used on the arm, 3- or 4-inch
padding on the lower leg, and 4- or 5-inch padding on the upper leg. Two
types of padding are available, cotton and synthetic. Cotton was the type of
cast padding originally used when plaster was the only type of casting
material available. When fiberglass casting materials became available,
synthetic cast padding was developed. An advantage of synthetic padding
is that it absorbs less water than cotton if it gets wet. For these reasons,
cotton padding is typically used with plaster, and synthetic padding with
fiberglass. Two layers of padding are usually sufficient, with additional
padding added to cast edges and over bony prominences. Too much
padding may lead to a loose cast as the padding flattens over time.
■ Cast material
Note: Cast material (i.e., plaster, fiberglass) is available in 2-, 3-, 4-, and
6-inch widths and is usually packaged in individual rolls or various length
strips. Smaller widths are used on the narrow, distal parts of the extremities
(i.e., wrists, hands, ankles, feet), whereas larger widths are used on the
wider and longer areas. The width of cast material selected is usually
similar to that of the cast padding. Fiberglass cast material must be kept in
its airtight foil package until it is ready to be applied, because the moisture
in the air will initiate the curing process. This is not a concern with plaster.
■ Large basin or bucket
Note: This is filled with water and used to fully immerse the casting material.
■ Apron and gloves
284 Chapter 21— Casting and Splinting
Note: These are used to protect the clinician's skin and clothing from the
sticky and permanently staining resin contained in fiberglass casting material,
and from the messy splatter that occurs when using plaster casting material.
Bandage scissors
Note: These are used to cut or trim the padding and casting materials, if
needed.
■ Cast saw and additional blades
Note: Specialized cast saws are used to remove or reshape casts after they
harden. A cast saw has an oscillating blade that vibrates (instead of
spinning like a conventional saw blade), thereby preventing the saw from
inadvertently cutting the skin during cast removal.
General Procedure for Applying Casts
1. Select the appropriate size of
stockinette.
2. Cut the stockinette to an appropriate
length so that there will be about 3 to 4
inches of excess stockinette on each end
of the cast (Fig. 21-7). Try to smooth out
all wrinkles from the stockinette. If
necessary, remove overlapping wrinkles
with your scissors.
3. Select the appropriate size of cast
padding. Roll the padding on smoothly,
overlapping each time by about 50%
(Fig. 21-8). It is easier to apply cast
padding by starting at the narrow end of
an extremity and rolling toward the
wider part. Extend the padding about 1
to 2 inches beyond each border of where
the cast material will be. One to two
layers of foundation padding usually
suffice.
Figure 2 1 -7. Stockinette.
Figure 21-8. Cast padding.
4. Add an additional layer or two of cast
padding at the intended top and bottom
borders of the cast. Add additional
padding over bony prominences and in
areas of potential cast friction by tearing
small sections of padding from the roll
and placing them where needed.
5. Put on your protective apron and gloves.
6. Immerse the casting material in a bucket
of water. For plaster, immerse the roll in
cool water until it is "sloppy wet." The
excess cool water helps disperse the
Chapter 21 — Casting and Splinting 285
Figure 2 1 -9. Casting material.
heat generated from the plaster's
exothermic curing process. For
fiberglass, immerse the roll in a bucket of
water for about 10 seconds, and then
squeeze it once gently to remove the
bulk of the water.
7. Roll the casting material on smoothly,
overlapping each time by about 50%.
Start and finish each roll of casting
material about 1 to 2 inches inside the
border of the cast padding so that there
will be sufficient padding to roll over the
edge of the cast (Fig. 21-9). It is easier to
apply cast material by starting at the
narrow end of an extremity and rolling
toward the wider part. Try to traverse
the entire length of the planned cast
with each roll. Avoid bunching or
wrinkling the casting material by folding
or tucking the roll when needed. Also,
avoid stretching or pulling the casting
material when applying. This is
especially important when applying the
first roll or two. The average cast may
require 4 to 6 layers of plaster or 3 to
4 layers of fiberglass, with additional
reinforcement at the foot for weight-
bearing casts. Be sure to maintain the
extremity in the position of function
while rolling the casting material, and
gently reposition it if needed.
8. Mold each layer to the contour of the
extremity by gently, but firmly, rubbing
the cast between the palms of your
gloved hands. Proper molding is
necessary to allow for a comfortable fit
and appropriate immobilization of the
extremity. With the proper amount of
cast padding, molding can be
accomplished with minimal discomfort
to the patient. While molding, continue
to ensure that the extremity is in the
proper position of function. Be especially
careful not to indent the cast with your
fingertips when supporting the
extremity!
9. Prior to rolling the final layer of cast
material, pull the stockinette and cast
padding over each cast edge and secure
them with the final layer of cast material.
This creates a nicely padded and rolled-
edge border.
10. Perform a post-application assessment
of the position of function, fit, extent of
immobilization, and comfort of the
cast.
Materials Utilized for Applying a Short-Arm
Cast
2-, 2V2-, or 3-inch stockinette (depending on arm size)
One roll of 2- or 3-inch cast padding
Two rolls of 2- or 3-inch fiberglass casting material
286 Chapter 21— Casting and Splinting
Procedure for Applying a Short-Arm Cast
Note: A short-arm cast should extend from
about two fingerbreadths distal to the
olecranon fossa to just proximal to the
metacarpal-phalangeal (MCP) joints of all
fingers. If properly applied, it should
immobilize the hand, wrist, and distal
forearm, yet allow for full flexion at the
elbow, full range of motion of all the MCP
joints (including the thumb), and an
unobstructed thumb-index pinch. A
short-arm cast is often used for hand,
distal radius, and distal forearm
fractures.
1. Place (and maintain) the extremity in the
proper position of function, as previously
described.
2. Apply stockinette, as previously
described. Be sure to extend the
stockinette well beyond the anticipated
cast borders. You will also need to cut an
extra (distal) hole in the stockinette for
the thumb when the stockinette is pulled
down before the final layer of cast
material is applied (see Fig. 21-7).
3. Apply cast padding, as previously
described. Be sure to extend the cast
padding beyond the anticipated cast
borders so that it (and the excess
stockinette) can later be folded over
the rough cast edges. Also apply extra
padding over the radial and ulnar
styloid processes.
4. Roll on the fiberglass casting material,
starting in the narrow wrist area, then do
a couple of figure eights around the hand
before proceeding up the arm (Fig. 21-10).
When rolling fiberglass through the
narrow thumb-index web space, pinch or
twist the tape so that it forms a small
bridge that allows for thumb-finger
opposition (Fig. 21-11).
Figure 21-10.
Figure 21-1 1.
Figure 21-12. Molding the cast.
5. After each roll of fiberglass is applied,
mold the cast to the arm (and hand) using
your palms, as previously described
(Fig. 21-12).
Chapter 21 — Casting and Splinting 287
6. Prior to rolling the final layer of cast
material, pull the stockinette and cast
padding over each cast edge and secure
them with the final layer of cast material.
This creates a nicely padded and rolled-
edge border.
Cut back to
allow thumb
to abduct
Properly molded
in palm
Able to flex elbow
to 90 degrees
7. Perform a post-application assessment,
evaluating each feature illustrated in
Figure 21-13.
Small bridge allows
thumb and first
finger to pinch
MCP joints must be
able to flex
to 90 degrees
Extra padding
at exit points
Extra padding
at ulnar styloid
Wrist in slight
extension
Soft border of
padding at this end
Figure 21-13. Short-arm cast assessment.
Materials Utilized for Applying a Short-Leg Cast
3- or 4-inch stockinette (depending on leg size)
Three rolls of 3- or 4-inch padding
Three rolls of 4-inch fiberglass casting material
288 Chapter 21— Casting and Splinting
Procedure for Applying a Short-Leg Cast
Note: A short-leg cast should extend from
the tibial tubercle to just proximal to the
metatarsal-phalangeal (MTP) joints of all
toes. If properly applied, it should immobilize
the foot, ankle, and lower leg, yet allow full
flexion at the knee and full range of motion
of all the MTP joints, including the little toe.
It is most often used for ankle fractures or
severe ankle sprains.
1. Place (and maintain) the extremity in the
proper position of function, as previously
described.
2. Apply stockinette, as previously described.
Be sure to extend the stockinette well
beyond the anticipated cast borders.
3. Apply cast padding, as previously
described. Be sure to extend the cast
padding beyond the anticipated cast
borders so that it (and the excess
stockinette) can later be folded over the
rough cast edges. Apply additional
padding at the proximal end of the cast
(at the tibial tubercle), over the
metatarsal pad area, over the head of the
fifth metatarsal, and especially over the
heel.
Caution: Do not pad the heel by wrapping
circumferentially because cast padding will
bulk up at the dorsal ankle area. To apply
heavy padding to the heel, tear strips of
cast padding and lay them over the heel.
4. Roll on the fiberglass casting material,
beginning at the ankle and proceeding
proximally up the lower leg.
5. After each roll of fiberglass is applied,
mold the cast to the leg (and foot) using
your palms, as previously described.
6. Prior to rolling the final layer of cast
material, pull the stockinette and cast
padding over each cast edge and secure
them with the final layer of cast material.
This creates a nicely padded and rolled-
edge border.
7. If the cast is to be used for walking, apply
extra layers of reinforcement to the
bottom surface and heel area for increased
strength and durability, and strap a cast
boot to the finished cast.
Note: Weight bearing must be restricted until
the cast material has fully cured and
hardened (1 to 2 hours for fiberglass casts;
4 to 6 hours for plaster casts). Premature
weight bearing will cause cracking and
denting of the cast.
8. Perform a post-application assessment,
evaluating each feature illustrated in
Figure 21-14.
Low enough to
allow 90 degree
knee flexion
Extra padding
at fibular head
Soft border of
padding on top edge
Extra padding over
tibial tubercle
Ankle dorsiflexed
to 90 to 100 degrees
to allow walking
Extra padding over
medial and lateral
malleoli
Soft border
of padding
at toes
Cast extends
to first MTP
joint to
support foot
Extra cast material at
foot to prevent breakdown
Figure 21-14. Short-leg cast assessment.
Chapter 21 — Casting and Splinting 289
Materials Utilized for Applying a Short-Arm Ulnar
Gutter Splint
3- x 12-inch prefabricated splint
Bucket of cool water
Dry towel
2- or 3-inch ACE bandage or Coban wrap
Procedure for Applying a Short-Arm Ulnar Gutter Splint
Note: A short-arm ulnar gutter splint extends
from the tip of the little finger to just below
the elbow and like a U-shaped gutter. It runs
along the ulnar border of the hand and
forearm. If properly applied, it immobilizes
the fourth to fifth digits, the ulnar border of
the hand, the wrist, and the distal forearm.
It is used to treat fractures of the fifth
metacarpal.
1. Although prefabricated splints contain a
layer of padding, additional padding can
be added over the ulnar styloid process
for additional comfort.
Note: No stockinette is used with splints
because of the risk of constriction from
acute swelling.
2. Immerse the splint in a bucket of cool water.
3. Remove excess water from the splint by
rolling it up tightly, or by rolling it like a
jellyroll in a dry towel.
4. With the help of an assistant, maintain the
patient's arm in the position of function
while properly positioning the splint on
the patient's bare arm. If the splint is too
long, simply fold it away from the arm at
the proximal end. Carefully avoid making
fingerprint indentations in the splint.
Caution: When using a prefabricated splint,
remember to place the padded side of the
splint against the patient's skin.
5. Secure the splint using an ACE bandage or
Coban wrap, beginning distally and
proceeding proximally
6. Gently mold the splint around the ulnar
aspect of the arm and hand.
7. After the splint sufficiently hardens,
remove the wrap and neatly rewrap
it. In order to permit mobility of the
thumb, index, and middle fingers,
exclude them from the final elastic
wrapping.
8. Perform a post-application splint
assessment.
290 Chapter 21— Casting and Splinting
Materials Utilized for Applying a Short-Leg Posterior
Mold Splint
5- x 30-inch prefabricated splint
Bucket of cool water
Dry towel
3- or 4-inch ACE bandage or Coban wrap
Procedure for Applying a Short-Leg Posterior Mold Splint
Note: A short-leg posterior mold splint
extends along the posterior aspect of the
lower leg, from two fingerbreadths distal to
the popliteal fossa to the distal ends of the
toes. If properly applied, it should
immobilize the foot and ankle yet allow full
flexion at the knee. This type of splint is
commonly used for initial immobilization of
ankle sprains and fractures.
1. Although prefabricated splints contain a
layer of padding, additional padding is
frequently used over the medial and
lateral malleoli, metatarsal pad area, head
of the fifth metatarsal, and heel.
Note: No stockinette is used with splints
because of the risk of constriction from
acute swelling.
2. Immerse the splint in a bucket of cool
water.
3. Remove excess water from the splint by
rolling it up tightly, or by rolling it like a
jellyroll in a dry towel. It is important to
remove as much water from the splint as
possible in order to prevent water from
pooling at the heel of the splint and
causing skin breakdown.
4. With the help of an assistant, maintain the
patient's foot and ankle in the position of
function. Properly position the splint on
the patient's lower leg, starting behind the
knee and progressing to the foot. If the
splint is too long, simply fold it back on
itself, away from the body, at the distal
end. Carefully avoid making fingerprint
indentations in the splint.
Caution: When using a prefabricated splint,
remember to place the padded side of the
splint against the patient's skin.
5. Secure the splint using an ACE bandage or
Coban wrap, starting just below the knee
and working to the foot. To prevent
pressure sores, be sure that the folds in
the splint at the ankle area are directed
outward and are not pointing in toward
the skin.
6. Gently mold the splint around the
posterior aspect of the lower leg, ankle,
and foot.
7. Perform a post-application splint
assessment.
Note: A long-leg posterior mold splint is
constructed in a similar fashion, except that
it includes the entire lower extremity with
the knee in full extension. It is constructed
using 2 to 3 rolls of 4-inch padding, a
5- x 45-inch splint, and additional padding
over the medial and lateral malleoli,
metatarsal pad area, head of the fifth
Chapter 21 — Casting and Splinting 291
metatarsal, and heel. It is often used for
initial stabilization of tibia fractures.
Note: A long-arm posterior mold is
constructed in a similar fashion, except that
the entire upper extremity is splinted with
90 degrees of elbow flexion and neutral
forearm pronation/supination. It is
constructed using three rolls of 3-inch
padding, a 4- x 30-inch splint, and additional
padding over olecranon, medial and lateral
epicondyles, and ulnar styloid process. It is
often used for initial stabilization of mid- or
proximal forearm fractures, or fractures of
the distal humerus.
Materials Utilized for Applying a Lower Leg Sugar
Tong Splint
3- x 45-inch prefabricated splint
Bucket of cool water
Dry towel
3- or 4-inch ACE bandage or Coban wrap
Procedure for Applying a Lower Leg Sugar Tong Splint
Note: A lower leg sugar tong (or "stirrup")
splint is a U-shaped splint that starts at the
medial aspect of the knee, passes under the
foot, and extends to the lateral aspect of
the knee. If properly applied, it provides
great mediolateral support to the ankle,
while allowing full range of motion of toes
and knee. The sugar tong splint is an
alternative to the posterior mold when
splinting the lower leg.
1. Although prefabricated splints contain
a layer of padding, additional padding
is frequently used over the bony
prominences, especially at the medial
and lateral malleoli.
Note: No stockinette is used with splints
because of the risk of constriction from
acute swelling.
2. Immerse the splint in a bucket of cool
water.
3. Remove excess water from the splint by
rolling it up tightly, or by rolling it like a
jellyroll in a dry towel.
4. With the help of an assistant, maintain the
patient's foot and ankle in the position of
function while properly positioning the
splint. Start by positioning the splint just
inferior to the knee on the medial side of
the leg, pass it under the heel, and then
up along the lateral side of the leg in a
symmetrical fashion. If the splint is too
long, simply fold it back on itself, away
from the leg, at its lateral end. Carefully
avoid making fingerprint indentations in
the splint.
Caution: When using a prefabricated splint,
remember to place the padded side of the
splint against the patient's skin.
5. Secure the splint using an ACE bandage or
Coban wrap, starting at the foot and
working to the knee.
continued
292 Chapter 21— Casting and Splinting
6. Gently mold the splint around the medial
and lateral aspects of the lower leg, ankle,
and foot.
7. Perform a post-application splint
assessment.
Note: An upper arm sugar tong splint is
constructed in a similar manner, but it starts
at the proximal medial upper arm, passes
under the elbow, and extends to the distal
lateral aspect of the upper arm. It requires a
3- x 30-inch splint and additional padding
over the medial and lateral epicondyles. If
properly applied, it provides good
stabilization (and some traction) of the
upper arm while allowing for some
pronation/supination and full range of
motion of the wrist and hand. It is often
used for initial stabilization of humeral
fractures.
Note: A lower arm (forearm, short-arm)
sugar tong splint is constructed in a similar
manner, but it starts at the volar wrist,
passes around the elbow, and extends to the
volar wrist. It requires two or three rolls of
2- or 3-inch cast padding, a 3- x 30-inch
splint, and additional padding over the bony
prominences, especially at the medial and
lateral epicondyles. If properly applied, it
provides good stabilization of the forearm
while allowing full range of motion of the
fingers and shoulder. It is often used for
initial stabilization of mid- or proximal
forearm fractures.
FOLLOW-UP CARE AND
INSTRUCTIONS
Evaluation After Casting
Perform a careful assessment of the cast or splint before sending the
patient out of the casting area.
Make sure that the cast or splint extends to the proper boundaries, yet
does not interfere with the range of motion of necessary joints.
Check for finger indentations and sharp edges. Using the cast saw or
bandage scissors, trim back the cast and repad or recast if necessary.
■ Be sure to ask the patient how the cast feels, allowing a few minutes so
he or she can determine whether there are areas of increased pressure
or sharp edges. If this step is neglected, an unhappy patient will return
hours later for cast modification.
Cast Aftercare
For upper extremity casts and splints, a sling provides elevation (to
reduce swelling) and support (for comfort). When issued a sling, the
patient should be instructed to briefly remove it three to four times each
day to perform shoulder and elbow range-of-motion exercises to help
prevent excessive stiffness and loss of function.
A cast boot is usually applied to protect a short-leg cast. Most lower
extremity casts initially are non-weight bearing until healing progresses
over the following days or weeks.
Chapter 21 — Casting and Splinting 293
Provide the patient with crutches, a walker, or another assistive device,
if needed, along with complete instructions.
Advise the patient to avoid getting the cast wet. A wet cast leads to cast
breakdown and skin maceration. Before showering, a towel should be
wrapped around the top of the cast, followed by a plastic bag that is
tightly secured over the cast with tape. Tell the patient that a hairdryer
may be used to dry a fiberglass cast and its padding, if needed. If
minimally damaged, a plaster cast can be reinforced with additional
casting material. More extensive damage may necessitate cast removal
and reapplication.
Instruct the patient not to insert any objects under the cast in an
attempt to relieve itching.
Instruct the patient to return for a cast or splint check in 3 to 7 days. A
splint may be replaced with a cast at this time.
Instruct patient to notify you promptly of any numbness, tingling,
weakness, skin lesions or discolorations, or, most important, increasing
pain in the immobilized extremity.
Cast Removal
Inform the patient that an oscillating cast saw (Fig. 21-15) is designed to
cut rigid cast material, but not padding, stockinette, or underlying skin.
The clinician may demonstrate to the patient that the saw does not cut
skin by gently touching the oscillating saw to the fleshy part of his or her
hand.
■ Sawing over bony prominences, however, should be avoided because
skin injuries can potentially occur in these locations. A long strip of rigid
plastic is sometimes used to slip inside the cast to form a barrier
between the saw blade and the patient's skin. This is especially useful
Figure 21-15. Oscillating cast saw.
294 Chapter 21— Casting and Splinting
when removing a cast from an especially anxious patient. If this device is
not available, a wooden tongue depressor can be used to protect the
skin at either end of the cast.
When sawing, the saw blade should be firmly pressed against the cast at
a 90-degree angle until it can be felt to completely pass through the cast
shell. It should then be lifted out, moved to an adjacent spot, and the
process repeated. This vertical "in-and-out" sawing motion minimizes the
heat generated by the cast saw and minimizes the potential for skin
burns or abrasions that frequently occur when the saw is improperly
angled and dragged or pulled along the cast.
If the cast saw becomes too hot, turn it off until it sufficiently cools.
Don't risk burning the patient.
The cast should be cut down both sides. A special instrument known as
a cast spreader is then used to further widen the cut until the two cast
shells can be separated and removed. A bandage scissors is then used to
carefully cut off the underlying cast padding and stockinette.
Cast Window
Occasionally a window-like opening must be cut into an existing cast, or
incorporated into a new cast, to provide access for wound care or for removal
of a foreign object. The cast window must be large enough to accomplish its
purpose, yet not so large that it leads to window edema, compromises the
structural integrity of the cast, or compromises fracture immobilization.
Generally, a cast window for wound care should be no more than V2 to 1 inch
larger than the underlying wound.
Bibliography
Bucholtz RW, Kasser JR, Heckman JD, Beaty JH (eds): Rockwood, Green,
and Wilkins' Fractures, 5th ed. Philadelphia, Lippincott Williams &
Wilkins, 2001.
Hart J: Cast window. Body Cast. Accessed July 28, 2005. Available at:
http://www.pappin.com/csot/summer_2004a.html
Hutchinson MR, Ireland ML: Chronic exertional compartment
syndrome: Gauging pressure. Phys Sportsmed 27:101-102, 1999.
Mercier LR: Practical Orthopedics, 5th ed. St. Louis, Mosby, 2000.
Swain R, Ross D: Lower extremity compartment syndrome. When
to suspect acute or chronic pressure buildup. Postgrad Med
105:159-162, 165, 168, 1999.
Chapter 99
Local Anesthesia
Michelle DiBaise
Procedure Goals and Objectives
Goal: To perform local anesthesia successfully while observing
standard precautions and with the minimal degree of risk to the
patient.
Objectives: The student will be able to ...
• Describe the essential anatomy and physiology associated with
administering local anesthesia.
• Describe the indications, contraindications, and rationale for
administering local anesthesia.
• Identify and describe common complications associated with
administering local anesthesia.
• Identify the materials necessary for the administration of local
anesthesia and their proper use.
• Identify the important aspects of care after administration of
local anesthesia.
295
296 Chapter 22 — Local Anesthesia
BACKGROUND AND HISTORY
Local anesthesia provides reversible blockade of nerves, leading to loss of
sensation of pain. Topical application and direct infiltration anesthetizes the
immediate area. Regional blocks are designed to anesthetize larger areas via
a nerve or field block. Local anesthesia is used for a variety of reasons,
including but not limited to elimination of pain so that the following can be
carried out: repair of lacerations, skin surgery, treatment of painful oral or
genital lesions, and the removal of superficial lesions by chemical or physical
means.
Nearly painless anesthesia may be achieved in wound repair or skin surgery
when the location, surface area involved, and estimated length of time for the
procedure are considered. A patient's emotional response is also critical in
ensuring nearly painless anesthesia, as most patients fear that the injection
will be painful. Throughout this chapter, a combination of certain anesthetics
and procedural techniques are discussed that can help lessen the patient's
pain and anxiety.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
Local anesthetics act to block the conduction of nerve impulses by selectively
binding to voltage-dependent sodium channels. The vast majority of local
anesthetics may be divided into two main categories: esters and amides.
Local anesthetics contain a hydrophobic and a hydrophilic end joined together
by an ester or amide linkage (Strichartz, 1998; Page, 1997). The hydrophilic
portion allows the anesthetic to be water soluble so that it can be injected in
solution and diffuse to the nerves requiring blockade. The hydrophobic
portion allows the anesthetic to be lipid soluble and enter the neuronal
membrane. It is the hydrophilic end that subsequently binds to the voltage-
dependent sodium channel. The ester anesthetics include benzocaine
(e.g., Anbesol), cocaine, procaine (Novocain), and tetracaine (Cetacaine,
Pontocaine). The amide anesthetics include lidocaine (e.g., ELA-Max,
Xylocaine), mepivacaine (Carbocaine), bupivacaine (Marcaine), dibucaine
(Nupercaine), and prilocaine (EMLA, Citanest) (Table 22-1).
When proper concentrations of anesthetic are used, the conduction of
action potentials is blocked. This effect is reversible and nonspecific. Once
anesthetics are absorbed by the local circulation and metabolized or excreted,
nerve function returns to normal. Because local anesthetics are nonspecific,
they can act on all sensory nerves, depending on the dose administered. A
number of factors affect the rate of onset, intensity, and duration of sensory
nerve anesthesia. After reading this section and reviewing the multiple
variables that affect the quality of local anesthesia, it can be understood that
sensory nerve impulses are lost in the order of temperature sensation, pain,
touch, deep pressure, and, finally, motor.
Chapter 22- Local Anesthesia 297
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298 Chapter 22- Local Anesthesia
Rate of Conduction
Local anesthetics are much more likely to bind to sodium channels that have
rapid action potentials (such as those that carry pain impulses) than those
with slower action potentials.
Presence of Myelin
Unmyelinated nerve fibers (such as C-type pain and temperature fibers) are
more easily blocked by local anesthetics because they are smaller in
diameter and lack the lipid barrier of the myelin sheath. Pressure, touch, and
motor conduction are transmitted by larger diameter, A-type myelinated
fibers. The lipophilic local anesthetics become bound by the highly lipid
myelin sheath, which slows the amount of drug at the node, leading to slower
onset but longer duration.
Nerve Fiber Diameter
Larger doses of drug are needed to anesthetize larger nerve trunks, such as
digital nerves, and the onset of action is slower.
Vascularity of the Location
Anesthetized
In highly vascular areas, drug is rapidly removed from the area that requires
anesthesia, leading to the need for more drug or a vasoconstricting agent. A
shorter duration of action also results. All the local anesthetics are
vasodilatory in nature, except cocaine, which is a vasoconstrictor.
Use of Epinephrine
Adding a vasoconstricting agent such as epinephrine decreases blood flow,
reduces systemic absorption, shortens onset, and extends duration of action.
Epinephrine tends to be more effective with the less lipid-soluble agents
(lidocaine and mepivacaine) than with the more lipid-soluble agents
(bupivacaine) (Strichartz, 1998; Gage, 1997). As a general rule, the use of
epinephrine doubles the duration of anesthesia achieved with lidocaine
(Gonzalez del Rey, 1997). Caution must be exercised in using vasoconstrictive
agents in regions of the body supplied by a single vascular source, because
tissue necrosis may result.
Chapter 22- Local Anesthesia 299
Anesthetic Solution and Tissue pH
Most anesthetic solutions are acidic in order to maintain their stability or
shelf life. Once injected, however, they equilibrate to the pH of normal tissues.
This leads to the sensation of burning on injection. Buffering the anesthetic
solution with sodium bicarbonate can effectively eliminate this undesirable
side effect. Although buffering decreases the onset of action and increases
the effectiveness of the blockade, it decreases the shelf life. Plain lidocaine
buffered with bicarbonate has a shelf life of approximately 7 days (Usatine,
1998; Gonzalez del Rey, 1997). In addition, buffering can degrade epinephrine
if it is kept in a container exposed to light (Gonzalez del Rey, 1997). It is
unknown what the shelf lives of buffered mepivacaine and bupivacaine are
because studies have not been performed.
Because anesthetic solutions work best at physiologic pH, they are less
effective in infected tissues than in normal tissues because of the resultant
metabolic acidosis, which decreases pH (Strichartz, 1998).
Method and Technique of Injection
The nerve fibers are present at the junction of the dermis and the sub-
cutaneous fat. Direct infiltration of an open wound at this level provides
immediate blockade (Gonzalez del Rey, 1997). Direct infiltration of intact
skin, if started at the junction of the dermis and the subcutaneous fat, also
provides immediate and nearly painless anesthesia. If the injection is started
higher in the epidermis or at the dermal-epidermal junction, the blockade is
slightly slower and more painful. Digital nerve block is slower in onset
because of the larger nerve fibers. Technique is important because place-
ment of anesthetic immediately adjacent to a digital nerve can lead to
blockade within minutes, whereas delivery that is further from the nerve
trunk can delay onset and can lead to inadequate blockade and the possible
need for repeat injections.
Concentration of Solution
Solutions of higher concentration may lead to a slightly shorter onset of
action when compared with solutions of lower concentration, but this
difference is not markedly significant. For example, adding epinephrine to 1%
lidocaine achieves the same effect as using 2% lidocaine (Gonzalez del Rey,
1997).
Total Dose Provided
Increasing the dose leads to more effective blockade; however, too much can
lead to side effects. Maximal doses of anesthetic solutions are provided in
Table 22-1.
300 Chapter 22- Local Anesthesia
Rate of Metabolism
The ester anesthetics undergo metabolism first by being hydrolyzed by
plasma cholinesterases and liver esterases and then being excreted by the
kidneys (Hruza, 1999; Strichartz, 1998). They tend to have a shorter half-life
than the amide anesthetics (Strichartz, 1998). Amide anesthetics are
metabolized by first being Af-dealkylated and then being hydrolyzed by the
liver's endoplasmic reticulum. Because bupivacaine is highly bound to plasma
proteins and tissue at the injection site, it is more likely to cause side effects
in patients with severe liver disease (Strichartz, 1998). This is because of
reduced liver metabolism and a decreased concentration of plasma proteins,
which are made in the liver.
INDICATIONS
Local anesthesia in any procedure can be confined to one area of the body in
which pain or discomfort associated with the procedure can be anticipated.
The most common indication is in minor surgical procedures, including
repair of lacerations, incision and drainage of abscesses, removal of lesions,
biopsies, and nail removal.
CONTRAINDICATIONS
Topical Anesthetics
■ Cocaine-containing products are occasionally used to anesthetize adult
nasal mucosa; however, contact with these agents should be avoided in
infants and neonates. Unless used by a provider skilled in the use of
cocaine-containing products on the nasal mucosa, these products should
not be administered on the conjunctiva or nasal or oral mucosa. There is
a case report of an infant death associated with the use of a cocaine-
containing solution that accidentally came into contact with the nasal
and oral mucosa (Dailey, 1988). Cocaine-containing products should also
not be administered on the fingers, toes, penis, nose, and pinna of the
ear because of their vasoconstricting properties.
There are a few relative contraindications to the use of non-cocaine-
containing topical anesthetics in premature infants. Studies are mixed
concerning the possibility of the development of methemoglobinemia in
premature infants who were given a topical eutectic mixture of lidocaine
anesthetics (EMLA), but overall EMLA appears to be safe and effective in
most infants and children (Frey, 1999; Essink-Tjebbes, 1999).
Chapter 22 — Local Anesthesia 301
Local Anesthetics
Listed contraindications to the use of local anesthetics include the following:
■ Severely unstable blood pressure
True allergy
■ Severe liver disease when amide anesthetics are being considered
Severe renal disease when ester anesthetics are being considered (esters
are renally excreted) and mental instability (which might mask the
symptoms of adverse effects of lidocaine) (Hruza, 1999; Gonzalez del
Rey, 1997).
Epinephrine
Absolute contraindications to the use of epinephrine include the following:
■ Untreated hyperthyroidism or untreated pheochromocytoma
■ Administration to locations of the body that have a single, dependent
blood supply — such as the fingers, toes, penis, nose, and pinna of the
ear — or for use in a digital block
Relative contraindications to the use of epinephrine include the following:
■ Untreated hypertension
■ Severe coronary artery or peripheral vascular disease
■ Pregnancy
Narrow-angle glaucoma
■ Use in patients taking (3-blockers, phenothiazines, monoamine oxidase
(MAO) inhibitors, or tricyclic antidepressants
Epinephrine should be used cautiously in patients with relative contraindi-
cations by diluting the epinephrine in half or using it sparingly, or determining
not to use it at all.
POTENTIAL COMPLICATIONS
The most common complication seen with injection of anesthesia follows:
Development of anxiety over the impending injection and a subsequent
vasovagal reaction demonstrated by hypotension, bradycardia, and
syncope (Hruza, 1999; Gonzalez del Rey, 1997)
Local complications of injection are not as common and include the following:
Bruising
■ Edema
Infection
302 Chapter 22- Local Anesthesia
■ Prolonged or permanent nerve damage
■ Temporary motor nerve paralysis (Hruza, 1999; Gonzalez del Rey, 1997)
Systemic complications are uncommon; when they occur it is usually because
anesthetic is inadvertently injected into a vessel. This complication can be
avoided by making sure that blood cannot be aspirated before injecting the
anesthetic. Systemic reactions include the following:
Hypotension
Bradycardia
■ Central nervous system depression or stimulation, leading to slurred
speech, drowsiness, disorientation, tremor, restlessness, weakness,
seizures, paralysis, coma, respiratory failure, and cardiac dysrhythmias
This last complication is more common with bupivacaine than with the
other anesthetics. Prilocaine in large doses can lead to methemoglobinemia
(Hruza, 1999).
Epinephrine can lead to a number of side effects such as the following:
Cardiac dysrhythmias
■ Increased blood pressure
■ Anxiety
■ Cardiac arrest
■ Cerebral hemorrhage
Ischemia if used in areas of end artery flow such as the digits, penis,
nose, and pinna of the ear, leading to skin necrosis, especially in patients
with poor circulation
Treatment of complications tends to be supportive. The patient should be
placed in the Trendelenburg position, which usually reverses hypotension
and bradycardia (Hruza, 1999; Gonzalez del Rey, 1997). If hypotension
continues, an intravenous infusion of normal saline can be started, an airway
maintained, supplemental oxygen administered, and cardiac monitoring with
frequent vital signs begun (Gonzalez del Rey, 1997). Seizures are generally
controlled by administration of intravenous diazepam (Valium).
Benzocaine is a para-aminobenzoic acid (PABA) derivative that has a
tendency to cause allergic contact dermatitis. The literature cites that
patients sensitive to benzocaine may also be sensitive to thiazide diuretics,
sulfonylureas, sulfonamides, paraphenylenediamine, and para-aminobenzoic
acid-based preparations. Because benzocaine is an ester anesthetic,
patients hypersensitive to this agent may also be sensitive to other ester
anesthetics such as procaine (Novocain), which is rarely used because of the
rate of true allergic reactions, and tetracaine, but they will not be sensitive to
the amide anesthetics.
True allergic reactions are rare among amide anesthetics but are more
frequent with the older ester anesthetics. Allergic reactions may be caused
Chapter 22- Local Anesthesia 303
by the preservative methylparaben or bisulfites, which are used in multiple-
dose vials. True allergy is characterized by a skin rash, localized or general
urticaria, angioedema, and, rarely, anaphylaxis with hypotension and
bradycardia. Only 1% of all patients receiving local anesthesia demonstrate
a true allergic response (Gonzalez del Rey, 1997).
Allergic reactions are managed with airway management and administration
of supplemental oxygen, intravenous access, and administration of
epinephrine, diphenhydramine, and corticosteroids as needed (Hruza, 1999,
Gonzalez del Rey, 1997).
Assessment of patients with a reported allergy to local anesthetics should
include determining the offending anesthetic and substituting it with a
different class (i.e., if allergic to an ester, use an amide, and vice versa) or
skin test the patient with a preservative-free anesthetic. If the patient has a
true anesthetic allergy, Benadryl, normal saline, no anesthetic, or conscious
sedation are all accepted alternatives.
to exercise clinical judgment based on the
Standard Precautions Practitioners should use patient's history and the potential for exposure
standard precautions at all times when to body fluids or aerosol-borne pathogens (for
interacting with patients. Determining the level further discussion, see Chapter 2).
of precaution necessary requires the practitioner
PATIENT PREPARATION
Several techniques have been offered to decrease the pain and anxiety that
can accompany an injection of anesthetic.
■ Because of the way local anesthesia affects the sensory nerve impulses
(see "Review of Essential Anatomy and Physiology"), an anxious patient
may perceive touch as if it were pain. Therefore, reassuring the patient
and explaining the expectations of the procedure are key to ensuring
nearly painless anesthesia.
■ Because the most common reaction to local anesthesia is a vasovagal
response or syncope, the patient needs to be in the supine position,
placed so that he or she cannot see the injection being administered.
Engaging in conversation should distract the patient.
■ Inform the patient what is being done at each step.
Encourage the patient to take deep, slow breaths to avoid hyperventilation.
Continue to reassure the patient throughout the procedure of injection.
■ For anxious patients or children, conscious sedation with a
benzodiazepine may be necessary; however, detailing its use is beyond
the scope of this chapter.
■ Use cryoanesthetic, such as ice, ethyl chloride, tetrafluoroethane (Medi-
Frig), fluoroethyl (25% ethyl chloride, 75% dichlorotetrafluoroethane), or
304 Chapter 22 — Local Anesthesia
liquid nitrogen before an injection. This technique can also be used for
anesthesia before curettage of superficial lesions as described in Chapter
24. Cryoanesthetics provide short periods of decreased pain sensation.
For purposes of anesthesia before injection, liquid nitrogen is not
preferred because it can be painful and may lead to unwanted tissue
destruction.
Warming the local anesthetic has not been known to reduce the pain of
anesthetic injection significantly and requires time and effort to warm
the vial or syringe to 37° C to 40° C and then rapidly inject the anesthetic
before it cools (Gonzalez del Rey 1997).
Materials Utilized for Administering Anesthetics
Topical Anesthesia
Note: There are a number of benefits to topical anesthesia compared with
injection and include lack of injection (therefore, no discomfort), ease of
administration, decreased need for physical restraints, and no distortion of
the anatomy. Topical anesthesia tends to work better on the highly vascular
face and scalp than on the trunk or proximal extremities (Gonzalez del Rey,
1997; Trott, 1997). When using topical anesthesia for wound closure, it
should be limited to lacerations of 5 cm or less in order to avoid the
complication of systemic absorption (Gonzalez del Rey, 1997; Trott, 1997).
Note: Topical anesthetics are divided into amides (lidocaine, prilocaine),
esters (benzocaine, tetracaine), and nonamides, nonesters (dimethisoquin,
dyclonine, pramoxine). Each specialty tends to have one topical anesthetic
that is preferred over others. Anesthesia of the conjunctiva can be
accomplished by the use of proparacaine or tetracaine eye drops (Hruza,
1999). Topical benzocaine is commonly added as an agent for sunburn
relief. It is, however, a common contact sensitizer and should generally be
avoided. Anesthetics available for use on the superficial mucous membranes
include dyclonine (Dyclone), benzocaine (Anbesol and others), tetracaine
(Cetacaine), viscous lidocaine, and lidocaine jelly. Deeper anesthesia of the
mucous membranes can be accomplished with a 4% to 10% solution of
cocaine. Cocaine-containing products increase the cost of the anesthetic
and need to be stored and disposed of under strict protocols. Cocaine-
containing products also may be used to anesthetize lacerations. Examples
of cocaine-containing products include:
■ TAC: tetracaine 0.5%, epinephrine 1:2000, cocaine 11.8%
■ TAC, V2 strength: tetracaine 1%, epinephrine 1:2000, cocaine 4%
or tetracaine 0.25%, epinephrine 1:4000, cocaine 5.9%
Other topical agents without cocaine used for wound repair include:
■ LAT: lidocaine 4%, epinephrine 1:2000, tetracaine 1%
Chapter 22 — Local Anesthesia 305
■ TLE: lidocaine 5%, epinephrine 1:2000
Note: All these products can be prepared by a pharmacist as a liquid or gel;
however, although gels decrease the risk of mucosal exposure, they may
also decrease the amount of total dose delivered (Usatine, 1998; Gonzalez
del Rey, 1997). Some authors have stated that TAC/LAT/TLE combinations
provide inconsistent anesthesia for lacerations on the extremities, leading
to the need for supplemental anesthetic injection (Gonzalez del Rey, 1997).
Note: For intact skin, superficial anesthesia can be achieved with EMLA
(eutectic mixture of lidocaine anesthetics) or ELA-Max (4% lidocaine).
EMLA is 50% lidocaine and 50% prilocaine in an acid-mantle cream. Neither
cream should be used on mucous membranes or conjunctiva because of
the risk of greater absorption leading to potential systemic side effects.
■ Other equipment
Cotton-tipped applicators or gauze pads
Materials to clean the wound or anesthesia site
Injection Anesthesia
The most commonly used agents follow:
Lidocaine (Xylocaine 1% and 2%, with and without epinephrine)
■ Rapid onset of action
■ Readily penetrates nerve sheaths, leading to an almost immediate
anesthesia with local infiltration
For direct wound infiltration, the duration of action is approximately 20
to 30 minutes and is approximately 60 to 120 minutes for nerve blocks
Caution: There is a subset of patients who metabolize lidocaine quickly and
require repeat injections.
Note: The use of epinephrine with lidocaine increases the duration of
action and improves local hemostasis.
Method of buffering lidocaine: 1 mL of bicarbonate + 9 mL of 1%
lidocaine
Note: Buffering of 2% solutions may cause precipitation.
Note: The shelf-life of buffered lidocaine is 7 days.
■ Mepivacaine (Carbocaine 1% and 2%)
■ Slightly longer onset of action with direct infiltration (6 to 10 minutes),
but the duration of action is longer, approximately 30 to 60 minutes
■ Does not cause as much vasodilation as lidocaine; therefore, does not
require epinephrine for hemostasis
Method of buffering mepivacaine: 0.5 to 1 mL of bicarbonate + 9 mL of
mepivacaine
Shelf life unknown; therefore, do not use after 24 hours
306 Chapter 22 — Local Anesthesia
■ Bupivacaine (Marcaine 0.25% and 0.5%)
Slow onset of action (8 to 12 minutes) with direct infiltration, but the
duration of action is much longer than with either lidocaine or
mepivacaine. It lasts approximately four times longer than lidocaine,
offering significant postsurgical relief from pain.
Method of buffering bupivacaine: 0.1 mL of bicarbonate + 20 mL of
bupivacaine
Note: The shelf life is unknown; therefore, do not use after 24 hours.
Diphenhydramine (Benadryl)
■ For allergic reaction to amide or ester anesthetics, or both,
alternatives include Benadryl and normal saline or no anesthesia.
Provide adequate anesthesia for at least 30 minutes.
■ Benadryl should be diluted to 12.5 mg/mL with normal saline.
Note: The technique for direct infiltration with Benadryl is the same as with
other anesthetics. Benadryl, however, is more painful to inject than
lidocaine and is not reduced by buffering.
Other equipment
Materials to clean the site or wound
Materials to ensure sterile technique
■ 27- or 30-gauge needle V2- to !4-inch length
■ A syringe, size dependent on the quantity of anesthetic to be injected
The injectable anesthetic
Procedure for Using Topical Anesthesia
1. For intact skin, achieve superficial
anesthesia with EMLA (50% lidocaine and
50% prilocaine in an acid-mantle cream)
or ELA-Max (4% lidocaine).
Note: Neither cream should be used on
mucous membranes or conjunctivae because
of the risk of greater absorption leading to
potential systemic side effects. Young
children should be watched closely to avoid
accidental ingestion.
2. When applying ELA-Max, do not keep on
skin for more than 2 hours at a time.
Note: Anesthesia with EMLA and ELA-Max
works best for removal of superficial skin
lesions, for some laser procedures, and
before injection of anesthetic. With both
creams, the depth of anesthesia is directly
proportional to the duration of application
and lasts for several hours. ELA-Max appears
to have a more rapid onset of action than
does EMLA. Neither cream appears to cause
irritating effects or hypersensitivity
reactions with repeated or prolonged use.
3. Gently remove blood clots from the area.
Chapter 22 — Local Anesthesia 307
4. For wound repair, saturate a gauze sponge
or cotton swab with anesthetic.
5. Fold the anesthetic-saturated sponge into
and around the wound and tape into
place.
6. Have the parent or assistant (or yourself)
apply constant, gentle pressure for 15 to
20 minutes.
Note: The person applying pressure should
wear gloves in order to avoid absorption.
Note: Anesthesia is complete when
blanching is observed around the wound.
One report stated that about 5% of wounds
require supplemental injection of local
anesthetic to achieve complete anesthesia.
Studies have also shown that about 2 to
3 mL of topical anesthetic is sufficient to
provide anesthesia for most wound repairs
(Gonzalez del Rey, 1997).
7. If administering EMLA or ELA-Max, cover
the area requiring treatment with a
^-inch-thick layer of cream.
Note: EMLA is then occluded with a plastic
adhesive dressing 1 hour before the
procedure. ELA-Max does not require
occlusion, although this may be performed.
8. Remove both creams before the start of
the procedure.
Procedure for Administering Local Anesthetic by Injection
Note: Nearly painless anesthesia is more
likely with the use of a 27- or 30-gauge
needle. This occurs not only because the
caliber of the needle is smaller but also
because it decreases the speed with which
anesthetic is injected. Rapid tissue
expansion is more uncomfortable for the
patient, so the provider should aim for a
slow injection technique, which will be
facilitated by selecting a 1- to 3-mL syringe.
Note: Needle length varies from V2 to
1!4 inch. The shorter length is adequate for
small punch biopsies, whereas longer
needles are better for larger excisions,
wound infiltration, and field and digital
blocks.
Direct Infiltration of
Wounds
1. Initiate the injection on the side where
sensory innervation originates and then
proceed distally
Note: Direct wound infiltration is
recommended in most minimally
contaminated wounds. The injection should
be located between the dermis and the
subcutaneous fat. Tissue resistance is less
and the sensory nerves are rapidly affected
by the anesthetic at this level.
2. Once the needle is inserted, aspirate to
ensure that the needle is not in a vessel. If
no blood is withdrawn, inject a small
amount of anesthetic.
3. Reposition the needle adjacent to, but still
within, the area where anesthetic was
placed.
4. Aspirate and proceed to inject if no blood
is withdrawn.
5. Continue to repeat the preceding steps
until all edges of the wound are
anesthetized.
6. If at any time bloody aspirate is obtained,
withdraw the needle slightly and aspirate
until clear. A 3- to 4-cm laceration should
continued
308 Chapter 22- Local Anesthesia
Field Block
Figure 22-1.
require about 3 to 5 mL of anesthetic
(Hruza, 1999; Gonzalez del Rey, 1997)
(Fig. 22-1).
Local Infiltration of Intact
Skin
1. Clean the intended procedure site with an
alcohol wipe or alternative antiseptic.
2. Pinch the skin in the vicinity of the
injection site. This decreases the
sensation of pain from the injection.
3. Infiltrate at the junction of the dermis and
subcutaneous fat and then reposition the
needle to the level of the epidermis and
inject a small amount of anesthetic.
Note: Always remember to aspirate before
injection. For punch biopsies, only 1 to 2 mL
of anesthetic is generally required.
Note: Field block is an alternative to direct
wound infiltration when a larger area
requires treatment or, in wounds that are
grossly contaminated, to avoid bacterial
spread. It has the advantage of fewer
injections than direct wound infiltration.
1. Start the injection in the same plane as
described in local infiltration of intact
skin; however, a larger bore (25- to
27-gauge), ll/4- to 2-inch needle is required.
2. Insert the needle into the skin and
advance to the hub parallel to the dermis
and subcutaneous fat. After aspiration, a
slow injection of anesthetic is left as the
needle is withdrawn to the insertion site.
3. Reinsert the needle at the end of the first
track and repeat the procedure until a
wall of anesthesia surrounds the area to
be treated (Usatine, 1998; Gonzalez del
Rey, 1997) (Fig. 22-2).
Figure 22-2. (Adapted from Pfenninger JL,
Fowler JC: Procedures for Primary Care Physicians.
St. Louis, Mosby-Year Book, 1994, p 147.)
Digital Block
Note: 1% lidocaine or 1% mepivacaine without
epinephrine, with or without bicarbonate,
and 2% lidocaine without epinephrine or
bicarbonate are commonly used for digital
blocks (Strichartz, 1998; Page, 1997; Gage,
1997). Lidocaine with bupivacaine is an
alternative. Bupivacaine's onset of action is
too slow to use alone. It does accord longer
duration of action for extended procedures
as well as significant postoperative relief of
discomfort for the patient.
Note: A digital block is generally
recommended for procedures distal to the
midproximal phalanx of the digit and is
preferred for nail avulsion, paronychial
drainage, and repair of lacerations of the
digits.
1. A digital nerve block is accomplished by
injecting anesthetic just distal to the web
space in the middle of the digit.
2. After aspirating, inject 0.1 mL of anesthetic
locally into the epidermis.
3. Advance the needle to the bone, withdraw
slightly, and then move dorsally, where
0.5 mL of anesthetic is injected after
aspiration.
4. Withdraw the needle again to the midline,
advance to bone, and move ventrally
where another 0.5 to 1 mL of anesthetic is
injected after aspiration.
5. Withdraw the needle and repeat the whole
procedure on the other side of the digit
(Fig. 22-3).
Note: Larger volumes of anesthetic are not
required if injected near the nerve. The
needle should always be withdrawn between
dorsal and ventral injections to avoid nerve
and vessel damage. Anesthesia is reported
to occur anywhere from 4 to 20 minutes after
injection, depending on the anesthetic and
technique used.
Dorsal
digital nerve
Chapter 22- Local Anesthesia 309
Bone
Palmar
digital nerve
Figure 22-3. (Adapted from Pfenninger JL,
Fowler JC: Procedures for Primary Care Physicians.
St. Louis, Mosby-Year Book, 1994, p 149.)
Note: There are alternatives to the method
described for performing a digital block.
Alternatives to Performing a
Digital Block
1. Since the second to fifth toes are small,
one technique uses a dorsal midline
injection. Anesthetic is then deposited on
one side of the toe.
2. Withdraw the needle and move to the
opposite side without completely
withdrawing the needle from the skin
(Gonzalez del Rey 1997).
Caution: This technique is not recommended
for the great toe.
Note: For surgery on the distal nail unit,
periungual administration may be performed.
It is essentially a field block technique of the
nail unit (see Chapter 28). It is more painful
than a digital block but is more rapid in
onset.
1. It is completed by injecting first along one
lateral nail fold, then perpendicularly
along the proximal nail fold, and then
along the opposite lateral nail fold. Lastly,
anesthetic is administered in the
hyponychial area (Gonzalez del Rey, 1997).
continued
310 Chapter 22 — Local Anesthesia
2. Another alternative is to inject at a
30-degree angle into the middle of the
proximal nail fold, where the needle is
then advanced distally under the nail
matrix.
3. After aspiration, inject anesthetic as the
needle pierces the nail plate, the nail
matrix, and the nail bed.
Note: The nail matrix and nail bed will
blanch with injection of anesthetic. It is
painful, but anesthesia is immediate. This
type of anesthesia can be used for most
procedures performed on the proximal half
of the nail unit, but not for removal of the
nail matrix or complete nail avulsion
(Gonzalez del Rey, 1997).
Note: Other digital blocks used include
supraorbital, supratrochlear, infraorbital,
mental, auricular, median, ulnar, radial, sural,
and tibial. These are used for procedures or
repair of lacerations covering a large surface
area; however, their description is beyond
the scope of this book.
FOLLOW-UP CARE AND
INSTRUCTIONS
Complications from local anesthesia are uncommon. Occasionally a patient
exhibits sensitivity to a component of the anesthetic, which may later
present as a rash or inflammatory reaction.
Instruct the patient to notify the office if there is any unusual skin color,
itching, or pain in the area where the anesthetic was injected, or if
sensation does not return promptly after the anesthesia was to have
worn off.
References
Dailey RH: Fatality secondary to misuse of TAC solution. Ann Emerg
Med 17:159-160, 1988.
Essink-Tjebbes CM, Hekster YA, Liem KD, et al: Topical use of local
anesthetics in neonates. Pharm World Sci 21:173-176, 1999.
Frey B, Kehrer B: Toxic methaemoglobin concentrations in premature
infants after application of a prilocaine-containing cream and
peridural prilocaine. Eur J Pediatr 158:785-788, 1999.
Gage TW: Drugs in dentistry. In Page CP, Curtis MJ, Sutter MC, et al
(eds): Integrated Pharmacology. St. Louis, CV Mosby, 1997,
pp 383-398.
Gonzalez del Rey JA, DiGiulo GA: Wound care and the pediatric patient.
In Trott AT (ed): Wounds and Lacerations: Emergency Care and
Closure, 2nd ed. St. Louis, CV Mosby, 1997, pp 38-52.
Hruza GJ: Dermatologic surgery: Introduction and approach. In
Fitzpatrick TB, Eisen AZ, Wolff K, et al (eds): Dermatology in
General Medicine, 5th ed. New York, McGraw-Hill, 1999,
pp 2923-2937.
Page CP, Curtis MJ, Sutter MC, et al: General principles of drug action.
In Page CP, Curtis MJ, Sutter MC, et al (eds): Integrated
Pharmacology. St. Louis, CV Mosby, 1997, pp 17-52.
Chapter 22 — Local Anesthesia 311
Strichartz GR: Drugs affecting peripheral transmission: Local
anesthetics. In Brody TM, Larner J, Minneman KP (eds): Human
Pharmacology: Molecular to Clinical, 3rd ed. St. Louis, CV Mosby,
1998, pp 151-156.
Trott AT: Infiltration and nerve block anesthesia. In Trott AT (ed):
Wounds and Lacerations, 2nd ed. St. Louis, CV Mosby, 1997, pp 53-89.
Usatine RP, Moy RL: Anesthesia. In Usatine RP, Moy RL, Tobinick EL,
et al (eds): Skin Surgery: A Practical Guide. St Louis, CV Mosby, 1998,
pp 20-30.
Bibliography
Fine JD, Arndt KA: Medical dermatologic therapy. In Orkin M, Maibach
HI, Dahl MV (eds): Dermatology. Norwalk, Conn, Appleton & Lange,
1991, pp 635-656.
Kechijian P: Nail surgery. In Fitzpatrick TB, Eisen AZ, Wolff K, et al
(eds): Dermatology in General Medicine, 5th ed. New York,
McGraw-Hill, 1999, pp 2992-3002.
Kongsiri AS, Ciesielski-Carlucci C, Stiller MJ: Topical nonglucocorticoid
therapy. In Fitzpatrick TB, Eisen AZ, Wolff K, et al (eds): Dermatology
in General Medicine, 5th ed. New York, McGraw-Hill, 1999,
pp 2717-2726.
Ries CR, Sutter FM, Sutter MC: Drugs used in surgery. In Page CP,
Curtis MJ, Sutter MC, et al (eds): Integrated Pharmacology. St. Louis,
CV Mosby, 1997, pp 399-410.
Roenigk HH: Dermatologic surgery in dermatology. In Orkin M, Maibach
HI, Dahl MV (eds): Dermatology. Norwalk, Conn, Appleton & Lange,
1991, pp 657-662.
Chapter OQ
Wound Closure
Karen A. Newell
Procedure Goals and Objectives
Goal: To reapproximate wound edges with sutures, staples, or skin
adhesive successfully in order to facilitate wound healing and
reduce the likelihood of infection.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing wound closure.
• Identify and describe common complications associated with
wound closure.
• Describe the essential anatomy and physiology of the skin
associated with the performance of wound closure.
• Identify the materials and tools necessary for performing wound
closure and their proper use.
• Identify the important aspects of post-procedure care after
wound closure.
313
314 Chapter 23-Wound Closure
BACKGROUND AND HISTORY
Wound closure has been in existence for many years in the practice of
medicine. Although wound closure typically is associated with suturing the
wound, many materials have been used over time. The word suture describes
any strand of material used to ligate (tie) blood vessels or approximate (sew)
tissues. The first written description of sutures used in operative procedures
is recorded in the Edwin Smith Papyrus, the oldest known surgical document.
This document has Egyptian origins and dates back to the 16th century bc.
Dating as far back as 2000 bc, written references have been found describing
the use of strings and animal sinews for suturing.
Rhazes of Arabia was credited in 900 ad with first using kit gut to suture
abdominal wounds. The Arabic word kit means a dancing master's fiddle. In
those days the musical strings of fiddles, called kit strings, were made of
sheep's intestines. It has been speculated that Rhazes used these to suture.
The term catgut is thought to have evolved from these origins.
Through the centuries, a wide variety of materials — silk, linen, cotton, horse-
hair, animal tendons and intestines, and wire made of precious metals — has
been used in operative procedures. Some of these materials are still in use
today. The evolution of suturing material has brought us to a point of refine-
ment that includes sutures designed for specific surgical procedures. They
not only eliminate some of the difficulties the surgeon may have previously
encountered during closure but decrease the potential for infection post-
operatively. Despite the sophistication of today's suture materials and surgical
techniques, closing a wound still involves the same basic procedure used by
physicians to the Roman emperors (Ethicon, 1985).
INDICATIONS
Most superficial wounds heal without intervention. However, a superficial
skin laceration extending into the subcutaneous tissues should be con-
sidered for closure in order to avoid undesirable outcomes. Suture, staple, or
skin adhesive closure of wounds may be warranted for the following reasons:
To decrease the time required for the wound to heal
To reduce the likelihood of infection
To decrease the amount of scar tissue likely to form
To repair the loss of structure or function, or both, of the tissue
To improve cosmetic appearance
CONTRAINDICATIONS
Before any wound or laceration repair is initiated, a thorough evaluation of
the patient must be carried out. Remember that all wounds, no matter how
Chapter 23-Wound Closure 315
minor they may appear, can be the result of serious injury to underlying
structures. The basic history, general physical examination, and wound
examination help define the repair strategy and help identify more serious
problems that may necessitate specialized care.
Contraindications to suture closure of wounds relate largely to the
risk of infection and disruption of underlying structures such as nerves,
arteries, and tendons. Wounds that have the following characteristics should
be left unclosed, or at least very careful consideration should be given
(weighing the pros and cons of closure) before electing to suture the
wound:
Wounds that have a high likelihood of contamination should not be closed
with sutures. Doing so may mask a developing underlying infection, thus
delaying appropriate treatment. This delayed treatment may result in
spread of infection to underlying and surrounding structures, which has
the potential to cause considerable morbidity. Classification of the
wound helps the clinician to make an informed decision about the
appropriateness of closing the wound (see "Review of Essential Anatomy
and Physiology").
■ Wounds that require suturing to minimize infection and scar potential
should be closed within 8 hours of the injury. Some wounds can be
closed up to 24 hours after injury if the anatomic location is highly
vascular (e.g., face, neck, and scalp) and the cosmetic appearance is an
important consideration.
The presence of foreign bodies in the underlying tissues is a consideration.
Foreign bodies may remain a source of repeated infections if not
thoroughly removed through irrigation, exploration, and extraction or
debridement of devitalized and contaminated tissue.
Extensive wounds involving tendons, nerves, or arteries should be
carefully considered before closure.
POTENTIAL COMPLICATIONS
The primary complications associated with wound closure include the
following:
Infection
■ Scarring, including keloid formation
■ Loss of function and structure (an example might be scarring of an
eyelid repair, resulting in incomplete closure of the eyelids)
Loss of a cosmetically desirable appearance
■ Wound dehiscence (wound margins separate and wound reopens)
■ Tetanus
316 Chapter 23-Wound Closure
Stratum
germinativum
Hair follicle
Duct of
sweat gland
Body of
sweat gland
- Epidermis
Dermis
Blood vessels
and nerves
Subcutaneous
fat
Superficial fascia
(subcutaneous
fascia)
Deep fascia
Muscle group
Blood vessels
Figure 23-1 . Anatomy of the skin, illustrating structures pertinent to wound
repair. (Redrawn from Trott AT: Wounds and Lacerations: Emergency Care and
Closure, 2nd ed. St. Louis, Mosby-Year Book, 1998, p 27.)
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
Anatomy of the Skin and Fascia
The epidermis is a thin layer of squamous epithelial cells located on the
outermost surface of the skin. This layer is void of blood vessels or nerve
endings. The epidermis provides an excellent protective barrier when healthy
and intact. The stratum germinativum, or basal layer, is the parent layer for
new cells. This layer provides the cells for new epidermis formation during
wound healing (Fig. 23-1).
The dermis is much thicker than the epidermis. It is composed largely of
connective tissue such as fibroblasts; macrophages, lymphocytes, and mast
cells are also present. Some small blood vessels and nerve fiber endings are
present at this level.
Deep to the dermis is a layer of loose connective tissue that composes the
superficial fascia or subcutaneous tissue. Many blood vessels and nerve
endings are located at this level. Subcutaneous fat is present here, and the
Chapter 23-Wound Closure 317
quantity varies depending on the region of the body. Sensory nerve branches
to the skin travel in the superficial fascia just deep to the dermis, which
makes it ideal for injecting local anesthetic, because the anesthetic spreads
easily along this plane and abolishes sensation in the overlying skin.
The deep fascia is a relatively thick, dense, and discrete fibrous tissue
layer. It lies just above muscle, tendon, or bone. If disrupted by the injury, it
should be repaired to re-establish the supportive function of this layer.
Failure to do so may result in disfiguration of the surrounding area.
Skin Tension Lines (Langer's Lines)
Skin tension lines, also known as Langer's lines or lines of cleavage, are linear
clefts in the skin that indicate the direction of orientation of the underlying
collagen fibers. If the skin is disrupted parallel to the long axis of the fibers,
the wound tends to reapproximate. However, if the wound crosses the long
axis of the fibers perpendicularly, they are disrupted in a manner that causes
the wound to gape open; therefore, greater tension is required to close the
wound. Lacerations that run parallel to these lines naturally reapproximate
the skin edges. Lacerations that run at right angles to the tension lines tend
to gape apart. Figure 23-2 illustrates the typical orientation of Langer's lines
throughout the body.
Wounds should be classified based on their degree of contamination with
bacteria or foreign matter, or both. Timing of the closure is also important to
consider. The chance of wound infection developing increases each hour
that wound closure is delayed. There is general agreement that wounds less
than 6 to 8 hours old that are considered clean are eligible for primary
closure with sutures. Highly vascular areas such as the face and scalp can be
considered for primary closure with sutures up to 24 hours after the injury.
In each case, the clinician must consider the degree of contamination and
evaluate each wound individually.
Classification of Wounds
■ Clean: incisions made during a surgical procedure in which aseptic
techniques were followed, without involvement of the gastrointestinal,
respiratory, or genitourinary tract; likelihood of infection is less than 2%
and warrants routine primary closure
■ Clean-contaminated: similar to clean wounds except that the
gastrointestinal, respiratory, or genitourinary tract is involved
■ Contaminated: similar to clean and clean-contaminated except there is
gross spillage (e.g., bile, stool); traumatic wounds fall into this category
■ Infected: established infection before wound is made (e.g., incision and
drainage of an abscess) or heavily contaminated wounds (e.g., gross
spillage of stool)
318 Chapter 23-Wound Closure
Figure 23-2. Skin tension lines of the body surface. (Adapted from Trott AT:
Wounds and Lacerations: Emergency Care and Closure, 2nd ed. St. Louis,
Mosby-Year Book, 1998, p 17.)
Wound Closure Classification
Primary intention: All layers are closed.
Best chance for minimal scarring
Usually performed in clean and clean-contaminated wounds
Secondary intention: The deep layers are closed, whereas superficial
layers are left open to granulate on their own from the inside out.
■ Often leaves a wide scar and requires frequent wound care, consisting
of irrigation and assorted types of packing and dressings
Chapter 23-Wound Closure 319
■ Prolonged process
Reasons for use include excessive tissue loss and infection
Third intention or delayed primary intention: The deep layers may be
closed primarily, whereas the superficial layers are left open until
reassessment on day 4 or 5 after initial closure, at which time the wound
is inspected for signs of infection.
If it looks clean and has begun to granulate, it is irrigated and closed.
If it looks as if it may be infected, it is left open to heal by secondary
intention.
■ These wounds often arise initially from contaminated wounds.
to exercise clinical judgment based on the
Standard Precautions Every practitioner should patient's history and the potential for exposure
use standard precautions at all times when to body fluids or aerosol-borne pathogens (for
interacting with patients, especially when further discussion, see Chapter 2).
performing procedures. Determining the level
of precaution necessary requires the practitioner
PATIENT PREPARATION
■ Take the patient's history to denote when, where, and how the injury
occurred. Other pertinent information in the history may include
handedness, tetanus status, other past or concurrent medical problems
(e.g., diabetes mellitus, peripheral vascular diseases, immune status),
smoking history, occupation, hobbies, family history, medications, and
allergies.
■ Begin the physical examination with a meticulous inspection detailing
the type of wound, anatomic location, extent of injury, and level of
contamination. Bleeding can usually be controlled with direct manual
pressure applied to the site with a clean bandage. A careful sensory and
motor examination should precede any wound exploration or anesthetic
infiltration.
■ Prepare the patient for the initial treatment of the wound. This involves
irrigation of the wound, which is the major step in reducing the likelihood
of infection. Some advocate cleansing the wound with 1% povidone-iodine
and then, with the patient properly anesthetized, suturing the wound.
■ Immunize the patient against tetanus, if necessary.
A discussion regarding tetanus status and potential risk is warranted in any
patient with a wound. Tetanus is a preventable endotoxin-mediated disease
caused by Clostridium tetani. When present, it may cause trismus, neck rigidity,
dysphagia, and severe, uncontrolled reflex spasms. Populations at particular
risk are the elderly and those who have immigrated to the United States and
had inadequate immunization, those who are immunocompromised, and
320 Chapter 23-Wound Closure
those who inject drugs regularly and have frequent skin abscesses, impaired
immune status, and reluctance to seek health care.
It is therefore important to determine when the patient last received a
tetanus immunization and to classify the wound as either tetanus prone or
non-tetanus prone.
Tetanus-prone wounds have the following characteristics:
■ Greater than 6 hours old
■ Greater than 1 cm deep
■ Stellate or have an avulsion configuration
■ Associated with devitalized tissue
■ Contaminated with soil, feces, or saliva
■ From a missile (e.g., gunshot wound)
■ From a puncture or crush
■ Associated with a burn or frostbite
All other wounds can be considered non-tetanus prone. To determine the
appropriate treatment, see Table 23-1 and the following guidelines:
■ A non-tetanus-prone wound in an adult patient with up-to-date
immunization requires tetanus and diphtheria toxoid (Td) if it has been
10 years since the last immunization.
A tetanus-prone wound in a patient with up-to-date immunization
requires Td if it has been more than 5 years since the last immunization.
A non-tetanus-prone wound in an adult patient with inadequate
immunization requires Td.
Table 23.1 Summary Guide to Tetanus Prophylaxis in Routine
Wound Management, 1991
HISTORY OF ADSORBED
TETANUS TOXOID (DOSES)
CLEAN,
MINOR WOUNDS
ALL OTHER WOUNDS*
Td+
TIG (250 U)
Td+ TIG (250 U)
Unknown or <3
>3*
Yes
No§
No
No
Yes Yes
No No
TIG, tetanus immune globulin.
*Such as, but not limited to, wounds contaminated with dirt, feces, soil, and saliva; puncture wounds;
avulsions; and wounds resulting from missiles, crushing, burns, and frostbite.
rFor children <7 years old, DTP (DT, if pertussis vaccine is contraindicated) is preferred to tetanus toxoid
alone. For persons >7 years of age, Td is preferred to tetanus toxoid alone.
:fIf only three doses of fluid toxoid have been received, a fourth dose of toxoid, preferably an adsorbed
toxoid, should be given.
§Yes, if >10 years since last dose.
fYes, if >5 years since last dose. (More frequent boosters are not needed and can accentuate side effects.)
Adapted from Diphtheria, tetanus, and pertussis: Recommendations for vaccine use and other preventive
measures. Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Recomm
Rep 40(RR-10): 1-28, 1991.
Chapter 23-Wound Closure 321
Tetanus-prone wounds in adult patients with inadequate immunization
require both passive immunity with tetanus immunoglobulin (TIG) and
active immunity with Td. When giving both Td and TIG, place them in
different syringes and deliver them at separate anatomic locations.
Adults with an unknown history should receive the three-dose regimen
and therefore will require follow-up. The initial dose of Td toxoid is given
at the time of wound closure; 4 to 8 weeks later, a second dose of Td
toxoid is administered. The last dose is given 6 to 12 weeks after the
second dose. Booster doses of Td toxoid should then be given every
10 years to maintain an adequate tetanus status.
Diphtheria, tetanus toxoid, and pertussis (DTP) or acellular pertussis
(DTaP) is used instead of Td in children.
TIG is considered safe in pregnancy, whereas Td toxoid can be safely
given in the second trimester and later in those who have high-risk
wounds.
Materials Utilized for Performing Irrigation,
Cleansing, and Debridement
■ Gloves and goggles
Irrigation
■ 60-mL syringe
■ 21-gauge plastic intravenous catheter or irrigation needle with "blunted"
end for fluid irrigation
■ Several liters of saline solution
Cleansing
■ A cleansing agent (Table 23-2) may be considered, but due to tissue
toxicity and lack of supportive evidence, it cannot be routinely
recommended.
Sterile, fenestrated drape
Several sterile square or rectangular drapes
Debridement
■ Scalpel or sharp tissue scissors
322 Chapter 23-Wound Closure
Table 23.2 Summary of Wound Cleansing Agents
ANTIBACTERIAL
SYSTEMIC
POTENTIAL
SKIN CLEANSER
ACTIVITY
TISSUE TOXICITY
TOXICITY
USES
Povidone-iodine
Strongly bactericidal
Detergent can
Painful to open
Hand
surgical scrub
against gram-
be toxic to
wounds
cleanser
positive and gram-
wound tissues
Other reactions
negative bacteria
extremely rare
Povidone-iodine
Strongly bactericidal
Minimally toxic
Extremely rare
Wound
solution
against gram-
to wound
periphery
positive and gram-
tissues
cleanser
negative bacteria
Chlorhexidine
Strongly bactericidal
Detergent can
Extremely rare
Hand
against gram-
be toxic to
cleanser
positive organisms,
wound
less strong against
tissues
Alternative
gram-negative
wound
bacteria
periphery
cleanser
Poloxamer 188
No antibacterial
activity
None known
None known
Wound
cleanser
(particu-
larly useful
on face)
Hexa-
Bacteriostatic
Detergent can
Teratogenic
Alternative
chlorophene
against gram-
be toxic to
with
hand
positive bacteria;
wound
repeated
cleanser
poor activity
tissues
use
against gram-
negative bacteria
Hydrogen
Very weak
Toxic to red
Extremely rare
Wound
peroxide
antibacterial agent
cells
cleanser
adjunct
Adapted from Trott AT: Wounds and Lacerations:Emergency Care and Closure, 2nd ed. St. Louis, Mosby-Year
Book, 1998, p 91.
Procedure for Irrigating and Cleansing the Wound
1. Put on gloves and goggles to
avoid exposure to blood-borne
pathogens.
2. Using a 60-mL syringe and a 21-gauge
plastic intravenous catheter or blunt
needle designed for irrigation, repeatedly
squirt normal saline into the site in short
bursts to dislodge remaining particulate
matter. Minimally, 250 to 500 mL of
irrigation solution should be used. Several
liters may be necessary for large wounds
that are heavily contaminated.
3. Apply a cleansing agent (see Table 23-2)
to the wound edges and surrounding skin
using a bull's-eye or circular motion from
the inside moving outward and repeat
three times. Avoid allowing the agent to
enter the wound.
Note: One example of a cleansing agent
might include three sterile diluted povidone-
iodine (l%)-soaked 4x4 pads. Please be
advised that standard povidone-iodine
solution is 10% and the scrub is even more
concentrated.
4. Place a sterile fenestrated drape over the
wound site and several sterile square or
rectangular drapes around the site to
create a sterile field.
Chapter 23-Wound Closure 323
Note: If the wound is on a limb, a sterile Note: Care should be taken to preserve
drape should be placed under the extremity tissue, yet conversion of a jagged laceration
before the other drapes are applied. Drapes to a surgical one may be required for
are often found in prepackaged suture kits or optimal closure to occur. Sometimes the
on a laceration tray and are placed after the subcutaneous tissue may need to be
clinician dons sterile gloves. undermined to allow for adequate closure of
5. If debridement is necessary to remove
dead or devitalized tissue, use a scalpel or
sharp tissue scissors.
tight wound edges.
Materials Utilized to Perform Suturing
Sterile gloves
Suture Selection
Note: Once it is determined that a wound should be closed primarily, suture
selection begins. The first item to consider is whether to use absorbable or
nonabsorbable suture based on anatomic location and healing potential.
■ Absorbable suture is used in mucosal areas such as the oral cavity and
tongue and disintegrates by one of two methods: enzymatic breakdown
of organic material (e.g., surgical gut — plain or chromic) or by hydrolysis
of synthetic material (e.g., polyglactin 910 [Vicryl]).
■ Nonabsorbable suture (silk, stainless steel, nylon, polypropylene,
polyester fiber) can be further classified into monofilament (single
strand) or multifilament (several strands, which are often braided).
Note: One advantage of monofilament is that it passes through tissue more
easily than does braided suture. However, a disadvantage is that it has less
tensile strength than a multifilament. Advantages of a multifilament suture
include better flexibility, whereas a disadvantage would be that it may
harbor organisms more easily within the braid. It is also important to
recognize that loss of tensile strength and absorption are separate
processes (i.e., suture may lose tensile strength rapidly but absorb slowly
or vice versa).
Note: Suture size is denoted by the number of zeros, and increases in
number as the diameter of suture decreases; for example, 7-0 is smaller
than 1-0. Refer to Table 23-3 as a guide for suggested suture size based on
anatomic location.
■ Needles
Note: The final consideration for proper suture selection is based on needle
characteristics and includes the following:
■ The smallest-diameter needle to accomplish the task should be
chosen to avoid unnecessary tissue trauma.
324 Chapter 23-Wound Closure
Table 23.3 Suggested Guidelines for Suture Material and Size
for Body Region
BODY REGION
PERCUTANEOUS (SKIN)
DEEP (DERMAL)
Scalp
Ear
5-0/4-0 monofilament*
6-0 monofilament
4-0 absorbable^
Eyelid
Eyebrow
Nose
7-0/6-0 monofilament
6-0/5-0 monofilament
6-0 monofilament
5-0 absorbable
5-0 absorbable
Lip
Oral mucosa
6-0 monofilament
5-0 absorbable
5-0 absorbable*
Other parts of face/forehead
Trunk
Extremities
Hand
6-0 monofilament
5-0/4-0 monofilament
5-0/4-0 monofilament
5-0 monofilament
5-0 absorbable
3-0 absorbable
4-0 absorbable
5-0 absorbable
Extensor tendon
4-0 monofilament
—
Foot/sole
Vagina
Scrotum
4-0/3-0 monofilament
4-0 absorbable
4-0 absorbable
5-0 absorbable*
Penis
5-0 monofilament
—
*Nonabsorbable monofilaments include nylon (Ethilon, Dermalon), polypropylene (Prolene), and
polybutester (Novafil).
'Absorbable materials for dermal and fascial closures include polyglycolic acid (Dexon, Dexon Plus),
polyglactin 910 (Vicryl), polydioxanone (PDS [monofilament absorbable]), and polyglyconate (Maxon
[monofilament absorbable]).
:f Absorbable materials for mucosal and scrotal closure include chromic gut and polyglactin 910 (Vicryl).
Adapted from Trott AT: Wounds and Lacerations: Emergency Care and Closure, 2nd ed. St. Louis,
Mosby-Year Book, 1998, p 179.
The type and shape of needle should be considered:
A conventional cutting needle is often used for skin and has
three cutting edges (two lateral and one on the inner concave
curve).
■ A reverse cutting needle is often used for tough tissue such as
ligament and also has three cutting edges (two lateral and one on
the outer concave curve).
A taper needle is circumferentially rounded with a point and it is
useful intraoperatively on delicate tissue such as peritoneum.
Figure 23-3 illustrates the various parts of a needle.
Other Instruments
Needle driver or holder, appropriate for the size of needle and suturing
material being used
Skin forceps
■ Suture scissors
Chapter 23-Wound Closure 325
Point Swage
Figure 23-3. The parts of a taper and reverse cutting needle. (Redrawn from
Trott AT: Wounds and Lacerations: Emergency Care and Closure, 2nd ed. St. Louis,
Mosby-Year Book, 1998, p 31.)
Procedure for Performing Suture Techniques (General Information)
Caution: Proper instrument technique is
paramount.
Needle Driver-Holder
1. Using sterile gloves, hold the needle
driver with the dominant hand while the
nondominant hand holds the forceps.
Note: The tripod grip is an excellent method
for use with both the needle driver and
scissors as it maximizes hand control
(Fig. 23-4). This may include the distal phalanx
of the thumb and fourth digit inserted into
the rings of the needle driver but never
allowing the digits to move into rings more
proximal than the distal interphalangeal joint.
2. Grasp the needle at the tip of the needle
driver and load so that it is perpendicular
to the needle driver, as shown in
Figure 23-5.
Figure 23-4. (A, Redrawn from Trott AT:
Wounds and Lacerations: Emergency Care and
Closure, 2nd ed. St. Louis, Mosby-Year Book,
1998, p 32.)
continued
326 Chapter 23-Wound Closure
Figure 23-5. (A, Redrawn from Trott AT: Wounds and Lacerations: Emergency Care and Closure, 2nd
ed. St. Louis, Mosby-Year Book, 1998, p 33.)
Note: The needle concavity will be furthest
from the clinician, and the point of the
needle will be pointing to the nondominant
shoulder as the clinician views the needle.
3. Grasp the needle at the junction of its
proximal and middle third. It can be
moved more distal (toward the point) for
smaller bites.
Note: The tip of the needle should never be
grasped because it can become dull. To
minimize needle stick injuries, needles
should never be touched with the fingers;
they can be loaded easily from the packet
they come in or from any flat surface.
Forceps
1. For maximal control, hold the forceps
like a pencil, as shown in Figure 23-4.
Note: If the forceps have teeth, avoid a tight
tissue grasp to eliminate skin trauma
("teeth marks").
2. One method lifts the tissue rather than
grasping it by placing one tooth of the
forceps into the wound edge and lifting
gently without closing the other toothed
face to the skin surface.
Chapter 23-Wound Closure 327
Scissors
1. Cut with the tips of the scissors using the
tripod grip and with the screw of the
scissors facing up and at a 45-degree
angle to the suture as in Figure 23-4.
Note: Scissors are manufactured to cut most
accurately with the tips.
Note: The technique of cutting at a
45-degree angle helps eliminate the
possibility of accidentally cutting out the
knots when no tail is left intraoperatively
One should never attempt to cut suture
without full visualization of the distal
scissor tips to avoid cutting tissue
inadvertently.
Procedure for Suture Placement
1. Introduce the suture needle into the
tissue at a 90-degree angle or less
(toward the wound) (see Figure 23-5);
try to approximate this angle as
closely as possible. This can be
maximized with full wrist
pronation.
Note: This is to promote skin eversion or a
slight tenting of the wound edge at closure
to minimize the ultimate scar visibility. With
time, a normal scar contracts and flattens
and appears flush, casting no shadow.
Conversely, a wound that initially is closed
flush often later "sinks-in" and creates a
shadow of light that highlights and draws
attention to the scar.
Note: The depth of needle penetration
is determined by the wound depth.
Sometimes a bite can be completed by one
pass through the tissue (skin surface,
wound edge, wound edge, skin surface);
other times the needle should be reloaded
halfway through or after it passes from skin
surface through the first wound edge. This
allows for specific placement of the wound
edge to the adjacent wound edge to
ensure a side-to-side match and is necessary
for larger bites in a deep wound. Typically,
the total stitch length should be as wide
as the wound is deep, as shown in
Figure 23-6.
^V^
Figure 23-6. (Modified from Trott AT: Wounds
and Lacerations: Emergency Care and Closure,
2nd ed. St. Louis, Mosby-Year Book, p 113.)
Note: If a needle begins to bend, excessive
pressure has been placed on it by either
poor technique or attempting too large a
bite. Taking a bite deeper than the wound
may cause important structures to be
traumatized from blind needle placement.
Conversely, taking too superficial a bite may
leave dead space below the closure, inviting
blood accumulation, bacterial growth, and
infection.
2. Place the needle bite just superficial to
the wound depth.
Note: This allows complete visualization of
structures penetrated and adequately closes
the wound.
328 Chapter 23-Wound Closure
Procedure for Performing the Instrument Tie
1. Place the needle driver between the
suture ends and, with the nondominant
hand, wrap the suture with the needle
attached over the instrument twice on the
first throw of the first knot only (surgeon's
knot, used to prevent slippage) (Fig. 23- 7A
and B).
Grasp the short end of the suture with the
needle driver, and the short and long
suture ends switch sides (see Fig. 23-7C).
Figure 23-7. (Redrawn from
Trott AT: Wounds and Lacerations:
Emergency Care and Closure, 2nd
ed. St. Louis, Mosby-Year Book,
1998, pp 98-102.)
Chapter 23-Wound Closure 329
Note: This is considered one throw. Two
throws makes one knot. Next, the needle
driver is placed between the two suture
ends and one wrap of the long suture over
the instrument is used (Fig. 23-7D).
3. Again, grasp the short suture end with the
needle driver. The long and short suture
ends again switch sides (see Fig. 23-7E).
Note: A circle should be seen as the suture
comes down to the skin surface. This suture
circle should be placed at 90 degrees to the
wound length for simple interrupted and
vertical mattress sutures (horizontal
mattress sutures will be parallel with the
wound) (see Fig. 23-7F).
4. Repeat these steps with only one wrap
over the needle driver on every
successive throw until the suture is cut.
Note: Remember the only throw that gets
two wraps is the first throw of the first knot
in a series. Therefore, an even number of
throws ensures completion of all knots.
Compare the diagrams of a typical knot
(see Fig. 23-6) with a surgeon's knot (see
Fig. 23-7G).
Note: The number of knots depends on
the anatomic location (below the skin
surface requires fewer knots; above the skin
surface requires more knots) and suture
material (those with "memory" often require
more knots). Usually three or four knots on
the skin surface are sufficient. The needle
remains connected throughout these steps
and usually poses no problem to the
clinician or patient, as it remains stationary
lying on the sterile field. There is no need to
remember where you are in a sequence with
this method, as in the "over-under
technique."
5. After an adequate number of knots are
secured, pull the suture knot to one side
to avoid knot placement directly over the
wound to minimize debris collection and
potential infection.
Note: The suture is now ready for cutting.
The "suture tail" or "suture tag" will be used
during suture removal.
Note: Two helpful rules can be used to
estimate this length: (1) The tail length
should be equal to the distance from the
wound edge to the suture border. (2) The tail
length should be slightly less than the
distance between adjacent knots. Use the
previously described scissor technique to
cut the suture.
Procedure for Performing the Simple Interrupted Stitch
Note: It is important to estimate carefully the
number and size of sutures necessary to
close the wound adequately without placing
too many and too small or too few and too
large stitches. Most simple interrupted
stitches should measure between 3 and
10 mm in length and should be about this
same distance apart. The method described
in the instrument tie section is consistent
with the simple interrupted stitch, which is
frequently used to close most lacerations.
1. One method of closure includes closure
by halves. Place the first stitch at the
halfway point along the length of the
wound.
2. Place the next stitches at the halfway
point between the first stitch and each
end of the wound.
3. Place the next stitches between each of
the previous stitches until the wound is
approximated.
continued
330 Chapter 23-Wound Closure
Note: An alternate method involves
beginning at one end of the wound and
placing evenly spaced sutures along the
length until you reach the opposite end of
the wound. Be careful to place the sutures
evenly on both sides of the wound; failure to
do so may result in an asymmetric end to
the wound known as a dog ear, in which one
side of the wound appears to be longer than
the other side, creating a redundant "ear" of
tissue.
Procedure for Correcting Dog Ear Deformity
If a dog ear develops, the sutures should be
removed and the closure reattempted. If it
appears that correction cannot be achieved
by reapproximation, the following method
illustrates an acceptable procedure for
correction.
1. Make an incision 45 degrees at the end of
the redundant side.
Note: This tissue is undermined to create a
small flap, which when gentle traction is
applied can be excised as shown.
2. Close the wound in the usual fashion,
creating a "hockey-stick" appearance
(Fig. 23-8).
tfte4^
Figure 23-8. (Redrawn from Trott AT: Wounds
and Lacerations: Emergency Care and Closure,
2nd ed. St. Louis, Mosby-Year Book, 1998, p 37.)
Chapter 23-Wound Closure 331
Procedure for Performing the Vertical Mattress ("Far-Far/Near-Near") Stitch
The next most commonly performed stitch
is the vertical mattress stitch. This stitch is
so named because the stitch lies in a plane
perpendicular (vertical) to the skin. It is
useful for closing deeper wounds (e.g., those
of the scalp) in which the closure occurs at
two levels (superficial and deep), eliminating
dead space.
1. To perform the vertical mattress stitch,
introduce the needle "far" and exit "far"
from the wound edge, diving deep but just
superficial to the wound depth (Fig. 23-9).
Note: Figure 23-9 illustrates a wound with
first stitch traversing the lower wound
margin. Most wounds will have the first
stitch traverse within the lower portion of
the wound margin, as illustrated in
Figure 23-6.
2. Next, starting on the same side as the first
exit point, load the needle backhand
(needle points to dominant shoulder
while all other criteria remain unchanged)
and enter "near" the wound edge and exit
on the original side "near" the wound
edge, both at a level more superficial than
the original deep first pass.
3. The remainder of the instrument tying
steps is the same (see Fig. 23-7).
Note: Performing the second step first, or a
"near-near/far-far" stitch, should be avoided
to eliminate "blind" needle placement and
creating inadvertent trauma to unseen
structures.
M-j*-^
Figure 23-9. (Redrawn from Trott AT: Wounds
and Lacerations: Emergency Care and Closure,
2nd ed. St. Louis, Mosby-Year Book, 1998, p 38.)
332 Chapter 23-Wound Closure
Procedure for Performing the Horizontal Mattress Stitch
The horizontal mattress stitch lies in a plane
parallel to the skin. It is useful when there is
a flap of tissue or when the tension of the
stitch is to be predominantly on one side
(the knotted side). For example, this method
works well in a wound with a vascular side
and a relatively avascular side, as the
avascular area is pulled toward the vascular
side, with most of the tension being on the
vascular side. In other stitch types, the
tension is shared equally by each side.
1. To perform the horizontal mattress stitch,
start on the vascular side and exit on the
relatively avascular side.
2. Re-enter backhanded on this avascular
side parallel to the wound edge and
adjacent to the original exit site; the final
exit is on the original vascular side.
Note: The stitch should look like a box. All
knot tying steps are performed as previously
discussed except that the stitch is brought
down parallel (not perpendicular) to the
wound line (Fig. 23-10).
Figure 23- 1 0. (Redrawn from Trott AT: Wounds
and Lacerations: Emergency Care and Closure,
2nd ed. St. Louis, Mosby-Year Book, 1998, p 39.)
Procedure for Performing the Continuous-Running-Baseball Stitch
The advantages of the continuous stitch is
that it can be performed quickly and can be
applied tightly if "locked." The
disadvantages are as follows:
• If one loop is broken, the entire wound
may open.
• It cannot be partially removed as can
other stitch types (e.g., every other or a
wound segment) to allow for drainage
when managing an early wound
infection.
• It may leave a cosmetically suboptimal
scar with a "railroad tracks"
appearance.
The continuous suture is performed as
follows:
1. Place a suture at the end of the wound in
the same fashion as that outlined for a
Chapter 23-Wound Closure 333
simple interrupted suture (only cut suture
on non-needle side after knot is tied).
2. Using the initial suture as an anchor,
additional sutures are placed (throws) in
a continuous fashion until the entire
wound is reapproximated. Enter next to
knot and exit on opposite side skin
surface at a 45-degree angle to the wound
and re-enter through skin surface directly
across and repeat (Fig. 23-11).
3. When the end of the wound is reached,
the final suture is tied in the same manner
Figure 23- 1 1 . (Redrawn
from Trott AT: Wounds and
Lacerations: Emergency Care
and Closure, 2nd ed. St. Louis,
Mosby-Year Book, 1998,
pp 123-128.)
as that outlined for the simple
interrupted suture, but the needle side is
tied to the last loop before it has been
pulled taut. When cut, it will yield three
tails.
Note: The method illustrated demonstrates
the "non-locking" method. To "lock" the
suture, bring the needle up through
the previous loop before it has been
pulled taut creating a tight seal, which
can be particularly useful
intraoperatively
334 Chapter 23-Wound Closure
Procedure for Performing the Subcuticular Stitch
The subcuticular stitch is often used to close
a surgical incision or a very clean wound.
Absorbable suture material must be used if
the suture will not be removed at a later time.
1. Create an initial buried knot to anchor the
suture (Fig. 23-12).
2. Begin making equal passes through the
wound edges in the horizontal plane until
you have traversed the length of the
wound (entering and exiting the dermal
layer from side to side).
Note: It is important to keep the bites equal
and approximate the tissue so that it aligns
properly.
3. A final buried knot is tied at the opposite
wound end to complete and anchor the
Figure 23- 1 2. (Redrawn
from Trott AT: Wounds and
Lacerations: Emergency Care
and Closure, 2nd ed.
St. Louis, Mosby-Year Book,
1998, p 41.)
opposite end of the suture. Leave the
needle side of the suture tail uncut (cut
the loop side).
Note: The suture is secure because of the
final buried anchor knot.
4. Bury the final tail by re-entering the
closed wound with the needle and
attached suture and exiting on the skin
surface 1 cm away from the wound
edge.
5. Cut it flush with the skin.
6. Apply skin tapes over the wound
surface.
Note: No suture will be visible on the skin
surface.
Chapter 23-Wound Closure 335
SPECIAL CONSIDERATIONS
Several important general concepts exist and are discussed based on
anatomic location.
Hair can be shaved to allow for better wound exploration, irrigation, and
closure, but this is not routinely recommended. Often just trimming the
surrounding hair is helpful without further traumatizing the skin by
creating potential sites of infection from the minute lacerations and skin
abrasions that often occur during the shaving process. Cutting the
suture tails longer than usual and using an alternate suture color also
facilitates removal in hairy anatomic locations and minimizes the need
for shaving hair.
■ Never shave an eyebrow, as the hair may not grow back at all or will
grow back irregularly. It is also critical to line up the hair and skin
borders exactly to avoid misalignment. If an eyebrow has been shaved
and the wound is sutured closed, it is difficult to know where these
borders exist. Therefore, the possibility of even slight misalignment of
the hair to the skin border can occur, and if the hair grows back it will
look very disfiguring. Usually these areas can be visualized well enough
to suture them adequately without the need for hair removal.
Following this same principle is the concept of aligning the vermilion
border of the lips. The best method for doing this begins by placing the
first stitch at the border of the skin and mucosal edges (use 6-0 nylon).
The remaining wound can be closed using nonabsorbable suture for the
skin and absorbable suture for the lip itself. It is critical that this border
be aligned exactly.
If an incision has to be made, it is important to recognize and follow the
natural skin tension lines. Scar visibility is minimized when it runs
parallel to these lines and is more prominent when placed perpendicular
or oblique to them (see Fig. 23-2).
Materials Utilized for Using Skin Staplers
Stapler with staples — sterile disposable type
Tissue forceps
Skin tape
336 Chapter 23-Wound Closure
Procedure for Using Skin Staplers
Note: Skin staplers are sterile, disposable,
cost-effective, and useful for long, linear
lacerations of the scalp, trunk, and extremities
because they can be applied quickly with the
same ultimate cosmetic result as suture.
1. Place staples over the approximated
wound and firmly squeeze the trigger to
deliver each staple, everting the tissue
edges.
Note: Staplers should not be used to close
lacerations of the face or hands or those
over a joint. They should also be avoided in
areas that might later require computed
tomography or magnetic resonance imaging
(e.g., head injury).
2. To remove, use a special sterile,
disposable device and squeeze this device
at each staple. The staple legs are
straightened. Then pull the staple from
the tissue.
Note: Skin tapes are often placed after
removal of the staples.
Materials Utilized for Applying Wound
Adhesives
Ampules or other delivery devices (ProPen) of wound adhesive
Cotton-tipped applicator
Procedure for Applying Wound Adhesives
Note: Wound adhesives are another variation
of wound closure that may be used; they can
be applied quickly and painlessly for easily
approximating skin edges of surgical
incisions or lacerations of the face, trunk,
and limbs. They are not recommended over
skin creases, areas of movement, or long
lacerations or for hand injuries. Other
contraindications include wounds with
active infection, those that involve mucosal
surfaces or occur at mucocutaneous
junctions, and areas exposed to body fluids.
In addition, some clinicians avoid areas of
dense hair such as the scalp. After the usual
cleaning, debriding, and care to achieve
hemostasis, the area is carefully dried.
1. Crush an ampule and invert it, soaking the
cotton-tipped applicator with solution.
2. With the applicator, lightly paint over the
approximated wound edge three times in
succession with 30 seconds' drying time
between.
Caution: It is important to avoid applying
the fluid into the wound and to avoid
spillage to surrounding areas such as the
eye.
3. Because the adhesive is of low viscosity
(runny), position the anatomic area in the
horizontal plane to avoid runoff or protect
surrounding skin with a barrier.
Chapter 23-Wound Closure 337
4. After full strength is reached at 2.5 Note: Follow manufacturer's instructions for
minutes, a protective dressing can be other application delivery devices, which
applied at 5 minutes, but it is not deliver a high viscosity version skin
required. adhesive.
FOLLOW-UP CARE AND
INSTRUCTIONS FOR SUTURED OR
STAPLED WOUNDS
Advise the patient to keep the wound site clean and dry. Some clinicians
advocate no contact with water at all for 48 hours, whereas others allow
gentle bathing with soap and water or a quick shower with careful drying
of the site afterward, but all emphasize no prolonged soaking of the site
in water.
■ If applicable, elevate the area.
■ Instruct the patient verbally and in writing regarding the desired frequency
of wound checking and dressing changing. It is suggested that the patient
remove the dressing twice each day to visualize the site for signs of
infection and to reapply antibiotic ointment. A clean, dry dressing should
then be applied. Some sites may be left open to the air (face, neck, scalp).
Instruct the patient to apply a cold compress for the first 48 hours after
surgery in sites with significant associated soft tissue involvement, such
as a contusion (20 minutes each time four to five times per day).
Verbalize and write the signs of infection for the patient to watch for and
instruct him or her to return if there is an increase in pain, redness
beyond the wound margin, or red streaking; if the area becomes warm,
swollen, and tender; if there is discharge or drainage from the wound; if
there is tenderness under the arms or groin; or if he or she experiences
fever or chills.
Consider possible activity restriction or immobilization.
■ Consider analgesics (acetaminophen, nonsteroidal anti-inflammatory
drugs [NSAIDs]).
■ Advise the patient about when he or she should return for a wound
check and suture or staple removal.
Educate the patient that scars take 1 year to fully mature and that after
initial healing it is best to avoid strong sunlight and to apply sunscreen
to the site.
■ Administration of antibiotics is sometimes advised, although small,
uncomplicated wounds and lacerations often do not require them. If the
particular wound is high risk, a wound check in 24 to 48 hours may be
necessary. It is always best to have the original provider assess the
338 Chapter 23-Wound Closure
wound if possible, because he or she has a baseline for comparison.
Antibiotics should be considered in the following high-risk wounds:
Wounds that are more than 12 hours old at initial presentation,
especially those of the hands
Human or animal bites, including those caused by the patient's teeth
(intraoral laceration)
■ Crush wounds
■ Heavily contaminated wounds
Wounds involving relatively avascular areas, such as the cartilage of
the ear
■ Wounds involving joint spaces, tendon, or bone
Severe paronychia and felons
Wounds in patients with a history of valvular heart disease
Wounds in patients with immunosuppression (diabetes, chronic
steroid use, infection with human immunodeficiency virus [HIV])
Suture Removal
Anatomic location dictates the length of time sutures should be left in place
to ensure adequate healing. Table 23-4 may be useful as a general guide. It is
important to remember that adults heal more slowly than do children and
that other medical conditions may increase healing time.
■ The wound should be inspected for signs of infection before the sutures
are removed, including erythema beyond the wound margin, discharge,
swelling, pain, or tenderness.
Some practitioners advocate the use of povidone-iodine (Betadine) both
before and after suture or staple removal.
Table 23.4 Recommended Intervals for Removal of
Percutaneous (Skin) Sutures
LOCATION
DAYS TO REMOVAL
Scalp
Face
Ear
Chest/abdomen
Back
Arm/leg*
Hand*
Fingertip
Foot
6-8
4-5
4-5
8-10
12-14
8-10
8-10
10-12
12-14
*Add 2 to 3 days for joint extensor surfaces.
From Trott AT: Wounds and Lacerations: Emergency Care and Closure, 2nd ed. St. Louis, Mosby-Year
Book, 1998, p 366.
Chapter 23-Wound Closure 339
Suture removal
Example of
correct removal
Example of
incorrect removal
If cut here,
will drag this
area ^^
x.
through v>
the wound
*
-v
v . / \
Cut here
Cut
here
t
i
Figure 23- 1 3. Suture removal.
Using sterile instruments, cut the suture to minimize dragging
contaminated suture through the patient's body.
If sutures are tight and difficult to cut, use of a No. 11 scalpel blade should
be considered. Turn the sharp side away from the patient to sneak under
the suture to avoid excessive pulling. Diagrams of correct and incorrect
methods of various stitch removals are shown in Figure 23-13.
It is important to ensure that all the nonabsorbable suture is removed
and that none is left inside the wound to act as a foreign body.
Often, minimal erythema surrounding the wound, secondary to local
reaction to these materials, is alleviated 24 to 48 hours after the sutures
are removed.
340 Chapter 23-Wound Closure
■ Some practitioners advocate the use of antibacterial ointment.
■ Most wounds should be left open to the air at this point and do not
require a dressing.
Staple Removal
■ Align the staple remover so that it is centered under the staple.
■ It is important to recognize that the staple removal device is squeezed
and then the staple is lifted in two distinct motions; combining them is
painful to the patient and traumatizes tissue.
Often, minimal erythema surrounding the wound, secondary to local
reaction to the staples, is alleviated 24 to 48 hours after the staples are
removed.
■ Some practitioners advocate the use of antibacterial ointment.
■ Most wounds should be left open to the air at this point and do not
require a dressing.
FOLLOW-UP CARE AND
INSTRUCTIONS FOR ADHESIVE-
CLOSED WOUNDS
■ Notify the patient that the adhesive naturally starts to slough off 5 to 10
days after placement.
■ Caution the patient to avoid scratching, rubbing, or picking at the site.
Instruct the patient that the area should not be scrubbed, soaked, or
exposed to prolonged wetness (the area should be kept dry; a quick
shower can be taken, if necessary).
■ Advise the patient not to apply medication in liquid or ointment form to
the site.
The cost of skin adhesives is comparable when costs for suture kits, suture
materials, clinician time, and follow-up visits for suture removal are
considered.
Reference
Ethicon: Wound Closure Manual. New Brunswick, NJ, Ethicon, 1985.
Available at: http://www.ethiconinc.com/
Chapter 23-Wound Closure 341
Bibliography
Pfenninger JL, Fowler GC (eds): Procedures for Primary Care
Physicians, St. Louis, CV Mosby, 1994.
Principles of Primary Wound Management: A Guide to the
Fundamentals. Fairfax, Va, Mortiere, 1996.
Trott AT: Wounds and Lacerations: Emergency Care and Closure, 2nd
ed. St. Louis, Mosby-Year Book, 1998.
Wedmore IS: Wound care: Modern evidence in the treatment of man's
age-old injuries. Emerg Med Pract 7:1-24, 2005.
Chapter O^
Dermatologic Procedures
Michelle DiBaise
Procedure Goals and Objectives
Goal: To perform biopsies, electrosurgery, and acne surgery
successfully while observing standard precautions and with the
minimal degree of risk to the patient.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing biopsies, electrosurgery, and acne surgery.
• Identify and describe common complications associated with
performing biopsies, electrosurgery, and acne surgery.
• Describe the essential anatomy and physiology associated with
performing biopsies, electrosurgery, and acne surgery.
• Identify the materials necessary for performing biopsies,
electrosurgery, and acne surgery and their proper use.
• Describe the steps in performing biopsies, electrosurgery, and
acne surgery.
• Identify the important aspects of post-procedure care after
biopsies, electrosurgery, and acne surgery.
343
344 Chapter 24 — Dermatologic Procedures
Is the lesion suspicious for a malignancy?
Yes
No
Melanoma
Atypical
Nevus
Basal cell
carcinoma (BCC)
Squamous cell
carcinoma
Excision
Punch
(If large, biopsy
darkest or
thickest portion)
Suspect
sclerosing
BCC
Shave or
punch
Yes
No
Punch
Shave
(If superficial
multicentric BCC,
can perform curettage
and desiccation)
Superficial
epidermal
lesion
Dermal lesion
or inflammatory
dermatosis
Shave or
curette
Punch
Figure 24-1 . Algorithm for biopsy technique based on clinical assessment.
Biopsies
BACKGROUND AND HISTORY
Skin biopsies are performed to determine the cause of a lesion or to remove
a lesion, or both. The general categories of biopsies include shave, punch,
and excision. A shave biopsy removes the epidermis and a portion of the
upper dermis and is performed along the horizontal plane. Variations on the
shave technique include snip excisions, as performed for skin tag removal,
and curettage, as performed for many benign superficial lesions. A punch
biopsy can be either incisional or excisional. An incisional biopsy removes
only a portion of a lesion, whereas an excisional biopsy removes the entire
lesion. Larger excisional biopsies can be completed using a No. 15 blade.
Incisional and excisional biopsies extend to the subcutaneous fat. Deter-
mining the correct biopsy technique is based on the clinical diagnosis
(Fig. 24-1) and the desired cosmetic outcome (Tobinick, 1998).
Chapter 24 — Dermatologic Procedures 345
SHAVE BIOPSY
INDICATIONS
Seborrheic keratoses
■ Verrucous lesions
Molluscum contagiosum
Superficial basal cell carcinomas
Occasionally, a shave biopsy may be performed on benign nevi, particularly
on the face, when a good cosmetic result is essential (Bennett, 1988a; Siegel
and Usatine, 1998b; Tobinick, 1998).
Snip excisions may be performed for the following (Bennett, 1988a; Siegel
and Usatine, 1998b):
Acrochordons (skin tags)
■ Pedunculated nevi
Care must be taken not to perform this technique on dermal nevi without
anesthesia, because the patient will experience greater discomfort because
of innervation of nevi.
Curettage may be performed on benign superficial lesions, such as the
following (Ho, 1999):
Molluscum contagiosum
■ Verruca vulgaris
■ Seborrheic keratoses, with or without cryotherapy
For superficial multicentric basal cell carcinomas and Bowen's disease,
curettage and desiccation are alternatives to excision (Bennett, 1988a;
Schwartz, 1999; Usatine, 1998a).
When curettage is used, histologic margins are impossible to determine. If
tumor margins need to be determined, an alternative biopsy technique
should be used.
CONTRAINDICATIONS
Contraindications for a shave biopsy include the following (Siegel and
Usatine, 1998b):
Most pigmented lesions, except in the case of benign nevi, as stated
earlier
■ For the diagnosis of infiltrative dermatoses
■ In a suspected sclerosing basal cell carcinoma
Any lesion with a dermal component
346 Chapter 24 — Dermatologic Procedures
POTENTIAL COMPLICATIONS
The most common complications seen with shave biopsy include the following
(Siegel and Usatine, 1998b):
Bleeding: Most bleeding is readily stopped with the use of 20% aluminum
chloride (Drysol). If bleeding is more brisk, as occurs when patients are
taking aspirin or warfarin, or if the shave is too deep into the dermis,
hand-held cautery may be used. Monsel's solution (ferric subsulfate) and
silver nitrate may be used, but tattooing can occur with their use. It is
not recommended that Monsel's solution or silver nitrate be used on the
face or highly visible areas (Siegel and Usatine, 1998b; Stasko, 1996;
Usatine, 1998b).
Infection
Regrowth of the lesion: Lesions such as warts and incompletely removed
nevi or seborrheic keratoses can regrow. An estimated 1 in 20 nevi
regenerates (Siegel and Usatine, 1998b).
Scarring: Scarring, which usually has the appearance of an atrophic,
lighter than normal area, may occur even when the procedure is
performed correctly. It is more of a risk if the shave is too deep into the
dermis.
■ Some discomfort may be experienced with the injection of anesthetic.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
For simplicity, the skin structure consists of the epidermis or topmost layer
of the skin, the dermal-epidermal junction, the dermis, and the subcutaneous
fat. It is essential that the practitioner have knowledge of the vasculature and
nerves of the biopsy site before performing any biopsy of the skin. In
addition, adequate knowledge of the lines of skin tension is required to
determine the orientation of punch and excisional biopsies. Suture lines are
less likely to develop into a widened scar if placed parallel to the lines of
tension (Fig. 24-2) (Moy and Usatine, 1998b; Zalla, 1996). In addition, placing
suture lines parallel to wrinkles improves the cosmetic appearance of the
end defect. Caution must be used when performing elliptical excisions on the
face — particularly on the forehead or near the eye or lips — so that distortion
does not occur. Large excisions in these areas may necessitate a graft or flap
closure.
to exercise clinical judgment based on the
Standard Precautions Every practitioner should patient's history and the potential for exposure
use standard precautions at all times when to body fluids or aerosol-borne pathogens (for
interacting with patients, especially when further discussion, see Chapter 2).
performing procedures. Determining the level
of precaution necessary requires the practitioner
Chapter 24 — Dermatologic Procedures 347
Figure 24-2. Skin tension lines of the body surface. (Adapted from Trott AT:
Wounds and Lacerations: Emergency Care and Closure, 2nd ed. St. Louis,
Mosby-Year Book, 1998, p 17.)
PATIENT PREPARATION
Explain the procedure to the patient or guardian, or both, and be
prepared to answer any questions.
The patient or patient's guardian must give informed consent before
start of the procedure.
A topical anesthetic can be provided, which must be applied 20 to
60 minutes before the procedure, depending on the topical agent used
(see Chapter 22 for selection of topical anesthetics). If topical anesthesia
is used, the occlusive tape, if any, is removed and cleaned with
gauze.
348 Chapter 24 — Dermatologic Procedures
Materials Utilized to Perform a Shave, Snip, or
Curettage Biopsy
■ Topical anesthetic, if used
Sterile gloves
■ Sterile towels
■ Alcohol pads
No. 15 blade or a razor blade
■ Lidocaine with or without epinephrine, as indicated
■ 3-mL syringe and 30-gauge needle for local anesthesia
4 x 4-inch gauze
■ Forceps
Cotton-tipped applicator and 20% aluminum chloride for hemostasis (for
more vascular lesions, hand-held cautery may be needed)
■ Specimen container
Note: Most biopsy specimens may be sent in formalin containers. The
exceptions to this are specimens sent for culture or immunofluorescent
studies and specimens in which formalin breaks down the tissue, such as in
xanthomatous lesions (Fitzpatrick, 1999; Schultz, 1996). In these instances,
specimens should be sent fresh. This is accomplished by placing the
specimen on sterile 4 x 4-inch gauze moistened with sterile water or normal
saline in a sterile urine cup. All fresh specimens need to be transported
immediately to the pathology department for examination.
Polymyxin B sulfate-bacitracin zinc (Polysporin) and an adhesive
bandage
If skin tags (acrochordons) are to be removed, the following equipment is
needed:
■ Alcohol pads
Forceps
■ Tonometry scissors
4 x 4-inch gauze
■ 20% aluminum chloride
■ Cotton-tipped applicator
Polymyxin B sulfate-bacitracin zinc (Polysporin) and an adhesive
bandage
Chapter 24 — Dermatologic Procedures 349
For curettage the following equipment is needed:
■ Alcohol pads
4 x 4-inch gauze
20% aluminum chloride
Cotton-tipped applicator
Polymyxin B sulfate-bacitracin zinc (Polysporin) and an adhesive bandage
Hand-held cautery and cryogun (optional)
Procedure for Performing a Shave, Snip, or Curettage Biopsy
Shave Biopsy
1. Place a sterile towel around the biopsy site.
2. Lightly clean the area with an alcohol
pad unless cautery use is anticipated.
Note: Because alcohol is flammable, use
nonflammable povidone-iodine and water to
prepare the skin if cautery may be used.
3. If the lesion has the potential to blanch
with an injection of lidocaine with
epinephrine, such as in basal cell
carcinomas, mark the margins of the
lesion with a sterile surgical marker
before the anesthetic is injected (Bennett,
1988a; Siegel and Usatine, 1998b).
4. Inject the lesion with anesthetic so that a
wheal is raised.
5. Hold the No. 15 blade flat and parallel
with the skin surface.
6. If a razor blade is used, snap it in half
lengthwise and bow the ends so that the
middle of the blade is flat and parallel
with the skin surface.
7. Use a gentle sawing motion to shave
through the lesion (Fig. 24-3).
Figure 24-3. Shave biopsy. (Redrawn from
Pfenninger JL, Fowler GC: Procedures for Primary
Care Physicians. St. Louis, Mosby-Year Book,
1994, p 22.)
8. The lesion may be elevated with the use
of forceps or by spearing the lesion with
a needle.
Note: Care must be taken not to crush the
lesion with the forceps, which will distort
the histologic specimen (referred to as crush
artifact).
9. Attempt to shave the base of the lesion
completely by shaving into the
uppermost portion of the dermis.
Note: If the specimen is too thin (just
epidermis), a good histologic diagnosis may
not be made.
10. To complete the shave, it is sometimes
useful to stabilize the far end of the
lesion with a cotton-tipped applicator to
cut against.
continued
350 Chapter 24 — Dermatologic Procedures
11. Once the lesion is removed, most light
bleeding can be stopped with direct
pressure and 20% aluminum chloride on
a cotton-tipped applicator.
Note: If bleeding is more brisk or is not
stopped with the preceding procedure,
hand-held cautery should be used.
12. Place an antibiotic ointment such as
mupirocin (Bactroban) or polymyxin B
sulfate-bacitracin zinc on an adhesive
bandage to dress the wound.
Snip Excision
1. Clean the area lightly with an alcohol pad.
Note: There is usually no need to anesthetize
the area. The exception is larger skin tags
because they may actually be dermal nevi.
2. Pick up the skin tag with forceps and cut
at the base with tonometry scissors.
3. If there is any bleeding, stop with 20%
aluminum chloride on a cotton-tipped
applicator.
4. Place antibiotic ointment on an adhesive
bandage to dress the wound.
Curettage
Note: For seborrheic keratoses, verrucous
lesions, or molluscum contagiosum,
cryotherapy (see Chapter 27) applied first
and followed quickly by curettage requires no
local injection because liquid nitrogen
acts as a partial anesthetic (Graham, 1999).
1. If the patient is apprehensive, a topical
anesthetic can be applied before the
procedure.
2. For superficial basal cell carcinomas or
any other lesion in which the use of
cautery is anticipated, the lesion should
be injected with anesthetic.
3. Hold the curette like a pencil with the
sharp side down.
4. Stabilize the skin and use quick scraping
motions.
Note: When the lesion has been removed,
the skin feels different under the curette.
Differentiating this change develops with the
experience of the provider.
5. Once the lesion is completely removed,
obtain hemostasis with 20% aluminum
chloride on a cotton-tipped applicator or
with hand-held cautery.
Note: Curettage and desiccation for basal
cell carcinomas and Bowen's disease
requires the following procedure: Curette the
lesion until all visible signs of tumor are
gone (generally 1 to 2 mm onto normal skin),
desiccate the whole base of the lesion with
hand-held cautery, and then repeat both
steps for three full cycles of curettage and
desiccation (Schwartz, 1999; Usatine, 1998a).
6. Place antibiotic ointment on an adhesive
bandage to dress the wound.
FOLLOW-UP CARE AND
INSTRUCTIONS
Written instructions on wound care can be provided.
Instruct the patient to keep the area clean and dry for 24 hours (Siegel,
1998; Zalla, 1996).
Chapter 24 — Dermatologic Procedures 351
After that time, instruct the patient to remove the adhesive bandage and
to clean the wound site with soap and water as usual.
Instruct the patient that if an adhesive bandage is applied, more
antibiotic ointment should be placed on the biopsy site. For most small
shave biopsy sites, however, the adhesive bandage does not need to be
reapplied after the first 24 hours.
■ Caution the patient that infection is a rare complication, as antibiotic
ointment is applied under the dressing after the procedure is complete.
■ Instruct the patient to call the office if the following signs appear:
erythematous, tender, warm skin with purulent drainage. When this
occurs, antibiotic treatment should be initiated. A broad-spectrum oral
antibiotic that covers Staphylococcus and Streptococcus species should be
used, such as cephalexin, dicloxacillin, or erythromycin (Moy and
Usatine, 1998a).
■ Barring infection, it is not necessary to schedule a return appointment,
but the patient should be informed of the results of the pathologic
examination.
PUNCH BIOPSY
INDICATIONS
When there is a lesion or dermatosis that covers a large surface area and
diagnosis needs to be confirmed before treatment is started, taking just a
portion of the lesion is indicated (Siegel and Usatine, 1998a).
It is important to take the most representative area of the lesion for the
highest diagnostic yield.
■ In the case of pruritic dermatoses, it is best to biopsy a lesion that has
not been excoriated.
For vesicular lesions, an intact vesicle or bulla may provide the best
diagnostic yield for general histology. If an autoimmune bullous disorder
is suspected, an additional punch biopsy should be obtained within 1 cm
but not on the vesicle or bulla. This specimen would be sent to
pathology for direct immunofluorescence staining. In suspected
melanoma that is too large to excise at that time, the biopsy should be
obtained from the darkest or thickest area of the lesion.
CONTRAINDICATIONS
Contraindications for an incisional biopsy would be any lesion with highly
suspected malignant potential, such as melanoma, that could be easily
excised at the initial visit (Siegel and Usatine, 1998a). Any lesion smaller than
352 Chapter 24 — Dermatologic Procedures
8 to 10 mm, regardless of malignant potential, can easily be removed completely
with a punch biopsy.
POTENTIAL COMPLICATIONS
The risks for a punch biopsy are similar to those of shave biopsies:
■ There is discomfort with the injection of anesthetic.
The risk for bleeding is higher than in shave biopsies because the skin is
incised to the subcutaneous fat, increasing the risk of severing small
vessels. Hand-held cautery is the method of choice to stop brisk bleeding.
■ In any punch biopsy of 8 mm or larger, subcutaneous sutures also
decrease the bleeding and improve wound healing.
The infection rate is higher because the procedure is slightly more
invasive. As with a shave biopsy, secondary infection can be easily treated
with a 5- to 7-day course of a broad-spectrum antibiotic.
■ Scarring will occur, but the extent depends on the patient's ability to
heal versus the size of the end defect. In punch biopsies of 1 cm or
larger, it is more cosmetically appealing to perform an excision with a
No. 15 blade (Moy and Usatine, 1998b; Siegel and Usatine, 1998a), which
avoids the potential problem of dog-eared closures.
to exercise clinical judgment based on the
Standard Precautions Every practitioner should patient's history and the potential for exposure
use standard precautions at all times when to body fluids or aerosol-borne pathogens (for
interacting with patients, especially when further discussion, see Chapter 2).
performing procedures. Determining the level
of precaution necessary requires the practitioner
PATIENT PREPARATION
Explain the procedure to the patient or guardian, or both, and be
prepared to answer any questions.
The patient or guardian must give informed consent before start of the
procedure.
■ A topical anesthetic can be provided, which must be applied 20 to
60 minutes before the procedure, depending on the topical agent used
(see Chapter 22 for selection of topical anesthetics). If topical anesthesia
is used, the occlusive tape, if any, is removed and cleaned with
gauze.
Chapter 24 — Dermatologic Procedures 353
Materials Utilized to Perform a Punch Biopsy
■ Topical anesthetic, if used
Metric ruler to determine the size of the lesion
Sterile gloves
■ Sterile towels
Alcohol pads
Lidocaine with or without epinephrine, as indicated
3-mL syringe and 30-gauge needle for local anesthesia (for larger lesions
use a 27-gauge, l^-inch needle)
4 x 4-inch gauze
■ Forceps
Curved scissors
■ Needle driver
■ Appropriate suture to close skin (see Chapter 23)
■ Specimen container
Polymyxin B sulfate-bacitracin zinc (Polysporin) and an adhesive
bandage
■ Appropriately sized punch (A punch is selected that is the appropriate
size to completely excise the lesion with minimal surrounding normal
skin.)
Note: Disposable punches are available in the following sizes: 2, 3, 4, 6, and
8 mm. Nondisposable punches are available in 10, 12, and 15 mm sizes. In
the case of incisional biopsies, a 3- or 4-mm punch should be sufficient to
make the diagnosis. If enough tissue is needed to send a portion for
histologic examination and another portion for culture or immunofluorescent
studies, two 3- or 4-mm biopsy specimens may be taken. Alternatively, one
6-mm specimen may be sent with a request to the pathology department
to split the specimen and explicit directions on what is to be done with
each half.
354 Chapter 24 — Dermatologic Procedures
Procedure for Performing a Punch Biopsy
1. With punch biopsy specimens smaller
than 1 cm, place a sterile towel around
the biopsy site.
2. Use an alcohol pad to lightly clean the
area.
3. If the punch biopsy specimen is to be
1 cm or larger, scrub the area first for
3 minutes with chlorhexidine or
povidone-iodine (Hruza, 1999; Moy and
Usatine, 1998b).
4. Drape the area with sterile towels.
5. If the lesion has the potential to blanch
with the injection of lidocaine with
epinephrine, such as in basal cell
carcinomas, the margins of the lesion
should be marked with a sterile surgical
marker before the anesthetic is
injected.
6. Inject the lesion with the anesthetic so
that the area where the punch will be
placed and the surrounding tissue will
be sutured is anesthetized.
Note: It is also important to ensure that the
full depth of where the punch will extend is
anesthetized. Local anesthetic works rapidly,
within a minute; however, in highly vascular
areas such as the scalp it is prudent to wait
10 minutes to allow the epinephrine to work
(Siegel and Usatine, 1998a).
o
B
7. After selecting the appropriate size
punch, hold the skin taut perpendicular
to the lines of tension, wrinkle, or skin
fold.
8. Hold the punch perpendicular to the
skin and place it so that the lesion is
centered within the punch area
(Fig. 24-4A).
9. Apply downward pressure while rotating
the punch.
Note: It is useful to get into the habit of
rotating the punch in one direction, as it is
necessary for the biopsy of vesicular or
bullous lesions. Rotating back and forth in
these cases distorts the plane of cleavage
(Bennett, 1988c).
10. The punch should extend to the
subcutaneous fat.
Note: When performing a punch biopsy over
large vessels or nerves and in areas of thin
skin, it is sometimes helpful to pinch the
skin upward to avoid damaging underlying
structures.
11. Once complete, remove the punch, and
the specimen will remain attached to
the subcutaneous fat by a pedicle (see
Fig. 24-4BJ).
12. Gently lift the specimen with a pair of
forceps and cut at the base with a pair of
scissors (Fig. 24-4C).
Figure 24-4. A-C, Punch
biopsy. (Redrawn from
Pfenninger JL, Fowler GC:
Procedures for Primary Care
Physicians. St. Louis,
Mosby-Year Book, 1994,
p23.)
Chapter 24 — Dermatologic Procedures 355
Note: Care must be taken not to crush the
lesion with the forceps, which could distort
the histologic specimen.
Note: If the punch is removed and the
pedicle is missing, it may be found in one of
two places. Most commonly it is inside the
punch. Removal can be accomplished by
spearing it with a needle and pulling it out.
It may also be under the skin. Gently explore
under the skin through the defect to look for
the specimen.
13. Once the specimen is removed
completely, place it in the specimen
container.
14. Suture the wound, placing half as many
sutures as the size of the punch (see
Chapter 23). For instance, a 6-mm punch
requires three evenly spaced sutures.
15. Apply an antibiotic ointment on an
adhesive bandage to dress the
wound.
FOLLOW-UP CARE AND
INSTRUCTIONS
Written instructions on wound care should be provided.
Instruct the patient to keep the area clean and dry for 24 hours. After
that time, the adhesive bandage may be removed and the site cleaned
with soap and water as usual.
If a new adhesive bandage is applied, instruct the patient to place more
antibiotic ointment on the biopsy site. For most punch biopsy sites,
however, the adhesive bandage does not need to be reapplied after the
first 24 hours. The exception to this is in areas of friction or if drainage
will get on the patient's clothing.
Schedule a return appointment in 5 to 21 days, depending on the area
biopsied. The head tends to heal faster, whereas areas of tension such as
the anterior tibia require longer healing times. A basic time schedule for
suture removal is as follows (Hruza, 1999; Moy, 1998):
■ Face and ears: 5 to 7 days
Neck: 7 days
■ Scalp: 7 to 10 days
■ Trunk and extremities: 7 to 14 days
■ Distal lower extremities: 10 to 21 days
Advise the patient to not do any heavy lifting or exercising that might
cause the sutures to break or lead to a widened scar.
The patient should be informed of the results of the pathologic
examination, either when the results are provided to the practitioner or
when the patient returns for suture removal.
356 Chapter 24 — Dermatologic Procedures
EXCISIONAL BIOPSY
INDICATIONS
Any lesion that is smaller than 8 to 10 mm can be completely excised as stated
earlier with a punch biopsy Most lesions larger than 1 cm have a better
cosmetic appearance if the excision is performed using a No. 15 blade.
Lesions that are excised routinely are as follows (Moy and Usatine, 1998b;
Schultz, 1996; Zalla, 1996):
■ Suspected melanomas
■ Epidermal inclusion cysts
Lipomas
Larger basal cell and squamous cell carcinomas
■ Dermal lesions larger than 1 cm
Mohs micrographic surgical procedures are beyond the scope of most
primary care providers, as they require special training to perform. However,
they bear mentioning with respect to removal of malignant lesions. Mohs
procedures are preferred in sclerosing and morpheaform basal cell
carcinomas, recurrent tumors, and any malignant tumor around the eyes,
nose, or lips, and on the ears. They use a special technique of excising and
color-coding the specimen before histologic examination. This method has a
higher overall cure rate and lower recurrence rate than do standard excisions
(Randle, 1996; Russell, 1999; Zalla, 1996). Patients who meet the preceding
criteria and in whom surgery is being considered should be referred to a
dermatologist trained in the Mohs technique.
POTENTIAL COMPLICATIONS
The complications are similar to those of punch biopsies.
■ There is discomfort with the injection of anesthetic.
■ The risk for bleeding is higher because a larger area of skin is incised to
the subcutaneous fat, increasing the risk of severing small vessels.
■ Hand-held cautery is the method of choice to stop brisk bleeding in
addition to subcutaneous sutures.
The infection rate is also higher because the procedure is more invasive.
Secondary infection can be easily treated with a 5- to 7-day course of a
broad-spectrum antibiotic covering Staphylococcus and Streptococcus
species.
Scarring will occur, but the extent depends on the patient's ability to
heal versus the size and placement of the end defect.
Chapter 24 — Dermatologic Procedures 357
■ More than with any other biopsy technique, adequate knowledge of the
lines of skin tension is required to determine orientation of excisional
biopsies (see Fig. 24-2).
Caution must be used when performing elliptic excisions on the face —
particularly on the forehead or near the eyes or lips — so that distortion does
not occur (Moy and Usatine, 1998b). Large excisions in these areas may
necessitate a graft or flap closure.
practitioner to exercise clinical judgment based
Standard Precautions Every practitioner should on the patient's history and the potential for
use standard precautions at all times when exposure to body fluids or aerosol-borne
interacting with patients, especially when pathogens (for further discussion, see
performing procedures. Determining the level Chapter 2).
of precaution necessary requires the
PATIENT PREPARATION
Explain the procedure to the patient or the patient's guardian, or both,
and be prepared to answer any questions.
■ The patient or guardian must give informed consent before the start of
the procedure.
A topical anesthetic can be provided, which must be applied 20 to 60
minutes before the procedure, depending on the topical agent used (see
Chapter 22 for selection of topical anesthetics).
■ If topical anesthesia is used, the occlusive tape, if any, is removed and
cleaned with gauze.
Materials Utilized to Perform an Excisional
Biopsy
Topical anesthesia, if used
Chlorhexidine or povidone-iodine
Sterile surgical marker
Sterile gloves
Sterile towels
Alcohol pads
Lidocaine with or without epinephrine, as indicated
3-mL syringe and 27-gauge, 1-inch needle for local anesthesia
4 x 4-inch gauze
358 Chapter 24 — Dermatologic Procedures
■ Forceps
Curved scissors
■ Needle driver
Appropriate suture to close subcutaneous tissue and skin (see
Chapter 23)
Hand-held cautery
Specimen container
Polymyxin B sulfate-bacitracin zinc (Polysporin) and a dressing of
4 x 4-inch gauze and paper tape or a large adhesive bandage
Metric ruler to determine the size of the end defect
Procedure for Performing an Excisional Biopsy
Note: Proper anesthetic technique is
determined by the size of the area being
excised and may warrant direct infiltration
of the biopsy site, digital block, or a field
block (see Chapter 22).
Note: It is also important to ensure that
anesthesia is adequate for the full depth and
width of the excision and placement of
sutures. Local anesthesia works rapidly,
within a minute; however, in highly vascular
areas such as the scalp it is prudent to wait
10 minutes to allow the epinephrine, when
used, to work.
1. Scrub the area for 5 minutes with
chlorhexidine or povidone-iodine.
2. Drape the area with sterile towels.
3. If the lesion has the potential to blanch
with the injection of lidocaine with
epinephrine, such as in basal cell
carcinomas, the margins of the lesion
should be marked with a sterile surgical
marker before the anesthetic is injected.
4. Use a sterile surgical marker to mark the
intended incision line, taking into
account the lines of tension, wrinkles, or
skin folds (see Fig. 24-2).
5. Hold the No. 15 blade like a pencil,
perpendicular to the skin.
6. Use the tip of the blade to incise the
corner of the ellipse, but use the belly
for the rest of the incision (Moy and
Usatine, 1998b; Zalla, 1996).
7. Continue the incision through the dermis
to the subcutaneous fat (Fig. 24-5).
3.5 cm
Figure 24-5. Excisional biopsy. (Redrawn from
Pfenninger JL, Fowler GC: Procedures for Primary
Care Physicians. St. Louis, Mosby-Year Book,
1994, p 24.)
Chapter 24 — Dermatologic Procedures 359
8. Use the forceps to lift the specimen
gently, taking care not to crush it.
9. Use the No. 15 blade to cut the specimen
at the base or subcutaneous fat.
Note: In the case of potentially malignant
lesions, it is useful to place a tag suture on
one corner of the specimen, indicating where
the tag was placed on the form sent to
pathology (e.g., tag is placed on medial
corner).
10. Once the specimen is completely
removed, place it in the specimen
container.
11. In larger excisions, push the skin edges
of the defect together or pull them
together with skin hooks to see how much
tension will be placed on the sutures.
Note: If there is tension, undermining is
needed. Undermining is performed by blunt
dissection to mobilize adequate tissue for
closure.
12. Stop any bleeding with hand-held
cautery.
13. Begin wound closure of the excision
with the placement of subcutaneous
vertical mattress sutures to
approximate the wound edges,
decrease wound tension, and reduce
the risk of wound dehiscence. This is
performed with an absorbable suture
material.
14. Place nonabsorbable sutures to close
the skin.
Note: This can be performed with running
or simple interrupted sutures for most
wounds. In areas of greater tension,
mattress sutures may need to be placed for
strength.
15. Leave the skin edges everted at the end
closure for the best outcome.
16. Apply an antibiotic ointment on a
dressing over the wound.
SPECIAL CONSIDERATIONS
With any invasive procedure, a good history and review of systems should
be taken to determine if there are any contraindications to surgery. In addition,
the patient's ability to heal, history of allergies, need for subbacterial
endocarditis (SBE) prophylaxis and use of anticoagulants should be
assessed. If possible, the patient should discontinue warfarin and
nonsteroidal antiinflammatory agents approximately 2 to 4 days before any
invasive procedure, and aspirin should be discontinued for approximately 10
days (Hruza, 1999; Moy and Usatine, 1998a; Stasko, 1996; Zalla, 1996).
It is difficult to perform biopsies on small children, particularly those
between the ages of 1 and 5. The provider needs to discuss the absolute need
for biopsy with the parents or guardian before deciding to perform the
procedure. Once it is determined that the biopsy is necessary, the child may
need to be sedated. However, with the use of topical anesthetics, many children
experience little discomfort.
360 Chapter 24 — Dermatologic Procedures
FOLLOW-UP CARE AND
INSTRUCTIONS
■ Written instructions on wound care should be provided.
■ Instruct the patient to keep the area clean and dry for 24 hours.
■ After that time, the dressing may be removed and the site cleaned with
soap and water as usual.
■ If a new dressing is applied, instruct the patient to place more antibiotic
ointment on the biopsy site. For most biopsy sites, however, the dressing
does not need to be reapplied after the first 24 hours. The exception to
this is in areas of friction or if drainage will get on the patient's clothing.
■ Schedule a return appointment in 5 to 21 days, depending on the area
biopsied. (Refer to the time schedule for suture removal given in
"Follow-up Care and Instructions" under "Punch Biopsy")
■ Inform the patient that care should be taken to not do any heavy lifting
or exercising that might cause the sutures to break or lead to a widened
scar.
Inform the patient of the results of the pathologic examination either
when the results are provided to the practitioner or when the patient
returns for suture removal.
Electrosurgery
BACKGROUND AND HISTORY
Electrosurgery encompasses electrodesiccation, electrocoagulation, electro-
fulguration, electrosection, electrolysis, and electrocautery. The focus of this
section is electrodesiccation. This is a high-voltage, low-amperage damped
current, which generates heat in the tissue, causing coagulation and
dehydration (Hruza, 1999; Pollack, 1997). There is no current channeling
along blood vessels and nerves with electrodesiccation, so it is relatively
safe in patients with cardiac pacemakers. Despite this, it should not be used
immediately near the pacemaker (Bennett, 1988b; Hruza, 1999; Pollack, 1997;
Usatine, 1998a). Lesions larger than 3 to 4 mm do better with cryosurgery,
whereas smaller, 1- to 2-mm lesions may respond better to electrodesiccation
(Graham, 1999).
INDICATIONS
Lesions commonly treated with electrodesiccation include the following:
■ Acrochordons
Chapter 24 — Dermatologic Procedures 361
■ Pyogenic granulomas and other vascular lesions
■ Verruca vulgaris
■ Condyloma acuminata
■ Actinic keratoses
■ Superficial multicentric basal cell carcinomas, in combination with
curettage
CONTRAINDICATIONS
■ The procedure should not be performed near a pacemaker.
■ It also should not be performed if flammable material or gases are
present in the immediate surgical field.
POTENTIAL COMPLICATIONS
Common complications of electrodesiccation include the following:
■ Pain
Scarring
Delayed bleeding
Risk of burns
■ Pigment alterations: A crust will form within 24 hours. Within 5 to 7 days,
the crust sloughs off. Once this occurs, there may be a hypopigmented
area remaining, which is generally temporary. Occasionally, an area of
hyperpigmentation may develop that could require further treatment
with keratolytic (e.g., topical retinoids) or bleaching agents (e.g., 4%
hydroquinone) to lighten the skin (Stasko, 1996). Scarring may be
hypertrophic, atrophic, or a keloid on rare occasions.
■ The use of alcohol to prepare the skin could lead to fire during
electrosurgery A nonflammable alternative preparation such as
povidone-iodine is preferred. Care must also be taken when electrosurgery
is performed in the perianal area. Bowel gas, which is composed of
methane and hydrogen gas, can ignite. This can be prevented with
adequate bowel preparation before the procedure or the placement of
cotton in the rectum (Bennett, 1998b).
■ Viral particles can be aerosolized in cautery and laser smoke, particularly
human papillomavirus (HPV) and human immunodeficiency virus (HIV).
There are no case reports of HIV transmission through cautery and laser
smoke. There are, however, reports of laryngeal papillomatosis in health
care providers from cautery and laser ablation of warts (Lowry, 1999;
Seabury-Stone, 1996; Usatine, 1998a).
362 Chapter 24 — Dermatologic Procedures
practitioner to exercise clinical judgment based
Standard Precautions Every practitioner should on the patient's history and the potential for
use standard precautions at all times when exposure to body fluids or aerosol-borne
interacting with patients, especially when pathogens (for further discussion, see
performing procedures. Determining the level Chapter 2)
of precaution necessary requires the
PATIENT PREPARATION
■ Explain the procedure to the patient or the patient's guardian, or both,
and be prepared to answer any questions.
The patient or guardian must give informed consent before start of the
procedure.
■ A topical anesthetic can be provided, which must be applied 20 to
60 minutes before the procedure, depending on the topical agent used
(see Chapter 22 for selection of topical anesthetics).
■ If topical anesthesia is used, the occlusive tape, if any, is removed and
cleaned with gauze.
Electrodesiccation does not induce partial anesthesia; therefore, the
procedure is better tolerated if a topical anesthetic is applied before
starting the procedure or local anesthesia infiltration is used. After the
procedure, patients rarely need any analgesia, but acetaminophen may
be required.
Materials Utilized to Perform Electrosurgery
Topical anesthetic, if used
Hyfrecator and desiccation electrode needle
Face mask (for protection from smoke generated during the procedure)
4 x 4-inch gauze
Antibiotic ointment and an adhesive bandage
5- or 7-mm curette and 4 x 4-inch gauze, if curettage of a lesion will follow
the electrosurgery
Chapter 24 — Dermatologic Procedures 363
Procedure for Performing Electrosurgery
1. Clean the area with povidone-iodine and
water only for electrodesiccation. Alcohol
is flammable, and therefore should not be
used.
2. For electrodesiccation, remove the
occlusive tape from the topical anesthetic.
3. Use the hyfrecator with desiccation
electrode needle.
Note: Set the hyfrecator to a low setting to
begin and turn it up as needed. Lightly touch
the lesion to determine if the power setting
is adequate.
4. Once the correct power setting is found,
ablate the lesion.
Note: Small lesions usually are ablated
immediately, whereas larger lesions
require gentle passes with the
electrode.
5. Gently wipe the charred lesion with
4 x 4-inch gauze or curette. No bleeding
should occur.
6. Apply an antibiotic ointment and an
adhesive bandage.
FOLLOW-UP CARE AND
INSTRUCTIONS
■ Written instructions on wound care should be provided.
■ For areas of electrodesiccation, instruct the patient to keep the area
clean and dry for 24 hours.
■ After that time, the dressing may be removed and the site cleaned with
soap and water as usual.
■ If a new dressing is applied, instruct the patient to place more antibiotic
ointment on the biopsy site. For most biopsy sites, however, the dressing
does not need to be reapplied after the first 24 hours. The exception to
this is in areas of friction or if drainage will get on the patient's clothing.
No return appointment is necessary.
Acne Surgery
BACKGROUND AND HISTORY
Acne surgery is performed on comedones and, occasionally, pustules. Open
comedones or "blackheads" are removed purely for cosmetic purposes.
Removal does not shorten the resolution of the acne lesions. Removal of
closed comedones or "whiteheads" does shorten the resolution time, as acne
surgery prevents them from rupturing and becoming larger papules or pustules
(Strauss, 1999).
364 Chapter 24 — Dermatologic Procedures
INDICATIONS
Acne surgery may be performed on most patients with comedonal or pustular
acne. Pretreatment with a topical retinoid by the patient for approximately
1 month greatly improves the removal of comedones (Baran, 1998; Strauss,
1999).
CONTRAINDICATIONS
Care should be taken with patients who may develop postinflammatory
hyperpigmentation or those who may bruise easily. They should be informed
of the possible risks of bruising and hyperpigmentation.
POTENTIAL COMPLICATIONS
■ Discomfort from the procedure
■ Immediate swelling and pinpoint bleeding
■ Small amounts of bruising
■ Postinflammatory hyperpigmentation
■ Rupture of the comedo if improper technique is used (Baran, 1998;
Strauss, 1999).
practitioner to exercise clinical judgment based
Standard Precautions Every practitioner should on the patient's history and the potential for
use standard precautions at all times when exposure to body fluids or aerosol-borne
interacting with patients, especially when pathogens (for further discussion, see
performing procedures. Determining the level Chapter 2).
of precaution necessary requires the
PATIENT PREPARATION
Explain the procedure to the patient or the patient's guardian, or both,
and be prepared to answer any questions.
The patient or guardian must give informed consent before start of the
procedure.
Materials Utilized to Perform Acne Surgery
Alcohol pads
No. 1 1 blade or a 25-gauge needle
Chapter 24 — Dermatologic Procedures 365
Unna-type comedo extractor
4 x 4-inch gauze
Procedure for Performing Acne Surgery
1. Clean the area with an alcohol pad.
2. Use a No. 11 blade or 25-gauge needle to
open the pore of the comedo or pustule
gently.
3. Place the Unna-type comedo extractor flat
against the skin.
4. Apply pressure downward while gently
sliding toward the comedo or pustule
(Fig. 24-6).
Note: The extractor may need to be moved
in all four quadrants to ensure all the
comedonal contents are removed.
5. Stop any bleeding with direct pressure
with 4 x 4-inch gauze.
Figure 24-6. Acne surgery. (Redrawn from
Pfenninger JL, Fowler GC: Procedures for Primary
Care Physicians. St. Louis, Mosby-Year Book,
1994, p 55.)
Note: The patient may want to wash his or
her face before leaving the office.
FOLLOW-UP CARE AND
INSTRUCTIONS
■ Instruct the patient to wash the area with soap and water as usual.
■ Advise the patient that topical retinoids and alpha-hydroxy acids may
need to be avoided for 24 hours to prevent irritation of the open areas.
■ No return appointment is necessary.
References
Baran R, Chivot M, Shalita AR: Acne. In Baran R, Maibach HI (eds):
Textbook of Cosmetic Dermatology, 2nd ed. London, Martin Dunitz,
1998, pp 433-444.
Bennett RG: Curettage. In Fundamentals of Cutaneous Surgery. St. Louis,
CV Mosby, 1988a, pp 532-552.
Bennett RG: Electrosurgery In Fundamentals of Cutaneous Surgery.
St. Louis, CV Mosby, 1988b, pp 553-590.
Bennett RG: The skin biopsy. In Fundamentals of Cutaneous Surgery.
St. Louis, CV Mosby, 1988c, pp 517-531.
366 Chapter 24 — Dermatologic Procedures
Fitzpatrick TB, Bernhard JD, Cropley TG: The structure of skin lesions
and fundamentals of diagnosis. In Fitzpatrick TB, Eisen AZ, Wolff K,
et al (eds): Dermatology in General Medicine, 5th ed. New York,
McGraw-Hill, 1999, pp 13-41.
Graham GF: Cryosurgery. In Fitzpatrick TB, Eisen AZ, Wolff K, et al
(eds): Dermatology in General Medicine, 5th ed. New York,
McGraw-Hill, 1999, pp 2980-2987.
Ho VCY: Benign epithelial tumors. In Fitzpatrick TB, Eisen AZ, Wolff K,
et al (eds): Dermatology in General Medicine, 5th ed. New York,
McGraw-Hill, 1999, pp 873-890.
Hruza GJ: Dermatologic surgery: Introduction and approach. In
Fitzpatrick TB, Eisen AZ, Wolff K, et al (eds): Dermatology in General
Medicine, 5th ed. New York, McGraw-Hill, 1999, pp 2923-2937.
Lowry DR, Androphy EJ: Warts. In Fitzpatrick TB, Eisen AZ, Wolff K, et al
(eds): Dermatology in General Medicine, 5th ed. New York,
McGraw-Hill, 1999, pp 2484-2497.
Moy RL: Suturing techniques. In Usatine RP, Moy RL, Tobinick EL, et al
(eds): Skin Surgery: A Practical Guide. St. Louis, CV Mosby, 1998,
pp 88-100.
Moy RL, Usatine RP: Complications and their prevention. In Usatine RP,
Moy RL, Tobinick EL, et al (eds): Skin Surgery: A Practical Guide.
St. Louis, CV Mosby, 1998a, pp 287-299.
Moy RL, Usatine RP: Elliptical excision. In Usatine RP, Moy RL, Tobinick
EL, et al (eds): Skin Surgery: A Practical Guide. St. Louis, CV Mosby,
1998b, pp 120-136.
Pollack SV, Kobayashi T: Cosmetic electrosurgery In Coleman WP III,
Hanke CW, Alt TH, et al (eds): Cosmetic Surgery of the Skin:
Principles and Techniques, 2nd ed. St. Louis, CV Mosby, 1997,
pp 272-286.
Randle HW, Roenigk RK: Indications for Mohs micrographic surgery. In
Roenigk RK, Roenigk HH (eds): Dermatologic Surgery: Principles and
Practice, 2nd ed. New York, Marcel Dekker, 1996, pp 703-730.
Russell BA, Amonette RA, Swanson NA: Mohs micrographic surgery. In
Fitzpatrick TB, Eisen AZ, Wolff K, et al (eds): Dermatology in General
Medicine, 5th ed. New York, McGraw-Hill, 1999, pp. 2988-2991.
Schultz BC: Skin biopsy. In Roenigk RK, Roenigk HH (eds): Dermatologic
Surgery: Principles and Practice, 2nd ed. New York, Marcel Dekker,
1996, pp 177-190.
Schwartz RA, Stoll HL Jr: Epithelial precancerous lesions. In
Fitzpatrick TB, Eisen AZ, Wolff K, et al (eds): Dermatology in General
Medicine, 5th ed. New York, McGraw-Hill, 1999, pp 823-839.
Seabury-Stone M, Lynch PJ: Viral warts. In Sams WM, Lynch PJ (eds):
Principles and Practice of Dermatology, 2nd ed. New York,
Churchill Livingstone, 1996, pp 127-133.
Siegel DM, Moy RL, Usatine RP: Wound care. In Usatine RP, Moy RL,
Tobinick EL, et al (eds): Skin Surgery: A Practical Guide. St Louis,
CV Mosby, 1998, pp 278-286.
Siegel DM, Usatine RP: The punch biopsy. In Usatine RP, Moy RL,
Tobinick EL, et al (eds): Skin Surgery: A Practical Guide. St Louis, CV
Mosby, 1998a, pp 101-119.
Siegel DM, Usatine RP. The shave biopsy. In Usatine RP, Moy RL,
Tobinick EL, et al (eds): Skin Surgery: A Practical Guide. St Louis,
CV Mosby, 1998b, pp 55-76.
Stasko T: Complications of cutaneous procedures. In Roenigk RK,
Roenigk HH (eds): Dermatologic Surgery: Principles and Practice,
2nd ed. New York, Marcel Dekker, 1996, pp 149-175.
Chapter 24 — Dermatologic Procedures 367
Strauss JS, Thiboutot DM: Diseases of the sebaceous glands. In
Fitzpatrick TB, Eisen AZ, Wolff K, et al (eds): Dermatology in General
Medicine, 5th ed. New York, McGraw-Hill, 1999, pp 769-784.
Tobinick EL, Usatine RP: Choosing the type of biopsy. In Usatine RP,
Moy RL, Tobinick EL, et al (eds): Skin Surgery: A Practical Guide.
St Louis, CV Mosby, 1998, pp 40-54.
Usatine RP: Electrosurgery. In Usatine RP, Moy RL, Tobinick EL, et al
(eds): Skin Surgery: A Practical Guide. St Louis, CV Mosby, 1998a,
pp 165-199.
Usatine RP: Hemostasis. In Usatine RP, Moy RL, Tobinick EL, et al (eds):
Skin Surgery: A Practical Guide. St Louis, CV Mosby, 1998b, pp 31-39.
Zalla MJ, Roenigk RK: Excision. In Roenigk RK, Roenigk HH (eds):
Dermatologic Surgery: Principles and Practice, 2nd ed. New York,
Marcel Dekker, 1996, pp 191-207.
Bibliography
Pollack SV, Grekin RC: Electrosurgery and electroepilation. In
Roenigk RK, Roenigk HH (eds): Dermatologic Surgery: Principles and
Practice, 2nd ed. New York, Marcel Dekker, 1996, pp 219-231.
Sinclair RD, Tzermias C, Dawber R: Cosmetic cryosurgery. In Baran R,
Maibach HI (eds): Textbook of Cosmetic Dermatology, 2nd ed.
London, Martin Dunitz, 1998, pp 691-700.
Usatine RP, Moy RL: Anesthesia. In Usatine RP, Moy RL, Tobinick EL,
et al (eds): Skin Surgery: A Practical Guide. St. Louis, CV Mosby, 1998,
pp 20-30.
Usatine RP, Tobinick EL: Cryosurgical techniques. In Usatine RP,
Moy RL, Tobinick EL, et al (eds): Skin Surgery: A Practical Guide.
St. Louis, CV Mosby, 1998, pp 137-164.
Zacarian SA: Complications, indications and contraindications in
cryosurgery. In Roenigk RK, Roenigk HH (eds): Dermatologic Surgery:
Principles and Practice, 2nd ed. New York, Marcel Dekker, 1996,
pp 259-272.
Cha
pfer 25
Incision and Drainage of an
Abscess
Patrick C. Auth and George S. Bottomley
Procedure Goals and Objectives
Goal: To incise and drain an abscess successfully while observing
standard precautions and with the minimal degree of risk to the
patient.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing incision and drainage of an abscess.
• Identify and describe common complications associated with
incision and drainage of an abscess.
• Describe the essential anatomy and physiology associated with
the performance of incision and drainage of an abscess.
• Identify the materials necessary for performing incision and
drainage of an abscess and their proper use.
• Identify the important aspects of post-procedure care after
incision and drainage of an abscess.
369
370 Chapter 25 — Incision and Drainage of an Abscess
BACKGROUND AND HISTORY
The world's oldest medical manuscript is a small clay tablet written in
Sumerian around 2100 bc. A portion of it translates as, "If a man, his skull
contains some fluid, with your thumb press several times at the place where
the fluid is found. If the swelling gives way (under your finger) and (pus) is
squeezed out of the skull, you shall incise, scrape the bone and (remove) its
fluid ..." (Manjo, 1977). Advances made over the last 4100 years in the use of
minor surgical procedures to treat abscesses are discussed in this chapter.
INDICATIONS
A localized collection of infection that is tender and is not resolving
spontaneously. The cardinal signs of infection (pain, fever, redness,
swelling, and loss of function) are usually present.
CONTRAINDICATIONS
■ Facial furuncles should not be incised or drained if they are located
within the triangle formed by the bridge of the nose and the corners of
the mouth. These infections should be treated with antibiotics and warm
compresses, as the risk of septic phlebitis with intracranial extension
can follow incision and drainage of a furuncle in this area.
Abscesses that occur very near the rectum or genitalia must be carefully
evaluated, and consideration should be given to referring these patients
to a general surgeon for treatment.
■ Patients with diabetes, debilitating disease, or compromised immunity
should be observed after incision and drainage of an abscess.
POTENTIAL COMPLICATIONS
■ Cellulitis or re-collection of pus: Bacteremia and septicemia are
complications of an inadequately treated abscess. In patients with
diabetes or disease that interferes with immune function, an abscess on
an extremity can be complicated by severe cellulitis or gangrene, with
subsequent loss of the affected extremity.
■ Perianal abscess incision and drainage frequently results in a chronic
anal fistula up to 50% of the time in adults.
An abscess in the palmar aspect of the hand can extend from superficial
to deep tissue via the palmar fascia.
■ Deep infection is suspected when the simple incision and drainage fails
to reduce the erythema, pain, pus, or swelling. More extensive surgical
Chapter 25 — Incision and Drainage of an Abscess 371
debridement, hospitalization, and intravenous antibiotics may be
necessary in a patient with deep palmar abscess.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
An abscess is a focal circumscribed accumulation of purulent materials (pus
and other inflammatory tissue). An acute or "hot" abscess has all the charac-
teristics of a classic inflammatory episode, producing redness, heat, pain,
and swelling. It is a suppurative reaction caused by the invasion of pyogenic
(pus-forming) bacteria into a tissue or organ. Grossly (on the skin or surface
of an organ), abscesses appear as focal, round, or ovoid areas of swelling
covered by skin or other tissue. On palpation, there is usually an area where
the covering is thin and comes to a head (point), and when palpated that area
is more easily compressible or fluctuant due to its liquid or gel-like contents.
A dry abscess is one that resolves without rupture. A sterile abscess is one
from which bacteria cannot be cultured. A chronic or cold abscess lacks the
redness, heat, pain, and swelling of an acute abscess and usually is associated
with liquefactive necrosis of tuberculous lesions.
CLINICAL EVALUATION
The patient usually complains of pain and swelling. Abscesses commonly
occur in the perianal region. A subcutaneous abscess is often seen. Evaluation
includes a search for the underlying cause of the abscess — that is, infection
secondary to puncture wound or foreign body, exposure to unusually patho-
genic organisms, a faulty or overwhelmed immune system, the presence of
hyperglycemia, bacteremic spread from another focus, and development of a
deep abscess in badly contused muscle tissue in which there was no preceding
penetration of skin. When a sweat gland or hair follicle forms an abscess, it
is called a furuncle or boil. When the furuncle extends into the subcutaneous
tissue, it is referred to as a carbuncle. Paronychia is an abscess that involves
the nail. Perifollicular abscesses are commonly found on the extremities,
buttocks, breasts, or in hair follicles. A subcutaneous abscess is often seen.
When signs and symptoms of localized infection or an abscess are present,
incision and drainage should be considered.
THERAPY
A small abscess may respond to warm compresses or antibiotics and may
drain spontaneously. If done properly, such treatment renders antibiotics
unnecessary.
If the abscess enlarges, the inflammation, collection of pus, and walling off
of the abscess cavity render such conservative treatments ineffectual.
372 Chapter 25 — Incision and Drainage of an Abscess
In nonlactating women, a breast abscess that is not subareolar is rare and
should prompt a biopsy in addition to incision and drainage of the abscess.
Indications include a localized collection of pus that is tender and is not
resolving spontaneously.
A culture should be obtained by aspiration or swabbing of the abscess
cavity, because unusual organisms may have caused the abscess. The
infection may also warrant the administration of antibiotics.
ETIOLOGY
Healthy skin and its protective mechanisms are usually successful at fending
off potentially pathogenic microorganisms. If, however, this barrier is inter-
rupted through trauma (mechanical, chemical, or thermal) to the stratum
corneum, inflammation, or through the often more ingenious mechanisms of
infectious agents themselves, skin infections and abscesses develop. Most
often, Staphylococcus aureus is the causative agent in abscesses, but some
abscesses are due to Streptococcus species or a combination of microorganisms,
including gram-negative and anaerobic bacteria. The flora found in the
affected area usually causes the abscess. Puncture wounds or the presence
of foreign bodies are common underlying causes of abscess formation. The
skin of the debilitated, elderly, diabetic (hyperglycemic state), or otherwise
immunocompromised patient may also offer a damaging agent easier access.
Histologically, an abscess is a central area of pus composed of dead white
blood cells, bacteria, degenerating tissue debris, and proteins from the immune
response to the bacteria. Surrounding this is a zone of healthy neutrophils.
Depending on the age of the abscess, peripheral to this is a circumferential
area of vascular dilation, macrophages, fibroblasts, and fibrocytes in varying
stages of development and collagen. Ultimately, a connective tissue capsule
surrounds the area, which inhibits the penetration of anti-infective agents.
A diffuse abscess is a localized accumulation of pus that is not well
encapsulated.
Abscesses can interfere with normal function of nearby tissue, either by
expansion and subsequent pressure on adjacent structures (such as an
abscess adjacent to the trachea) or through expulsion of its contents and
seeding of bacteria into surrounding areas or the vascular system, with
resultant septicemia.
In the treatment of abscesses, the important anatomic structures under-
lying the abscess must be appreciated and anticipated before an incision is
performed. The location of the abscess is critical to the direction of the
incision. The abscess locations listed here are in close proximity to major
vessels and should be aspirated with an 18-gauge needle attached to a 10-mL
syringe before drainage to avoid inadvertent incision into an artery:
■ Peritonsillar and retropharyngeal regions
Anterior triangle of the neck
Supraclavicular fossa
Chapter 25 — Incision and Drainage of an Abscess 373
Deep in the axilla
Antecubital space
Groin
Popliteal space
practitioner to exercise clinical judgment based
Standard Precautions Every practitioner should on the patient's history and the potential for
use standard precautions at all times when exposure to body fluids or aerosol-borne
interacting with patients, especially when pathogens (for further discussion, see
performing procedures. Determining the level Chapter 2).
of precaution necessary requires the
PATIENT PREPARATION
■ Advise the patient regarding the potential benefits and risks associated
with the procedure.
■ Be sure to describe the care required to pack the wound after the
procedure.
■ Provide an opportunity for the patient to ask questions and receive
answers.
Assist the patient into a comfortable supine position that affords
complete access to the abscess site.
Materials Utilized for Performing Incision and
Drainage of an Abscess
Alcohol or povidone-iodine (Betadine) wipe
1% to 2% lidocaine (Xylocaine) without epinephrine
19- to 22-gauge needle
Three or four towels for drapes
No. 11 or No. 15 scalpel blade
Scalpel handle
Kelly clamps
Adson forceps
Curved hemostats
4 x 4-inch gauze pads
Sterile gloves
374 Chapter 25 — Incision and Drainage of an Abscess
500 mL of normal saline solution
■ V4- to ^-inch Nu-Gauze strip for packing the wound
Bandage scissors
■ Dressing of choice to cover wound
Procedure for Performing Incision and Drainage of an Abscess
Skin Preparation
1. Apply a single layer of povidone-iodine to
the abscess and allow to air-dry before
performing the incision.
Anesthesia
1. Use a regional field block anesthetic
technique to anesthetize the abscess by
injecting a ring of anesthetic agent
approximately 1 cm away from the
erythematous border of the abscess
around its perimeter.
Note: This will allow the lesion to be
anesthetized circumferentially The onset of
action of the anesthetic is approximately 5
to 10 minutes. Complete anesthesia is
difficult to provide, especially when breaking
the septum within the cavity of the abscess
with a hemostat.
2. After alcohol preparation of the skin,
superficially infiltrate the skin in a linear
course across the abscess and then
traverse the second linear course directly
perpendicular to the first. Be careful to
remain superficial to the abscess
cavity.
Drapes
1. Place drapes to ensure isolation of the
abscess and the prepared surrounding
skin.
Incising and Drainage
1. Make the incision along the relaxed skin
tension lines (Langer's lines) to reduce
scarring (Fig. 25-1).
2. Open the abscess widely by extending the
incision across its full dimension (Fig. 25-2).
If more drainage is desired, make a
second incision perpendicular to the first,
forming a cruciate pattern.
Note: This technique typically results in a
less aesthetically pleasing scar when fully
healed.
3. Obtain a specimen for culture as soon as
the purulent material is expressed from
the abscess cavity.
Note: If a culture is obtained, it should be
from the abscess cavity and not from the
superficial skin over the abscess.
Alternatively, the abscess cavity can be
aspirated with a large-bore (18-gauge) needle
before the incision is made. The aspirated
contents can then be sent for the
Chapter 25 — Incision and Drainage of an Abscess 375
Figure 25- 1 . Skin tension
lines of the body surface.
(Adapted from Trott AT:
Wounds and Lacerations.
Emergency Care and
Closure, 2nd ed. St. Louis,
Mosby-Year Book, 1998,
pl7.)
Figure 25-2. (Redrawn from Rosen P, Barkin R,
Sternback G: Essentials of Emergency Medicine.
St. Louis, Mosby-Year Book, 1991, p 645.)
continued
376 Chapter 25 — Incision and Drainage of an Abscess
Hemostat
Figure 25-3.
appropriate cultures in more complicated
cases. It is rarely helpful in routine cases.
4. Explore the abscess cavity thoroughly.
This can be accomplished with a sterile
cotton-tipped applicator or with
hemostats. Insert the blunt end of the
hemostat into the abscess cavity and
spread the hemostat to break up the
septum and loculations within the
abscess, thus releasing any further
pockets of purulent material (Fig. 25-3).
5. Thoroughly irrigate the cavity with
normal saline before any gauze is inserted
to pack the cavity (Fig. 25-4).
6. After complete drainage of the cavity,
insert iodoform gauze into the abscess
cavity, with 1 cm of gauze exiting from the
cavity (Fig. 25-5), and then pack the cavity
with packing material, such as iodoform
gauze. The length and width of the gauze
depend on the abscess size.
Syringe with
irrigation needle
Figure 25-4.
Figure 25-5. (Redrawn from Rosen P, Barkin R,
Sternback G: Essentials of Emergency Medicine.
St. Louis, Mosby-Year Book, 1991, p 645.)
Note: The iodoform gauze serves two
purposes: it prevents the incision from
sealing over and provides for adequate
drainage of the abscess cavity. The iodoform
gauze is removed and reinserted every 12 to
24 hours by either the patient or a caregiver.
Chapter 25 — Incision and Drainage of an Abscess 377
Note: Healing should progress from the foreign materials from entering the
inside out, that is, epithelialization of the wound.
abscess cavity should occur before healing n T
~( *v^ ;„^P^„ 0:f^ f^ ™;™™;^ fuQ ^™^ „r 8. Instruct the patient or caregiver on the
or the incision site to minimize the chance or ^ &
procedure for packing the wound and
twice daily changes at home until healthy
7. Apply a sterile dressing over the abscess closure of the wound occurs.
recurrence.
site to absorb drainage and prevent
SPECIAL CONSIDERATIONS
Primary management of abscesses should be incision and drainage and
routine culture. Usually incision and drainage is sufficient treatment to cure
an abscess. Antibiotic therapy is not indicated for the typical abscess in
patients with normal defenses. However, additional treatment may be
necessary for patients in the following situations:
■ Abscesses to be treated with oral antibiotic therapy are those that are
surrounded with lymphangitis or a large area of cellulitis. The cellulitis is
determined by tenderness peripheral to the area of the abscess as well
as increased warmth and redness, as opposed to the nontender
induration palpated around an abscess that is well localized and that
would not benefit from the addition of oral antibiotics. When surrounding
cellulitis is present or when the patient has risk factors mentioned
previously, dicloxacillin (250 to 500 mg every 6 hours) may be used.
Alternative antibiotics can be used, but they must cover Staphylococcus
organisms until the culture results have been returned and a more specific
antibiotic treatment is determined.
■ Purulent material from immunosuppressed patients (including diabetic
patients) should be cultured, with the patient placed on oral antibiotics
pending the culture results. Antibiotics may be used in conjunction with
surgical incision and drainage in patients who are immunocompromised
(i.e., those who have diabetes, leukemia, or acquired immune deficiency
syndrome or those who are undergoing chemotherapy). This purulent
material should be examined by Gram stain, and the specimen should be
sent for culturing (both aerobic and anaerobic) and sensitivity testing
before any antibiotic treatment is started.
Aspiration is used for diagnostic confirmation. The rationale to drain the
abscess is to avoid incision of a mycotic aneurysm and imminent
exsanguination. The aspiration confirms that the material within the
cavity is purulent and not serosanguineous or pure blood.
■ In nonlactating women, a breast abscess that is not subareolar is rare
and should prompt the consideration of a biopsy in addition to incision
and drainage of the abscess. A culture should be obtained by aspiration
or swab of the abscess cavity, because unusual organisms may have
caused the abscess. The infection may also warrant the administration of
antibiotics.
378 Chapter 25 — Incision and Drainage of an Abscess
PAIN RELIEF
If the packing is tight in the abscess cavity, the pain can be sufficient to
warrant the use of acetaminophen or nonsteroidal anti-inflammatory drugs.
Narcotics are rarely needed beyond the initial incision and drainage
procedure. The procedure alone may provide sufficient pain relief from a
tense abscess so that no pain medication is needed.
FOLLOW-UP CARE AND
INSTRUCTIONS
■ Advise the patient that following removal of the iodoform pack, the
patient is to apply warm wet soaks to the area four to six times a day for
5 to 7 days.
■ A nonadherent dressing (Adaptic, Telfa) should be applied over the
wound and covered with sterile gauze.
Immobilization
■ Advise the patient that in some areas of the body (particularly hand and
foot injuries involving joints), motion may interfere with healing.
■ Instruct the patient to elevate an injured extremity to help improve
venous and lymphatic drainage and control swelling and pain and focal
edema control.
Analgesics
■ Usually a nonsteroidal analgesic provides sufficient pain relief.
General Follow-up Care
■ Advise the patient to keep the wound clean and dry.
■ Instruct the patient about how to remove the dressing 2 days after the
procedure, replace with a dry, sterile dressing, and change the dressing
daily.
■ Some patients can be taught to change their own packing, replace the
dressings, and advance the drain.
Instruct the patient to watch for signs of recurrence of the abscess or for
evidence of further infection such as cellulitis.
■ Instruct the patient to notify the clinician immediately if any of the
following occurs: re-collection of pus in the abscess, fever and chills,
Chapter 25 — Incision and Drainage of an Abscess 379
increased pain or redness, red streaks near the abscess, increased
swelling in the area.
Reference
Manjo G: The Healing Hand: Men and Women in the Ancient World.
Cambridge, Mass, Harvard University Press, 1977, pp 58-59.
Bibliography
Goroll HA, Mulley AG: Primary Care Medicine, 5th ed. Philadelphia,
Lippincott Williams & Wilkins, 2006, pp 1242-1243.
Kelly WN: Essentials of Internal Medicine. Philadelphia, Lippincott
Williams & Wilkins, 2001, pp 570-574.
Lawrence PF: Essentials of General Surgery, 4th ed. Philadelphia,
Lippincott Williams & Wilkins, 2006, pp 167-168, 330-301.
Simon RR, Brenner BE: Emergency Procedures and Techniques, 4th ed.
Baltimore, Lippincott Williams & Wilkins, 2002, pp 416-419.
Cha
Pte 26
Wound Dressing Techniques
Paul F. Jacques
Procedure Goals and Objectives
Goal: To apply wound dressings correctly, which will optimize
conditions for healing.
Objectives: The student will be able to ...
• Describe the indications and contraindications for applying a
dressing over a wound.
• Identify the common complications associated with wound
dressings.
• Describe the types of wounds.
• Describe the three biologic phases of wound healing.
• Identify the appropriate types of dressings and the rationale for
their use.
• List the complications of dressing application and recognize the
associated signs and symptoms.
• Describe the patient wound follow-up care instructions.
381
382 Chapter 26— Wound Dressing Techniques
BACKGROUND AND HISTORY
There are several types of skin lesions that benefit from the application of
dressings: wounds from trauma or surgical intervention; ulcers from an
arterial, venous, diabetic or pressure-type cause; or burn injury This chapter
presents some of the basic principles of dressing techniques for wounds. The
sources in the bibliography are provided for more in-depth information for
the clinician who works in a setting where wound management is an ongoing
responsibility
Research and technology have significantly enhanced the medical
community's ability to optimize healing and thus better treat wounds. Many
new dressing materials are available, and much more is known and under-
stood about the body's mechanisms of wound healing. When trauma occurs,
either by accident or surgical intervention, the goal of managing the wound
is to optimize the healing potential while preventing possible complications
such as infection or deformity.
During the Middle Ages, Henri de Mondeville (1260-1320) made a major
stand on the principle of cleanliness to avoid suppuration, a popular belief
that remained in effect for centuries. In 1460, Heinrich von Pfolspeund wrote
a book regarding trauma titled Bundth-Ertznel, which means "bandage treat-
ment." Von Pfolspeund had considerable war experience, where he developed
a breadth of knowledge about war-related traumatic wounds. He subscribed
to the belief that only certain types of wounds should be closed and that for
most war wounds, oil of turpentine should be poured into the wound, with
the resulting suppuration being a sign of healing. Von Pfolspeund wrote that
wounds should be bound with clean white cloths, for if not clean, harm
would result. He also advocated that physicians wash their hands before
tending to individual patients.
In 1545, Ambroise Pare, a military surgeon, was accustomed to treating
wounds with boiling oil. The custom was to pour boiling oil into the wound
to stop suppuration. When Pare's supply of boiling oil ran out he simply
dressed the wounds with clean cloths and minimal medication. He was
dumbfounded to find on the following morning that the soldiers treated
without the boiling oil were relatively free of pain, afebrile, and resting
comfortably. Pare spent the rest of his life advocating keeping medications
out of wounds and letting nature work. His expression, "I dressed him, and
God healed him," made medical history.
It was during the 19th century that a better understanding of wound healing
emerged, and antiseptic surgery was introduced in 1867. With the develop-
ment of general anesthesia in 1847, surgeons were better able to carry out
more deliberate surgical procedures. However, at that time, pus was still
believed to be necessary to the healing of wounds. The brilliant work of
Louis Pasteur in France and the discovery of bacteria as the source of
infection changed the management of surgical cases. A British surgeon,
Joseph Lister, concluded that microorganisms were the cause of the high
mortality rate and implemented the use of carbolic acid (a powerful antiseptic).
With the advent of spraying carbolic acid into the wound and around the
c
Chapter 26— Wound Dressing Techniques 383
V02 C02 Vapor
Bacteria
Dressing
-_-'->.; r I
[>-.. Moist environment
Figure 26-1. The ideal
Heat dressing.
surgical operative site, Lister's patient mortality rate dropped precipitously.
The theory of asepsis was developed and is the standard of care today.
Today, there are more than 2000 brands of wound dressings. The clinician
should be aware of the major types and categories of dressings and the
indications for each.
INDICATIONS
A wound dressing decreases the risk of infection, and the correct material
covering the wound optimizes the healing process. The ideal dressing
accomplishes the following:
Maintains a high degree of humidity between the wound and the
dressing
Provides a thermal insulation for the wound, which provides a better
environment for cellular growth (Fig. 26-1)
Removes excess exudate and toxic substances from the wound
Allows gas exchange
■ Is impermeable to bacteria to prevent infection
■ Does not leave particulate material or contaminants within the wound
Dressings are also indicated for the following:
■ To apply the aesthetic principle of hiding the injury
■ To protect the wound from accidental trauma, abrasions, self-inflicted
"picking," or other irritations
■ To provide support, immobilization, and compression
There is no single ideal product available that provides all these functions at
once, but the clinician should consider carefully which characteristics of the
dressing are the most important for the patient's wound. The wound treat-
ment plan should consider factors such as the cause, severity, environment,
size and depth, anatomic location, volume of exudate, and the risk or presence
of infection. Patient considerations such as medical status, preferences, level
384 Chapter 26— Wound Dressing Techniques
of comfort, and cost-benefit analysis must also be taken under advisement.
The final factors to consider are the availability, durability, adaptability, cost,
and uses of the wound care products.
CONTRAINDICATIONS
Ultimately, the dressing should not cause pain or traumatize the wound with
removal. It is essential to avoid applying a dressing that may compromise the
blood supply to the tissue within and surrounding the wound. There are no
other significant contraindications to dressing a wound. Relative contraindi-
cations include the following:
Skin sensitivity to the dressing and related products (i.e., allergies to
tape, adhesives, latex, iodoform gauze, povidone, neomycin or bacitracin)
should be discussed with the patient before application of the dressing
of choice.
Persistent povidone application to a wound causes damage to the normal
tissue and inhibits healing, and thus should be avoided.
■ Decreased circulation in the affected area: Dressings can interfere with
circulation in a digit or extremity if applied too tightly. Therefore, only
material that stretches should be applied when the dressing will encircle
the extremity.
■ Application of gauze dressings, such as gauze squares (2 x 2-inch or
4 x 4-inch squares), directly on a wound: The gauze can adhere to the
wound as the epithelial cells intertwine within the gauze. Removal of the
dressing can cause removal of the eschar (scab) and new epithelial cells
from the wound as well as cause the patient some significant discomfort.
If a dressing has become adherent to a wound, it should be soaked in
normal saline for approximately 10 minutes before removal is attempted.
Some dressing materials have been designed to adhere less to wounds
than does traditional gauze, and these should be considered when the
potential for wound adherence is high.
■ When dealing with elderly patients, carefully consider the texture and
integrity of the skin before applying an adhesive tape directly to the
skin. With the aging process, there is a loss of collagen within the dermis
and an increased friability of the skin. Therefore, adhesives can readily
tear the "normal" aged skin when removal of the adhesive tape is
warranted to change the dressing. The way to keep a dressing in place
is to use a gauze roll or elastic roll over the dressing and around the
body part affected and apply tape only to the gauze or elastic roll ends
or edges.
When treating infants and children, be sure to reinforce the wound
dressing with additional gauze covering the wound, thereby making it
more difficult for the child to remove the dressing.
Chapter 26— Wound Dressing Techniques 385
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
Wound Types
The material used for a dressing depends on the type, size, and location of
the wound. The wound types include closed, open (full- or partial-thickness),
necrotic, infected, granulating, and epithelializing.
Closed and Open Wounds
For a closed wound, in which the skin integrity is intact, there is no evidence
that a dressing decreases the risk of infection. Nonadherent gauze dressing
absorbs exudate and prevents irritation. For an open wound, the objective is
to encourage clean granulation by creating a moist environment without
slough.
Necrotic Wounds
Necrotic wounds must be surgically debrided, if possible, to remove non-
viable tissue, because necrotic tissue impedes the healing process. If the
patient is not a surgical candidate, the use of hydrocolloids or hydrogels
can facilitate debridement. Contact with the exudate causes the hydrophilic
particles of the hydrocolloids to swell and form an impermeable gel.
Rehydrating necrotic tissue separates from the normal tissues and sloughs
off. Separation may take a few weeks depending on the size of the lesion.
Hydrocolloids (DuoDerm) absorb exudate and produce a moist environment
without maceration of the surrounding tissues.
Infected Wounds
Infected wounds should be treated with normal saline irrigation. Minor
infections are adequately treated with saline bathing. Alginates are used for
more extensive infected wounds. These products contain calcium and
sodium alginic acid prepared in a fiber form. Moisture causes the calcium
alginate to convert to a soluble sodium salt and produces a hydrophilic gel.
The gel is easily removed with saline irrigation or by bathing. Dressing
removal is easy and comfortable for the patient.
Granulating Wounds
Granulating wounds require a moist environment, and removal of the dressing
should not damage the tissue. Impregnated gauze [Xeroform] works well as
long as the dressing is not allowed to dry out, in which case it then debrides
the wound of new granulation tissue when the dressing is pulled off. Hydro-
386 Chapter 26— Wound Dressing Techniques
colloids or hydrogels with a transparent film covering are good alternatives
to impregnated gauze.
Epithelializing Wounds
Epithelializing wounds (abrasions) should be treated in the same manner
as granulating wounds, being careful not to remove the new epithelial
layer when changing the dressing. Therefore, they should be covered
with a nonadherent dressing (Telfa), a biosynthetic sheet, or a transparent
film.
Wound Healing
There are three stages in the healing process of a wound, regardless of
whether the wound is surgical or traumatic in nature.
Inflammatory (O to 6 Days)
Edema, erythema, heat, and pain characterize the inflammatory phase,
which begins at the time of injury and lasts 4 to 6 days. Hemostasis controls
bleeding, and polymorphonuclear leukocytes control bacterial growth. After
about 4 days, macrophages migrate into the wound area and produce chemo-
attractants and growth factors, which facilitate wound healing.
Proliferative (4 to 24 Days)
In an open wound, granulation tissue is generated, which produces red,
beefy, shiny tissue with a granular appearance. This tissue consists of macro-
phages, fibroblasts, immature collagen, blood vessels, and ground substance.
As the granulation tissue proliferates, fibroblasts stimulate the production of
collagen, which gives tissue its tensile strength and structure.
As the wound fills with granulation tissue, its margins contract, decreasing
the wound's surface area. During epithelialization, cells migrate from
the wound margins, ultimately sealing it. Epithelialization can occur only
in the presence of viable, vascular tissue. When this phase is complete, a scar
forms.
Maturation (21 Days to
24 Months)
During the maturation phase, the collagen fibers reorganize, remodel, and
mature, gaining tensile strength. The maximal tensile strength that is regained
is approximately 80%.
Chapter 26— Wound Dressing Techniques 387
Poor Wound Healing
Advanced age, diabetes mellitus, immunosuppression, radiation therapy,
vitamin deficiency, malnutrition, cancer, vascular insufficiencies, or wound
infection are some of the more common causes of poor wound healing. If a
wound is not healing readily, the clinician should undertake a comprehensive
evaluation of the patient, looking for systemic inhibitors of wound healing.
Environmental factors can impede the healing of a wound, such as recurrent
trauma or pressure on the site of the wound (which may occur with bending
the affected area), edema that impedes oxygen flow to and from the wound,
necrotic tissue within the wound, and patient incontinence, which can
expose the wound to urine or feces. Poorly healing wounds are at increased
risk for infection, hemorrhage, dehiscence, evisceration, and fistula formation.
Prevention of Infection in Wounds
Clinicians must wash their hands before and after dressing a wound. A study
conducted in April 2000 demonstrated a 16% compliance with hand washing
before patient interaction and a 25% hand-washing rate after patient contact.
Nosocomial infections can be prevented only by increased compliance with
effective hand washing (Bishoff, 2001).
The skin is the barrier against infection. When the skin is compromised,
through trauma or surgical intervention, the patient is at risk for bacterial
growth within the wound. The longer the wound is exposed to air particles,
dirt, water, and so forth, the risk of infection increases exponentially. The
appropriate surgical management, such as debridement, irrigation, or
suturing, should be undertaken before wound dressings are applied. Debride-
ment refers to the removal of tissue that is likely to impede the healing
process, such as necrotic and unnecessary fibrinous tissue or damaged
tissue that is unlikely to survive. This is typically performed as a surgical
procedure and its description is beyond the scope of this chapter. Irrigation
involves cleaning the wound to minimize contamination by infectious and
foreign materials. Typically, large quantities of normal saline solutions are
used, and large-capacity syringes can be used to spray the solution with
sufficient pressure to irrigate structures that may be difficult to reach.
Wound closure and wound contamination classification are covered in depth
in Chapter 23.
There are four steps in the prevention of wound infection in the trauma
patient. First and foremost is adequate and timely resuscitation of the patient.
Hypoxia or hypovolemia, or both, increase the risk of infection. Second is
early wound care, which includes debridement, hemostasis, irrigation, and
primary wound closure. Third is the application of antibiotics. Although most
wounds do not require antibiotic therapy, if antibiotics are indicated, they
should be administered early, using an agent that provides appropriate
coverage of the most likely infecting microbes. In addition, achieving adequate
concentrations of the antibiotic for bactericidal effects is essential. The
388 Chapter 26— Wound Dressing Techniques
fourth stage is tetanus immune prophylaxis when indicated (see Chapter 23).
These basic infection prevention principles are also applicable for non-
traumatic wounds.
Standard Precautions Every practitioner should
use standard precautions at all times when
interacting with patients, especially when
performing procedures. Determining the level
of precaution necessary requires the
practitioner to exercise clinical judgment based
on the patient's history and the potential for
exposure to body fluids or aerosol-borne
pathogens (for further discussion, see
Chapter 2).
PATIENT PREPARATION
Inform the patient about the procedure of wound dressing.
Explain to the patient exactly what is being done and why, and answer
any questions that he or she might have.
Materials Utilized for Performing Wound
Dressing
Note: Dressings should have the following characteristics: softness,
permeability, sterility, and elasticity.
Primary Dressings
■ Alginates
Note: These products are derived from brown seaweed. Alginates (AlgiDerm,
AlgiSite, Dermastat) are absorbent and conform to the shape of a wound
because they are provided in the shape of a rope (twisted fibers) or pads.
An alginate interacts with wound exudate to form a soft gel that maintains a
moist healing environment. Alginates can absorb up to 20 times their weight.
These products absorb heavy exudate from a deep, draining wound,
regardless of whether the wound is infected (Fig. 26-2).
Use alginate in presence of
heavy exudate with or without
the presence of infection.
Use collagen with or without
the presence of infection.
Collagen particles or gel
Figure 26-2. Alginate is
used in the presence or
absence of infection.
Chapter 26— Wound Dressing Techniques 389
Biosynthetic or
transparent film
y^f^k±9 •• •••••••••••♦ c -^M^^t — Epidermis
WM^'y^^-V*™ Figure26-3. The
Epidermal cells Abrasion biosynthetic dressing.
■ Biosynthetic dressings
Note: Biosynthetic dressings (E-Z Derm, Glucan II) were developed as
temporary coverings for burns. A biosynthetic dressing may be a gel or a
semiocclusive sheet that can be left in place for 1 to 10 days, depending on
the clinical situation. Biosynthetic dressings facilitate wound healing by
re-epithelialization. These dressings may be used to treat partial-thickness
wounds, such as tears, burns, abrasions, and some pressure ulcers (Fig. 26-3).
■ Collagens
Note: Collagen dressings may be used as primary dressing for partial- and
full-thickness wounds, regardless of whether they are infected (see
Fig. 26-2). During wound healing, collagen encourages the deposition and
organization of newly formed collagen fibers and granulation tissue in the
wound bed. It stimulates new tissue development and wound debridement.
With the use of collagen, a secondary dressing needs to be applied to
absorb exudate. Collagen dressing products are available as sheets, pads,
particles, and gels (Fibracol Plus, Kollagen Medifil, hyCURE).
■ Foams
Note: Foam dressings (Curafoam Plus, Sof-Foam Dressing, 3M Reston Self-
Adhering Foam, Tielle hydropolymer dressing) are absorbent, nonadhering,
and lint free. Foams may be either hydrophilic or hydrophobic and are
nonocclusive unless they have a film coating. They are used as either a
primary dressing, directly on the wound to provide absorption and
insulation, or as a secondary dressing overlying a wound packing. Foams may
require a secondary dressing to hold them in place if they do not have an
adhesive border or film coating as an additional bacterial barrier. (Fig. 26-4).
■ Hydrocolloids
Note: Hydrocolloids (DuoDerm, ExuDerm, OriDerm hydrocolloid, 3M
Tegasorb hydrocolloid dressings) are occlusive or semiocclusive dressings
that can be composed of gelatin, pectin, or carboxymethylcellulose (see
Fig. 26-4). These types of dressings provide a moist healing environment
that allows clean wounds to granulate or necrotic lesions to debride
autolytically. These types of products are manufactured in various shapes,
sizes, and forms, such as wafers, pastes, and powders. Hydrocolloid
390 Chapter 26— Wound Dressing Techniques
Epidermis
Full-thickness wound is
Dermis through the epidermis,
dermis, subcutaneous
tissue, and possibly
muscle/bone.
Subcutaneous tissue
Secondary dressing
Hydrocolloid paste or gel
(no infection)
Hydrogel (with or without
infection)
With or without necrosis
Secondary dressing
Foam
Figure 26-4. The foam
dressing.
dressings are self-adhesive, provide light to moderate absorption capacity,
minimize skin trauma, and may be used underneath a compression product
such as Unna boots. However, they are not recommended for infected
wounds or wounds with heavy exudate or exposed tendons or bones.
Another benefit of this type of dressing is that it protects the lesion from
contamination and can be left in place 1 to 10 days, depending on the type
of lesion and placement.
■ Hydrogels
Note: Hydrogels are water or glycerin-based amorphous gels (Curasol, SK
Integrity amorphous hydrogel, 3M Tegagel hydrogel wound filler products).
The gels can be applied to wounds directly, or gauze or sheets impregnated
with the hydrogel are available. They do not absorb exudate because of
their high water content. These dressings maintain a moist wound
environment, thereby promoting granulation and epithelialization or
autolytic debridement of necrotic lesions. They are indicated for the
management of partial- and full-thickness wounds, deep wounds, wounds
Chapter 26— Wound Dressing Techniques 391
Epidermis
Dermis
Partial-thickness wound
is confined to the skin,
involving the epidermis
and dermis.
Subcutaneous layer-
adipose tissue and muscle
Transparent film (if no infection)
Hydrocolloid (if no infection)
Hydrogel (can be used in
presence of infection)
Nonadhesive dressing
Sutured wound
Figure 26-5. The hydrogel
dressing.
with necrosis, slough, minor burns, and tissue damaged by radiation
(Fig. 26-5). These dressings are applied and removed easily and can be used
when infection is present.
Secondary Dressings
■ Transparent films
Note: Transparent films (OpSite, Bioclusive transparent dressing, Polyskin
II, 3M Tegaderm transparent dressing) are adhesive, semipermeable,
polyurethane membrane dressings that vary in thickness and size. These
films are waterproof and impermeable to bacteria, yet they permit water
vapor to cross the barrier. Transparent films allow direct observation of the
wound and do not require a secondary dressing. The limitations are that
they should not be used on fragile skin or with infected wounds.
392 Chapter 26— Wound Dressing Techniques
■ Dressing gauze
Note: Gauze dressings are manufactured in many forms. They can be used
as primary, secondary, or securing dressings. Gauze for cleaning, debriding,
packing, and covering usually is available in the form of packets containing
sterile 4 x 4-inch or 2 x 2-inch squares. Nonadherent gauze [Telfa pads] are
an important improvement in gauze dressings because they do not stick to
wounds and facilitate exudate transmittal away from the wound. Gauze also
comes impregnated with many different substances, such as oil emulsions,
petrolatum, saline, scarlet red, sodium chloride, water, Xeroform, or
zinc-saline solution. Some impregnated gauze dressings serve as occlusive
dressings and prevent drainage from the wound.
■ Flexible collodion
Note: Flexible collodion is a preparation of nitrocellulose dissolved in
alcohol and ether. It is a plastic-like substance that is applied aseptically to
a wound and forms a thin, clear sealant layer of plastic over the wound.
This product is a good choice for scalp lacerations, where gauze dressing is
difficult to apply.
■ Dressing stabilizer (wrapping or rolling gauze)
Note: Rolls of dressing material are used to hold other materials against a
wound. The ideal roll gauze has some elastic properties; it is used to add
bulk and cushion to the dressing (Kling, Kerlix). Another type of wrapping
gauze that is categorized as a dressing stabilizer is tubular gauze used to
stabilize a dressing circumferentially (Tube-gauze). These types of dressings
are applied using a stainless steel metal-cage applicator and are useful for
dressing digits.
■ Tape
ACE bandage
■ Tube gauze
■ Cleansing materials
Irrigation set
■ Normal saline
■ Hydrogen peroxide
Povidone-iodine
Note: Antiseptic agents such as povidone-iodine can injure skin, delaying
healing; therefore, they should be used only when necessary and used
sparingly on damaged skin.
Chapter 26— Wound Dressing Techniques 393
Procedure for Performing Wound Dressing
1. Wash hands and put on clean sterile gloves.
2. Clean the wound.
Note: Clean wounds with dirt or grease
contamination with mild soap and irrigate
with water to remove the detergent. Irrigate
deep wounds to remove excessive exudate,
slough, or loose necrotic tissue (see
Chapter 23). Closed wounds should be
cleansed gently with normal saline or
hydrogen peroxide to remove clotted blood
from the wound edge, which can contribute
to scarring or infection, or both. Excessive
exposure to hydrogen peroxide can injure
damaged skin, so an effort should be made
to limit exposure to intact, dry skin surfaces
only.
3. Determine the appropriate primary
dressing based on the factors described
previously. Maintain aseptic technique
when applying dressings (see Chapter 3).
4. Apply the secondary dressing to absorb
excessive exudate as well as to provide a
cushion (Figs. 26-6 and 26-7).
5. Secure the dressing in a fashion that will
provide flexibility and not restrict the
movement of the patient, unless such
restriction is warranted by the nature of
the wound (Fig. 26-8).
6. Make sure that the tape is wide enough
and long enough to adhere the gauze to
the skin.
Put 31/2 x length
of the finger.
(2) Hold gauze at (q\
^ base of finger ^
Figure 26-6. Application of tubular gauze.
7. Wounds overlying flexor surfaces on the
extremities or digits will be unduly
stressed with flexion of the joint;
therefore, range of motion should be
continued
394 Chapter 26— Wound Dressing Techniques
Forearm
Not correct, awkward
1 . Apply dressing from
distal — ► proximal
2. Leave distal anatomy
exposed to periodically
assess perfusion
Elbow
Overlap gauze by 60%
Figure 26-7. Proper application using Kling or
Kerlix roll gauze.
o
o
o
Correct
Wrong
Artery
Bone
Artery
Bandage
Circumferential
Swelling
t
Occlusion of arteries
Figure 26-8. Prevent tamponade.
Chapter 26— Wound Dressing Techniques 395
somewhat restricted to prevent
dehiscence (Fig. 26-9). Splints or bulky
dressings should be considered to
reduce the range of motion of the
affected joint.
8. Apply dressings to cover sutured wounds.
Tape applied to a dressing must be wide/long
enough to keep the dressing in place. Dressings
should allow for movement of the body without
hindering range of motion or dislodging the dressing.
Thigh
Figure 26-9.
FOLLOW-UP CARE AND
INSTRUCTIONS
When indicated, the patient or caregiver should undertake dressing
changes. Carefully explaining the procedure helps to facilitate timely,
appropriate, and effective wound management. Noncompliance or the
inadequate communication of information can result in poor healing,
infection, pain, and disfiguring scars.
Instruct the patient to change the dressing after cleansing the wound, if
the dressing becomes wet or dirty, or after a certain amount of time has
passed, typically 2 to 3 days.
Instruct the patient to clean the wound gently approximately three times
a day using some hydrogen peroxide on cotton swabs or gauze and then
gently blot the wound dry. Dried blood or superficial coagulum should
be removed from the wound edges to prevent widening of the final scar.
Reassure the patient that body hygiene can be maintained by showering
but that the shower spray should not spray directly on the wound.
396 Chapter 26— Wound Dressing Techniques
Advise against bathing in a tub because of the possibility of an infection
developing in the wound.
Instruct the patient to observe the wound edges for increased redness or
increased tenderness and to contact the office for assessment.
Make the patient aware of what to expect concerning the progress of the
wound over time. Normal wound healing often exhibits characteristics
that can be confused with wound infections; therefore, describe in detail
what the wound should look like and feel like in the course of the normal
healing process. The normal healing process often involves a limited
inflammatory response that produces erythema and tenderness for a
few days.
Additionally, make the patient aware of the signs and symptoms of a
wound infection, which include erythema, pain, warmth, edema, discharge,
throbbing, fever, regional adenopathy, and spreading erythema.
Patients not able to perform dressing changes or evaluate the progress
of their wounds may be candidates for visiting nursing services.
Wound infections may require interventions that vary by factors such as
severity and the proximity to other organ systems. Infections in closed
wounds may require that sutures be removed or incision and drainage
be performed. Some infections may require aggressive systemic antibiotic
therapy, especially those that are spreading by vascular or lymphatic
systems or are following tissue lines such as fascia or muscle.
Infected wounds should be cleaned with normal saline solution at least
four times a day and the dressing changed.
Instruct the patient to wash his or her hands with soap and water before
and after tending to the wound.
Instruct the patient to use the same primary and secondary dressing
materials as used by the health care provider.
When a wound is free of infection, sutures have been removed, all skin
surfaces are dry, and the wound is no longer draining, the use of
dressings can be discontinued. At this point, dressings may be still be
used when indicated as padding to protect the fragile, newly healed
tissues from damage due to physical trauma. However, in most cases,
dressings can be discontinued when the indications for them, primarily
protection of the wound, are no longer present.
CONCLUSION AND RESOURCES
Wound management of the chronic wound is a complex topic with extensive
ongoing research to identify etiologic factors and to develop better materials
and methods of dealing with the chronic wound. The June 2005 issue of The
Chapter 26— Wound Dressing Techniques 397
Nursing Clinics of North America provides thirteen excellent articles on
wound care.
Surgical Materials Testing Laboratory (SMTL) sponsors a website
(www.dressings.org) that contains an exhaustive list of wound care products.
SMTL provides dressings datacards as well as technical papers and test
reports. The datacards contain information on many wound care products
and detail the indications, contraindications, methods of use, frequency of
change, warnings, presentation of the product, and sizes of the dressing
products. The datacards also include a bibliography for each product.
SMTL is sponsored by the government of Wales to provide information to
the National Healthcare Service. SMTL is a not-for-profit organization that
sponsors the Wound Management Practice Resource Centre, which is yet
another great resource that can be found online (www.smtl.co.uk/WMPRC/
index.html).
Reference
Bischoff WE, Reynolds TM, Sessler CN, et al: Handwashing compliance
by health care workers: The impact of introducing an accessible,
alcohol-based hand antiseptic. Arch Intern Med 60:1017-1021, 2001.
Bibliography
Felciano DV, Moore EE, Mattox KL: Trauma. Norwalk, Conn, Appleton &
Lange, 1996.
Grossman JA: Minor Injuries and Disorders: Surgical and Medical Care.
Philadelphia, JB Lippincott, 1984.
Hess CT, Salcido R: Wound Care, 3rd ed. Springhouse, Pa, Springhouse,
2000.
Pieper B (ed): Wound Care. The Nursing Clinics of North America,
vol 40, no. 2. Philadelphia, Saunders, June 2005.
Trott AT: Wounds and Lacerations: Emergency Care and Closure, 2nd ed.
St. Louis, Mosby-Year Book, 1997.
Wardrope J, Edhouse J: The Management of Wounds and Burns, 2nd ed.
Oxford, England, Oxford University Press, 1999.
Westaby S: Wound Care. St. Louis, CV Mosby, 1998.
Schwartz SI: Principles of Surgery, 7th ed. New York, McGraw-Hill, 1999.
Chapter 0*7
Cryosurgery
P. Eugene Jones and Theresa E. Hegmann
Procedure Goals and Objectives
Goal: To perform cryosurgery on a lesion successfully, using
techniques that will facilitate wound healing and minimize the
likelihood of complications.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing cryosurgery.
• Identify and describe common complications associated with
the use of cryosurgery on skin lesions.
• Describe the essential anatomy and physiology of the skin as it
pertains to the performance of cryosurgery.
• Identify the materials and tools necessary for performing
cryosurgery on skin lesions.
• Identify the important aspects of post-procedure care after
cryosurgery on small skin lesions.
399
400 Chapter 27 — Cryosurgery
BACKGROUND AND HISTORY
The therapeutic use of cold for treatment of injuries and inflammation dates
back as early as 2500 bc, when Egyptians appreciated its adjunctive value.
Over the centuries, famous physicians such as Hippocrates and Napoleon's
chief army surgeon Dominique Jean Larrey used cold for analgesia and
hemorrhage control (Graham, 1999). The modern era of cryosurgery began
when James Arnott developed the application of cold for a variety of
conditions. He achieved a temperature of -24° C with a salt and crushed ice
brine to treat neuralgia and for palliative care in terminally ill cancer
patients. The first dermatologic application of cryosurgery was in New York
in 1899 when the dermatologist A. C. White applied liquefied air via cotton-
tipped applicators to warts, nevi, and premalignant and malignant skin
lesions (Graham, 1999). Liquid nitrogen was introduced as a cryogen about
1948. By 1962, Irving Cooper developed a more modern apparatus that
facilitated cryosurgical spray application techniques (Grekin, 1990).
Biologic effects on the skin and subcutaneous tissue are achieved by
selective destruction of tissue as heat is transferred from the skin to a heat
sink (typically liquid nitrogen). The subzero temperatures achieved result in
intra- and extracellular ice crystal formation, disruption of cell membrane
integrity, pH changes, and thermal shock (Kuplik, 1997). The degree of tissue
damage depends on the rate of cooling and the minimum temperature
achieved, so to achieve maximal tissue destruction effect, longer freeze times,
slow thaw times, or a series of freeze-thaw cycles can be used (Gage, 1978;
Andrews, 2004). Generally, these more aggressive approaches to cryosurgery
are unnecessary for benign skin lesions. Milder freezing techniques destroy
the more sensitive cells of the epidermis, while leaving the dermis and under-
lying structures intact. This leads to dermo-epidermal separation and is
usually sufficient for treating many common benign lesions. Post-treatment
inflammation may trigger an immune reaction that contributes to destruction
of the target lesion.
INDICATIONS
Cryosurgery is indicated for many common benign skin conditions, and for
certain malignant conditions in carefully selected patients for whom the
diagnosis has been definitively established. Specific lesions that may be
treated with cryosurgery are listed in Table 27-1. Lesions with more sharply
demarcated borders tend to be more responsive to cryosurgery. Common
skin conditions that respond well to the technique include seborrheic
keratoses, skin tags, sun-damaged skin (e.g., actinic keratoses and solar
lentigines), and skin lesions caused by viral infection (e.g., common warts,
condyloma acuminatum, and molluscum contagiosum).
The technique has several advantages over other surgical modalities in
selected patients with appropriate lesions. These include its technical ease,
portability, and the brief period of time required for treatments, all of which
Chapter 27— Cryosurgery 401
Table 27.1 Lesions Treatable with Cryosurgery
BENIGN LESIONS
PRECANCEROUS LESIONS
OR TUMORS OF
UNCERTAIN BEHAVIOR
MALIGNANT LESIONS
Acne vulgaris
Angiolymphoid hyperplasia
Angiokeratoma
Angioma, cherry and spider
Chondrodermatitis nodularis
chronica helicis
Condyloma acuminata
(venereal warts)
Dermatofibroma
Disseminated superficial actinic
porokeratosis
Granuloma faciale
Granuloma fissuratum
Hemangioma
Hidradenitis suppurativa
Keloid
Leishmaniasis
Lentigines, lentigo simplex,
solar lentigo
Lichen planus
Lichen sclerosis et atrophicus
Lichen simplex chronicus
Lymphocytoma cutis
Molluscum contagiosum
Mucocele
Myxoid cyst
Nevi
Porokeratosis of Mibelli
Prurigo nodularis
Psoriatic plaques
Pyogenic granuloma
Rosacea
Sebaceous hyperplasia
Seborrheic keratosis
Skin tags (acrochordons)
Syringoma
Venous lake
Verrucae, including common warts,
plantar warts, and flat warts
Other
Actinic cheilitis
Actinic keratosis
Keratoacanthoma
Lentigo maligna
Bowenoid papulosis
Leukoplakia
Basal cell carcinoma
Bowen's disease
Kaposi's sarcoma
Squamous cell
carcinoma
Actinic keratosis with
squamous cell
carcinoma
From Drake LA, Ceilley RI, Cornelison RL, et al: Guidelines of care for cryosurgery. J Am Acad Dermatol
31:648-653, 1994.
make it ideal for clinic settings. Additionally, minimal patient preparation is
required, there is low risk of infection or other major complications, and there
is no need for expensive supplies or injectable anesthesia.
Because of the ease of application and relatively minimal associated risks,
cryosurgery is especially useful in the following subsets of patients:
■ Elderly, high-risk surgical patients
402 Chapter 27 — Cryosurgery
Patients allergic to local anesthetics
Patients with coagulopathies and pacemakers (Drake, 1994)
CONTRAINDICATIONS
Cryosurgery is absolutely contraindicated in patients with the following:
Lesions requiring tissue pathology for diagnostic reasons
Lesions located in a body area with compromised circulation
■ Lesions known or suspected to be melanoma, sclerosing basal cell
carcinoma, or recurrent basal cell or squamous cell carcinomas
■ Previous adverse reaction to cryosurgery
Relative contraindications to cryosurgery include:
■ Lesions overlying nerves (Arndt, 1997)
Lesions located in pretibial areas, eyelid margins, nasolabial fold, ala
nasi, or on hair-bearing areas
■ Lesions of dark-skinned individuals; treatment in these individuals may
leave hypopigmented scars
■ Patient history of cold intolerance, cold urticaria, cryoglobulinemia, or
Raynaud's disease
■ Autoimmune disease or concurrent treatment with immunosuppressive
drugs
POTENTIAL COMPLICATIONS
■ Immediate complications can include dizziness or vasovagal syncope,
blister formation, edema, bleeding, and pain. Treating lesions of the scalp,
forehead, or temple may produce a transient headache (Arndt, 1997).
Occasionally, large, bloody post-procedural bullae may be seen, though
facial lesions typically crust over without vesicle or bulla formation.
Delayed complications can include infection, hemorrhage, and excessive
formation of granulation tissue (Young, 1997). It is not uncommon for
verruca vulgaris lesions to recur as a larger circumferential lesion after
cryosurgery. Patients should be cautioned about the possible appearance
of these "ring warts" at previously treated sites.
■ Prolonged and possibly permanent complications include post-procedure
hypopigmentation, alopecia in hair-bearing areas, and atrophy. Patients
may also note altered sensation, hyperpigmentation or, rarely, hypertrophic
scarring; these changes, though sometimes protracted, are usually
temporary.
Chapter 27— Cryosurgery 403
Table 27.2 Cryogens and Their Effective Celsius Temperature
CRYOGEN
TEMPERATURE (°C)
Ice
Salt ice
C02 slush
C02 snow
C02 solid
Liquid nitrous oxide
Liquid nitrogen
Liquid nitrogen
0
-20
-20
-70
-78.5
-89.5
-20 (swab)
-195.8 (spray/probe)
■ Damage to underlying structures can be prevented by avoidance of
overfreezing, and by continually moving the skin back and forth while
performing cryosurgery in order to avoid freezing the skin to underlying
bone, cartilage, or tendon tissue.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
Knowledge of local neurovascular anatomy is imperative before performing
cryosurgery When in doubt, the clinician should consult an anatomy reference
before proceeding. Areas of concern include the skin near the medial
epicondyle of the elbow and the lateral aspects of the digits and the angle of
the mandible, as nerves are more superficial in these areas and are prone to
freeze injury (Habif, 1996). The pretibial area is also problematic, as patients —
especially the elderly — may experience slow wound healing in this area after
cryosurgery. Cryotherapy is contraindicated in areas of the body with
compromised circulation, such as a lower extremity lesion in a patient with
peripheral vascular disease. Patient selection criteria include lesion location,
skin color and type, size and number of lesions, response to previous therapy,
condition of the skin and subcutaneous tissue, and coexisting medical
conditions. Because melanocytes are more sensitive to cold injury, post-
inflammatory hypopigmentation is more common in darker skin. Cryogens
and their effective Celsius temperatures are noted in Table 27-2.
Standard Precautions Every practitioner should
use standard precautions at all times when
interacting with patients, especially when
performing procedures. Determining the level
of precaution necessary requires the
practitioner to exercise clinical judgment based
on the patient's history and the potential for
exposure to body fluids or aerosol-borne
pathogens (for further discussion, see
Chapter 2).
PATIENT PREPARATION
Thoroughly explain the procedure and its attendant risks, as well as
alternative treatment options available to the patient. Document
404 Chapter 27 — Cryosurgery
informed consent by having the patient sign a consent form, or by
dictation into the procedure note, depending on local policies and
procedures.
Ensure patient comfort in a seated or supine position, if possible.
Choosing a supine position may help prevent syncopal episodes.
The application of liquid nitrogen can be painful, particularly for
children; therefore, additional efforts may be necessary to prepare
children psychologically before the procedure is performed.
Use of precryosurgery anesthesia with topical agents such as lidocaine-
prilocaine (EMLA) or lidocaine (ELA-Max) cream is worth considering,
especially in pediatric patients, unless contraindicated.
Outlining the lesion with a surgical marking pen may be helpful, as
freezing may temporarily obliterate visual lesion margins.
Materials Utilized for Performing Cryosurgery
Sterile Cotton-Tipped
Applicator/Swab Method
■ Liquid nitrogen
■ Styrofoam cup
■ Cotton-tipped applicator (with a solid, not hollow, handle)
■ Gloves
Spray Method
■ Liquid nitrogen spray gun
■ Gloves
■ Spray extension (necessary to treat difficult-to-reach lesions) (Fig. 27-1)
Cryoprobe Method
■ Liquid nitrogen spray gun
Probes (see Fig. 27-1)
■ Gloves
Probe extension (necessary to treat difficult-to-reach lesions; see
Fig. 27-1)
Chapter 27— Cryosurgery 405
0
Figure 27- 1 . Materials used
to perform cryosurgery.
Procedure for Performing Cryosurgery
Note: Because longer time and depth of
freeze destroys more tissue, care must be
exercised to not overtreat. It is better to
treat conservatively and re-treat a lesion at a
later date than to overtreat once and risk
permanent hypopigmentation or damage to
underlying structures.
Note: Lesion thickness typically dictates
length and depth of freeze. For example, a
large, flat, thin seborrheic keratosis should
be frozen in sections and not from the center
out, as this results in too deep a freeze.
Thicker lesions, such as a hyperkeratotic
verruca, require more prolonged freezing
that typically results in hemorrhagic bulla
formation beneath the lesion (Habif, 1996).
The depth of freeze achieved typically
approximates 1.5 times the lateral spread of
the visible cutaneous ice ball (Torre, 1979).
See "Special Considerations" for more
information on recommended freeze
duration.
Cotton-Tipped
Applicator/Swab Method
Note: The cotton-tipped applicator/swab
method is useful on smaller lesions and
around the eye or ear canal where
unconcentrated spray may be deleterious.
1. Pour enough liquid nitrogen from holding
tank into a disposable polystyrene
(Styrofoam) cup to cover cotton tip of
applicator when dipping applicator into
cup.
2. With gloved fingertips, loosen tight weave
of the cotton tip on the swab to allow
absorption of more liquid nitrogen. If
desired, the cotton tip may be twisted to a
point to allow more focal application of
the liquid nitrogen to small lesions.
3. Dip swab in liquid nitrogen and apply
swab tip to lesion (Fig. 27-2).
continued
406 Chapter 27 — Cryosurgery
Figure 27-2. Swab method.
4. Repeat dipping and application procedure
until an ice ball extends 1 to 2 mm beyond
the clinical lesion, lasting from 5 to 30
seconds (see "Special Considerations").
Spray Method
Note: This method is more useful for larger
or multiple lesions.
1. Hold the spray tip 1 to 2 cm from the
lesion surface and gently squeeze the
trigger mechanism (Fig. 27-3).
2. Apply spray in a pulsatile, rotary, spiral,
or paintbrush fashion.
3. For better control, maintain an
intermittent, pulsatile spray rather than a
continuous spray. Cones or a disposable
ear speculum can be used to confine
spray to a specific focal point.
Figure 27-3. Spray method.
Figure 27-4. Cryoprobe method.
Cryoprobe Method
Note: More commonly used for malignant
lesions such as superficial or nodular basal
cell carcinoma, the cryoprobe technique
requires additional training and experience
before it can be used clinically.
1. Select the appropriate probe based on the
size and shape of the lesion (see Fig. 27-1).
2. Precool the tip to prevent skin adhesion.
3. Apply the tip to the lesion with direct
pressure for the specified period (Fig. 27-4)
(Arndt, 1997).
Chapter 27— Cryosurgery 407
Table 27.3 Comparison of Freeze Times for Benign and
Using Intermittent Spra
Rights were not granted to include this table in electronic media.
Please refer to the printed publication.
BCC, basal cell carcinoma.
From Freedberg IM, Eisen AZ, Wolff K, et al (eds): Fitzpatrick's Dermatology in General Medicine, vol II,
5th ed. New York, McGraw-Hill, 1999, p 2982.
SPECIAL CONSIDERATIONS
Tissue damage increases with longer freeze-thaw cycles. Thinner lesion depth
(e.g., actinic keratoses, lentigines) requires less freezing, whereas thicker
lesion depth (e.g., dermatofibromas, keloids) requires more. Freeze times
refer to the interval after the initial ice ball margin, or halo, forms, and range
from 5 to 10 seconds for skin tags, actinic keratoses, and solar lentigos, to 20
to 30 seconds for dermatofibromas or hypertrophic scars and keloids. Some
examples of typical freeze times for different types of lesions are presented
in Table 27-3.
Treating twice with a slow thaw between cycles is more destructive to cells
than a single treatment with a rapid thaw. Continuous freezing for longer
than 30 seconds after an adequate ice ball is achieved around the target area
should be avoided when treating benign lesions, as it may cause scarring
(Andrews, 2004). Cryosurgery of malignant lesions requires additional
expertise and training acquired under the tutelage of an experienced cryo-
surgeon. Ice ball margins of 5 mm are needed for treatment of malignant
lesions in order to ensure adequate tissue destruction. A thermocoupled
temperature probe needle device positioned under the base of the lesion
facilitates appropriate length and depth of tissue freeze until sufficient
experience is acquired.
408 Chapter 27 — Cryosurgery
FOLLOW-UP CARE AND
INSTRUCTIONS
Lesion care after cryosurgery should include the following:
■ Instruct the patient to gently wash the area with soap and water twice
daily
■ Severe residual pain is not uncommon after cryosurgery to thicker
tissue areas such as the palms, soles, and anatomically confined areas
such as periungual tissue (Habif, 1996). Post-procedure pain may be
treated with over-the-counter acetaminophen or ibuprofen, if not
contraindicated.
■ Advise the patient not to use gauze or an occlusive dressing because of
the possibility of prematurely removing the eschar.
■ Recommend polymyxin B sulfate-bacitracin zinc (Polysporin) or other
similar topical ointment to soften hardened eschar.
■ Inform the patient that, after cryosurgery, it is common for a blister to
form. This blister may be hemorrhagic at the treated site and dries,
crusts, and peels along with the lesion.
Reassure the patient that erythema and edema are common immediately
after cryosurgery.
■ Tell the patient to expect crusting to separate in approximately 10 days.
References
Andrews MD: Cryosurgery for common skin conditions. Am Fam
Physician 69:2365-2372, 2004.
Arndt KA, Wintroub BU, Robinson JK, LeBoit PE (eds): Primary Care
Dermatology. Philadelphia, WB Saunders, 1997.
Drake LA, Ceilley RI, Cornelison RL, et al: Guidelines of care for
cryosurgery. J Am Acad Dermatol 31:648-653, 1994.
Gage AA: Experimental cryogenic injury of the palate: Observations
pertinent to cryosurgical destruction of tumors. Cryobiology
21:157-169, 1978.
Graham GF: Cryosurgery. In Freedberg IM, Eisen AZ, Wolff K, et al (eds):
Fitzpatrick's Dermatology in General Medicine, 5th ed. New York,
McGraw-Hill, 1999, pp 2980-2987.
Grekin RC: Physical modalities of dermatologic therapy. In Arnold HL,
Odom RB, James WD (eds): Andrews' Diseases of the Skin:
Clinical Dermatology, 8th ed. Philadelphia, WB Saunders, 1990
pp 1008-1015.
Habif TP: Clinical Dermatology: A Color Guide to Diagnosis and
Therapy, 3rd ed. St. Louis, Mosby-Year Book, 1996.
Jones SK, Darville JM: Transmission of virus by cryotherapy and
multi-use caustic pencils: A problem to dermatologists? Br Dermatol
121:481, 1989.
Kuplik EG: Cryosurgery for cutaneous malignancy. Dermatol Surg
3:1081-1087, 1997.
Chapter 27— Cryosurgery 409
Torre D: Understanding the relationship between lateral spread of
freeze and depth of freeze. J Dermatol Surg Oncol 5:51-53, 1979.
Young R, Sinclair S: Practical cryosurgery. Aust Fam Physician
26:1045-1047, 1997.
Chapter Oft
Treating Ingrown Toenails
Sue M. Nyberg
Procedure Goals and Objectives
Goal: To treat problems associated with an ingrown toenail by
removing all or part of the affected nail.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
removing an ingrown toenail.
• Identify and describe common complications associated with
removing an ingrown toenail.
• Describe the decision process used to determine when to
remove an ingrown toenail.
• Describe the essential anatomy and physiology associated with
removal of an ingrown toenail.
• Identify the materials necessary for performing removal of an
ingrown toenail and their proper use.
• Identify the important aspects of post-procedure care after
removal of an ingrown toenail.
411
412 Chapter 28— Treating Ingrown Toenails
BACKGROUND AND HISTORY
The management of an ingrown toenail is one of the most common procedures
that the primary care practitioner is asked to perform. The ingrown toenail
can be painful, causing limitation in function and mobility in many patients.
Typically, only the great toe is affected, and either the medial or lateral
border may be involved. In their protective role, nails bear the brunt of daily
activities. Walking, running, wearing shoes, or participating in sports are just
a few of the stresses that feet must endure. The most frequent underlying
cause of an ingrown toenail is improper trimming of the nail, resulting in
impingement, inflammation, and even infection in the surrounding and over-
lying skin of the nail fold. Improperly fitted (e.g., high-heeled, narrow-toe)
shoes that compress the toes together are also a significant contributing
factor to the development of ingrown toenails. Other injuries to the nail bed
that change the shape of the nail or a congenitally increased curvature of the
lateral edges of the nail plate may also result in an ingrown nail.
Patients present with pain along the margin of the toenail that is
aggravated by any type of pressure, especially when wearing shoes. Erythema
and swelling are usually present and, if infection has occurred, pustular
drainage may be noted. Conservative measures such as elevation of the nail
plate with a small cotton wick, frequent soaking, wearing loose-fitting shoes,
and selective trimming of the nail may be attempted; however, either partial
or total removal of the nail remains the definitive treatment (Peggs, 1994).
INDICATIONS
The most common indication for the removal of a nail is onychocryptosis
(ingrown nail).
Other indications include the following:
■ Onychomycosis (fungal infection of the nail)
Chronic, recurrent paronychia (inflammation of the nail fold)
■ Onychogryposis (deformed, curved nail) (Peggs, 1994)
CONTRAINDICATIONS
Relatively few contraindications to the procedure exist but include a bleeding
diathesis or an allergy to local anesthesia (Peggs, 1994). In these rare situ-
ations, conservative measures should be attempted first, with consideration
of referral to a specialist if operative treatment is still indicated.
POTENTIAL COMPLICATIONS
Infection is a possible complication; however, it should be easily treatable
with appropriate antibiotics and frequent soaks. If the nail bed is not
Eponychium = proximal nail bed
Intermediate
Ventral
Dorsal
Chapter 28— Treating Ingrown Toenails 413
Distal free edge
Nail plate (nail)
Hyponychium
(distal ridge)
Nail bed
(sterile matrix)
Stratum corneum
Figure 28-1 . Anatomy of the nail and nail bed. (Redrawn from Pfenninger JF,
Fowler GC: Procedures for Primary Care Physicians. St. Louis, Mosby-Year Book,
1994, p 40.)
cauterized (ablated), the nail will regrow and symptoms may return. If the
nail bed is cauterized, there is still a potential for regrowth and return of
symptoms (approximately 10% with phenol ablation).
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
Nails are derived by keratinization of cells from the nail matrix, which is
located at the proximal end of the nail plate (Fig. 28-1). The nail plate consists
of the nail root embedded in the posterior nail fold, a fixed middle portion,
and a distal free edge. The whitish nail matrix of proliferating epithelial cells
grows in a semilunar pattern. It extends outward past the posterior nail fold
and is called the lunula (Swartz, 1998). Sensory supply to the great toe is
through the digital nerves that have an extensor and plantar branch on both
the medial and lateral aspects of the toe.
Standard Precautions Every practitioner should
use standard precautions at all times when
interacting with patients, especially when
performing procedures. Determining the level
of precaution necessary requires the
practitioner to exercise clinical judgment based
on the patient's history and the potential for
exposure to body fluids or aerosol-borne
pathogens (for further discussion, see
Chapter 2).
PATIENT PREPARATION
Explain the procedure to the patient to help alleviate as much anxiety as
possible.
Reassure the patient that the procedure is not painful except for the
initial injection.
Indicate the need for the patient's cooperation in keeping the foot still.
414 Chapter 28— Treating Ingrown Toenails
Materials Utilized to Remove an Ingrown
Toenail
Local anesthetic without epinephrine (vasoconstricting agents should
never be used in anesthetizing a digit)
5-mL syringe with a 1- to 1^-inch, 25- to 27-gauge needle
Povidone-iodine (Betadine) swabs
Sterile drape
Rubber band or small Penrose drain
Straight hemostats
Sterile straight scissors
Sterile periosteal elevator
Sterile gauze pads
Sterile cotton-tipped applicators
Phenol solution (88%) if permanent ablation of nail bed is desired
Isopropyl alcohol
Antibiotic ointment
Rolled or tubular gauze dressing
Procedure for Removing an Ingrown Toenail
1. Place the patient in a supine position.
2. Scrub the digit with povidone-iodine and
drape the toe in a sterile fashion.
Anesthesia (see Chapter 22)
3. Withdraw approximately 5 mL of local
anesthetic (without epinephrine) into
syringe.
4. Inject the anesthetic in a ring fashion
around the toe. The initial injection
should be proximal to the edges of the
medial nail fold on the dorsal surface of
the toe. There are four digital nerves
that should be anesthetized: both
extensor and plantar branches of the
medial and lateral nerves.
5. Inject approximately 1 mL of anesthetic
around each nerve site, starting dorsally
and directing the needle gently in a
plantar direction, injecting around the
plantar digital nerve.
6. Repeat the procedure on the lateral
side of the toe.
7. After the toe is anesthetized
(approximately 5 to 10 minutes), apply a
tourniquet to the base of the toe (either
a rubber band or small Penrose drain
clamped with a hemostat).
Chapter 28— Treating Ingrown Toenails 415
Cut nail in
this fashion to
begin removal
Figure 28-2. Toenail removal.
Toenail Removal
8. For partial nail removal, first cut the nail
lengthwise with sterile scissors or nail
cutters, 4 to 5 mm from the affected nail
fold (Fig. 28-2).
Note: If the entire nail is to be removed,
cutting the nail in half in a lengthwise
manner facilitates easier removal.
9. Loosen and lift the nail with a narrow
periosteal elevator, flat edge of the
scissors, or any similar instrument. If the
entire nail is to be removed, the nail can
first be cut in half with sterile scissors or
nail cutters.
10. Gradually separate the nail from the
underlying nail bed by applying gentle,
upward pressure, taking care to minimize
trauma to the underlying nail bed. It is
important to ensure that the proximal
nail underneath the cuticle is fully
loosened.
Ablation of the Nail
Matrix
11. If permanent removal of the nail is
desired to prevent recurrent problems,
the matrix of the nail bed must be
ablated.
12. Dry the nail bed with sterile gauze and
apply an 88% phenol solution to the nail
matrix with a sterile cotton-tipped
applicator for approximately 3 minutes.
Caution: Care must be taken not to expose
surrounding tissue to the phenol solution.
13. Neutralize the area with isopropyl
alcohol.
14. Remove the tourniquet.
Post- Procedure Care
15. Apply antibiotic ointment to the nail bed
and apply a sterile gauze pad to the site.
16. Wrap the toe with rolled or tubular
gauze
FOLLOW-UP CARE AND
INSTRUCTIONS
Instruct the patient to keep the foot elevated for 24 to 36 hours, with
gradual return to ambulation.
■ Over-the-counter analgesics are generally sufficient for pain relief.
416 Chapter 28— Treating Ingrown Toenails
Advise the patient to change the dressing in approximately 24 hours and
to soak the toe in warm water twice a day for several days.
Instruct the patient to report back to the office with any signs of
infection (fever, increasing swelling or erythema, pustular drainage).
To prevent recurrence of the ingrown nail, advise the patient to wear
low-heeled shoes with adequate room for the forefoot and toes.
■ Instruct the patient not to trim the nails too short and to trim in a flat,
straight-across fashion.
References
Peggs JF: Treatment of ingrown toenails. In Pfenninger JL, Fowler GC
(eds): Procedures for Primary Care Physicians. St. Louis, Mosby-Year
Book, 1994, p 38-43.
Swartz MH: Textbook of Physical Diagnosis: History and Examination,
3rd ed. Philadelphia, WB Saunders, 1998, p 94.
Chapter OQ
Draining Subungual Hematomas
Darwin Brown
Procedure Goals and Objectives
Goal: To drain a subungual hematoma successfully with a minimal
degree of risk and discomfort to the patient.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
draining a subungual hematoma.
• Identify and describe common complications associated with
draining a subungual hematoma.
• Describe the essential anatomy and physiology associated with
draining a subungual hematoma.
• Identify the materials necessary for draining a subungual
hematoma and their proper use.
• Identify the important aspects of post-procedure care after
draining a subungual hematoma.
417
418 Chapter 29 — Draining Subungual Hematomas
BACKGROUND AND HISTORY
Subungual hematoma is an injury that is common to the nail bed of fingers
and toes. The vast majority are caused by simple trauma, which can result in
bleeding into the space between the nail bed and fingernail. The subungual
hematoma may also occur as a result of repetitive, indirect trauma to the
distal end of the nail plate, typically from a tight-fitting shoe.
The patient often presents with intense pain secondary to the pressure
produced by the hematoma. The primary goal of treatment is to relieve the
pressure created by the hematoma. Drainage of the hematoma provides
dramatic pain relief for the patient and decreases the secondary pressure
effects to the digit. If the pressure is not relieved, damage to the nail matrix
and the germinal layer may occur, causing delayed regrowth or dystrophy of
the nail plate (Donnelly, 1992). The procedure itself is simple and can be
performed safely in the practitioner's office.
Clinicians who perform this procedure should familiarize themselves with
the anatomy of the nail bed and surrounding structures. The procedure is
easy to perform with basic training and can be one of the more rewarding
clinical treatments encountered in primary care or urgent care settings.
INDICATIONS
This procedure is indicated for relief from the acute pain associated with
visible, painful subungual hematomas.
CONTRAINDICATIONS
All patients presenting with nail trauma must be carefully assessed by
history, physical examination, and, when indicated, radiography. Based on
the clinical impression from these data, a decision can be made about the
appropriateness of proceeding with the draining of the hematoma. Potential
contraindications include the following:
■ Crushed or fractured nails
■ Fracture of the distal phalanx, which can inadvertently be converted to
an open fracture by draining the hematoma
■ Suspected subungual melanoma
■ Artificial acrylic nails are flammable and cautery should be avoided
(Buttaravoli, 2005)
Hematomas involving 50% or more of the nail may indicate laceration of
the underlying nail bed (Zook, 1999; Van Beek, 1990). It has been
generally recommended that these patients be referred for nail removal
and repair of the laceration (Simon, 1987; Melone, 1985; Wang, 2001).
Others, however, recommend leaving the nail in place because
Chapter 29 — Draining Subungual Hematomas 419
insufficient data exist supporting improved cosmetic outcomes with
removal of the nail (Buttaravoli, 2005; Fieg, 2002; Meek, 1998).
POTENTIAL COMPLICATIONS
Significant complications associated with this procedure are rare. Patients
should be informed that there is potential for nail bed deformities to persist
even after healing of the injury has occurred.
■ The most likely complication resulting from a subungual hematoma is
permanent nail deformity, especially if a nail bed injury is missed. Meek
and White (1998) noted that from the perspective of many patients, nail
deformity resulting from a subungual hematoma is considered minimally
important.
Infection of any remaining hematoma is uncommon but can occur. Using
sterile technique and covering the site with a dressing after the
procedure is completed can minimize the risk of this complication.
■ Use of a cautery may result in an inadvertent burn to the nail bed after
penetrating the nail, causing permanent damage.
■ Functional deficits (numbness) are also a rare complication.
The procedure itself has no significant complications.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
The nail anatomy is shown in Figure 29-1. The nail plate is produced by the
underlying matrix or nail bed. The nail plate and the underlying nail bed are
supported by the distal phalanx. The nail plate is not directly innervated;
Eponychium = proximal nail bed
Intermediate
Ventral
Dorsal
Distal free edge
Nail plate (nail)
Hyponychium
(distal ridge)
Nail bed
(sterile matrix)
Stratum corneum
Figure 29-1 . Anatomy of the nail and nail bed. (Redrawn from Pfenninger JF,
Fowler GC: Procedures for Primary Care Physicians. St. Louis, Mosby-Year Book,
1994, p 40.)
420 Chapter 29 — Draining Subungual Hematomas
however, the nail bed is richly innervated. The nail bed consists of all the
tissue directly beneath the nail that functions in nail generation and
migration. The arterial blood supply to the nail bed comes from two terminal
branches of the volar digital artery (Zook, 1999).
practitioner to exercise clinical judgment based
Standard Precautions Every practitioner should on the patient's history and the potential for
use standard precautions at all times when exposure to body fluids or aerosol-borne
interacting with patients, especially when pathogens (for further discussion, see
performing procedures. Determining the level Chapter 2).
of precaution necessary requires the
PATIENT PREPARATION
Describe the procedure to the patient and reassure him or her that there
is rarely any more pain than what is already being experienced.
■ Ask the patient if they have artificial acrylic nails, because the answer
will determine the technique to be used.
■ Anesthesia usually is not needed and is often more painful than the
procedure.
■ If the hematoma is to be evacuated using a large-bore needle or scalpel
blade, a digital block may be useful (see Chapter 22), as this method is
more painful than cautery because of the pressure applied to the nail
(Concannon, 1999). However, this is rarely required.
Inform the patient that, depending on the selected technique, an
irritating odor may occur.
■ The patient should be instructed to hold the digit very still during the
procedure.
Materials Utilized for Draining a Subungual
Hematoma
Gloves
Face shield
Povidone-iodine (Betadine) or other antiseptic-germicidal solution
Alcohol wipes
Cautery (battery-operated or electrocautery unit), No. 11 scalpel,
18-gauge needle, or a paper clip and hemostat
Lighter to heat paper clip
Sterile gauze
Chapter 29 — Draining Subungual Hematomas 421
Antibiotic ointment
Bandage
Procedure for Draining a Subungual Hematoma
1. Place the patient in a sitting or supine
position in which he or she can rest
comfortably during the procedure
without risk of further injury should
lightheadedness occur. Examine the
injured digit to determine the extent of
injury
2. Note the size of the hematoma.
3. Assess for fractures of the digit, especially
the distal phalanx.
4. If a nondisplaced fracture is suspected,
splint in an anatomic position until
swelling improves.
Note: Radiographs should be obtained
whenever you suspect a fracture.
5. Allow the affected digit to soak in an
antiseptic solution such as povidone-
iodine.
Note: Care must be taken to use aseptic
technique in preparation for evacuation.
6. Clean the nail with alcohol.
Caution: Alcohol is a highly flammable
material. Wash off alcohol with sterile
water or allow the alcohol to dry before
placing hot cautery or flame near the nail.
7. Burn a small hole in the nail using a
conventional hand-held cautery or the
straightened end of a paper clip
(Fig. 29-2).
8. If using a paper clip, hold it with a
hemostat.
9. Heat the straightened portion of the
paper clip with a lighter until the tip is
red hot.
Figure 29-2. (Redrawn from Pfenninger JF,
Fowler GC: Procedures for Primary Care
Physicians. St. Louis, Mosby-Year Book, 1994,
P48.)
Figure 29-3. (Redrawn from Pfenninger JF,
Fowler GC: Procedures for Primary Care
Physicians. St. Louis, Mosby-Year Book, 1994,
p48.)
10. Apply the hot tip with gentle pressure to
the nail over the site of the hematoma
(Fig. 29-3).
Note: It may take two or three attempts to
burn through the nail with the heated paper
clip.
continued
422 Chapter 29 — Draining Subungual Hematomas
11. Make a 1- to 2-mm hole, which is large
enough to allow for long-term drainage.
Note: A sudden burst of blood may occur if
the pressure beneath the nail is great
enough.
12. Alternatively, with an 18-gauge needle or
a No. 1 1 scalpel blade, use a rotary
motion to bore a hole through the nail to
the hematoma. Consider using a digital
block for this method if the patient is
unable to tolerate pressure on the nail
(see Chapter 22).
Note: After the blood has drained, the
associated pain should improve significantly.
If pain does not subside significantly,
underlying fractures should be reconsidered.
13. Clean the area with alcohol wipes.
14. Apply antibiotic ointment and a light
dressing to the nail.
SPECIAL CONSIDERATIONS
For young children, providing parents or guardians more information on the
procedure can be helpful. Also, secure immobilization may be needed when
performing this procedure in this population.
FOLLOW-UP CARE AND
INSTRUCTIONS
Advise the patient of the proper follow-up care after this procedure.
The affected digit should be soaked in warm, soapy water two or three
times a day.
■ A light dressing should be kept over the area until the evacuation site
closes completely.
■ The patient should notify the practitioner if pain persists. The
practitioner should also be notified if there is a change in sensation,
purulent or foul-smelling drainage, fever, or erythema of the skin
surrounding the area.
■ The patient should understand that the nail and discomfort should
improve progressively over the following few days.
If any change occurs or the injury is not improving as expected, the
patient should call or return to the office.
References
Buttaravoli PM, Stair TO: Common Simple Emergencies. Published
online by Longwood Information (accessed July 1, 2005). Available at:
www.ncemi.org/cse/csel007.htm
Concannon MJ: Common Hand Problems in Primary Care. Philadelphia,
Hanley & Belfus, 1999, p 119.
Chapter 29 — Draining Subungual Hematomas 423
Donnelly RE: Step-by-step procedures for treating common nail
problems. Part I: Paronychia and subungual hematoma. J Am Acad
Phys Assist 5:145-150, 1992.
Fieg EL: Management of nail bed lacerations. Am Fam Physician
65:1997-1998, 2002.
Meek S, White M: Subungual haematomas: Is simple trephining enough?
J Accid Emerg Med 15:269-271, 1998.
Melone CP, Grad JB: Primary care of fingernail injuries. Emerg Med Clin
North Am 3:255-261, 1985.
Simon R, Wolgin M: Subungual haematoma: Association with occult
laceration requiring repair. Am J Emerg Med 5:302-304, 1987.
Van Beek AL, Kassan MA, Adson MH, et al: Management of acute
fingernail injuries. Hand Clin 6:23-35, 1990.
Wang QC, Johnson BA: Fingertip injuries. Am Fam Physician
63:1691-1696, 2001.
Zook EG, Brown RE: The perionychium. In Green DP, Hotchkiss RN,
Pederson WC (eds): Green's Operative Hand Surgery, 4th ed, vol II.
Philadelphia, Churchill Livingstone, 1999, pp 1354, 1356.
Bibliography
Chang P: Nail bed repair. In Blair WF (ed): Techniques in Hand Surgery.
Baltimore, Williams & Wilkins, 1996.
Kaya TI, Tursen U, Baz K, Ikizoglu G: Extra-fine insulin syringe needle:
An excellent instrument for the evacuation of subungual hematoma.
Dermatol Surg 29:1141-1143, 2003. (Describes a different technique for
removal of subungual hematoma.)
Skinner PB Jr: Management of traumatic subungual hematoma. Am Fam
Physician 71:856, 2005. (Describes a slight variation in technique.)
Chapter OQ
Anoscopy
Sue M. Nyberg
Procedure Goals and Objectives
Goal: To examine the anus and rectum thoroughly, with minimal
discomfort to the patient, and obtain accurate information while
maintaining patient modesty.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing anoscopy.
• Identify and describe potential complications associated with
performing anoscopy.
• Describe the essential anatomy and physiology associated with
the performance of anoscopy.
• Describe how to perform a digital rectal examination.
• Identify the materials necessary for performing anoscopy and
their proper use.
• Properly perform an anoscopy.
425
426 Chapter 30— Anoscopy
BACKGROUND AND HISTORY
Anorectal disorders are a common source of discomfort for many patients,
and adequate visualization of the anorectal canal is important for appropriate
diagnosis and treatment of these conditions. Anoscopy is a relatively simple
procedure to perform, but adequate patient education and clinical skill
are required to reduce the patient's anxiety and embarrassment about the
procedure. This procedure is performed in ambulatory, emergency, and
inpatient settings and is commonly carried out before colonoscopy.
INDICATIONS
Indications for performing anoscopy include, but are not limited to, the
evaluation of the following:
Rectal bleeding
■ Anorectal pain
Pruritus
■ Anal discharge
■ Prolapse of the rectum
Mass detected in the rectal vault on digital examination
Therapeutic procedures may be performed along with routine anoscopy and
include biopsy of suspicious lesions, removal of foreign bodies, and collection
of a specimen for culture.
CONTRAINDICATIONS
Relatively few contraindications to the procedure exist; however, in the
following situations, further patient education or referral to a specialist may
be necessary if the examination is indicated:
■ Presence of severe rectal pain
■ Anoscopic examination in patients with perirectal abscess, acutely
thrombosed hemorrhoid, or acute anal fissure, as severe discomfort may
result as well as, in the case of anal fissure, possible bleeding
■ Patient unwilling to have the procedure performed
■ Patient not able to cooperate appropriately so that an adequate
examination can be performed
Presence of severe anal stricture
Chapter 30— Anoscopy 427
POTENTIAL COMPLICATIONS
■ Anal or perianal tears may occur but are usually mild and respond to
conservative measures (Fry, 1985).
■ Bleeding is rare but may occur with an anal tear or in the presence of
internal hemorrhoids and usually responds to conservative measures
unless a coagulation defect is present.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
Understanding the anatomy of the anus and surrounding tissues facilitates
accurate diagnosis and treatment of anorectal disorders. Careful visual
inspection of the perianal region may reveal evidence of hemorrhoids, skin
tags, fissures, dermatitis, abscesses, fistulous openings, or lesions. A thorough
digital examination before anoscopy should evaluate the competency of the
external anal sphincter and assess for palpable lesions.
The rectum is the distal 10- to 12-cm portion of the alimentary tract
continuous proximally with the sigmoid colon and distally with the anal
canal (Fig. 30-1). The rectum ends anteroinferior to the tip of the coccyx by
turning sharply posteroinferiorly (the anorectal flexure) as it perforates the
pelvic diaphragm (levator ani) to become the anal canal. The most distal
point of the anal canal is the anal verge. The anal verge, the dentate line, and
the anorectal ring are the three main anatomic points of reference.
■ The anal verge, the external boundary of the anal canal, is the junction
between the anal and perianal skin.
■ The dentate line, the cephalad border of the anatomic anal canal, is a
true mucocutaneous junction. Squamous epithelium is located distal to
the dentate line, and columnar epithelium is located proximal to the
dentate line in the rectum. At this junction is a circular ring of glands
Rectum
Internal Y^aJ
sphincter \<~^
External
sphincter -
Dentate line
Anal canal
Figure 30-1.
rectum.
Anatomy of the
428 Chapter 30— Anoscopy
that secrete mucus to lubricate the anal canal. The dentate line lies
approximately 1 to 2 cm above the anal verge.
■ The anorectal ring, 1 to 2 cm above the dentate line, is the upper border
of the anal sphincteric complex and is easily palpable during digital
examination.
The superior rectal artery, the continuation of the inferior mesenteric artery,
supplies the proximal portion of the rectum. The two middle rectal arteries,
usually arising from the inferior iliac arteries, supply the middle and inferior
portions of the rectum, and the inferior rectal arteries, arising from the internal
pudendal arteries, supply the anorectal sphincter muscles and anal canal. It
is important to remember that the internal hemorrhoidal plexus arises above
the dentate line and that the external hemorrhoidal plexus arises below the
dentate line.
Both sympathetic and parasympathetic nerves innervate the rectum. The
external sphincter (a voluntary skeletal muscle) and the levator ani muscles
are innervated by the inferior rectal branch of the internal pudendal nerve
(S2, S3, S4) as well as by fibers from the fourth sacral nerve. The internal
sphincter (an involuntary muscle approximately 2.5 cm in length) is innervated
by both sympathetic and parasympathetic nerves. It is generally accepted
that either an intact functional external sphincter or anorectal ring (pubo-
rectalis muscle that encircles the very distal rectum) can provide nearly
perfect anal continence. The internal sphincter plays little part in maintaining
voluntary anal continence. This is important when counseling patients who
are considering surgical treatment of anal fissures (Surrell, 1994).
practitioner to exercise clinical judgment based
Standard Precautions Every practitioner should on the patient's history and the potential for
use standard precautions at all times when exposure to body fluids or aerosol-borne
interacting with patients, especially when pathogens (for further discussion, see
performing procedures. Determining the level Chapter 2).
of precaution necessary requires the
PATIENT PREPARATION
The only patient preparation needed is adequate education about the purpose
of the examination and the technique used. Many patients have a degree of
embarrassment about undergoing the examination and should be reassured
that they will be appropriately draped. Although the procedure may be slightly
uncomfortable and may cause an urge to defecate, it should not be painful
(unless predisposing conditions are present). No bowel preparation is usually
necessary.
Chapter 30— Anoscopy 429
Materials Utilized for Anoscopy
Anoscope: The anoscope is a cylindrical instrument with a removable
obturator, made of clear polyethylene or reusable metal (Fig. 30-2). Some
anoscopes have their own attached light source; if not, another external
light source must be used.
Water-soluble lubricant
Disposable gloves
Light source (directed or worn on the head)
Appropriate culture swabs (when indicated)
Monsel's solution
Large-tipped cotton swabs
Figure 30-2. An anoscope.
430 Chapter 30— Anoscopy
Procedure for Anoscopy
Position
1. Place the patient in a lateral decubitus or
dorsal lithotomy position with
appropriate draping.
Inspection
1. Know the anatomy of the anus and
surrounding tissues to facilitate accurate
diagnosis and treatment of anorectal
disorders.
2. Make a careful visual inspection of the
perianal region to reveal any evidence of
fissures, dermatitis, abscesses, fistulous
openings, or lesions.
3. Ask the patient to bear down during
inspection; this may reveal prolapsing
hemorrhoids.
Digital Rectal Examination _
A thorough digital examination should be
performed before anoscopy.
1. With a gloved, lubricated finger, gently
press on the anal verge and ask the
patient to relax. This should allow the
finger to enter the anal canal.
2. The examiner should then evaluate the
competency of the external anal sphincter
by asking the patient to simulate
interrupting a bowel movement.
3. After the patient relaxes, the examiner
should also assess the rectal canal for any
palpable lesions or masses. Finally, the
prostate gland should be assessed in the
male patient. The examiner should rotate
the finger a full 360 degrees to ensure that
all rectal structures are fully evaluated.
4. Generally, internal hemorrhoids and the
dentate line are not palpable.
5. Any stool present on the examining finger
should be examined for occult blood
(Fry, 1985).
Anoscopy
1. After lubricating the anoscope, gently
spread the patient's buttocks and gently
insert the anoscope into the anal canal.
Slowly advance the anoscope until the
flange at the base rests on the perianal
skin.
2. Remove the obturator and inspect the
mucosa of the perianal canal thoroughly
for suspected pathology (Fig. 30-3).
Figure 30-3. (From Wigton RS: Gastrointestinal
procedures. In Mosby's Primary Care Procedures,
CD-ROM series. St. Louis, CV Mosby, 1999.)
Chapter 30— Anoscopy 431
3. Repeat the procedure, if needed, to 5. Control any bleeding with Monsel's
ensure adequate inspection of the entire solution and pressure (Moesinger,
canal (Fry, 1985). 2000).
4. If a biopsy is necessary, one of a variety of
long-handled biopsy instruments may be
used.
FOLLOW-UP CARE AND
INSTRUCTIONS
Examination findings should be discussed thoroughly with the patient.
Complications are rare with this procedure, and follow-up care should be
based on the treatment of any condition found during the examination. The
patient should be instructed to notify the provider if significant, unexpected
bleeding or pain occurs after the procedure.
References
Fry RD, Kodner IJ: Anorectal disorders. Clin Symp 37:2-5, 1985.
Moesinger RC: Gastrointestinal procedures. In Chen H, Sonnenday CJ
(eds): Manual of Common Bedside Surgical Procedures. Philadelphia,
Lippincott Williams & Wilkins, 2000, pp 159-160.
Surrell JA: Clinical anorectal anatomy and examination. In
Pfenninger JL, Fowler GC (eds): Procedures for Primary Care
Physicians. St. Louis, Mosby-Year Book, 1994, pp 898-901.
Bibliography
Moore KL, Dalley AF: Clinically Oriented Anatomy, 4th ed. Philadelphia,
Lippincott Williams & Wilkins, 1999.
Varma JR: Clinical anorectal anatomy and examination. In Pfenninger JL,
Fowler GC (eds): Procedures for Primary Care Physicians.
Philadelphia, Mosby-Year Book, 1994, pp 902-905.
Chapter O '
Flexible Sigmoidoscopy
Dawn Morton-Rias
Procedure Goals and Objectives
Goal: To perform flexible sigmoidoscopy on a patient safely and
accurately
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing flexible sigmoidoscopy.
• Identify and describe common complications associated with
performing flexible sigmoidoscopy.
• Describe the essential anatomy and physiology associated with
the performance of flexible sigmoidoscopy.
• Identify the materials necessary for performing flexible
sigmoidoscopy and their proper use.
• Describe the steps associated with the safe performance of a
flexible sigmoidoscopy examination.
433
434 Chapter 31 — Flexible Sigmoidoscopy
BACKGROUND AND HISTORY
The need to examine and evaluate the rectum and colon has existed for
centuries. Hippocrates mentioned the use of a rectal speculum for the diag-
nosis and treatment of anal disorders. Early instrumentation of the lower
bowel was hampered by the lack of light. Several inventors experimented
with endoscopic illumination, but Max Nitze of Germany (1879) and Howard
Kelly of the United States (1895) are credited with the development of modern
rigid proctosigmoidoscopy. Early proctosigmoidoscopy involved visual
inspection of the lower bowel through a rigid scope inserted into the patient's
anus and advanced to the rectum and sigmoid colon. Later, distal illumination,
proximal illumination, and air insufflation expanded the visualization
capabilities. Overholt of the United States reported the first experiences with
fiberoptic flexible sigmoidoscopy by successfully examining the colon beyond
the 25-cm limit of rigid sigmoidoscopy.
Modern flexible sigmoidoscopy involves the visual inspection and evalu-
ation of the anal canal, rectum, and variable portions of the sigmoid colon.
The procedure facilitates evaluation of lower bowel pathology, such as rectal
bleeding, pain, constipation or diarrhea, and pathologic findings identified on
digital or radiologic examination of the colon. Rigid sigmoidoscopy, con-
sidered optimal for visualization, biopsy, or culture of large surfaces, was
not a welcome clinical intervention. Patient comfort was secondary to the
evaluative and diagnostic benefits obtained from the procedure. Screening
and diagnostic benefits of rigid sigmoidoscopy were minimal because of a
lack of public awareness of the value of the test, limited clinical training of
physicians to perform sigmoidoscopy properly, a high cost-benefit ratio in
asymptomatic patients, and, perhaps most important, poor patient perception
and dissatisfaction with rigid sigmoidoscopy. Consequently, rigid sigmoidos-
copy has not been well utilized. This remains so even today.
According to the American Society for Gastrointestinal Endoscopy,
Standards for Training and Practice Committee, flexible sigmoidoscopy, which
also involves direct visualization and evaluation of the lower colon, enables
detection of three to four times as many precancerous polyps and is more
widely accepted by patients. Both flexible and rigid sigmoidoscopy are
appropriate for evaluation of colonic symptoms, and yet neither substitute
for full colonoscopy when the latter is indicated. Modern biotechnology
has facilitated the integration of instrument flexibility, illumination, and
therapeutic as well as photographic capabilities into the modern flexible
sigmoidoscopy.
Colorectal cancer is the third most common cancer and the third leading
cause of cancer death in both sexes, accounting for approximately 10 percent
of cancer deaths overall (Jemal, 2005). Screening and surveillance guidelines
endorsed by federal agencies and professional medical societies call for
enhanced use of flexible sigmoidoscopy in conjunction with a complete
history and physical examination, digital examination, and fecal occult blood
assessment in the early detection and treatment of colon cancer. Evidence
exists that a reduction in mortality from colorectal carcinoma is feasible
Chapter 31 — Flexible Sigmoidoscopy 435
through early detection and removal of polyps. Flexible sigmoidoscopy is a
valuable screening tool in the early detection of changes in colonic mucosa,
even before symptoms become evident. The 60-cm sigmoidoscope can reach
to the splenic flexure and therefore directly identify about one half of colonic
lesions (either cancers or polyps). An additional 20% of neoplasms are found
if abnormal sigmoidoscopies are followed by colonoscopic examination of
the entire colon. It allows direct visualization of changes, polyps, and other
lesions and direct sampling. Flexible sigmoidoscopy is a reliable and cost-
effective procedure that yields accurate findings when proper techniques
are used.
Flexible sigmoidoscopy is safely and effectively performed by primary care
physicians, physician assistants, nurse practitioners, and clinical nurse
specialists. All health care providers are strongly encouraged to acquire
proper training and supervision in performing this procedure. It is recom-
mended that providers perform at least 20 flexible sigmoidoscopies under
direct supervision by a physician trained in the technique before attempting
to perform the procedure independently. Flexible sigmoidoscopy is a thera-
peutic and diagnostic procedure that is best used in conjunction with other
screening and diagnostic practices. The screening protocol includes
assessment of risk, a digital examination, assessment of occult blood, and
sigmoidoscopy. Full colonoscopy and barium radiography of the colon may
be indicated. Flexible sigmoidoscopy is not simply a one-time test. The
optimal screening interval after a negative sigmoidoscopy has not been
determined; the American Gastroenterological Association guidelines
recommend repeat screening after 5 years (Winawer, 2003). Continuity of
care and follow-up are key to realization of the benefit of this diagnostic
procedure.
INDICATIONS
Specific indications for flexible sigmoidoscopy include evaluation and
diagnosis of the following:
■ Frank rectal bleeding
■ Occult blood
■ Hemorrhoidal inflammation
■ Anal fissures
■ Polyps
Inflammatory conditions of the colon
In addition, flexible sigmoidoscopy is indicated for the following:
To monitor inflammatory bowel disease.
■ For follow-up and further evaluation of findings identified through
barium enema radiography.
436 Chapter 31 — Flexible Sigmoidoscopy
Current cancer screening guidelines outlined by the American Cancer
Society recommend baseline flexible sigmoidoscopy for all adults by age
50 (Smith, 2001).
The American Society for Gastrointestinal Endoscopy recommends
baseline and annual flexible sigmoidoscopy for individuals with a
positive family history of familial polyposis, for individuals who have a
first-degree relative with a history of colonic neoplasia, and for those
with a positive family history of hereditary nonpolyposis or colon cancer.
Some surgeons recommend flexible sigmoidoscopy before hernia repair
to rule out a colonic tumor.
CONTRAINDICATIONS
Flexible sigmoidoscopy is a relatively safe procedure with few contraindi-
cations. Some sources suggest that polypectomy is not recommended using
flexible sigmoidoscopy because of possible hemorrhage and risk of
electrocautery-induced explosion. Others suggest that removal of polyps
that are smaller than 0.5 cm during flexible sigmoidoscopy is safe and
acceptable.
Contraindications to flexible sigmoidoscopy include:
■ Fulminant colitis
■ Severe or acute diverticulitis
■ Toxic megacolon
Acute peritonitis
■ Poor bowel preparation
■ Poor patient cooperation
■ Severe cardiopulmonary disease
As with any diagnostic or therapeutic procedure, one must always weigh the
importance of the information to be obtained against the risks associated
with the procedure.
POTENTIAL COMPLICATIONS
Complications are rare but they can occur.
■ Minor complications from flexible sigmoidoscopy include spotting and
minor bleeding from the site.
■ The most serious complication of flexible sigmoidoscopy is perforation
of the bowel. This may occur if the instrument is pushed directly
through the mucosa, usually in an area of sharp flexion or through a
diverticulum, which has been mistaken for bowel lumen.
Chapter 31 — Flexible Sigmoidoscopy 437
Transverse
colon
Ascending
colon
Appendix
Descending
colon
Rectosigmoid — IrAi ^^J^ Sj jd FlGURE 31-1. Anatomy of
colon r >L 1 >^ , , ,
colon the large intestine and
Rectum
rectum.
■ Tears at the site of an anastomosis in patients who have undergone
rectal surgery is also a possible complication.
■ A perforation or tear of the lumen requires surgical repair.
These complications may be avoided by taking a complete history, using
proper technique, obtaining supervision and training, and using a reduced
pace and rate of examination.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
The anal canal is the terminal end of the gastrointestinal tract (Fig. 31-1). It is
a tubular structure of approximately 3 to 4 cm in length. The anorectal
junction is an important landmark, characterized by a change in the pinkish
mucosa to pale squamous epithelium. This landmark will not be observed if
the instrument is advanced too rapidly. The rectum is the fixed terminal
portion of the large intestines. The rectum is generally 15 cm long, and its
inferior portion is continuous with the anal canal. The rectal mucosa is
generally pink, moist, and glistening. The lumen of the rectum has three
shelflike projections called the superior, middle, and inferior valves of Houston.
These values are composed of mucous membranes, circular muscle, and
fibrous tissue. The entrance to the sigmoid colon is marked by the presence
of haustrations that are seen as small mucosal projections into the lumen.
These haustrations appear to divide the sigmoid lumen into compartments.
Branches of the inferior mesenteric artery and sigmoid arteries provide
the arterial blood supply of the sigmoid colon. Venous drainage is achieved
via the inferior mesenteric vein. Lymphatic drainage is achieved via
the intermediate colic lymph nodes on the branches of the left colic arteries
and left inferior mesenteric lymph nodes around the inferior mesenteric
artery.
438 Chapter 31 — Flexible Sigmoidoscopy
to exercise clinical judgment based on the
Standard Precautions Every practitioner should patient's history and the potential for exposure
use standard precautions at all times when to body fluids or aerosol-borne pathogens (for
interacting with patients, especially when further discussion, see Chapter 2).
performing procedures. Determining the level
of precaution necessary requires the practitioner
PATIENT PREPARATION
Explain the procedure to the patient, allowing an opportunity for the
patient to ask questions and for them to be answered satisfactorily.
■ Obtain informed consent for the procedure.
Preparation before the procedure may include:
■ A liquid diet for 24 hours before the procedure
■ One or two bowel-cleansing enemas before the procedure. Patients are
encouraged to use a commercially prepared enema product. Harsh
laxatives may irritate the mucosa and cause retention of soft or watery
stool, which may interfere with the quality of the examination. Complete
and meticulous bowel preparation must be achieved to avoid explosion
of combustible gases.
Patients are to continue taking their prescribed medications.
Patients are generally advised to discontinue use of aspirin, non-
steroidal anti-inflammatory agents, and blood thinners before the
procedure because these agents generally interfere with coagulation.
■ Prophylactic antibiotic therapy may be prescribed for patients with
cardiac valvular disease.
■ The patient must be aware of the indications and expected outcomes as
well as the logistics of the examination before positioning and draping.
Materials Utilized to Perform a Flexible
Sigmoidoscopy
A standard, small-caliber, flexible fiberoptic sigmoidoscope, either 35 or
60 cm in length (Fig. 31-2), and an appropriate light source
Note: The basic unit consists of a control head, flexible insertion tube, and
maneuverable tip. The most important features of the scope are flexibility,
optics, and a small outside diameter with the largest internal biopsy channel
possible. Durability as well as ease of cleaning and maintenance are essential.
The coated glass fibers allow transmission of images longitudinally and
transmit light to the distal end of the scope as well as to the proximal end.
Smaller channels within the scope allow for the insufflation of air that is
Chapter 31 — Flexible Sigmoidoscopy 439
Figure 31-2. Schematic diagram of a fiberoptic sigmoidoscope. (Redrawn from
Pfenninger JL, Fowler GC: Procedures for Primary Care Physicians. St. Louis,
Mosby-Year Book, 1994, p 916.)
necessary for distention of the lumen, water infiltration, and fulguration
apparatus. These are useful for aspiration of retained liquid stool, mucus,
or enema water. The water, suction, and air controls are located on the
control head and the scope. The exterior of the scope is housed in a plastic
sleeve.
■ Large, cotton-tipped swabs, to push aside stool or to assess mucosal
integrity
Culture and biopsy materials, so that lesions and suspicious mucosa
may be adequately sampled
■ Appropriate draping materials to protect patient modesty
Unsterile gloves
Water-soluble lubricant
■ Suction machine
■ Containers with and without water
Forceps
Procedure for Performing a Flexible Sigmoidoscopy
Note: Flexible sigmoidoscopy is an outpatient
procedure. The success of the examination
relies on provider technique and rapport
with the patient, as well as patient comfort,
preparation, and cooperation.
Note: Sedation is rarely necessary.
Low-dose intravenous diazepam may be
indicated for patients with significant
apprehension or anal disease or for
children.
continued
440 Chapter 31 — Flexible Sigmoidoscopy
1. Place the patient in any one of three
positions: knee-chest position, an
inverted position, or left Sims' position.
Some prefer the left Sims' position in
that it is perceived to be a less
embarrassing position. The knee-chest
position as well as the inverted position
allows for greater access, as the bowel
tends to move away from the pelvis.
Encourage the patient in the knee-chest
position or inverted position to remain
still and to keep the hips straight.
2. Dim the room lighting; an assistant should
be available in the examination room.
3. Begin the procedure with a
well-lubricated digital examination of
the anus.
Note: This examination also serves to ensure
proper rectal clearance as well as to relax the
rectal sphincter and lubricate the anal canal.
4. Palpate the anal region for abnormalities,
fissures, and inflammation of internal or
external hemorrhoid tissue. Palpate the
ischioanal fossae and perineum between
the thumb and forefinger.
5. Insert the examining finger farther to
palpate the anterior wall and then sweep
down to the posterior wall.
Note: This step in effect becomes a bidigital
examination because while the index finger
is within the anus, the thumb is palpating
the tissue of the perineum, ischioanal fossae,
and coccygeal areas. In addition, this step
allows the provider to assess the anal
diameter to determine if the selected caliber
scope is appropriate.
6. The distal 10 to 15 cm of the scope may
be lubricated, but care should be used
to avoid lubrication of the tip, as this
will cloud the lens.
7. To minimize the patient's discomfort, a
common approach for insertion of the
scope involves gradual replacement of
Figure 31-3. (Redrawn from Wigton RS:
Gastrointestinal procedures. In: Mosby's Primary
Care Procedures, CD-ROM series. St. Louis,
CV Mosby, 1999.)
the examining digit during withdrawal
with the insertion of the scope (Fig. 31-3).
8. While advancing the scope, you will feel
a slight "give" as the scope passes the
anal canal and enters the rectum.
9. Advancement, as well as deflection, of
the scope via the hand-held control
knobs must be slow and gradual.
10. Small turns of the control knobs result in
significant movement of the scope. You
may observe a "red out" during
advancement of the scope. This finding
suggests that the lens of the scope is
pressed against the lumen, and the
instrument must be retracted slightly.
11. Avoid excessive suctioning during the
procedure, as the mucosal wall may be
suctioned directly to the scope and may
become dry and erythematous as well.
12. Use the least amount of air insufflation
as possible for visualization to minimize
distention and avoid patient discomfort.
Chapter 31 — Flexible Sigmoidoscopy 441
Note: Overinsufflation may cause the
mucosa to become less flexible and may
cause perforation or serosal lacerations.
Note: The normal healthy mucosa is pink
and glistening. Plaques, lesions, masses, and
polyps must be noted.
Note: Transition to the rectum is generally
evident by recognition of three prominent
haustral folds, the valves of Houston. These
angulations must be successfully negotiated,
and this component of the examination is
considered most technically challenging.
Note: Dutta and Kowalewski (1987) suggest
the following general rules for insertion of
the flexible fiberoptic sigmoidoscope.
• Clockwise torque decreases bowel
angulation; counterclockwise torque does
the reverse.
• Slight suction may aid in negotiation of
sharp angulation in the bowel.
• If spasm occurs, pause and then resume.
• If you reach sharp curves, withdraw a bit
before advancing the scope.
13. Throughout the procedure, sampling,
culture, and biopsy specimens may be
obtained. Use the largest forceps
available that will fit through the scope.
Survey samples should be obtained from
fold edges because they yield the
greatest results.
14. Under rare circumstances and with
specialized and specific training and
certification, small polyps may be
removed via electrosurgery under
endoscopic conditions.
15. Small sessile polyps (5 mm or less) may
be removed with hot biopsy forceps.
Note: Some providers attempt polypectomy
of larger lesions through mechanical
debulking.
Note: Dutta and Kowalewski's 10 overall
golden rules for flexible sigmoidoscopy are
as follows:
• Never attempt the procedure on an
uncooperative or unwilling patient.
• Always obtain written consent.
• Talk with your patient before, during, and
after the procedure.
• Allow yourself enough time.
• Do not spend 20 minutes inserting the
scope. The best visualization of colonic
mucosa may be on the way out.
• Proper bowel preparation is essential.
Postpone the test if necessary.
• Do not insist on inserting the instrument
the full 60 cm; 30 to 40 cm may be all that
is possible.
• Never advance the scope blindly.
• The 90- to 180-degree deflection available
on most scopes is very helpful. Use it.
• Use less air; suction as necessary.
16. Withdraw the scope gradually, and
carefully inspect the colon during this
process.
Note: Withdrawal of the scope is a crucial
part of the examination. The examiner must
ensure that the steering knob is not locked,
and he or she must use torque combined
with in-and-out movements to deflect and
observe while exiting.
17. When the tip of the sigmoidoscope is
withdrawn from the anus, be careful that
it does not strike anything, as the anus
can be easily damaged.
18. Reinsert the scope 5 to 6 cm to remove
the remaining air. Take care not to suck
the mucosa into the scope. The patient
can be instructed to tell the examiner
when all the air has been removed.
19. Inspect the anal canal thoroughly using
either an anoscope or the sigmoidoscope.
This can also be performed at the
beginning of the procedure.
442 Chapter 31 — Flexible Sigmoidoscopy
SPECIAL CONSIDERATIONS
Flexible sigmoidoscopy of infants, children, teenagers, and elders requires
attention to positioning, preparation, and communication. Infants and children
may be understandably apprehensive and may require mild sedation. Special
attention to concerns and an explanation of details may be necessary in
preparing teenagers and young adults. Teenagers and young adults may be
particularly sensitive to traffic within the examination suite. Hence, attention
should be paid to limiting exposure. Elders, patients with limited mobility,
and those with circulatory compromise may prefer or require left lateral
(Sims') positioning for enhanced patient comfort. Full disclosure, communi-
cation, and rapport remain key in attending the needs of special populations.
FOLLOW-UP CARE AND
INSTRUCTIONS
Flexible sigmoidoscopy is a relatively safe and benign procedure. Post-
procedure complications are rare but may include the following:
■ Patients may complain of mild cramping and bloating from distention of
the colon. Patients may also notice spotting after biopsy. These reactions
are normal.
Instruct the patient to seek immediate medical attention if he or she
experiences severe abdominal pain, significant abdominal distention,
nausea, vomiting, fever, chills, or a rectal bleed of greater than V2 cup
after the procedure.
References
Dutta S, Kowalewski E: Flexible Sigmoidoscopy for Primary Care
Physicians. New York, Alan R. Liss, 1987.
Jemal A, Murray T, Ward W, et al: Cancer statistics, 2005. CA Cancer
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Smith RA, von Eschenbach AC, Wender R, et al: American Cancer
Society guidelines for the early detection of cancer: Update of early
detection guidelines for prostate, colorectal, and endometrial
cancers. Also: Update 2001 — Testing for early lung cancer detection.
CA Cancer J Clin 51:38, 2001.
Winawer S, Fletcher R, Rex D, et al: Colorectal cancer screening and
surveillance: Clinical guidelines and rationale — Update based on new
evidence. Gastroenterology 124:544, 2003.
Chapter 31 — Flexible Sigmoidoscopy 443
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Society for Gastrointestinal Endoscopy. Gastrointestinal Endoscopy
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Charette A: Patient information: Flexible sigmoidoscopy: USDA
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Clinical Abstracts — Guidelines for Colorectal Cancer Screening.
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Fincher RK, Osgard EM, Jackson JL, et al: A comparison of bowel
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Chapter OO
Removal of Cerumen and
Foreign Bodies from the Ear
Tammy Dowdell Ream
Procedure Goals and Objectives
Goal: To remove cerumen impaction or foreign bodies from the
auditory canal while observing standard precautions and with the
minimal degree of risk to the patient.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing cerumen or foreign body removal.
• Identify and describe common complications associated with
cerumen or foreign body removal.
• Describe the essential anatomy and physiology associated with
performance of cerumen or foreign body removal.
• Identify the necessary materials for performing cerumen or
foreign body removal and their proper use.
• Identify the important aspects of post-procedure care following
cerumen or foreign body removal.
445
446 Chapter 32 — Removal of Cerumen and Foreign Bodies from the Ear
BACKGROUND AND HISTORY
Cerumen is a normal substance produced and found in the external auditory
canal. Cerumen serves as protective coating, trapping fine dust and repelling
water away from the tympanic membrane. The acidic nature of cerumen is
not suitable for bacterial growth, thus aiding in prevention of otitis externa
development. Fine hair located in the auditory canal moves the cerumen out
of the external meatus, preventing obstruction. Many factors can interfere
with this physiologic process, leading to cerumen impaction and obstruction,
including a narrowed auditory canal or external meatus, overproduction of
cerumen, or use of cotton-tipped applicators in the canal. Although commonly
asymptomatic, cerumen impaction can lead to tinnitus, vertigo, and the
perception of fullness or pain (Tintinalli, 2004). The most common cause of
conductive hearing impairment is cerumen impaction.
It is not unusual to see patients with complaints of a foreign body in the
ear in the primary care setting. Foreign bodies found in the auditory canal
may include insects, beans, beads, cotton, and other things. Children frequently
place small items in the ear. Insects may crawl or fly into the canal. If an
insect remains alive in the canal, patients may complain that they can feel it
moving or hear it. Patients may be asymptomatic but more commonly report
some discomfort due to the presence of the foreign body. This discomfort
may be quite severe if there is an infection present or if there is a live insect.
Occasionally, the presenting complaint is a change in hearing or sense of
fullness.
INDICATIONS
Cerumen removal is indicated when the patient is symptomatic or a cerumen
impaction is noted on physical examination, preventing needed visualization.
Any foreign body present in the auditory canal is an indication for removal.
CONTRAINDICATIONS
Removal of cerumen impaction or a foreign body from the auditory canal is
generally a simple procedure, but there are times when patients should be
referred to an otolaryngologist for evaluation. The use of a microscope or
removal of the cerumen or foreign body under general anesthesia may be
necessary in the following cases:
■ Uncooperative patient
Suspected tympanic membrane rupture
Inability to visualize the tympanic membrane when rupture is suspected
■ Contact of the foreign body with the tympanic membrane
Chapter 32 — Removal of Cerumen and Foreign Bodies from the Ear 447
POTENTIAL COMPLICATIONS
■ Tympanic membrane perforation
■ Ossicle damage
Abrasion of the canal
Movement of the foreign body further into the canal
■ Temporary vertigo
■ Tinnitus
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
The ear is made up of the external, middle and inner divisions (Fig. 32-1). The
inner ear includes the cochlea and semicircular canals. The middle ear is
protected by the tympanic membrane and includes the bony structures (incus,
stapes, and malleus) utilized in normal hearing. The external ear is made up
of the pinna and external auditory canal.
Prior to removal of a cerumen impaction or foreign body, an examination
is required to evaluate the tympanic membrane and external auditory canal.
Minor movement of the pinna is painful in the patient with otitis externa and
otoscopic evaluation will reveal erythema and swelling of the canal. The
Semicircular
canals
Pinna
External
auditory canal
I
External ear
Figure 32-1.
I
Middle ear
Ear anatomy.
I
Inner ear
448 Chapter 32 — Removal of Cerumen and Foreign Bodies from the Ear
tympanic membrane will not be visualized if a cerumen impaction is present.
Evidence of tympanic membrane rupture is an indication for otolaryngology
referral.
to exercise clinical judgment based on the
Standard Precautions Practitioners should use patient's history and the potential for exposure
standard precautions at all times when to bodily fluids or aerosol-borne pathogens (for
interacting with patients. Determining the level further discussion, see Chapter 2).
of precaution necessary requires the practitioner
PATIENT PREPARATION
■ Discuss the proposed procedure with the patient, including the
associated risks.
■ Advise the patient to remain still during the procedure.
Warn the patient that the procedure may be uncomfortable but if it
becomes painful the removal attempt will be stopped.
■ The patient should be placed in an upright and comfortable position.
Discuss any concerns the patient expresses regarding the procedure.
Materials Utilized to Perform Cerumen or Foreign
Body Extraction
Syringe (metal ear syringes are available [Fig. 32-2], but any 30- to 60-mL
syringe will work)
Otoscope
Body temperature water
Figure 32-2. Metal ear syringe.
Chapter 32 — Removal of Cerumen and Foreign Bodies from the Ear 449
D
B^
C*=
3
Figure 32-3. Cerumen spoon (A), cerumen loop (B), and right-angle hook (Q.
■ Cerumen spoon (Fig. 32-3A)
■ Cerumen loop (see Fig. 32-3B) or right-angle hook (see Fig. 32-3C)
Alligator forceps
■ Lidocaine or mineral oil for live insects
Cup-shaped forceps for round foreign bodies
■ Small-diameter suction tip if suction is available
■ Magnet if the foreign body is metal
■ Cyanoacrylate glue (super glue) and a wooden cotton swab
Procedure for Cerumen and Foreign Body Extraction
Cerumen Removal
1. After confirming the presence of cerumen
impaction with an otoscopic examination,
place the patient in an upright,
comfortable position.
2. Place a waterproof barrier-backed
absorbent pad across the patient's
neck and shoulder, on the side of the
affected ear.
3. Fill the large syringe with body
temperature water.
4. Have the patient or an assistant hold a
basin under the affected ear to collect
the fluid during irrigation unless using
an ear wash system with suction built in.
5. Place the syringe tip (you also may attach
an 18-gauge intravenous catheter or
butterfly catheter tubing to the syringe)
into the lateral canal (Fig. 32-4).
6. Irrigate, targeting the superior canal
surface, allowing the fluid to flow behind
the impaction and pushing it toward the
canal orifice.
7. The canal and tympanic membrane
should be inspected frequently during
the procedure for injury or rupture.
8. Repeat as needed until the impaction is
removed or the patient voices pain.
continued
450 Chapter 32 — Removal of Cerumen and Foreign Bodies from the Ear
Foreign Body Removal
Figure 32-4. Irrigation.
9. If irrigation is not successful, manual
removal with a cerumen spoon may be
attempted. This is generally more
uncomfortable for the patient.
10. Using the otoscope to visualize the
cerumen, place the cerumen spoon into
the canal. Your aim is to put the spoon
at one edge of the impaction and pull it
distally It is vital the patient remain still
during this maneuver to prevent
tympanic membrane rupture or abrasion
of the canal.
11. If the cerumen does not dislodge easily,
reattempt irrigation after inspection.
Frequently the manual attempt loosens
the impaction, allowing irrigation to be
successful.
12. After the cerumen is removed, a final
inspection of the canal and tympanic
membrane is mandated.
1. After confirming the presence of a foreign
body with an otoscopic exam, place the
patient in a comfortable position.
2. The foreign body type drives the approach
for removal. Irrigation is not an option
for absorbent material (e.g., beans).
3. If a live insect is present, warm oil or
lidocaine may be dropped into the canal
to immobilize or kill the insect (Hall,
2003). Lidocaine may also provide an
anesthetic effect (Tintinalli, 2005).
4. Insert the cerumen loop or right-angle
hook into the canal through the otoscope.
Caution: Do not make a blind insertion.
5. Aim the instrument at the superior edge
of the foreign body, sliding it behind and
then pulling the material toward the
external orifice.
6. Alligator forceps are useful for items that
are soft and easily grasped (e.g., cotton).
7. Round material (e.g., beads) are
removed more easily with cup-shaped
forceps to prevent movement of the
body toward the tympanic membrane.
8. If suction is available, a small-diameter
suction tip may be placed against the
object for removal.
9. Metal objects may be removed with a
magnet (Hall, 2003).
10. Skilled clinicians have used cyanoacrylate
glue (super glue) applied to the wooden
end of a cotton swab. Insert the wooden
tip into the canal, placing it against the
foreign body until the glue dries, and
then withdraw the swab and foreign body
together.
Caution: It is important that the glue not
come in contact with the patient's skin.
Chapter 32 — Removal of Cerumen and Foreign Bodies from the Ear 451
11. After the foreign body is removed, a final membrane is mandated to evaluate for
inspection of the canal and tympanic canal or tympanic membrane damage.
SPECIAL CONSIDERATIONS
■ Any infection should be treated promptly, but the tympanic membrane
may appear slightly erythematous immediately following irrigation.
■ There are commercial ear irrigation systems available that provide
irrigation with simultaneous suction.
■ Home dental irrigation units have been used but are not recommended.
The narrow irrigation stream may cause a tympanic membrane rupture.
Backsplash is also increased with these units.
FOLLOW-UP CARE AND
INSTRUCTIONS
■ If tympanic membrane rupture occurs, otolaryngologist evaluation
should be scheduled within 1 to 2 weeks; treat for pain and provide
reassurance (Tintinalli, 2004).
To decrease the risk of development of resultant otitis externa, dry the
auditory canal after the irrigation by placing 2 or 3 drops of isopropyl
alcohol into the canal (in the absence of tympanic membrane
perforation) or using a warm blow dryer on a low setting (Jacker, 2005).
■ If the patient had decreased hearing due to cerumen impaction,
improved hearing is usually noted immediately following removal of the
cerumen.
The patient should be instructed to report any signs or symptoms of
infection to the clinician as soon as they are noted. These include, but
are not limited to, localized pain, erythema, and swelling.
References
Hall KL, Curry RW Jr: Selected disorders of the ear, nose, and throat. In
Taylor RB (ed): Family Medicine: Principles and Practice, 6th ed. New
York, Springer-Verlag, 2003, pp 612-621.
Jacker RK, Kaplin MK: Ear, nose, and throat. In Tierny LM Jr, McPhee JJ,
Papadakis MA (eds): Current Medical Diagnosis and Treatment, 44th
ed. New York, Lange Medical Books/McGraw-Hill, 2005, pp 177-214.
Tintinalli A, Lucchesi M: Common disorders of the external, middle, and
inner ear. In Tintinalli JE, Kelen GD, Stapczynski JS (eds): Emergency
Medicine: A Comprehensive Study Guide, 6th ed. New York,
McGraw-Hill, 2004, pp 1464-1471.
452 Chapter 32 — Removal of Cerumen and Foreign Bodies from the Ear
Bibliography
Gates GA, Rees TS: Otologic changes and disorders. In Cassel CK,
Leipzig RM, Cohen HJ, et al (eds): Geriatric Medicine: An Evidence
Based Approach, 4th ed. New York, Springer-Verlag, 2003.
LeBlond RF, DeGowin RL, Brown DD: The head and neck. In DeGowin's
Diagnostic Examination, 8th ed. New York, McGraw-Hill, 2004
pp 191-338.
Mantooth R: Foreign Bodies, Ear. Accessed 7/6/05. Available at:
http://www.emedicine.com/emerg/topicl85.htm
MDchoice, Inc: Wax Blockage. Accessed 7/6/05. Available at:
http://www.drkoop.com/ency/93/000979.html
Pray WS, Pray JJ: Earwax: Should it be removed? US Pharm 5:21-27,
2005.
Chapter QQ
Trauma -Oriented Ocular
Examination, Corneal Abrasion,
and Ocular Foreign Body
Removal
Jonathon W. Gietzen
Procedure Goals and Objectives
Goal: To perform a trauma-oriented ocular examination, treat
corneal abrasion or ulceration, and perform ocular foreign body
removal safely and with minimal degree of risk to the patient.
Objectives: The student will be able to ...
• Describe the indications, contraindications and rationale for
performing a trauma-oriented ocular examination.
• Identify the common precautions and potential complications
associated with the performance of a trauma-oriented ocular
examination.
• Describe the essential anatomy and physiology associated with
the performance of a trauma-oriented ocular examination.
• Identify the materials necessary for performing a trauma-
oriented ocular examination.
• Demonstrate the essential steps necessary to perform a trauma-
oriented ocular examination, identification of corneal injury,
and safe and complete ocular foreign body removal.
• Identify the important aspects of post-procedure patient care,
including recommended treatment strategies.
453
454 Chapter 33— Trauma-Oriented Ocular Examination, Corneal Abrasion, and Ocular Foreign Body Removal
BACKGROUND AND HISTORY
Ocular trauma is a commonly encountered condition in the primary care
setting. Ocular trauma can occur as part of work, hobby, recreation, or
leisure activities, usually of an accidental nature. It is estimated that each
year in emergency departments in the United States almost 900,000 patients
are treated for eye injuries. The rate of eye injuries is approximately 3.15 per
1000 population (95% confidence interval [CI], 2.66-3.63), with the injury rate
among males being 4.52 per 1000 (95% CI, 3.77-5.20) (McGwin, 2005; Harwood-
Nuss, 2005; Moeller, 2003).
The most common injuries to the eye are contusion or abrasion (44.4%),
foreign body (30.8%), burns (10.2%), and conjunctivitis (9.9%). Lacerations
and punctures account for 1.8% and 0.5% of ocular traumas, respectively.
The settings for these injuries include home (44.6%), public places (23.6%),
and industrial locations (20.3%). The most prevalent causes of injury are
foreign body (44.6%), struck against or by an object (33%), and burns (12%).
The most common patient is a male in his 20s to 30s (McGwin, 2005;
Harwood-Nuss, 2005; Moeller, 2003).
In the primary care setting a rapid and systematic approach to examination
of the patient with ocular trauma enables the clinician to accurately delineate
the type, location, and degree of ocular impairment. This examination is
frequently performed in primary care settings (Harwood-Nuss, 2005; Janda,
1991)
Once the clinician has accurately assessed the eye injury, an appropriate
treatment plan can be developed. Many uncomplicated or simple corneal
abrasions and/or superficial corneal foreign bodies are easily removed in the
primary care setting. Primary care clinicians should be able to perform basic
care for the most common eye injuries. They should also know when the
patient's condition is beyond their scope of practice and when to refer the
patient to either an optometrist or an ophthalmologist (Harwood-Nuss, 2005;
Janda, 1991; Bunuel-Jordana, 2004).
INDICATIONS
A trauma-oriented eye examination is indicated for any potential eye injury,
including blunt force, suspected scratch or abrasion, suspected foreign
body, or any acute visual disturbance (Harwood-Nuss, 2005; Janda, 1991).
Properly performed, the examination adds little additional risk to the patient's
vision (Harwood-Nuss, 2005). Symptoms of a corneal abrasion include foreign
body sensation, tearing, pain, and photophobia. Symptoms range from mild
foreign body sensation to severe pain. The degree of pain appears to be
strongly associated with the degree of damage to the cornea. Symptoms
typically begin instantly after the injury and can last from minutes to days.
Conjunctival injection and eyelid swelling may be present (Harwood-Nuss,
2005; Janda, 1991; Ophthalmology, Cornea [www.emedicine.com]).
Chapter 33— Trauma-Oriented Ocular Examination, Corneal Abrasion, and Ocular Foreign Body Removal 455
000000000^
0°o°o0°°ooo 0°0°0
Figure 33- 1 . Fox shield.
CONTRAINDICATIONS (or, when to refer
to an ophthalmologist for emergent treatment)
Ruptured Globe
Patients with a high level of suspicion for a ruptured globe, globe laceration,
or intraocular foreign body should not be examined further and the clinician
should immediately refer the patient to an ophthalmologist. Suspect a
penetrated globe if the patient was in a situation in which the particle may
have had a high velocity (e.g., grinding metal) when it struck the eye
(McGwin, 2005; Harwood-Nuss, 2005; Janda, 1991).
If the globe is ruptured, do not use topical agents on the eye. Make the
patient comfortable as soon as possible. Cover both eyes with a Fox shield
(Fig. 33-1) or other dressing (e.g., flattened paper cup) to reduce the move-
ment of the injured eye (Harwood-Nuss, 2005).
An actively draining globe laceration often demonstrates ocular hypotony
(intraocular pressure [IOP] < 5 mm Hg). Although a trained ophthalmologist
or optometrist may roughly estimate hypotony due to a draining globe by
having the patient close his or her eyes and gently applying light pressure
with the thumbs to feel the eyes, this is not recommended. The injured eye
may feel "softer" than the non-injured eye. Some authors question the benefit
of checking IOP in the setting of an obvious globe injury as it may increase
risk for infection or extension of the injury (Fig. 33-2) (Harwood-Nuss, 2005;
Janda, 1991; Lima-Gomez, 2004).
If the penetrated globe is leaking aqueous humor, application of
fluorescein may demonstrate a dark blue stream of fluid leaking from the site
456 Chapter 33— Trauma-Oriented Ocular Examination, Corneal Abrasion, and Ocular Foreign Body Removal
A Schiotz manometer B Tonopen
Figure 33-2. Measuring intraocular pressure with a Schi0tz manometer (A) and Tonopen (B).
Figure 33-3. Eyelid laceration.
of the injury, through the pool of fluorescein (Seidel sign) (Harwood-Nuss,
2005; Janda, 1991). An eye with a laceration to the globe without active
aqueous humor leak may have a positive Seidel sign if the eye is gently
pressed after the fluorescein has been applied.
Eyelid Laceration
Almost every patient with eyelid lacerations should be evaluated immediately
and treated by an ophthalmologist (Fig. 33-3). Vertically oriented lacerations
in the medial portion of the lower eyelid are of particular concern as
Chapter 33— Trauma-Oriented Ocular Examination, Corneal Abrasion, and Ocular Foreign Body Removal 457
Figure 33-4. Use of the Morgan lens to flush the eye.
they may involve the tear ducts. These repairs are best left to either an
ophthalmologist or plastic surgeon (Janda, 1991). The only exception to this
is superficial, horizontally oriented (parallel to the eyelid) lacerations. These
may be safely repaired in the primary care setting.
Caustic Splash Exposure
Caustic or other serious splash injuries require rapid dilution of the offending
chemical. The clinician should treat the condition first and then assess the
patient after the eye has been adequately flushed. Flushing should begin as
soon as possible, including flushing of the eye at home in the sink or shower
or outside with a garden hose. The lids should be held open during the
flushing either manually or with a Morgan lens, which is a special contact
lens that can be attached to a fluid source to flush the eye thoroughly
(Fig. 33-4) (Harwood-Nuss, 2005; Janda, 1991).
CAUTIONS AND CONSIDERATIONS
The clinician must follow standard infection control precautions. Patients
who have received a direct blow to the eye may present with pupillary abnor-
malities, which may be misinterpreted as a sign of intracranial pathology
(Harwood-Nuss, 2005). Patients with severe eye injuries often present with a
significant degree of nausea and vomiting. Rectal, intravenous, or intra-
muscular anti-emetics may reduce the nausea and indirectly calm the patient
to reduce the likelihood of further eye damage (Harwood-Nuss, 2005).
Patients with prior corneal flap surgical procedures may have dislodgement
of this flap with trauma (e.g., finger in eye) (Fig. 33-5). This should be
carefully examined and cleaned judiciously and the flap made to lie back in
its normal position. Refer the patient to the on-call ophthalmologist prior to
discharge.
Contact lens wearers presenting with a corneal ulceration are at risk for
Pseudomonas infection. A Pseudomonas infection of the cornea can cause
458 Chapter 33— Trauma-Oriented Ocular Examination, Corneal Abrasion, and Ocular Foreign Body Removal
Figure 33-5. Dislodgement of
corneal flap following surgical
procedure.
permanent vision disability or loss in as short a time period as 24 hours
(Harwood-Nuss, 2005; Moeller, 2003; Alberti, 2001). Patients with exposure to
organic debris in the eye are at increased risk for infection. A broad-spectrum
topical antibiotic should be prescribed (Moeller, 2003; Alberti, 2001).
When considering imaging the eye, do not perform a magnetic resonance
image (MRI). MRI is not recommended because it may inadvertently move a
metallic foreign body into or around in the eye, causing further damage. Plain
radiography and/or computed tomography (CT) are recommended, as neither
causes further injury to the eye.
Cooperation with this procedure is essential. The inebriated patient,
confused elderly, children, and others who may be cognitively impaired or
unable to control their responses to a recommended procedure may need
sedation. These patients may necessitate a consultation with an ophthal-
mologist before any further examination or treatment is attempted.
COMMON COMPLICATIONS
The patient may experience increased eye pain, photophobia, nausea, and/or
vomiting due to the eye examination. This is primarily due to how the body
responds to the intraocular injury. Judicious use of topical anesthetics;
darkening the room; and use of either oral, intravenous, intramuscular, or
rectal anti-emetics can be useful to reduce overall patient discomfort (e.g.,
eye pain, nausea and vomiting, and/or the anxiety accompanying eye injury)
(Harwood-Nuss, 2005). Anti-emetics can reduce further eye injury because
uncontrolled vomiting increases intraocular pressure and increased intra-
ocular pressure may cause additional bleeding to occur in patients who have
bled into their eye.
Chapter 33— Trauma-Oriented Ocular Examination, Corneal Abrasion, and Ocular Foreign Body Removal 459
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
The eye is a complex organ, with six extraocular muscles and four cranial
nerves that work in tandem. It can allow for blinking to prevent desiccation
(with muscles other than the six extraocular), to adjust near and far vision
and pupillary response to light stimulus. Together the eyes produce images
at the occipital lobe of the brain. Bilateral visual input is essential for proper
visual cortex data interpretation. The overlapping of both left and right
visual fields compensates for visual loss on one side, thus enabling adequate
visual function in a person who has experienced significant visual field loss,
to retain a reasonable visual field. The eye possesses several features that
serve to protect it from innocuous conditions, such as dry eyes, to a "blow
out" injury:
■ The ability to produce tears, to heal the surface of the eye rapidly
The ability to adjust intraocular pressure
■ Accommodating for direct injury with the ability for the orbit to give in
or "blow out" and the eye to change shape to absorb impact forces
It is important to know and understand terms related to the anatomy of the
eye (Fig. 33-6). This knowledge is useful when examining the patient, docu-
menting the findings, and discussing the case with other clinicians. The
anterior chamber is the area bounded in front by the cornea and in back by
Artery
(central retinal)
Optic nerve
Canal of
Schlemm
Posterior
chamber
Vein
(central retinal)
Conjunctiva
Rectus medialis
Figure 33-6. Anatomy of the eye.
460 Chapter 33— Trauma-Oriented Ocular Examination, Corneal Abrasion, and Ocular Foreign Body Removal
the iris, and is filled with aqueous fluid. The aqueous fluid is a clear, watery
solution in the anterior and posterior chambers. The canal of Schlemm is the
passageway for the aqueous fluid to exit the eye to maintain normal intra-
ocular pressures. The choroid, which carries blood vessels, is the inner coat
between the sclera and the retina. Its main function is to deliver nutrients
and remove waste products. The conjunctiva is a clear membrane covering
the white of the eye (sclera). It functions as protection from external injury.
The cornea is a clear, transparent portion of the outer coat of the eyeball
through which light passes to the lens, modulating light refraction and
providing further protection. The corneal epithelium of the eye heals from
most injuries in 1 or 2 days without any further consequences. The clinician
must realize that the cornea is an avascular structure; oral medication will be
delivered to it indirectly, primarily through the tears. Thus, topical medi-
cations are the drug of choice for most eye injuries, providing the direct
application of the medication to the site where it is needed. The iris gives our
eyes color and it functions like the aperture on a camera, enlarging in dim
light and contracting in bright light. The aperture itself is known as the pupil.
The lens helps to focus light on the retina.
The macula is a small area in the retina that provides our most central,
acute vision. The optic nerve conducts visual impulses to the brain from the
retina. The posterior chamber is the area behind the iris, but in front of the
lens, that is filled with aqueous. The pupil is the opening, or aperture, of the
iris. The retina is the innermost coat of the back of the eye, formed of light-
sensitive nerve endings that carry the visual impulse to the optic nerve. The
retina may be compared to the film of a camera. The sclera is the white of the
eye; it serves to provide support and strength to the eye. The vitreous is a
transparent, colorless mass of soft, gelatinous material filling the eyeball
behind the lens, providing greater structural support to the eyes.
PATIENT PREPARATION
The patient is often seated at the edge of an examination table. The
patient could also be placed in a recumbent position in an eye or ENT
chair, if available, to facilitate the examination.
■ Darkening the room as much as possible reduces any photophobia.
A calm and assured demeanor helps the patient to relax.
■ The patient should be made aware that the anesthetic drops may
initially burn.
The fluorescein may cause the patient's vision to turn yellow/orange.
■ Some topical antibiotics burn slightly when applied. The patient should
be educated that slight burning is normal and that he or she likely is not
experiencing an allergy or problem from the drop or ointment
prescribed.
Chapter 33— Trauma-Oriented Ocular Examination, Corneal Abrasion, and Ocular Foreign Body Removal 461
Materials Utilized for Trauma -Oriented Ocular
Examination, Corneal Abrasion, and Ocular Foreign
Body Removal (Janda, 1991)
Vision chart (near point, distance)
Anesthetic drops (e.g., Alcaine)
Fluorescein strips
Black light or cobalt blue light
Magnifier (slit lamp, ophthalmoscope, or other magnification source)
Cotton-tipped swabs
Corneal spud, or small-gauge needle on 1- to 3-mL syringe
Corneal burr
Normal saline or equivalent for eye rinse
Tissue or wash cloth
Fox shield
Universal precautions: gloves, hand washing soap or similar solution,
sharps container
Emesis basin
Procedure for Examination of an Injured Eye (Harwood-Nuss, 2005;
Bunuel-Jordana, 2004)
1. Obtain a history of the injury, detailing
how and when the injury occurred, what
agents were involved (i.e., chemical,
blunt or sharp instrument, and so on),
and what, if anything, has been applied
to the injured eye. This will help you
decide what type of injury or foreign
body may be present.
2. Identify medication allergies, especially
to anesthetics, fluorescein, and topical
antibiotics.
3. A distance and/or near point vision
examination is useful to demonstrate
visual acuity. Record whether the
examination was performed with or
without corrective lens(es). Perform
this examination prior to any additional
procedures in order to demonstrate
existing vision deficits. Record findings
of right eye (OD), left eye (OS), and both
eyes (OU).
Note: Patients with significant visual
disturbance (e.g., native refractive disorder,
blood in anterior chamber, or other changes
in the vitreous) may find their visual acuity
improved when looking through a pinhole
occluder. Patients in whom visual acuity fails
to improve with a pinhole occluder may
have more significant defects in the retina,
macula, or optic nerve.
continued
462 Chapter 33— Trauma-Oriented Ocular Examination, Corneal Abrasion, and Ocular Foreign Body Removal
4. Position the patient for examination in
sitting or semi-recumbent position.
Ultimately the best position is the position
in which the patient is most comfortable
and the clinician has the best access to
perform the visual examination.
5. Explain the procedure to the patient
using non-medical terms at the patient's
level of understanding.
6. Examine the eye for deformity, pupil
reaction, extra-ocular movements,
fundus, and obvious foreign body. This
examination can be performed with a slit
lamp, ophthalmoscope, or magnifying lens.
Note: Many foreign bodies will be found on
the surface of the cornea, others might be
stuck on the inner portion of the eyelid, and
still others might be found penetrated into
the cornea. The minority will have penetrated
the globe. If a superficial foreign body is
identified, decide which method you will use
to remove the foreign body (see "Procedure
for Foreign Body Removal from the Eye").
7. Apply 1 or 2 anesthetic drops into the
affected eye.
8. Moisten fluorescein strip with anesthetic
drop or normal saline (Fig. 33-7)
9. Instruct the patient to hold his or her
head straight and to gaze upward
nasally. Apply strip to lower part of
conjunctiva just above the lower lid.
10. Ask the patient to blink the affected eye.
11. Visualize the cornea with black light or
cobalt blue light. As the patient's tears
break up or dilute the fluorescein, you may
need the patient to blink to redistribute
the fluorescein over the cornea.
12. Instruct the patient to hold his or her
head straight and gaze upward, nasally
and temporally, while you simultaneously
evert the lower lid to increase the visual
field.
Figure 33-7. Application of fluorescein to the
eye using fluorescein strip.
13. To evert the upper eyelid, have the
patient look downward but not close the
eyes (Fig. 33-8). Apply a cotton-tipped
applicator against the mid-portion of the
lid, parallel to the surface. Gently grasp
the eyelashes, lift upward and flip the lid
back over the cotton applicator. This
should enable an increased visual field
for the cornea as well as expose the
undersurface of the upper lid. Instruct
the patient to hold his or her head
straight and to gaze downward nasally
and temporally to allow you to view the
upper portion of the cornea.
14. Occasionally, it may be beneficial to
expose more of the eye to increase your
view of the corneal surface. If it is
necessary to do so, with the cotton
applicator still in place, rotate the tip of
the applicator toward the superior
portion of the upper lid. This will
effectively raise the lid a few more
degrees. This technique is called double
lid eversion.
Chapter 33— Trauma-Oriented Ocular Examination, Corneal Abrasion, and Ocular Foreign Body Removal 463
B
Findings
If several scratches (oftentimes linear) are
found on the cornea, be careful to inspect
the inner surface of the eyelids (usually
superior lid) for a foreign body (Fig. 33-9). If
a corneal abrasion is identified without an
offending foreign body, the foreign body or
mechanism that caused the injury may no
longer be present in the eye or may have
floated into the fornices (corners) of the
orbit. If foreign body is suspected, but not
visualized, carefully swab the fornices using
a saline-moistened, cotton-tipped swab
(Fig. 33-10). Estimate the depth and length of
the abrasion. Report the abrasion location
relative to normal eye landmarks, such as
nasal, temporal, pupil, or as points on a
watch face (e.g., 3-mm superficial corneal
abrasion located at 3 o'clock on the right eye
medial to the border of the iris).
Figure 33-8. Everting
the eyelid (see text).
Figure 33-9. Corneal scratches.
continued
464 Chapter 33— Trauma-Oriented Ocular Examination, Corneal Abrasion, and Ocular Foreign Body Removal
Figure 33-1 0. Swabbing the fornices using a
saline-moistened, cotton-tipped applicator.
Some patients with prior corneal damage
develop recurrent corneal ulcerations. A
typical presentation involves the reporting
of eye symptoms upon arising in the
morning with no recent history of trauma.
The erosion will be in the same location as
the initial eye injury and has an appearance
similar to a typical corneal abrasion. The
cause of post-eye trauma ulcer formation is
failure of the ocular basement membrane to
adhere properly. The patient should be
treated with standard treatment for corneal
abrasion. Some authors suggest nighttime
use of ointments to help moisten the eye. One
controlled study revealed long-term, treatment
actually increased the likelihood of recurrent
corneal ulceration (Eke, 1999). If a clinician
suspects a pattern of recurrent ulceration,
referral to an optometrist or ophthalmologist
Figure 33-1 1 . Dendritic keratitis.
is in order to identify the cause. Causes of
recurrent corneal ulceration include
granulation tissue abnormalities, subclinical
infection, or residual tissue overgrowth
requiring debridement (Roberts, 1996).
If the appearance of the lesion on the
surface of the cornea resembles a stellate
or an irregular branching pattern, the patient
may have a viral infection. A fluorescein
examination might reveal dendritic keratitis,
which is characteristic of ocular viral
infections (Fig. 33-11). The treatment
includes (topical, systemic) preparations
with good antiviral activity. Lack of good
response to topical antibiotics should cause
the clinician to reflect on the accuracy of
the previous diagnosis and to consider
whether this finding was missed initially.
Chapter 33— Trauma-Oriented Ocular Examination, Corneal Abrasion, and Ocular Foreign Body Removal 465
Procedure for Foreign Body Removal from the Eye
1. Foreign body removal may be as simple as
flushing the eye; however, if more than a
simple flushing is required, the eye should
be anesthetized prior to using any device
to remove the foreign body
2. Surface foreign bodies may be easily
removed with a moistened cotton swab.
3. Superficial metallic foreign bodies may be
removed using either a small-gauge needle
(e.g., 25-gauge needle on a 1-mL syringe)
(Fig. 33-12) or a corneal spud, which is
specially designed to remove corneal
foreign objects (Fig. 33-13).
4. The patient's gaze should be directed so
that the foreign body is clearly visible.
Approaching the patient's eye from the
side and inferiorly distracts the patient
from the procedure and minimizes anxiety
and blinking reflexes.
5. The needle should be held with bevel up,
and approach the cornea at a flat angle.
The needle tip should scoop the foreign
body while removing little or none of the
surrounding corneal tissue.
Metallic foreign bodies often leave a rust
ring in the cornea that should be removed
either immediately or within a few days
using a device called a corneal burr (see
Fig. 33-13). Not removing the rust ring
may cause a disturbance in the patient's
vision and may delay healing of the
corneal tissue (Fig. 33-14). Sometimes the
rust ring can be left for a day or two and
removed during re-examination. The rust
actually causes the cornea to soften a bit
in that area, so the burr procedure may
be somewhat easier to perform at that
time.
Figure 33- 1 2. Removal of superficial metallic
foreign body using a small-gauge needle.
A Corneal spud B Corneal burr
Figure 33- 1 3. Corneal spud (A) and corneal
burr (B).
continued
466 Chapter 33— Trauma-Oriented Ocular Examination, Corneal Abrasion, and Ocular Foreign Body Removal
Concluding the
Examination _
Rinse the eye generously with normal saline
or equivalent to remove the fluorescein dye
and also flush out any offending debris.
Instruct the patient that the fluorescein dye
will drain through the tear ducts into the
nose and may be present in the nasal
discharge for the next few hours and that it
may stain white clothing.
Figure 33- 1 4. Rust ring in the cornea created
by metallic foreign body.
SPECIAL CONSIDERATIONS
Update tetanus immunization if the patient's last tetanus was given more
than 10 years ago or no record of the last immunization exists. Use precaution
not to leave anesthetic drops unattended. Patients might ask to take extra
anesthetics with them for pain control. It is important to educate your
patients that even short-term repeated use of the drops can cause the cornea
to soften and slough off (Harwood-Nuss, 2005; Moeller, 2003). If the rust ring
from the metallic foreign body cannot be removed completely, refer the
patient to an eye care practitioner for definitive care.
It is important to emphasize the need to practice eye injury prevention
strategies. Patients who may be at greater risk for potential eye injuries need
to know the possible long-term consequences, such as recurrent, nonhealing
ulcer. Children are at high risk for ocular re-injury; therefore, it is essential
that parents understand and implement eye-protecting sports gear. Clinicians
should have information available to share with their patients regarding the
distribution of protective eyewear. (McGwin, 2005; Michael, 2002).
Cycloplegic drops are sometimes prescribed in an effort to help reduce
pain by limiting the constriction and dilation movement of the ciliary muscle
in the pupil; however, continued use of some of these medications may
contribute to the development of hallucinations. If this occurs, ask the patient
to call for advice. Typically advise the patient to stop the cycloplegic drops,
and follow up in the next few days. The hallucinations usually stop after
several hours but may take up to a day.
Chapter 33— Trauma-Oriented Ocular Examination, Corneal Abrasion, and Ocular Foreign Body Removal 467
FOLLOW-UP CARE AND
INSTRUCTIONS
There are four main goals in the treatment of corneal abrasions: controlling
pain, reducing risk for secondary infections, promoting corneal re-
epithelization, and risk avoidance to reduce reoccurrence (Moeller, 2003).
Pain Control
The anesthetic will wear off after a short period of time, so eye pain will
return. Topical non-steroidal anti-inflammatory drugs are often prescribed
for pain reduction and appear to be effective (Moeller, 2003; Alberti, 2001;
Kaiser, 1997; Harris, 2005; Solomon, 2000). Patching the eye is no longer
largely recommended due to studies showing no benefit to pain control and
possibly increased rates of infection. Advising the patient to wear sunglasses
may improve overall vision comfort during healing (Moeller, 2003; Michael,
2002; Kaiser, 1997; Flynn, 1998; Patterson, 1996; Cullum, 1994; Hulbert, 1991;
Kirkpatrick, 1993; Kaiser, 1995). Bandage contact lenses are usually prescribed
by the optometrist or ophthalmologist if the condition is severe enough to
have considered patching to prevent lid/epithelium interaction.
Reduce Secondary Infection
Often a topical antibiotic drop or ointment is prescribed (Moeller, 2003;
Alberti, 2001). Patients who develop a corneal ulcer from contact lens use
often grow Pseudomonas; therefore, patching is contraindicated. Patching a
patient with a pseudomonal ulcer will create the ideal Pseudomonas breeding
environment. In a short time (24 to 48 hours), a patient may develop
permanent visual impairment or blindness due to the Pseudomonas bacteria
burrowing into the deeper portion of the eye. Ideally, these patients should
be treated with a broad-spectrum antibiotic that is effective against a wide
variety of bacteria, including Pseudomonas. A follow-up examination the next
day with the ophthalmologist or optometrist is essential (Alberti, 2001;
Roberts, 1996; Gorbach, 2001; Tierney, 2005; Dambro, 2005). Patients with deep
corneal abrasions, abrasion from contaminated organic material, or corneal
abrasion from contact lens use need to follow up with an optometrist or
ophthalmologist to ensure proper healing. Deep corneal abrasions may
require a prescription of narcotic analgesics for pain control.
Re-epithelization
A follow-up visit for a patient with a superficial corneal abrasion or uncompli-
cated foreign body is usually not necessary. Educate the patient that the
symptoms will resolve in 1 or 2 days. Larger abrasions may take up to a week
468 Chapter 33— Trauma-Oriented Ocular Examination, Corneal Abrasion, and Ocular Foreign Body Removal
to heal fully. If in doubt, the patient should return to the primary care clinic
daily and if more seriously injured, the patient should be followed daily by
optometry or ophthalmology (Harwood-Nuss, 2005; Moeller, 2003; Bunuel-
Jordana, 2004). Contact lens wearers should refrain from using their contact
lens(es) until the eye has healed, plus another 5 to 7 days to let the eye
"rest." This will avoid the risk of reaction in the eye, which would cause the
patient to not be able to wear contact lenses in the future. This is another
reason why contact lens wearers should have a current prescription for their
glasses. Before prescribing topical steroids, consult with an eye care
practitioner about the use of this medicine in any situation (Moeller, 2003).
Reduce Reoccurrence
Avoidance of reoccurrence via the use of appropriate eye protection, such as
safety guards on equipment and safety glasses or goggles (e.g., American
National Standards Institute [ANSI] certified lens for paintball, carpentry work,
and racquetball) should be reinforced (McGwin, 2005; Harwood-Nuss, 2005;
Moeller, 2003; Michael, 2002).
Patient Discharge Instructions for
Corneal Abrasion
Inform the patient that most eye injuries heal fully over a few days. The
patient should also be given the following instructions:
■ Use ice compresses and oral painkillers to relieve pain.
Use ointment or eye drops exactly as prescribed.
Return in 1 day for re-examination of the eye (if the patient is unable to
return, make arrangements to communicate with the patient).
■ Avoid touching or rubbing the eye, especially when waking up.
■ Don't wear contact lenses until the eye has healed and the patient has
finished all ointments or drops for at least 1 day, preferably as long as a
week, to allow the eye to "rest."
The patient should visit his or her eye care practitioner prior to resuming
contact lens wear.
■ Avoid exposure to bright light. Sunglasses or a hat with a brim may be
helpful to avoid glare.
■ To avoid future injury, advise the patient to wear appropriate eye
protection, such as safety goggles, when working near materials that
could become airborne and cause eye damage, or sports glasses, when
playing sports (FIRST Consult [www.firstconsult.com]).
Chapter 33— Trauma-Oriented Ocular Examination, Corneal Abrasion, and Ocular Foreign Body Removal 469
■ Advise the patient to call for advice or return for a recheck if he or she
experiences increasing pain that doesn't respond to medications
prescribed, a change in vision or change in vision tolerance (e.g., bright
lights, increased eye watering or tearing), new discharge from the eye, or
failure of the eye to improve or completely heal in 1 or 2 days.
References
Alberti MM, Bouat CG, Allaire CM, Trinquand CJ: Combined
indomethacin/gentamycin eyedrops to reduce pain after traumatic
corneal abrasion. Eur J Ophthalmol 11:233-239, 2001.
Bunuel-Jordana L, Fiore DC: Is ophthalmologic follow-up for corneal
abrasions needed? Am Fam Physician 70:32, 2004.
Cullum RD, Benjamin C: The Wills Eye Manual, 2nd ed. Philadelphia,
JB Lippincott, 1994.
Dambro MR: Griffith's 5-Minute Clinical Consult. Philadelphia,
Lippincott Williams & Wilkins, 2005.
Eke T, Morrison DA, Austin DJ: Recurrent symptoms following traumatic
corneal abrasion: Prevalence severity and the effect of a simple
regimen of prohylaxis. Eye 13:345-347, 1999.
FIRST Consult. Available at: www.firstconsult.com
Flynn CA, D'Amico F, Smith G: Should we patch corneal abrasions? A
meta-analysis. J Fam Pract 47:264-270, 1998.
Gorbach SL, Falagas M: 5-Minute Infectious Diseases Consult.
Philadelphia, Lippincott Williams & Wilkins, 2001.
Harris DR, Grafstein E, Hunte G: Topical non-steroidal anti-inflammatory
drugs for treating traumatic corneal abrasions. Cochrane
Collaboration, vol 4, 2005. Available at: www.cochrane.org
Hulbert MF: Efficacy of eyepad in corneal healing after corneal foreign
body removal. Lancet 337:643, 1991.
Janda AM: Ocular trauma: Triage and treatment. Postgrad Med 90:51-52,
55-60, 1991.
Kaiser PK, Pineda IR, An B, et al: A study of topical nonsteroidal
anti-inflammatory drops and no pressure patching in the treatment of
corneal abrasions. Ophthalmology 104:1353-1359, 1997.
Kaiser PK: A comparison of pressure patching versus no patching for
corneal abrasions due to trauma or foreign body removal.
Ophthalmology 102:1936-1942, 1995.
Kirkpatrick JN, Hoh HB, Cook SD: No eye pad for corneal abrasion. Eye
7:468-471, 1993.
Lima-Gomez V, Cornejo-Mendoza AM: Value of ocular hypotony as a
predictor of open-globe injury in patients with ocular trauma. Cir Cir
72:177-181,2004.
McGwin G, Owsley C: Incidence of emergency department-treated eye
injury in the United States. Arch Ophthalmol 123:662-666, 2005.
Michael JG, Hug D, Dowd MD: Management of corneal abrasion in
children: A randomized clinical trial. Ann Emerg Med 40:67-72, 2002.
Moeller JL, Rifat SF: Identifying and treating uncomplicated corneal
abrasions. Phys Sportsmed 31:15-17, 2003.
Ophthalmology, Cornea. Available at:
http://www.emedicine.com/oph/CORNEA.htm
Patterson J, Fetzer D, Krall J, et al: Eye patch treatment for the pain of
corneal abrasion. South Med J 89:227-229, 1996.
470 Chapter 33— Trauma-Oriented Ocular Examination, Corneal Abrasion, and Ocular Foreign Body Removal
Roberts JR: Myths and misconceptions: An eye patch for simple corneal
abrasions. In Roberts' Practical Guide to Common Medical
Emergencies. Philadelphia, Lippincott-Raven, 1996, pp 41-62.
Solomon A, Halpert M, Frucht-Pery J: Comparison of topical
indomethacin and eye patching for minor corneal trauma. Ann
Ophthalmol 32:316-319, 2000.
Tierney LM, McPhee SJ, Papadakis MA: Current Medical Diagnosis and
Treatment. New York, McGraw-Hill, 2005.
Weicherthal L: Corneal abrasion and foreign bodies. In Wolfson AB (ed):
Harwood-Nuss' Clinical Practice of Emergency Medicine, 4th ed.
Philadelphia, Lippincott Williams & Wilkins, 2005, pp 123-126.
Websites
Ophthalmology Teaching Website, Faculty of Medicine, University of
Toronto: Lectures, 2005. Available at:
http://eyelearn.med.utoronto.ca/lecture05-06.htm
Ophthalmology Teaching Website, Faculty of Medicine, University of
Toronto: Slit lamp techniques, 2004. Available at:
http://eyelearn.med.utoronto.ca/ClinicalSkills/SlitLamp/01Outline.htm
Pramanik S: Assessment of Ocular Trauma, 2005. Available at:
http://webeye.ophth.uiowa.edu/eyeforum/trauma.htm
Chapter O^
Endometrial Biopsy
Martha Petersen
Procedure Goals and Objectives
Goal: To obtain a high quality sample of endometrial tissue for
histology while observing standard precautions and with minimal
risk to the patient.
Objectives: The student will be able to ...
• Describe the rationale, indications, and contraindications for
performing an endometrial biopsy.
• Identify common complications associated with the performance
of endometrial biopsy.
• Describe the essential anatomy and physiology associated with
endometrial biopsy.
• Identify necessary materials for performing endometrial biopsy
and their proper use.
• Demonstrate the correct and safe technique for obtaining an
adequate sample of endometrial tissue.
• Describe post-procedure care and patient education and
counseling following endometrial biopsy.
471
472 Chapter 34 — Endometrial Biopsy
BACKGROUND AND HISTORY
Endometrial cancer is the most common invasive gynecologic cancer in
women in the United States, with abnormal uterine bleeding (AUB) being the
primary presenting symptom. The mean age at diagnosis is 60 years, making
it essentially a postmenopausal condition. Mortality is low because the disease
is usually diagnosed at an early stage, when women seek medical attention
for unexpected bleeding. In perimenopausal women, 70% of gynecologic office
visits are due to AUB, which often requires ruling out endometrial cancer. In
women younger than 30 years of age, AUB is never an endometrial malignancy
(Paraskevaidis, 2002).
Before 1935 the procedure of choice for the evaluation of AUB and the
endometrium was dilation of the cervix and curettage (D&C) of the endo-
metrial lining. The use of suction as opposed to scraping was introduced
with the Novak curette. In addition to the Novak curette, there are other
choices of instruments, such as the flexible Pipelle aspirator or Tis-U-Trap.
Suction is provided by a syringe attached directly to the insertion device or
by an external pump (Mounsey, 2002).
INDICATIONS
The only true screening indication for endometrial biopsy (EMB) is in women
at high risk for endometrial cancer secondary to a history of hereditary
nonpolyposis colorectal cancer. The current American Cancer Society guide-
lines recommend screening via endometrial biopsy starting by age 35, and
performed annually thereafter. Otherwise, EMB is used in the assessment of
the lining of the uterus for causes of AUB, possible malignancy, infertility, and
monitoring of hormonal therapy. Sensitivity of EMB is as high as 96% in
detecting endometrial abnormalities (Albers, 2004; Smith, 2005). Indications
for EMB are summarized in Table 34-1.
CONTRAINDICATIONS
The contraindications for EMB are summarized in Table 34-2.
POTENTIAL COMPLICATIONS
■ Vasovagal reaction: The most common complication of EMB is a
transient vasovagal reaction. This reaction is strongest and seen more
frequently in women on P-blocker medications.
Uterine perforation: If sound or cannula passes greater than 12 cm in
normal-sized uterus, perforation must be suspected. Stop the procedure
and monitor the patient for 1 hour in the office. If in-office ultrasound is
available, evaluate for bleeding into the cul-de-sac. If present, refer the
Chapter 34— Endometrial Biopsy 473
Table 34.1 Indications
Monitor Abnormal uterine bleeding (AUB) with adjuvant therapy with tamoxifen
citrate
Endometrial response to progesterone therapy for adenomatous hyperplasia
Evaluation Prior to initiating estrogen therapy in women at risk for endometrial cancer
due to: low parity, family history of endometrial, breast, ovarian cancer;
liver failure; hypothyroidism; hirsutism; alcohol abuse; unopposed
estrogen
Enlarged uterus (as confirmed by ultrasound)
AUB: Postmenopausal bleeding, with hormonal replacement therapy,
possible hyperplasia
Malignancy Atypical glandular cells of undetermined significance (AGUS) on Pap screening
"Endometrial cells" or "estrogen effect" on Pap report in postmenopausal
women
Endometrial stripe > 5 mm on transvaginal sonography (TVS) in a
postmenopausal woman
Adapted from Albers (2004), Mounsey (2002), Stenchever (2001), and Zuber (2001).
Table 34.2 Contraindications*
Absolute
Perform in hospital setting
During menses
Possibility of pregnancy
Uncooperative patient
History of unstable angina
Moderate to severe cervical stenosis
Coagulation disorder or on anticoagulant or antiplatelet therapy
Morbid obesity
*Rule out cervicitis and pelvic inflammatory disease prior to biopsy in all patients.
Adapted from Albers (2004), Mounsey (2002), and Stenchever (2001).
patient to the emergency room. If no bleeding is seen, the patient can be
discharged home. Be certain the patient has someone to monitor her at
home for the next 24 hours, and instruct the patient to call with any
fever, excessive pain, or blood loss. Wait 6 to 8 weeks for uterine healing
before attempting biopsy again.
Inadequate sample: If specimen is reported as inadequate, repeat the
procedure or use another method of evaluation, such as D&C,
hysteroscopy, or transvaginal sonography (TSV), or a combination.
Infection: Post-procedure infection is rare if the procedure is performed
properly and there is no pre-existing infection. Patients should notify the
office immediately if fever or pain develops. Antibiotic prophylaxis for
endocarditis is considered unnecessary (Mounsey, 2004), but patients at
risk may be treated with tetracycline (500 mg bid for 4 days) following
the procedure, at the clinician's discretion (Zuber, 2001).
474 Chapter 34 — Endometrial Biopsy
Fundus
Fallopian tube
Myometrium
Endometrium
Vaginal canal
Figure 34- 1 . Anatomy of the
uterus and surrounding
structures.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
Anatomy
Figure 34-1 illustrates the anatomy of the uterus and its surrounding
structures.
Physiology and Pathophysiology
The endometrium consists of two layers, the stratum basale and the stratum
functionale. The stratum functionale cells proliferate under the influence of
estrogen and desquamate at the time of menses. The thickness of the endo-
metrium varies throughout the menstrual cycle from 1 to 2 mm at the time of
menses to 4 mm in the early proliferative (follicular) phase, to about 12 mm
at ovulation, and maintaining 12 mm during an appropriate secretory (luteal)
phase. Hyperplasia is defined as the abnormal proliferation of endometrial
cells usually caused by estrogen unopposed by the action of progesterone.
The presenting symptom is AUB. Endometrial hyperplasia is described
as mild, moderate, or complex and in histological terms such as cystic,
adenomatous, or glandular. The major findings on endometrial biopsy sample
are as follows (Canavan, 1999):
Proliferative, secretory benign or atrophic endometrium
■ Simple or complex (adenomatous) hyperplasia without atypia
■ Simple or complex (adenomatous) hyperplasia with atypia (considered
precancerous)
Endometrial carcinoma
Chapter 34— Endometrial Biopsy 475
PATIENT PREPARATION
The EMB is a safe and quick procedure. Clarify the procedure completely to
the patient and discuss possible alternative techniques. Endometrial
evaluation can be achieved by a variety of methods, so it is important that
the patient understands the choices and reasons for the chosen procedure.
Obtain informed consent.
Explain to the woman that she may experience slight cramping during and
after the biopsy, but it is not painful. The patient may take a non-steroidal
anti-inflammatory drug (NSAID) 1 hour before the biopsy to reduce any dis-
comfort. The patient can expect to remain in the office for about 1 hour after
the procedure, but she may then drive and resume normal daily activities.
Materials Utilized for Endometrial Biopsy
The choice of equipment depends on the reason for the biopsy and clinician
preference. The smaller the canula type, the more comfortable for the
patient but less tissue will be obtained. Conversely, the larger curettes
acquire more tissue sample but produce more discomfort. For evaluation of
possible malignancy, the biopsy should be preceded by endocervical
curettage (ECC).
For endometrial sampling, the choices include:
Novak curette: This is a nondisposable rigid canula made of stainless
steel that attaches to a syringe plunger for suction. The tissue sample is
drawn through the canula into the syringe.
■ Pipelle aspirator: This is a disposable device made of clear, flexible
polypropylene sheath, 23 cm in length with a small opening in the distal
end. It has an inner plunger that when pulled back provides suction. It is
marked so that the uterus cavity can be measured and biopsy performed
in one step.
■ Tis-U-Trap set: This is a sterile plastic disposable device that requires
external suction. It consists of a clear plastic tissue collection chamber
with a flat filter and one of several types of curettes. Endometrial tissue
is collected directly into the collection chamber, thereby eliminating the
need to transfer the tissue sample into another container.
■ Tao Brush: This is a narrow polypropylene brush covered by a clear
protective sheath. After insertion into the uterine cavity, the sheath is
pulled back to allow for sampling with the brush. The sheath is then
replaced over the brush, trapping the tissue sample (Figs. 34-2 and 34-3).
Suction: Suction is created by a syringe or internal piston system. An
external source, such as a wall or portable pump providing 25 to
27 inches Hg of negative pressure, is needed.
476 Chapter 34 — Endometrial Biopsy
Figure 34-2. Endometrial biopsy setup (from top): anesthetic, tenaculum, Novak
curette, and cervical dilators.
n
Figure 34-3. Instruments (left to right):
uterine sound, Novak curette, Tis-U-Trap,
and Pipelle.
Chapter 34— Endometrial Biopsy 477
General equipment:
■ Absorbent material to go under the patient
■ Disinfectant material of choice for cleansing the cervix
■ Topical or injectable lidocaine or benzocaine for the cervix
Labeled tissue containers with appropriate preservative (not
needed if sampling device has container attached, such as the
Tis-U-Trap)
■ Sanitary napkins for post-procedure hygiene
■ Fluid-proof gown and protective eyewear
Unsterile gloves
Sterile equipment:
■ Gloves
■ Speculum
■ Uterine sound (depending on type of biopsy instrument used)
Endocervical curette (if ECC is to be performed)
4 x 4-inch gauze pads
Ring forceps
■ Tenaculum
■ Cervical dilators (two types are available): Mechanical (unopened but
available if needed) — sterile rigid metal or plastic curved rods in
graduated thicknesses; Medical (particularly useful for the
postmenopausal cervix) — either laminaria (sizes 2 mm through
10 mm), a natural osmotic cervical dilator made from seaweed and
packaged as narrow tampon, which is inserted into the cervix 2 to
12 hours prior to the procedure to soften and open the cervix, or
synthetic laminaria (Dilateria, Lamicel, Dilapan), an absorbent
polyvinyl acetal sponge, impregnated with less than 500 mg of
magnesium sulfate (Epsom salt) and compressed and inserted into the
cervix 2 to 12 hours prior to the procedure to absorb fluid and gently
open the cervix
■ Anesthetic (optional) — one of the following: 2% lidocaine with
epinephrine, 5 mL injected into the cervix before procedure or 0.5% to
1% lidocaine without epinephrine; 20% benzocaine spray or gel
applied to cervix
478 Chapter 34 — Endometrial Biopsy
Procedure for Endometrial Biopsy
1. Put on a gown and protective eyewear.
2. Review the specific directions for
equipment and sampling device being
used and be certain all parts are in
working order before beginning the
procedure. Place the patient in the
lithotomy position with her legs in
stirrups and drape appropriately. Perform
a bimanual examination with unsterile
gloves to evaluate size and position of
the uterus and the uterocervical angle.
Palpate the adnexa to rule out
tenderness that may indicate infection.
3. Change to sterile gloves.
4. Using a vaginal speculum, inspect the
cervix for discharge, stenosis, or other
abnormalities. Using ring forceps holding
cotton or gauze, wipe the cervical os
with water-based antiseptic.
5. Perform ECC if indicated (see later,
"Supplementary and Alternative
Procedures")
6. Apply or inject anesthetic to the cervix
5 to 10 minutes prior to starting
procedure.
• Spray or apply gel or
• Inject lidocaine at 4 o'clock and 8 o'clock
positions
7. Grasp the anterior lip of the cervix with
the tenaculum in a horizontal position
and lock in place. To avoid lacerating the
cervix, grasp enough tissue. The
tenaculum is used to stabilize the cervix
and uterus during the procedure. Apply
gentle traction on the tenaculum to
straighten the uterocervical angle.
8. Measure the depth of the uterine cavity
with the uterine sound. Document
uterine depth.
Note: This step is optional if biopsy device is
marked for measurement.
• Using moderate pressure, insert the sound
through the os until gentle resistance is
encountered, usually at a depth of 6 to
9 cm. Note the measurement of the
uterine cavity and remove the sound.
• Use dilators if it is difficult to pass the
sound through the internal os. Start with
the smallest dilator, progressing to the
next size until the os is opened enough for
the sound to pass. (This is unnecessary if
medical dilators are used prior to the
procedure.)
9. Collect the endometrial sample
(Figs. 34-4 and 34-5).
10. Steady and straighten the cervix with
slight traction on the tenaculum.
11. Insert the sampling cannula through the
os being careful to avoid touching vulvar
or vaginal tissue that would cause
contamination.
12. Rotate the sampling cannula device
between the thumb and forefinger as it
passes through the os. Apply gentle
pressure until it reaches the fundus, as
indicated by previous measurement or
by resistance, then withdraw very
slightly.
13. Stabilize the sampling cannula with one
hand while activating suction with the
other.
• If using a syringe sampling device,
steadily withdraw plunger in one smooth
motion, being sure not to advance the
cannula or to let the plunger slide
forward.
• If using external suction, activate suction
according to manufacturer's instructions.
Chapter 34— Endometrial Biopsy 479
Pull plunger to
create suction
Rotate Pipelle while moving in and out
(Do not pull out past internal os)
Tenaculum on cervix
Novak curette
Figure 34-5. Endometrial biopsy using Novak
curette.
Figure 34-4. Endo-
metrial biopsy using
Pipelle.
14. Gently pull the cannula toward the
internal os and then push it back into
the uterine cavity at least four times,
being careful not to withdraw past the
internal os. Rotate the cannula
consistently in a clockwise direction
several times, and then counterclockwise,
while performing the movement in all
four quadrants of the endometrial cavity
in a systematic fashion in a vacuuming
type pattern.
15. Release suction pressure and remove the
cannula.
16. Deposit the sample into an appropriate
labeled and fixative-filled specimen
container. With the Pipelle, use sterile
scissors to cut off the tip to expel the
sample.
Note: This step is not necessary with the
Tis-U-Trap.
continued
480
Chapter 34 — Endometrial Biopsy
17.
Remove the tenaculum.
19.
Remove the speculum.
18.
Cleanse the vagina and cervix gently
with gauze.
20.
Dispose of equipment according to
standard biohazard precautions.
FOLLOW-UP CARE AND
INSTRUCTIONS
The patient should remain in the examination room for 15 minutes and in the
office for another 30 minutes. A vasovagal reaction typically occurs within
the first 10 minutes after the procedure, if at all. The patient should be
instructed that slight spotting and cramping is considered normal. The
patient may drive after discharge from the office.
Patient may be advised to take NSAIDs as needed for cramping after the
biopsy, as these provide the additional benefit of antiprostaglandin activity.
Acetaminophen is an acceptable option for discomfort. The patient should
use sanitary napkins only and report if bleeding is heavier than her normal
menses or if a fever develops. It is recommended that women refrain from
sexual activity until the bleeding has stopped.
SUPPLEMENTARY AND ALTERNATIVE
PROCEDURES
Endocervical curettage is always indicated prior to endometrial biopsy if
any malignancy needs to be ruled out. ECC samples must be deposited
into a separate container.
■ Hysteroscopy can be used with or without concurrent biopsy.
■ Transvaginal sonography may be used to assess endometrial thickness,
with an endometrial stripe <4 mm having 96% sensitivity in ruling out
endometrial cancer (Mounsey, 2002).
■ Saline infusion sonography involves filling the uterine cavity with saline
prior to ultrasound and allows for visualization of endometrial thickness
and polyps.
References
Albers J, Hull S, Wesley R: Abnormal uterine bleeding. Am Fam
Physician 69:1915-1926, 2004.
Canavan T, Doshi N: Endometrial cancer. Am Fam Physician
59:3069-3077, 1999.
Katz V: Diagnostic procedures. In Stenchever M, Proegemeuller W,
Herbst A, Mischell D (eds): Comprehensive Gynecology, 4th ed. St.
Louis: Mosby, 2001, pp 232-233.
Chapter 34— Endometrial Biopsy 481
Mounsey A: Postmenopausal bleeding: Evaluation and management.
Clin Fam Pract 4:173-192, 2002.
Paraskevaidis E, Kalantaridou SN, Papadimitriou D, et al: Transvaginal
uterine ultrasonography compared with endometrial biopsy for the
detection of endometrial disease in perimenopausal women with
uterine bleeding. Anticancer Res 22:1829-1832, 2002.
Smith RA, Cokkinides V, Eyre HJ: American Cancer Society guidelines
for the early detection of cancer, 2005. CA Cancer J Clin 55:31-44,
2005.
Zuber T: Endometrial biopsy. Am Fam Physician 63:1131-1135, 2001.
Bibliography
American College of Nurse-Midwives: Clinical Bulletin No. 5,
Endometrial Biopsy, 2001. Accessed 6/2/2005:
http://www.acnm.org/pubs/Clinical_Bulletin_5.pdf
Schwayder JM: Pathophysiology of abnormal uterine bleeding. Obstet
Gynecol Clin North Am 27:219-234, 2000.
Chapter OC
Foot Examination of the Patient
with Diabetes
Nikki Katalanos
Procedure Goals and Objectives
Goals: To perform a thorough routine foot examination on the
patient with diabetes.
Objectives: The student will be able to ...
• Describe the indications, contraindications, and rationale for
performing a routine foot examination on the patient with
diabetes.
• Describe the essential anatomy and physiology associated with
examination of the foot of the patient with diabetes.
• Describe the logical order of steps used to perform a foot
examination of the patient with diabetes.
• Describe normal and abnormal findings associated with
examination of the foot of the patient with diabetes.
• Describe foot self-care information to be provided to the patient
with diabetes for the prevention of future complications.
483
484 Chapter 35 — Foot Examination of the Patient with Diabetes
Table 35.1 Categories of Diabetes Mellitus
Rights were not granted to include this table in electronic media.
Please refer to the printed publication.
From American Diabetes Association: Standards of medical care in diabetes. Diabetes Care 28:S4-S36, 2005.
Table 35.2 Criteria for the Diaanosis of Diabetes
Rights were not granted to include this table in electronic media.
Please refer to the printed publication.
From American Diabetes Association: Standards of medical care in diabetes. Diabetes Care 28:S4-S36, 2005.
BACKGROUND AND HISTORY
Diabetes mellitus is a group of diseases that are characterized by higher than
normal levels of blood sugar. The disease is a result of defects in insulin
production or insulin action, or both (Table 35-1). The Centers for Disease
Control and Prevention (CDC, 2004) estimates that the prevalence (existing
cases) of diabetes across all ages is 18.2 million Americans, including 13 million
diagnosed and 5.2 million undiagnosed cases. The incidence (new onset) is
1.3 million people per year. Regardless of type, the morbidity from this
ubiquitous disease is quite costly, with total costs for direct care reaching
$92 billion and costs for indirect care, which would include time lost from
work, disability, and early death, adding another $40 billion.
Lifestyle changes and early detection (Table 35-2) can delay or prevent
many of the complications from diabetes. Estimates of the number of people
with nervous system damage, ranging from mild to severe, directly caused
by diabetes, is as high as 60% to 70%. As a result, the person with diabetes
often has sensory or pain impairments in their hands and feet. In the United
States, more than 60% of all nontraumatic amputations of the lower limb are
among people with diabetes. According to the CDC (2004), aggressive foot
care can reduce amputation by as much as 45% to 85%.
INDICATIONS
The most common sequelae of diabetic neuropathy are foot ulceration,
infection, and, ultimately, amputation. Early recognition and aggressive
Chapter 35 — Foot Examination of the Patient with Diabetes 485
management of foot care can prevent or delay the associated morbidity. The
longer the person has diabetes, the greater the risk for ulcerations of the
foot. Evidence indicates that these events are strongly related to poor glucose
control and/or vascular co-morbidities.
Risk factors that increase the potential for ultimate foot damage that may
lead to amputation include the following:
■ Peripheral neuropathy
■ Increased pressure on the foot
■ Deformities of the foot or toenails
■ Peripheral vascular disease
■ Previous history of foot ulcers (or amputation)
Acute or chronic infection of the foot or toenails
■ Poor foot hygiene
The patient with diabetes should be asked at each routine visit whether he
or she has pain, numbness, or tingling sensations of the extremities. The
patient should also be asked if he or she has any problems or leg cramping
with walking, Any positive response to these questions warrants a
comprehensive foot examination. In addition, note how far the patient can
comfortably walk, and if the patient's shoes are a comfortable fit.
The value of the foot examination in a person with diabetes is well
documented. The American Diabetes Association (2005) recommends that a
comprehensive foot examination be performed annually on the low-risk
patient and that a visual examination be conducted at each routine visit.
Patients with any of the above-mentioned risk factors should be closely
examined on a quarterly basis, at minimum.
CONTRAINDICATIONS
There are no medical contraindications to the examination of the foot in a
person with diabetes. In some cultures, however, the foot is considered
unclean and should be the last part of the body that is examined.
POTENTIAL COMPLICATIONS
There are no reported complications to this examination when the
procedure is performed as described. The medical-legal concerns are that
the clinician performs the examination incorrectly and too infrequently. It is
essential that the method and tools used for examination be fully docu-
mented in the medical record. Many facilities use a diabetes flow chart for
routine examinations.
486 Chapter 35 — Foot Examination of the Patient with Diabetes
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
In order to perform the foot examination, an understanding of the anatomy
of the vascular system is needed. Figure 35-1 shows the basic anatomy of the
foot and the vascular supply of the lower extremities.
PATIENT PREPARATION
After the diagnosis of diabetes has been made, the patient needs time to
adjust and accept that many lifestyle changes will need to be made. The first
visit is usually best spent discussing the disease itself and answering any
questions the patient may have. The patient should be encouraged to view
this as a partnership, one in which he or she will make many of the actual
decisions with regard to self-care and treatment. A thorough history and
physical examination should then be performed if time permits, or, at a
minimum, at a timely follow-up visit. A foot examination, as described later,
should be included in this initial evaluation.
The diagnosis of diabetes, in particular type 2 diabetes, brings with it
many preconceived notions and fears. Often there are family members with
diabetes who have had bad experiences. Patients have heard stories of blind-
ness, amputations, dialysis, and early death. The patient is often already con-
ditioned to fear the disease and its consequences; therefore, it is essential
that the initial approach to the patient with diabetes be reassuring and
optimistic. Above all, the patient (or parents) should not be led to feel at fault
for having developed diabetes.
After the first visit, the preparation of the patient should include having
the patient remove his or her shoes and socks before the examiner enters the
room.
Materials Utilized for Performing the Diabetic Foot
Examination
Semmes-Weinstein monofilament 5.07 (10 g) (Fig. 35-2)
128-Hz tuning fork
Common iliac artery
External iliac artery
Deep femoral artery
Anterior tibial artery
Dorsalis pedis artery
Chapter 35 — Foot Examination of the Patient with Diabetes 487
Abdominal aorta
Internal iliac artery
Common femoral artery
Superficial femoral artery
Popliteal artery
Posterior tibial artery
Peroneal artery
Medial malleolus
Popliteal vein
Greater
saphenous vein
Lesser
saphenous vein
Phalanges
bones
Metatarsal
bones
Tarsal
bones
Arteries
and nerves
Cartilage
B C
Figure 35-1 . A, Arterial system of the lower extremity. B, Venous system of the
lower extremity C, Anatomy of the foot.
488 Chapter 35 — Foot Examination of the Patient with Diabetes
Figure 35-2. Semmes-Weinstein
monofilament.
Procedure for Performing the Diabetic Foot Examination
The comprehensive foot examination entails
visual inspection, palpation, and tests for
sensation.
Visual Inspection
The foot should always be examined with
the shoes and socks off. The foot should be
visually inspected at each routine visit for
the following:
1. Color: Pale, bluish, or dusky coloration
of the feet may mean poor perfusion.
Erythema may indicate an area of
excessive friction or it may be evidence
of an ongoing or new infection. Yellow
toenails may indicate a long-standing
fungal infection.
2. Callus: Look for areas of skin thickening,
particularly corns, callus, and over
bunions. There may be an infection
beneath the build-up. Evaluate the cause
of the callus. Do the shoes fit well?
3. Fissures: Tears in the skin, particularly
between the toes, are easy access to
future infection. It may be a sign of a
fungal infection or excessive moisture.
4. Ulcers: Look for signs of old or healing
ulcerations. New ulcerations need to be
immediately evaluated.
5. Maceration: Signs of excessive sweating,
skin breakdown, or tinea pedis may also
open avenues for infection.
6. Lack of hair: A possible indication of
vascular disease — or is it just where the
socks rub?
7. Toenails: Look for signs of fungal
infections or injury. Are the toenails
solidly adhered to the nail bed? Are they
thickened or "flaky" looking?
8. Appearance: Look for misshapen feet
that may forewarn of potential problems,
such as bunions, hammertoes, "rocker"
bottoms, or other soft tissue and bony
deformities. Is the skin of the foot thin
looking or shiny? Note hygiene as well.
Chapter 35 — Foot Examination of the Patient with Diabetes 489
9. Shoe wear: Evaluate the shoes for signs
of excessive pressure or friction on the
feet. Are the shoes capable of protecting
the foot from punctures or injury? Do
they support the foot properly?
10. Socks: Do they fit the foot well? Are
there areas of wear or holes?
Palpation
The foot should be palpated for the following:
1. Temperature: A cool or cold foot may
mean poor perfusion. A warm foot,
especially if the heat is localized, may be
a sign of infection.
2. Pulses: Evaluate the pedal pulses. They
should be strong (2+) and equal in both
feet.
3. Perfusion: Press on the toenail and
observe the capillary filling. A healthy
foot reperfuses in 3 seconds or less.
Greater than 5 seconds is an indication of
poor perfusion.
4. Edema: Press on the ankle and evaluate
for pitting. If edema is present, the skin
may crack easily.
Tests for Sensation
The tests for sensation allow the practitioner
to evaluate for the presence of neuropathy.
A focused history and physical examination
should help to establish both the presence
and degree of the neuropathy. Pain or
temperature may also be checked, using
great care, as part of the sensory evaluation.
1. Vibration: Press the vibrating tuning fork
against the bony prominence of the first
(big) toe on the dorsal-lateral aspect. Ask
the patient to tell you when he or she feels
the vibration start and when it stops.
2. Pressure: Press the monofilament lightly
against the specified areas of the foot
until it bows (Fig. 35-3). Record the
presence or absence of sensation for
each area tested.
Right
foot
O Left
1 foot
Figure 35-3.
Demonstration of
monofilament testing and
areas of the foot that
should be tested.
490 Chapter 35 — Foot Examination of the Patient with Diabetes
SPECIAL CONSIDERATIONS
Consideration should be given to previous pathology (e.g., foot ulcers,
deformities, tinea pedis). Tinea pedis can be very difficult to eradicate in any
patient, but it is especially difficult in the patient with diabetes. Tinea pedis,
minor infections, and shallow ulcerations can often be treated in the office.
More severe cases and most deformities are best referred to podiatry, or in
the case of infection, to an infectious disease consultant.
FOLLOW-UP CARE AND
INSTRUCTIONS
Patient education is critical in the prevention of future morbidity. There are
many prepared handouts available, and a few of these resources are listed at
the end of the chapter.
General advice to the patient:
■ Check your feet every day. Look for cuts, sore spots, red spots, and
blisters. A mirror can be used to see the bottom of the feet. A good way
to use it is to mount it on the lower wall.
■ Wash your feet everyday. Use only warm water and a mild soap. Check
the temperature of the water before getting into the tub or shower. Use
the back of your hand. Clean carefully between the toes and dry the foot
thoroughly. Apply a mild lubricating ointment to the heels and any dry
areas. Do not use lotion between the toes.
■ Keep the toenails trimmed. Be sure to trim straight across. Gently file the
edges. Do this twice a month. Women should take off any toenail polish
before being checked at the office.
■ Always wear shoes and socks. Make sure the shoes are a good fit and do
not pinch anywhere. Closed-toe shoes are safer, but sturdy sandals are
fine. Check your shoes for foreign objects before putting them on. Socks
should fit well, be without holes, and be kept clean and dry. Never, ever
walk barefoot! Not even at the beach, where the sand can be hot enough
to burn you.
Check your blood sugar regularly. The best prevention of foot problems
is well-controlled blood sugar.
References
American Diabetes Association: Standards of medical care in diabetes.
Diabetes Care 28:S4-S36, 2005.
Centers for Disease Control and Prevention. National diabetes fact
sheet: General information and national estimates on diabetes in the
United States, 2003, Rev. ed. Atlanta, Ga: U.S. Department of Health
and Human Services, Centers for Disease Control and Prevention, 2004.
Chapter 35 — Foot Examination of the Patient with Diabetes 491
Bibliography
American Podiatric Medical Association: Available at:
http://www.apma.org/s_apma/index.asp
Feet Can Last a Lifetime: A Health Care Provider's Guide to Preventing
Diabetes Foot Problems: An excellent resource for the practitioner
that includes flow sheets and management plans for foot care.
Available at: http://www.diabetic.com/education/feet/feet2/index.htm
Habershaw GM: Management of the diabetic foot. In Leahy JL, Clark NG,
Ceflu WT (eds): Medical Management of Diabetes Mellitus.
Philadelphia, Saunders, 2000, pp 479-498. Slightly out of date, but still
one of the best overall books on diabetes care.
McCullock DK: Evaluation of the diabetic foot. Up To Date online
14.2.2006. Available at: www.utdol.com
Chapter Q£
Procedural Sedation
Tony Brenneman
Procedure Goals and Objectives
Goal: To minimize patient discomfort while attempting to maintain
spontaneous respirations and airway-protective reflexes in order to
facilitate appropriate medical care.
Objectives: The student will be able to ...
• Differentiate between conscious sedation and procedural
sedation.
• Describe current JCAHO sedation care standards.
• Identify indications and contraindications for procedural
sedation.
• Describe potential complications and techniques that may be
employed to avoid or treat problems during sedation.
• Describe the essential anatomy and physiology associated with
administration of procedural sedation.
• Identify the materials necessary for the administration of
procedural sedation.
• Identify the agents used in procedural sedation, dosing
methods, and discharge criteria.
493
494 Chapter 36 — Procedural Sedation
BACKGROUND AND HISTORY
Procedural sedation provides a way in which clinicians can perform
diagnostic tests and clinical procedures that are sometimes painful or highly
anxiety provoking in a manner that prevents or minimizes patient discomfort.
Historically this method has been labeled conscious sedation, but this term
has now become antiquated and imprecise, as all sedation causes some type
of change in consciousness. The current accepted phrase is procedural
sedation, which more accurately reflects the goal behind the process.
Procedural sedation then refers to the techniques of managing a patient's
pain and anxiety to facilitate appropriate medical care in a safe, effective, and
humane fashion (Brown, 2005), with the main goal being to minimize patient
discomfort while attempting to maintain spontaneous respiration and airway-
protective reflexes. Procedural sedation is currently used in inpatient,
emergency services and most outpatient settings. Practitioners must be
aware of current guidelines and terminology in order to provide procedural
sedation.
The move to procedural sedation intimates that there is a continuum of
sedation for the patient no matter the amount of sedative used. There also
has been a lack of objective measures in levels of sedation. Based on this,
criteria have been established to help define goal levels for procedural
sedation. In 2001, the revised Joint Commission on Accreditation of Health-
care Organizations (JCAHO) sedation care standards replaced the term
"conscious sedation" with "moderate sedation/analgesia" and attempted to
provide clearer definitions of what this meant. The difficulty remains that
this is still a subjective process and that each clinician must always be aware
of how the patient is responding to the sedatives and dissociatives that he or
she is being given. The JCAHO sedation guidelines provide qualitative goals
for each practitioner while conducting procedural sedation, but ultimately
we must strive to maintain safety by minimizing risks and ensuring safe
discharge.
Definitions
The progression from mild sedation to general anesthesia is a continuum,
and definitions of sedation are evolving. Useful definitions include the following:
■ Analgesia — Relief of pain without intentionally producing a sedated state.
Altered mental status may be a secondary effect of medications
administered for analgesia.
■ Anxiolysis — A state of decreased apprehension concerning a particular
situation; in this state, the level of awareness does not change.
The continuum of and definition of levels of sedation/analgesia according to
the American Society of Anesthesiologists include:
Minimal sedation (anxiolysis) — A drug-induced state during which the
patient responds normally to verbal commands. Cognitive function and
Chapter 36 — Procedural Sedation 495
coordination may be impaired, but ventilatory and cardiovascular
function are unaffected.
■ Moderate sedation/analgesia (conscious sedation) — A drug-induced
depression of consciousness during which the patient responds
purposefully to verbal commands either alone or accompanied by light
tactile stimulation. No interventions are required to maintain airway and
adequate ventilation. Cardiovascular function is usually maintained.
■ Deep sedation/analgesia — A drug-induced depression of consciousness
during which the patient cannot be easily aroused but responds
purposefully following repeated or painful stimulation. The ability to
independently maintain ventilatory function may require assistance in
maintaining a patent airway and adequate ventilation. Cardiovascular
function is usually maintained.
General anesthesia — A drug-induced loss of consciousness during which
the patient cannot be aroused, even by painful stimulation. The ability to
independently maintain ventilatory function is often impaired. The
patient often requires assistance to maintain a patent airway, and
positive-pressure ventilation may be required because of depressed
spontaneous ventilation or drug-induced depression of neuromuscular
function. Cardiovascular function may be impaired.
(Developed by the American Society of Anesthesiologists [ASA] and approved
by the ASA House of Delegates, October 13, 1999. Referenced http://www.
asahq.org/publicationsAndServices/sedationl017.pdf; accessed 07/15/05
at 1545.)
INDICATIONS
Sedation/analgesia provides two general types of benefit: (1) sedation/
analgesia allows patients to tolerate unpleasant procedures by relieving
anxiety, discomfort, or pain; and (2) in children and uncooperative adults,
sedation/analgesia may expedite the conduct of procedures that are not
particularly uncomfortable but that require the patient not move (ASA, 2002).
Ultimately, the goals of procedural sedation and analgesia are to alleviate
anxiety, minimize physical pain and discomfort, minimize negative psycho-
logical responses to treatment, maximize amnesia, control behavior to expedite
performance of procedures, maintain safety by minimizing risks, and ensure
safe discharge (Hsu, 2005).
CONTRAINDICATIONS
Patients should be evaluated prior to the procedure for their suitability for
sedation. From this a decision must be made if there are contraindications
for sedation or anxiolytic medication use. Allergies to possible medications
496 Chapter 36 — Procedural Sedation
used in the procedure may exclude the patient unless alternative medications
may be substituted. Previous reactions to sedation or general anesthesia
should be noted and may contraindicate the use of procedural sedation
depending on the outcomes of prior use. Food ingested within the past 6
hours or clear liquids within the past 2 hours would preclude the patient
from sedation unless there was an emergency situation involved, and then
the benefits of the procedure must be weighed against the potential of
aspiration.
Absolute contraindications are uncommon, but the practitioner should
consider comorbid illness or injury and the ability to manage the patient's
airway. Patients with significant comorbid cardiac, hemodynamic, or
respiratory compromise should be approached with caution, as should
patients who may be difficult to intubate or manually ventilate. If the patient
is classified as a Class IV or V, as defined by the ASA physical status classifi-
cation system, a nonanesthesiologist should not provide moderate sedation
or anesthesia for that patient, but should refer the patient on to an
anesthesiologist who may recommend general anesthesia or other treatment
course (Table 36-1).
Ultimately, the largest contraindication may be the practitioner. If the
practitioner does not have the understanding of the medications administered,
the ability to monitor the patient's responses to the medications given, or the
skills necessary to intervene in managing all potential complications, he or
she should be excluded from performing the procedure with procedural
sedation or anxiolytics. Practitioners also need to be in compliance with the
institution's requirements, whether special credentials and privileges are
Table 36.1 American Society of Anesthesiologists (ASA)
Physical Status Classifications
PATIENT CLASSIFICATION
EXAMPLE
ASA 1: A normal, healthy patient. The pathologic process
for which surgery is to be performed is localized and
does not entail a systemic disease.
ASA 2: A patient with systemic disease, caused either by
the condition to be treated or other pathophysiologic
process, but which does not result in limitation of
activity
ASA 3: A patient with moderate or severe systemic
disease caused either by the condition to be treated
surgically or other pathophysiologic process, which
does limit activity
ASA 4: A patient with severe systemic disease that is a
constant potential threat to life
ASA 5: A patient who is at substantial risk for death
within 24 hr and is submitted to the procedure in
desperation
E: Emergency status — added to the ASA designation only
if the patient is undergoing an emergency procedure
An otherwise healthy patient
scheduled for a cosmetic
procedure
A patient with asthma, diabetes,
or hypertension that is well
controlled with medical
therapy, and has no systemic
sequelae
A patient with uncontrolled
asthma that limits activity, or
diabetes that has systemic
sequelae such as retinopathy
A patient with heart failure, or
renal failure requiring dialysis
A patient with fixed and dilated
pupils status post head injury
A healthy patient undergoing
sedation for reduction of a
displaced fracture, classified
ASA IE
Chapter 36 — Procedural Sedation 497
required, or if there are particular state, professional association, or regulatory
body requirements to perform procedural sedation.
POTENTIAL COMPLICATIONS
Complications to procedural sedation include, but are not limited to,
vomiting, respiratory depression, hypoxia, hypotension, and cardiac arrest.
The most serious complication is respiratory failure from airway obstruction
or hypoventilation. Advanced airway management skills are a mandatory
prerequisite for performing these techniques. Cardiac depression also may
occur and must be rapidly recognized to avoid cardiac arrest or death.
Complications are most likely to occur within 5 to 10 minutes after
administration of intravenous medication and immediately after the procedure
when procedural stimuli are removed (Krauss, 2000). Thus, monitoring
should be especially close during these periods. These complications are
less likely to occur when using alternative routes of administration, such as
oral, nasal, rectal, or intramuscular, but these routes do not preclude them
from occurring.
Intravenous sedative/analgesic drugs should be given in small, incremental
doses that are titrated to the desired end points of analgesia and sedation
(ASA, 2002). Sufficient time must elapse between doses to allow the effect of
each dose to be assessed before subsequent drug administration. When drugs
are administered by nonintravenous routes (e.g., oral, rectal, intramuscular,
transmucosal), allowance should be made for the time required for drug
absorption before supplementation is considered. Because absorption may
be unpredictable, administration of repeat dosing of oral medications to
supplement sedation/analgesia is not recommended.
As a practical consideration, unnecessary stimulation, such as inflation of
a blood pressure cuff, may hinder the induction of sedation in a young or
anxious child or adult. Once a complete set of vital signs has been obtained,
deflate the cuff and monitor the patient visually until the drugs have begun
to take effect. At this point, monitoring of pulse oximetry and heart rate, at a
minimum, should be initiated. This could avoid additional doses of sedatives
being given to the patient and pushing the patient into a much deeper level
of depression than intended when the cuff is deflated or removed.
Hepatic or renal abnormalities may impair drug metabolism and excretion,
resulting in increased drug sensitivity and longer duration of drug action.
This does not preclude the patient from procedural sedation, but the patient
should be monitored closely.
Medications that the patient is currently taking may interact with the
sedatives and analgesics. Checking for specific drug interactions prior to
starting the procedural sedation is recommended. Alcohol or illicit substance
abuse may increase a patient's tolerance to sedatives and analgesics. In
addition, if the patient has been using these substances prior to sedation, the
addition of sedatives/analgesics may be additive or synergistic and may
require intubation earlier than anticipated with normal dosing of medications.
498 Chapter 36 — Procedural Sedation
Tobacco use can increase the risk of airway irritability, bronchospasm, and
coughing during sedation, requiring additional airway monitoring.
PATIENT PREPARATION
Identify the patient by armband identification as well as verbal questioning.
Be sure to ask the patient what procedure he or she is there for and that it is
the correct procedure. Prior to giving any anxiolytic or analgesic medication,
get consent for both the procedural sedation as well as the procedure that
the patient is to undergo. The patient should be told of any risks involved
with either the procedure or the sedation that is going to be used, as well as
any post-sedation side effects to be expected.
A directed history taking and physical examination should precede
sedation (Krauss, 2000). Underlying medical problems should be assessed,
and information about medication use, allergies, previous adverse experiences
with sedation or general anesthesia, and the time and nature of the last oral
intake should be obtained.
Auscultation of the heart and lungs should be performed, vital signs taken,
and the airway evaluated. Patients who have stridor, significant snoring,
sleep apnea, advanced rheumatoid arthritis, dysmorphic facial features,
Down's syndrome, upper respiratory infections, or an abnormal airway
examination (including Class III or class IV oral examination) should be con-
sidered to be at increased risk for airway obstruction during sedation. Also,
these patients potentially have a difficult airway to manage if mask ventilation
or intubation becomes necessary.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
A normal airway examination should consist of the following:
Opens mouth normally (Adults: greater than 2 finger widths or 3 cm)
■ Able to visualize at least part of the uvula and tonsillar pillars with
mouth wide open and tongue out (patient sitting)
Normal chin length (Adults: length of chin is greater than 2 finger widths
or 3 cm)
Normal neck flexion and extension without pain/paresthesias
An abnormal airway examination can consist of the following:
Small or recessed chin
Inability to open mouth normally
■ Inability to visualize at least part of uvula or tonsils with mouth open
and tongue out
Chapter 36 — Procedural Sedation 499
Class I Class II Class III Class IV
Figure 36- 1 . The progression of diagrams from left to right suggests increased
difficulty in airway management during sedation (Hata, 2005). (Referenced May 9,
2005: http://www.vh.org/adult/provider/anesthesia/ProceduralSedation)
High arched palate
Tonsillar hypertrophy
Neck with limited range of motion
Low-set ears
Significant obesity of the face and neck
Class III or Class IV oral examination (Fig. 36-1)
Materials Utilized for Procedural Sedation
Although rare, procedural sedation and analgesia may result in an allergic
reaction, respiratory arrest, or cardiopulmonary arrest (Godwin, 2005). The
incidence of complications is dependent on the drugs used, rate and dose
of administration, and patient sensitivities. Although the literature is mixed
regarding what specifically needs to be at bedside, there is clear agreement
that pulse oximetry be performed. In addition, if the patient has a history
of cardiac disease, ongoing monitoring with electrocardiography should be
performed.
Other equipment that must be immediately available, but not necessarily
at bedside, includes:
■ Pharmacologic antagonists and appropriately sized equipment for
establishing a patent airway and providing positive-pressure ventilation
with supplemental oxygen
Suction, advanced airway equipment, and resuscitation medication,
which should be immediately available and in good working order
500 Chapter 36 — Procedural Sedation
■ A functional defibrillator for whenever deep sedation is administered and
when moderate sedation is administered to patients with mild or severe
cardiovascular disease
Intravenous access should be maintained when intravenous procedural
sedation and analgesia is provided (Godwin, 2005). Intravenous access may
not be necessary when procedural sedation and analgesia is provided by
other routes.
MONITORING
Monitoring the patient during sedation involves visual observation for
ventilatory function, response to verbal commands (unless they are unable
to respond in a meaningful way [e.g., very young children]), and deter-
mination of vital signs at regular intervals. Monitoring of exhaled carbon
dioxide should be considered for all patients receiving deep sedation and for
patients whose ventilation cannot be directly observed during moderate
sedation.
Vital signs should be recorded at specific and regular intervals. At a
minimum this should include before starting the procedure, after adminis-
tration of the drug, when the procedure is complete, during early recovery,
and when recovery is completed and patient is ready for discharge. Capnog-
raphy, or monitoring of exhaled carbon dioxide, is becoming increasingly
available and may be useful in assessing ventilation during sedation and
analgesia. Capnometry is a technique used to monitor end tidal C02 and,
therefore, may detect early cases of inadequate ventilation before oxygen
desaturation takes place (Godwin, 2005). This is currently not required by
any of the literature but has been indicated as useful when ventilatory
monitoring is impaired or if the patient is unable to respond to verbal stimuli
during the procedure itself.
AGENTS FOR PROCEDURAL
SEDATION
The appropriate choice of agents and techniques that are used for sedation
or analgesia is practitioner dependent and reflects the comfort level and
experience that he or she has with administering the particular medication.
It also is dependent on the constraints imposed by the patient, supervising
physician, type of procedure, and the facility. Once these constraints are
identified, the choices of analgesics/sedatives may be more limited. The
following are common medications used in sedation and analgesia to achieve
minimal to moderate sedation. However, one must keep in mind that all of
these drugs have the potential to push the patient into deep sedation,
requiring airway management, reversing agents, cardiac dysfunction, and
need for additional airway support. Therefore, the practitioner should be
Chapter 36 — Procedural Sedation 501
able to rescue patients whose level of sedation becomes deeper than initially
intended.
Multiple agents and various combinations of agents can be used to provide
sedation and analgesia. Opioids are used primarily when analgesia is required.
Sedation is often an added benefit for the patient's comfort during the pro-
cedure, but it is not the primary indication for administration. Benzodiazepines
and other sedatives, such as barbiturates and chloral hydrate, are useful
medications when achieving anxiolysis and amnesia. They are best given just
prior to a procedure or during the procedure itself. When considering the
selection of an agent, it is important to consider the properties of the agent
as well as the type of procedure that is being performed (painful or non-
painful). This can dictate using only one medication as opposed to multiple
medications and possibly drug-drug interaction. However, if the procedure is
painful and the patient would benefit from an anxiolytic, it is appropriate to
use a combination of opioids and benzodiazepines, recognizing that there is
an additive/synergistic effect of these medications and that additional
monitoring will be required. These medications are listed in Tables 36-2 and
Table 36.2 Opioids
AGENT
ROUTE
USUAL DOSAGE ONSET/PEAK DURATION
COMMENTS
Fentanyl
IV— Adult
IV— Peds
Morphine IV— Adult
IV— Peds
Meperidine IV — Adult
IV— Peds
Start with
0.5-0.1 jug/kg over
2 min
Titrate 0.25-0.5 ug/kg
every 5 min to a
maximum of
4-5 |ig/kg
Start with 0.5 ug/kg
over 2 min
Titrate 0.25-0.5 ug/kg
every 5 min
Initial dose 3-4 mg
over 2 min
Titrate 1-2 mg every
5 min
Initial dose
0.05 mg/kg over
2 min
Titrate
0.02-0.05 mg/kg
every 5-10 min
Start with 25-50 mg
over 2 min
Titrate 10-15 mg
every 5 min to a
maximum of
150 mg total
Start with 0.5 mg/kg
over 2 min
Titrate 0.25-0.5 mg/kg
every 5 min
1-2 min/3-5 min 30-60 min
2-5 min/20 min 4-5 hr
5 min/20 min
2-4 hr
Analgesia, reversible with naloxone
Respiratory depression increased with
other respiratory depressants,
cardiacarrhythmias increased
Analgesia, reversible with naloxone
Respiratory depression increased with
other respiratory depressants,
hypotension possible
Analgesia, reversible with naloxone,
produces generalized CNS
depression and increased
respiratory depression with
additional agents
CNS, central nervous system; IV, intravenous; Peds, pediatric population.
502 Chapter 36 — Procedural Sedation
Table 36.3 Benzodiazepines
AGENT
ROUTE
USUAL DOSAGE
ONSET/PEAK DURATION
COMMENTS
Midazolam IV — Adult
IV— Peds
PO— Peds
Diazepam IV — Adult
PO— Adult
Lorazepam IV — Adult
PO— Adult
Initial dose 0.02 mg/kg
or 0.5-2 mg over 2 min
Titrate by 0.5 mg
every 5 min to a
maximum of 5 mg
total
Initial dose 0.05 to
0.1 mg/kg over 2 min
Titrate by 0.025 mg/kg
every 5 min, not to
exceed a cumulative
dose of 0.6 mg/kg
0.25-0.75 mg/kg
Initial dose 2.5-5 mg
over 5 min
Titrate by 2.0-2.5 mg
every 5 min
Note: Not
recommended for
pediatric patients
due to long duration
5-10 mg
Initial dose 0.5 mg to
2 mg over 5 min
Titrate to a maximum
dose of 4 mg
Initial dose 2 mg
May repeat times once
after 20-30 min
Note: Not
recommended for
pediatric patients
due to long duration
1-3 min/3-5 min
<2hr
10-20 min/
20-50 min
1-5 min/5-8 min
30-60 min/
30-90 min
6-8 hr
5 min/ 15-20 min 6-8 hr
20-30 min/
60-90 min
6-8 hr
Requires another agent for analgesia
Causes respiratory depression,
hypotension
Prolonged sedation may occur in
elderly
Requires another agent for analgesia
Causes respiratory depression,
hypotension
Prolonged sedation in elderly
Not used in pediatric population
Same as diazepam
IV, intravenous; Peds, pediatric population; PO, oral.
36-3. The gold standard remains fentanyl and midazolam in combination due
to their fast onset, short duration of action, ease in titration, and favorable
cardiovascular profile.
Reversing agents for the opioids is naloxone, and flumazenil for the
benzodiazepines. These are dosed as indicated in Table 36-4. If the patient
has received both medications and is in respiratory distress, encouraging
deep breathing or bag-mask device assistance may be all that is required.
However, if this is inadequate and a reversing agent is indicated, always use
naloxone as the first agent of choice.
Chapter 36 — Procedural Sedation 503
Table 36.4 Reversing Agents
AGENT
ROUTE
USUAL DOSE
ONSET/PEAK
DURATION
COMMENTS
Naloxone IV-
-Adult
0.04-0.1 mg for first
dose for partial
reversal of opioid-
induced respiratory
depression. May
repeat every 2 min
until arousal level is
obtained
May give up to
0.4-2 mg for first dose
if apnea has
developed but with
concern for increased
side effects (see drug
label)
May repeat every
2-3 min to maximum
of 10 mg
Note: If patient is on 2 min/5-15 min
Variable;
May be cleared faster than
opioids prior to
monitor
opioid. Monitor closely for
additional sedation
patient
resedation. Use with extreme
(as in cancer pain),
closely
caution in elderly or those with
initial dosing should
cardiac conditions. Acute
be started at 0.04 mg
withdrawal syndrome may also
and instilled every
be seen
2 min until arousal
occurs to avoid
withdrawal syndrome
IV-
-Peds
0.01 mg/kg for
children <20 kg
Flumazenil IV-
-Adult
0.2 mg over 15 sec
May repeat every 1-2 min/
30-90 min but
Benzodiazepine reversal use is
60 sec with 6-10 min
variable;
discouraged; potential for
additional 0.2 mg to
monitor
benzodiazepine withdrawal or
a maximum of 1 mg
patient
status epilepticus
IV-
-Peds
0.01 mg/kg for
children <20 kg over
15 sec
May repeat every
60 sec with
additional 0.01 mg/kg
to a maximum of 1 mg
or 0.05 mg/kg,
whichever is lower
closely
Limited efficacy in reversing
respiratory depression
Procedure for Procedural Sedation
1. Confirm patient identity by two
methods prior to procedure or
sedation.
2. Obtain consent for the procedure and
sedation and discuss with the patient
the risks involved with both the
procedure and sedation.
3. Have a family member (or whoever will
accompany the patient home) present
when discussing post-procedure
sedation side effects, especially when
using amnestic medications.
4. Obtain a thorough history to ascertain
any prior history of allergic reaction to
continued
504 Chapter 36 — Procedural Sedation
anxiolytics or analgesics. Avoid use of
these medications if indicated.
5. Perform a physical examination, including
the heart, lungs, vital signs, and
visualization of the oral airway, prior to
sedation.
6. After the patient has been examined,
prepare the room for any need that may
arise during the procedure. At a minimum,
the patient should be monitored by
pulse oximetry, and, if he or she has a
history of cardiac arrest, with
electrocardiography as well.
Note: A minimum of two people is needed in
the room during the administration of
sedation and the procedure. This ensures
that one person can monitor airway,
ventilation function, and responsiveness
while the other performs the procedure.
7. Make available a cart containing
intubation kits, antagonists, and
suctioning equipment in case the patient
should develop apnea or slip into deep
sedation, requiring intubation. The
airway assessment prior to sedation is of
utmost importance in determining which
intubation kit to use.
8. Administer the sedative/amnestic as
indicated by prior consent. If oral, these
typically are given 20 to 30 minutes prior
to the procedure being performed with
someone present to monitor the patient.
If given intravenously, these can typically
be given 5 to 10 minutes prior to the
procedure, again with physically present
monitoring.
9. Monitor during sedation through visual
observation for ventilatory function and
response to questioning.
Note: If patient is unresponsive to
questioning or the observed ventilatory
function decreases anytime following the
dosing of sedation, monitor oximetry. If 02
saturations decrease below 92%, initiate
oxygen, consider reversing agents and
ventilatory support, call for support, and
initiate respiratory support as indicated.
10. Record vital signs, at minimum, before
starting the procedure, after
administering the drug, after the
procedure is completed, during early
recovery, and immediately prior to
discharge.
Note: If at any time during this monitoring
the patient appears to need support, start
oxygen immediately, call for support and
initiate respiratory support as indicated by
patient's oxygen saturation and
responsiveness to questioning.
11. Monitor the patient until near-baseline
levels are obtained and he or she is no
longer at risk for cardiopulmonary
depression. Drowsy patients should not
be left unattended, or in areas in which
ventilation cannot be adequately
observed.
12. Give aftercare instructions to both the
patient and whoever accompanies him
or her, because it is not unusual for the
patient to forget information heard
when still partially sedated. Remind
both the patient and whoever
accompanies him or her that after the
use of sedative medications the patient
should not drive or make legally binding
decisions for 24 hours following the
procedure.
13. Discharge the patient home with
instructions on when to call if side
effects or complications develop. Inform
the patient and person accompanying
him or her that if nausea or vomiting
develops, to change to a clear liquid diet
until it resolves.
Chapter 36 — Procedural Sedation 505
DISCHARGE CRITERIA
Patients recovering from procedural sedation must be monitored until they
are near baseline levels and are no longer at risk for cardiopulmonary
depression. Vital signs should be monitored and be stable and at baseline
prior to discharge. This includes checking pulse oximetry until they are no
longer at risk for hypoxemia. Drowsy patients should not be left unattended
or in areas of the facility that may not have adequate observation available.
Prior to undergoing procedural sedation, the patient and family member
should be instructed that when sedation is used, whether it includes amnesties
or not, that they may have impaired cognitive ability for a prolonged period.
They should plan to avoid driving, operating machinery, or making legally
binding decisions for at least 24 hours following the procedure.
Written instructions must accompany the patient due to the potential of
impaired ability to remember. Post-procedure instructions should include
signs and symptoms of potential adverse outcomes and complications.
Contact information that includes a 24-hour contact number is advisable in
case an emergency does arise. The patient should be instructed to switch to
a clear liquid diet until symptoms resolve if he or she develops nausea or
vomiting. Generally this is short lived and diet can be advanced as tolerated.
References
American Society of Anesthesiologists Task Force on Sedation and
Analgesia by Non-Anesthesiologists: Practice guidelines for sedation
and analgesia by non-anesthesiologists. Anesthesiology 96:1004-1017,
2002.
Brown TB, Lovato LM, Parker D: Procedural sedation in the acute care
setting. Am Fam Physician 71:85-90, 2005.
Godwin SA, Caro DA, Wolf SJ, et al: Clinical policy: Procedural sedation
and analgesia in the emergency department. Ann Emerg Med
45:177-196,2005.
Hata T, Nickel E, Hindman B, Morgan D: Procedural Sedation Resource
Center: Guidelines, Education, and Testing for Procedural Sedation
and Analgesia. Accessed May 9, 2005:
http://www.vh.org/adult/provider/anesthesia/ProceduralSedation/
Hsu DC: Procedural Sedation and Analgesia in Children. Accessed April
19, 2005:
http://utdol. com/application/topic. asp?file=pedi_em/10221&type=A&s
electedTitle=5~13
Krauss B, Green S: Primary care: Sedation and analgesia for procedures
in children. N Engl J Med 342:938-945, 2000.
Bibliography
Bahn EL, Holt KR: Procedural sedation and analgesia: A review and new
concepts. Emerg Med Clin North Am 23:503-517, 2005.
Chudnofsky CR, Lozon MM: Sedation and analgesia for procedures. In
Marx JA, Hockberger RS, Walls RM (eds): Rosen's Emergency
506 Chapter 36 — Procedural Sedation
Medicine: Concepts and Clinical Practice, 5th ed. St. Louis, Mosby,
2002, pp 2578-2587.
O'Donnell JM, Bragg K, Sell S: Procedural sedation: Safely navigating the
twilight zone. Nursing 33:36-44, 2003.
Chapter Q*7
Patient Education Concepts*
Richard D. Muma
Goals and Objectives
Goal: To perform effective patient education.
Objectives: The student will be able to ...
Describe why patient education is a worthwhile effort.
Identify and describe Cole's suggestions for enhancing the
patient education process.
Identify and describe the proposed factors that influence patient
education.
Identify several sources for patient education materials.
*This chapter was adapted from Muma R, Lyons BA, Newman TA, Carnes BA (eds): Patient Education:
A Practical Approach. New York, McGraw-Hill, 1996.
507
508 Chapter 37 — Patient Education Concepts
BACKGROUND AND HISTORY
This chapter summarizes recommendations as originally proposed by Collier
and colleagues in Patient Education: A Practical Approach (Cole, 1996; Muma,
1996). Cole points out that there have been dramatic changes in the number
of providers, advances in medical technology, and the understanding of
disease, as well as striking developments in various methods to treat these
problems. The goal of these advancements in health care delivery is to be
able to provide better patient treatment, working toward the goal of effecting
a healthy outcome. The chief means to accomplish this goal is through an
interactive educational process. Whether it involves asking an individual to
take medication or to make substantial lifestyle changes to promote better
health, providers must be able to communicate, educate, and motivate the
patient effectively.
Various approaches to patient education have been outlined over the
years. All emphasize the importance of providing accurate information and
encouraging patients to assume more responsibility for their own treatment.
Many of the techniques used to accomplish such education share common
characteristics. For example, explanations need to be given in simple terms,
avoiding jargon that might be confusing. Also, the health care provider must
assess the patient's understanding of the information in case further explanation
is necessary to clarify questions or reduce confusion. Careful attention must
also be given to patients' emotional responses to a particular diagnosis or
treatment method, as these reactions can have a significant impact on outcome.
Effective patient education should be duly recognized as an integral building
block in the entire health delivery process, of equal importance to clinical
and technologic advancements in the field. Good patient education provides
the following benefits (Greenberg, 1989):
■ Enables patients to assume greater responsibility for their own health
care
■ Improves patients' ability to manage acute and chronic illness
■ Provides patients with opportunities to choose healthier lifestyles and
practice preventive medicine
■ Improves compliance with medication and treatment regimens
■ Increases patients' satisfaction with their medical care and thus reduces
the risk of liability
■ Attracts patients to your practice
■ Leads to a more efficient, cost-effective health care system
Chapter 37 — Patient Education Concepts 509
COLE'S SUGGESTIONS FOR
ENHANCING THE PATIENT
EDUCATION PROCESS
Pay Attention to Using Good
Interviewing Techniques
Helping patients deal successfully with medical problems involves being able
to both educate and motivate for change. This requires the use of skillful
interpersonal techniques. One needs to be attuned to both verbal and non-
verbal aspects of the interaction. With time and practice, one develops a
sense of when it is best to be silent and listen to a patient and when to
provide specific educational information or support. Being prepared and
organized beforehand (e.g., having laboratory work on the chart, pulling
together handouts, having a treatment plan written out specifically for the
patient) facilitates the entire process and will likely improve understanding
and compliance.
Present Information through Several
Channels
Do not rely solely on direct verbal communication to ensure a patient's
understanding. For some individuals, verbal learning is not as successful as
visual learning. Some individuals may understand and retain information
better if they are able to view a handout or chart or follow an explanation
concerning a radiograph. Also, some patients may benefit from the opportunity
to meet and talk with others who have dealt with a certain problem or are
currently undergoing treatment for a particular medical condition. Such peer
support can be an effective tool in motivating an individual to comply with
treatment.
Always Supplement the Educational
Process with Patient Education
Resources
The patient education process can be overwhelming because so much
information may need to be covered. It is therefore recommended that patients
be provided with brochures, handouts, medication inserts, an outline of the
treatment plan, listing of internet sites, or other materials that will permit
later perusal to reinforce what was covered during the actual interview.
510 Chapter 37 — Patient Education Concepts
Involve Families or Significant Others
When Possible
Remember that patients are part of a larger family system. Most often, these
family members are concerned about the health of their loved one, and
involving them in the treatment process can be useful. Indeed, such involve-
ment may in some cases ensure compliance with a treatment plan. Ask how
the patient is going to explain a particular health problem to his or her
family. Invite family members to attend a follow-up appointment so that they,
too, can hear about the situation and learn how they can help.
Be Sure to Raise the Sensitive Issues
There are certain subjects that tend to be highly sensitive, and some patients
may have underlying concerns or fears that they may not openly voice.
Topics such as sexuality or death and dying often fall into this category.
Because these topics may produce embarrassment or feelings of despondency,
a patient may be reluctant to inquire about them. Therefore, it is critical for
the health care professional to initiate such discussion when it is clearly
pertinent to the treatment plan (e.g., medications that might interfere with
sexual functioning, the need for a patient to recognize that the treatment
options for a particular condition may be only palliative). Raising these issues
signals that it is all right to talk about more sensitive matters and allows the
patient to express his or her underlying fears and concerns openly.
Be Attuned to Emotional Reactions
As already noted, patients experience emotional reactions to learning of a
particular illness and the need to follow a course of treatment. Providing
comprehensive health care requires exploring these emotional topics. Whether
the patient is expressing fear, anger, anxiety, or depression, unless the health
care professional inquires about such reactions and takes steps to address
them, treatment outcome may be in jeopardy. Allowing the patient to express
feelings and offering him or her support are viewed as an integral part of the
patient education process.
Do Not Feel That Once the Topic Is
Covered It Is Completely Resolved for
the Patient
For some individuals, providing education about a disease or treatment plan
is enough to motivate them to go forward and carry out the prescribed treat-
ment. For others, however, there may be lingering confusion or questions
after the interview that need to be addressed at a later time. In addition,
Chapter 37 — Patient Education Concepts 511
certain aspects of the treatment plan that are more difficult for a patient to
deal with (e.g., making lifestyle changes such as smoking cessation or weight
reduction) need to be reviewed and re-encouraged at a later appointment. It
is always prudent to review a patient's treatment plan at each subsequent
follow-up visit, offering praise for the accomplishments and noting areas that
need additional attention.
PROPOSED FACTORS THAT
INFLUENCE PATIENT EDUCATION
There are many parts to the concept of health, including how one thinks
about disease and its cures. Health care in the United States is based primarily
on treating acute, well-advanced disease processes, using an infectious
disease paradigm. However, the causes of poor health and serious disease
processes are linked to multiple factors, particularly behavioral and cognitive
habits, along with specific social and physical environments. Patients often
react to illness and its management in ways learned from others, according
to their cultural norms, and according to their own perception of the severity
of the illness. Before engaging in a patient education session, one must
realize that every patient responds differently, and several variables or factors
play a role in that response. Some of those factors identified for discussion
in this chapter include age, ethnicity, family issues, socioeconomic status,
and the chronicity of illness.
Age
Although an obvious consideration, age is not always reflected in patient
education materials and is often overlooked in the patient education
counseling session. One must remember that the range of care starts with
infants and ends with the elderly. Let us start with children. They are not
small adults, and their wants, needs, thinking process, and emotional and
physical status differ from those of an adult. For example, small children
often view hospitalization as a punishment, not as a means of getting well
(Anderson, 1990). This belief is further reinforced when parental figures
make statements such as, "If you go outside without a coat you may get sick
and have to go see the doctor." This type of belief often leads to false per-
ceptions about clinicians and to a child's difficulty in accepting medical
advice or treatment. Infants, although not directly involved in patient
counseling sessions, have special needs and respond to touch and nonverbal
communication (Anderson, 1990). As children grow older, however, one must
keep in mind the current fads, language, and norms that exist. For example,
teenagers often believe themselves to be experts in every area, and in some
cases do not heed advice. Furthermore, certain instructions given to
teenagers regarding prevention of illness may not be "cool" or in line with the
thinking of their peer group.
512 Chapter 37 — Patient Education Concepts
Adults are more mature and have concerns that are different from those of
adolescents. For instance, young adults (ages 20 to 40) are at a point in life
in which multiple activities (e.g., college, relationships, children) keep them
busy (Anderson, 1990). These patients need practical approaches to education;
approaches that are not time-consuming and unrealistic in relation to their
lives. As adults grow older (ages 41 to 60), they become more conscious of
the possibility of health problems and in most cases are willing to follow a
patient education prescription. However, some may lack self-confidence,
which can cause avoidance of the risk of failure in learning anything new
(Anderson, 1990). Adults older than 65 years are similar to middle-aged
adults in their willingness to learn new ideas, but the provider must be aware
of individuals' past experiences, involve them in the learning process, and
motivate them to learn (Anderson, 1990). Elderly patients may feel that it is
hardly worth the effort to learn new information and skills because they
think their life is nearing an end (Anderson, 1990).
Ethnicity
Before we discuss ethnicity, it is important to define the adjective ethnic.
Ethnic is defined in the 1982 edition of The American Heritage Dictionary of
the English Language as "of or pertaining to a social group that claims or is
accorded special status on the basis of complex, often variable traits including
religious, linguistic, ancestral, or physical characteristics." Ethnicity is defined
as the condition of belonging to a particular ethnic group. Examples of ethnic
groups in the United States include African American, Asian, white, Hispanic,
and Native American. There are at least 106 ethnic groups, including more
than 170 Native American groups, in the United States (Thernstrom, 1980).
Ethnic groups should not be confused with minority groups, as the latter are
seen as different from the majority group of which they are part. However,
some ethnic groups are also classified as minorities (e.g., African Americans
in the United States). One can see that the phenomenon of ethnicity is
complex, ambivalent, paradoxical, and elusive (Senior, 1965). As clinicians, it
is important to be aware of the ethnic backgrounds of patients. The differences
in language and culture each group exhibits certainly influence the way
patient education is communicated. For example, some think that human
immunodeficiency virus (HIV) infection prevention literature is not communi-
cated effectively to African-American populations. HIV prevention programs
are hampered because of the presence of culturally specific attitudes and
beliefs, including those pertaining to the roles of males and females (Lyons,
1994).
Family
Although consideration of the individual is important in patient education,
the patient's family is also of central importance if teaching is to be effective
(Falvo, 1985). How a family functions influences the health of its members as
Chapter 37 — Patient Education Concepts 513
well as how an individual reacts to illness. Including the family members and
significant others in patient education sessions facilitates adherence,
understanding of the disease process, and the confidence needed to perform
specific skills. Hence, the health care professional should capitalize on what
family members can do for the patient and work with them in encouraging
the patient in tasks that may be difficult. For example, when educating a
patient with diabetes mellitus who requires insulin injections, involvement of
the family in teaching sessions that demonstrate insulin injections most likely
will improve adherence. Family members can also serve as troubleshooters
when the patient has difficulty performing complex tasks. However, not all
patients have family or significant others available for support. This is
frequently seen in cases of HIV infection. Patients are often isolated from
others after their diagnosis is made known. These patients are often on
complex medical regimens involving the use of intravenous catheters. Lack
of support sometimes leads to poor care, missed doses, and increased
morbidity and mortality.
The health care professional can do much to facilitate the effectiveness
of patient teaching by fostering discussion among significant others. A
professional who has continued contact with the patient and his or her
significant others may check on the progress of the patient when necessary
and appropriate, and identify any new problems that may interfere with
optimal care.
Socioeconomic Status
The socioeconomic status of the patient should be carefully considered
when initiating education sessions. Individuals in lower socioeconomic groups
are less likely to seek treatment; if they seek treatment they tend to access
health care later in the course of their illness, and they die sooner than do
individuals in higher socioeconomic classes. Hence, the clinician should be
aware of the patient's personal income, living arrangements, and employment
status but should also have an increased awareness of the patient's health.
Lower socioeconomic status has been linked to the development of disease
states, the most noted being coronary artery disease (Marmot, 1978;
Morgenstern, 1980). For example, the provider clearly cannot erase poverty
and improve access to health care for all; however, he or she can exert a
positive impact on lower socioeconomic groups by working with their
members to promote healthier lifestyles (Lyons, 1994). Some individuals
often do not know what resources are available. The provider should point
individuals to local resources that provide services and, if that is not
possible, attempt to arrange for those services for the patient.
Chronicity of Disease
Finally, acute illnesses present differently from chronic ones and cause a
variety of reactions among patients. Health care providers must be aware of
514 Chapter 37 — Patient Education Concepts
the illnesses that require extra emotional support and possible psychiatric
intervention when preparing for patient education sessions. Furthermore, it
is not enough to simply inform a patient of his or her medical condition
without time for an initial reaction. Patients require time to react to a new
diagnosis. The perceived seriousness and natural course of a disease help
determine how a patient will respond. For instance, the patient diagnosed
with acute pharyngitis may feel really terrible during the illness but knows
that it is a curable disease and usually self-limiting. Hence, this patient may
have fewer emotional problems and require less counseling. Conversely, the
patient diagnosed with stage IV breast cancer, in which the long-term prog-
nosis is known to be poor, may have an emotional response that needs
further intervention involving a psychiatrist, social worker, or nursing care.
SOURCES OF PATIENT EDUCATION
Finally, as pointed out by many (Lyons, 1996), patient education draws on a
broad-based set of materials that can help explain a spectrum of topics.
Traditionally, patient education has been accomplished with fact sheets;
pamphlets; disease picture books; magazines; anatomic pictures; audiovisual
materials such as videotapes, interactive video, computer-assisted instruction,
laser disk technology, and the internet; and verbal instructions or materials
of a practitioner's own creation (Graber, 1999; Lyons, 1996). The internet has
become a ready source of educational materials, but clinicians should be
cautious because much of this material is not written at a level that is
comprehensible to many of our patients (Graber, 1999). Further investigation
of these resources is necessary by the clinician or others knowledgeable
about patient education materials before referring patients to these internet
sites. Particular attention should be paid to readability and accuracy of the
information. Many of the chapters in this text refer to appropriate sites for
patient education, and the reader should refer to those chapters for specific
website addresses.
References
Anderson C: Patient Teaching and Communicating in an Information
Age. Albany, NY, Delmar, 1990, pp 76-102.
Cole CM: An approach to patient education. In Muma RD, Lyons BA,
Newman TA, Carnes BA (eds): Patient Education: A Practical
Approach. New York, McGraw-Hill, 1996, pp 3-9.
Falvo DR: Effective Patient Education. Rockville, Md, Aspen, 1985,
pp 99-109.
Graber MA, Roller CM, Kaeble B: Readability levels of patient education
material on the World Wide Web. J Fam Pract 48:58-61, 1999.
Greenberg L: Build your practice with patient education. Contemp
Pediatr September, 85-106, 1989.
Lyons BA, Valentine P: Prevention. In Muma RD, Lyons BA, Borucki MJ,
et al, (eds): HIV Manual for Health Care Professionals. Norwalk,
Conn, Appleton & Lange, 1994, p 257.
Chapter 37 — Patient Education Concepts 515
Lyons BA: Selecting and evaluating sources of patient education
materials. In Muma RD, Lyons BA, Newman TA, Carnes BA (eds):
Patient Education: A Practical Approach. New York, McGraw-Hill,
1996, pp 15-21.
Marmot MG, Adelstein AM, Robinson N, et al: Changing social-class
distribution of heart disease. Br Med J 2:1109-1112, 1978.
Morgenstern H: The changing association between social status and
coronary heart disease in a rural population. Soc Sci Med
14A:191-201, 1980.
Muma RD: Factors influencing patient education. In Muma RD,
Lyons BA, Newman TA, Carnes BA (eds): Patient Education:
A Practical Approach. New York, McGraw-Hill, 1996, pp 11-12.
Senior C: The Puerto Ricans: Strangers Then Neighbors. Chicago,
Quadrangle Books, 1965, p 21.
The American Heritage Dictionary of the English Language. New York,
Dell, 1982, p 247.
Thernstrom S: Harvard Encyclopedia of American Ethnic Groups.
Cambridge, Mass, Belknap Press of Harvard University, 1980, p vii.
Bibliography
Bickley LS, Szilagyi PG: Bates' Guide to the Physical Examination and
History, 8th ed. Philadelphia, JB Lippincott, 2002.
Bernstein L, Bernstein RS: Interviewing: A Guide for Health
Professionals, 4th ed. Stamford, Conn, Appleton & Lange, 1985.
Coulehan J, Block M: The Medical Interview: Mastering Skills for Clinical
Practice, 4th ed. FA Davis, 2001.
Guckian J (ed): The Clinical Interview and Physical Examination.
Philadelphia, JB Lippincott, 1987.
Henderson G: Physician-Patient Communication. Springfield, 111, Charles
C Thomas, 1981.
Sherilyn-Cormier L, Cormier W, Weissen RL: Interviewing and Helping
Skills for Health Professionals. Monterey, Calif, Wadsworth Health
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Stevenson I: The Diagnostic Interview, 2nd ed. New York, Harper & Row,
1971.
Cha
p,e 38
Outpatient Coding
Lynn E. Caton
Goals and Objectives
Goal: To increase understanding of the coding process as applied
to outpatient medical services for financial reimbursement and to
provide clinicians with a systematic framework to assist in the
accurate coding of outpatient activities.
Objectives: The student will be able to ...
• Explain the history, purpose, and importance of outpatient
coding.
• Describe the mechanism for coding the components of the
patient history.
• Describe the mechanism for coding the components of the
physical examination.
• Describe the mechanism for coding the components of clinical
thinking in diagnosis and treatment within a patient encounter.
517
518 Chapter 38 — Outpatient Coding
BACKGROUND AND HISTORY
The coding of medical diseases is not a recent undertaking. In England, about
the time of Sherlock Holmes and Dr. Watson, a list of diseases began with the
London Bills of Mortality, 1845. The tracking of births and deaths actually
began in the 1500s to provide details of the infamous bubonic plague
epidemics. The "Great Plague" killed nearly 25% of Londoners from 1563-1665
(London Bills of Mortality from uuhsc.utah.edu). In 1874 the Registration
Amendment Act required medical practitioners to formally issue death
certificates, and failure to do so incurred a penalty. In 1881 William Ogle set
up an inquiry system in an attempt to cut down on ambiguously worded death
certificates. Shortly thereafter, the Royal College of Physicians established
the revised nomenclature for causes of death classifications (Beacon Health-
care Solutions, 2000-2003).
In 1900 the International Classification of Diseases, Clinical Modification
(ICD-CM) codes were introduced and have been used to classify diseases
since then. In 1977 the Ninth Revision (ICM-9-CM) was published by the World
Health Organization and has attained widespread recognition and use. The
United States Congress passed the Medicare Catastrophic Coverage Act in
1988 and, even though the Act was later repealed, the mandate for use of ICD-
9-CM remained a requirement for each Medicare Part B claim submitted for
payment. The Centers for Medicare & Medicaid Services (CMS) has published
guidelines that have been put into effect in each state, and the most recently
published guidelines in use are from 1997 (CMS, 1997; Beacon Healthcare
Solutions, 2000-2003).
The current procedural terminology (CPT) system (American Medical
Association, 2005) is a method of describing and coding the components of
a patient encounter, including medical, surgical, and diagnostic services. CPT
was developed by the American Medical Association (AMA) and first
published in 1966. CPT is maintained and updated by an editorial panel of
physicians and advised by two committees of physicians and other health
care professionals (Rose, 2001).
Documentation Guidelines for Evaluation and Management Services provides
CPT codes that identify a service rather than a procedure (E/M codes). E/M
codes are a subset of CPT as developed by the AMA. There are two sets of
guidelines for E/M codes, one published in 1995 and another published in
1997. Although the 1997 version is more complex, it is most widely used by
physicians, probably because the 1997 guidelines are less ambiguous.
The most difficult components of CPT to understand are related to docu-
mentation of the patient encounter. These components are history, physical
examination, medical decision making, and surgical and diagnostic procedures.
Tables and examples included in this chapter will clarify CPT E/M components
and their application to documentation and coding.
Chapter 38 — Outpatient Coding 519
PURPOSE OF MEDICAL RECORD
DOCUMENTATION AND CODING
Medical records should be complete and legible and describe each patient
encounter in the patient medical record, including electronic communications
(see Chapter 39).
Documentation should include the following:
Reason for encounter (chief complaint)
■ Relevant history, physical and diagnostic tests
■ Assessment, diagnosis, and plan for care and treatment
■ Date of encounter and identity of provider
■ Rationale for ordering diagnostic tests and other services
■ Past and present diagnoses for future reference
Identification of risk factors
Patient progress and success of treatments or revisions of treatment and
diagnoses
Documentation of treatment success and disease remission is an important
component of coding the complexity of a patient encounter. Therefore, noting
that diabetes or hypertension, for example, is controlled or uncontrolled is
helpful in monitoring a patient's condition and an element of medical decision
making.
Documentation should support the CPT and ICD-9-CM codes used for
billing insurance companies (CMS, 1997).
How to Code
The first step is to select the ICD-9-CM code that best defines the diagnosis.
Once the diagnosis code is selected, then the CPT E/M code is selected based
on the criteria outlined in following sections and summarized in Table 38-1.
Effective coding requires using the elements that are part of any good
history and physical examination, applying the ICD-9-CM numbering system
to the diagnosis, and then fitting the information documented in the medical
record to the proper CPT E/M service level and including any CPT codes for
procedures performed during the patient encounter. The next step is to use
the above information to appropriately generate a billing statement.
IMPORTANCE OF DOCUMENTATION
AND CODING
It is important to provide an accurate evaluation of each patient encounter
and record a well-documented report of the history, examination, and diag-
nostic and treatment plans. This ensures that each patient's medical treat-
520 Chapter 38 — Outpatient Coding
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Chapter 38 — Outpatient Coding 521
ment is available for review by other health care professionals on subsequent
visits as well as documentation of the progression, remission, or resolution
of acute and chronic diseases. The accurate coding of the diseases contributes
to the ability of medical professionals to provide detailed communication to
their peers and enhances population-based medical research. The most
important impact of excellent documentation is improved patient care.
The use of documentation and coding should be primarily to provide
continuity of appropriate and necessary preventive, diagnostic, and thera-
peutic services, not just a task oriented to billing for medical services and
satisfying insurance claims.
The following patient example has an E/M code, an ICD-9-CM code and a
CPT procedure code for the throat culture. The elements are marked for each
section of the note. Summary of the documentation elements is as follows:
History Types
Problem Focused
■ Expanded Problem Focused
■ Detailed
■ Comprehensive
Elements of Patient Clinical History
HPI — history of present illness
■ PFSH — past, family, social history
ROS — review of systems
Example A
Chief complaint (CC): "Sore throat for five days" (required of all E/M levels)
Subjective (S): This patient is a 25-year-old nonsmoking male in for acute
onset of sore throat 5 days ago. (HPI-Duration, one element) He has had a
fever, measured at home at 103° F and chills. (Associated symptoms, second
HPI element) He denies cough, ear pain, nasal congestion, or eye itching or
drainage. His neck has been sore and it is painful to swallow. (Location and
severity of pain, third HPI element) He denies nausea, vomiting or diarrhea.
He takes no medications regularly and has no known allergies to medication.
He has been taking fluids and eating soft foods. He missed work today as an
accountant and didn't sleep well last night. (Fourth HPI context element)
The HPI also includes ROS of the eyes, ears, nose, throat, neck, respiratory,
allergies, and gastrointestinal systems, or six systems.
Past medical history positive for appendectomy at age 14.
Objective (O):
522 Chapter 38-Outpatient Coding
General appearance (GA): A fatigued appearing 25-year-old male in no
distress. VS: BP 136/88, P 92 regular, Respirations 12, T: 101.4° F orally. Wt:
155 lbs, Ht: 70".
HEENT:
Eyes: clear, without discharge or erythema, conjunctivae are clear, PERRLA
Ears: Pinna normal and nontender, external auditory canal patent without
erythema or cerumen, TM's dull without fluid levels or inflammation.
Nose: clear, minimal clear discharge, septum deviated to the left, no
lesions noted.
Throat: Inflamed with 2+ tonsils and large amount of exudates bilaterally.
NECK: Thyroid normal, smooth without masses, 3+ anterior change
adenopathy tender to palpation.
HEART/LUNGS: normal, no murmurs, rubs: Lungs clear to auscultation
and percussion anteriorly, posteriorly, and laterally.
Because the ears, nose, mouth, and throat (ENT) examination is considered
by CPTas one examination, the number of systems examined and
documented is five in this example.
Quick Strep positive for strep CPT code 87060 is the code for bacterial
culture of the nose/throat.
Assessment (A): Strep Throat— ICD-9-CM code is 034.0
Plan (P): Pen Vee K 500 mg four times a day (qid) for 10 days
The considerations for determining the CPT E/M service code for the above
example are as follows:
■ HPI — four elements
ROS — six, PFSH — three elements
Examination — seven systems
■ Decision making and risk exists since prescription drugs were used, the
problem is acute, and the problem is an undiagnosed new one. There is a
moderate differential diagnosis and minimal data to review.
■ Time — generally around 15 minutes for this problem
The E/M code for Example A is a level four based on the information included
in the HPI, ROS/PFSH and the prescribing of medication.
OVERVIEW OF CODING
The CPT/ICD-9-CM process begins with a patient encounter. The clinician
performs a history and physical examination, determines a diagnosis, and
formulates a plan, which may include diagnostics, therapeutics, and patient
education (counseling). Working backward in this scenario, the first step is
to select the ICD-9-M code that best defines the diagnosis. ICD-9 is not unlike
the Dewey decimal system, with three numeric places to the left of the
decimal and two places to the right, further defining the diagnosis. For
Chapter 38 — Outpatient Coding 523
example, the ICD-9 code for sore throat is found under pharyngitis, not sore
throat. The code for pharyngitis is 462 if the problem is acute. The number
is 472.1 if the problem is chronic. If the diagnosis is tonsillitis, the code is 463,
and if the etiology were streptococcal, the code would be 034.0. Once the
diagnosis code is selected, then the CPT E/M code is selected based on the
criteria outlined in following sections and summarized in Table 38-1.
Patient History
The levels of history are coded as one of four types. Each type of history
includes all or some of the following elements. The extent of obtaining and
recording the various types of history depends on the clinical situation,
nature of the presenting problem (chief complaint), and the clinical judgment
of the health care professional.
It is important to note here that the CPT guidelines have not reinvented the
basic medical history that all physicians use to guide the evaluation of each
and every patient. The history types may be less recognizable terms, but the
elements of a clinical history will be very familiar to all clinicians. CPT has
taken the universal language of medicine and added some quantifiable
terminology and a numerical classification system for reproducibility.
History Definitions
Chief Complaint (CC)
This is a statement of the reason for the encounter, usually in the patient's
own words.
History of Present Illness (HPI)
The HPI is a chronological description of the patient's present illness. The
CPT definition and elements are not different from the standard medical
history. It is important for coding that the questions that typically are asked
in the history of present illness be recorded to validate the thought process
of the history taker. These elements are also part of a standard HPI.
Elements
1. Location
2. Quality
3. Severity
4. Duration
5. Timing
6. Context
7. Modifying factors
8. Associated signs and symptoms
524 Chapter 38 — Outpatient Coding
Table 38.2 Elements of CPT E/M Levels of Service
99212 LEVEL II
99213 LEVEL III
99214 LEVEL IV
99215 LEVEL V
CPT E/M Service
CPT E/M Service
CPT E/M Service
CPT E/M Service
Brief Problem
Brief Problem
Extended Problem
Extended Problem
Focused
Expanded
Detailed
Comprehensive
1 HPI
1 HPI
4 HPI
4 HPI
OROS
1 ROS
2 ROS
10 ROS
OPFSH
OPFSH
1 PFSH
3 PFSH
1 Exam
2-4 Exam
5-7 Exam
8+ Exam
Straight DM
Low DM
Moderate DM
High DM
10 minutes
15 minutes
25 minutes
40 minutes
DM, decision making; HPI, history of present illness; PFSH, past family and/or social history; ROS, review of
systems.
Review of Systems (ROS)
Review of systems coding is the classic history taking of all body systems.
This review is based on a series of questions asked of the patient about
various signs and symptoms related to organ systems. A complete review of
systems includes all 14 or 16 components, depending on your method of
inclusion or exclusion. The E/M guidelines note 14 systems and include skin/
breast and allergic/immunologic together rather than separately. The appro-
priate ROS is based on the problem. Either the problem requires a pertinent
ROS with just those systems related to the problem reviewed or an extended
ROS in which additional systems possibly related to the chief complaint and
HPI are reviewed. The complete ROS is all systems pertinent to the CC and
HPI plus all other systems reviewed and documented. This documentation
must specifically note patient responses, positive or negative. These responses
must be individually documented (Table 38-2; see also Table 38-1).
Past, Family, and/or Social History
(PFSH)
Past medical history includes history pertinent to the CC and HPI, and at
least one item from each of the three areas (Past, Family, Social) is required
for a detailed report of a comprehensive patient encounter. Logically the
PFSH should be complete for a new patient encounter. See Table 38-1 for
examples of what must be included for each PFSH area.
Code Levels and Elements of History,
Examination and Decision Making
Examinations
The coding of the physical examination uses the same nomenclature as the
E/M coding of the history. The four categories are brief problem focused, brief
problem expanded, extended problem detailed, and extended problem compre-
hensive (see Table 38-2). The types of examinations described by CPT are
Chapter 38 — Outpatient Coding 525
general multisystem or a complete examination of a single organ system. The
single organ system examination may also document the examination of other
symptomatic or related organ systems.
Both the multisystem and the single organ system codes are open for use
by any health professional in any specialty area of medicine. This includes
consultation codes.
Code Levels and Elements of History
and Examination
The elements of each examination required by CPT increase with the E/M code
level. In Table 38-2 the E/M level for an extended visit or code 99215 requires
that eight or more elements of the physical examination be documented. In
addition, the physical findings need to be described if there is an abnormality.
It is not sufficient to examine an organ system or body area and describe it
as abnormal without elaboration of the physical findings (see Example B).
Example B
S: The patient is a 25-year-old male in for acute onset of sore throat 5 days
ago. He has had a fever, measured at home at 103° F and chills. He denies
cough, ear pain, nasal congestion or eye itching or drainage. His neck has
been sore and it is painful to swallow. He denies nausea, vomiting or
diarrhea. He has been taking fluids and eating soft foods. He missed work
today as an accountant and didn't sleep well last night.
O:
GA: A fatigued appearing 25-year-old male in no distress.
VS: BP 136/88, P 92 regular, Respirations 12, T: 101.4° F orally. Wt: 155 lbs,
Ht: 70".
HEENT: Normal except for an abnormal appearing throat and tonsils.
(This description would be unacceptable by CPT)
NECK: Normal, no masses, thyroid smooth and nontender.
HEART/LUNGS: Normal, no murmurs, rubs or abnormal lung sounds.
A: Strep Throat
P: Pen Vee K 500 mg qid for 10 days
However, when describing an area of the body or organ system that is
normal or negative for physical findings, the term normal or negative is
sufficient (see above example for the examination of the neck).
The elements of a general multisystem examination as well as the single
organ system examination are outlined in Table 38-3. It should be noted that
an examination of the eye constitutes a single organ examination for CPT
purposes and the examination of the ears, nose, mouth, and throat (ENT) is
also one organ system.
526 Chapter 38 — Outpatient Coding
Table 38.3 Coding Elements for the Physical Examination
SYSTEM/BODY AREA
ELEMENTS OF EXAMINATION
Constitutional
Ears, nose, mouth,
and throat (ENT)
Eyes
Neck
Chest (breasts)
Respiratory
Cardiovascular
Gastrointestinal
(abdomen)
Genitourinary
Lymphatic
Musculoskeletal
Neurologic
Psychiatric
Skin
Measurement of any three of the following seven vital signs: (1) sitting or standing BP; (2) supine
BP; (3) pulse rate and regularity; (4) respirations; (5) temperature, (6) weight, (7) height
General appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to
grooming)
Inspection of the external ears, nose (overall appearance, lesions, masses, or scars noted).
Otoscopic examination of the external ear and tympanic membrane
Hearing assessment (whisper test, finger rub, or tuning fork)
Inspection of nasal mucosa, septum, and turbinates
Inspection of lips, teeth, and gums
Examination of the oropharynx: oral mucosa, salivary glands, hard and soft palate, tongue, tonsils,
and posterior pharynx
Inspections of the lids and conjunctivae
Examination of the pupils and irises (PERRLA)
Ophthalmoscopic examination of the optic discs (full funduscopic examination)
Examination of the neck for masses, symmetry, tracheal position, and crepitus
Examination of the thyroid
Inspection of the breasts
Palpation of the breasts and axillae
Assessment of respiratory effort (e.g., intercostals, retractions, use of accessory muscles,
diaphragmatic movement)
Percussion of the chest
Palpation of the chest (e.g., tactile fremitus)
Auscultation of the lungs (e.g., breath sounds, adventitious sounds, rubs)
Palpation of the heart (location, size, thrills)
Auscultation of the heart with notation of abnormal sounds and murmurs
Examination of carotid arteries, abdominal aorta, femoral arteries, pedal pulses
Extremities for edema and/or varicosities
Examination of abdomen with notation of masses of tenderness; liver and spleen;
presence or absence of hernia; when indicated, anus, perineum, and rectum, including sphincter
tone, presence of hemorrhoids, and rectal masses
Obtain stool sample for occult blood test when indicated
Male:
Examination of scrotal contents, with notation of hydrocele, spermatocele, tenderness of cord,
testicular mass; penis; digital rectal, with notation of size, symmetry, modularity, tenderness of
the prostate
Female:
Pelvic examination with or without collection for smears and cultures, including examination of
external genitalia; vagina; urethra; bladder; uterus; adnexa, for masses, tenderness, organomegaly,
modularity
Palpation of lymph nodes in two or more areas: neck, axillae, groin, other
Gait and station
Inspection and/or palpation of digits (e.g., clubbing, cyanosis, inflammation, petechiae, ischemia,
infections, nodes)
Examination of joints, bones, and muscles of one or more of the following six areas: head and neck;
spine, ribs, and pelvis; right or left upper extremity; right or left lower extremity
The examination is to include the following for each area: inspection and/or palpation noting
misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions; assessment of range
of motion, noting pain, crepitation, or contracture; assessment of muscle strength and tone with
notation of atrophy or abnormal movements
Cranial nerves with notation of deficits
Deep tendon reflexes noting pathology
Sensation (sharp, dull, vibrations, proprioception)
Description of patient's judgment and insight
Mental status: orientation to time, place, and person; recent and remote memory; mood and effect
Inspection of skin and subcutaneous tissues (rashes, lesions, or ulcers)
Palpation of skin and subcutaneous tissues (for indurations, nodules and tightening)
Chapter 38 — Outpatient Coding 527
Single Organ System Examinations
The single organ system examination (SOSE) is the same as the multisystem
examination (MSE) except that the single systems are more detailed. For
example, the E/M documentation for a comprehensive examination would
include at least nine organ systems or body areas. The single organ system
examination would include all the elements specified for that organ system.
These elements are very specific to each organ system. The examination
elements that must be documented for a SOSE of the cardiovascular system
for a comprehensive examination code include additional specified exami-
nations of the vital signs and respiratory, cardiovascular, gastrointestinal,
and neurologic systems. These elements are primarily related to differential
diagnoses of cardiovascular diseases. See the complete 1997 E/M guidelines
for details.
Clinical Thinking in Diagnosis and
Treatment
Medical Decision Making
Medical decision making in coding is one of the most confusing areas for
clinicians to understand and code appropriately. The terminology can be
misleading, so instead of medical decision making, think of the clinical
thinking process of differential diagnoses and evaluation of patients with
extensive medical histories and several comorbidities. If the chief complaint
generates a long list of differential diagnoses with a large amount of diag-
nostic data to review, and a high risk of mortality or morbidity could result
from either the treatment or disease itself, the clinical thinking is usually
complex and the code for the decision making is likely to be high complexity.
See Table 38-4 for a summary of E/M code levels and elements of medical
decision making. To qualify for a given type of decision making, two of the
three elements outlined in Table 38-4 must be met or exceeded. For high
complexity criteria to be met, two of the elements listed below must be
extensive or high to qualify.
There are four types of medical decision making:
■ Straightforward
Low complexity
Table 38.4 Types of Medical Decision Making
AMOUNT AND
DIFFERENTIAL
COMPLEXITY OF
RISK OF COMPLICATIONS,
CLINICAL THINKING
DIAGNOSES
REVIEWED DATA
MORBIDITY AND MORTALITY
Straightforward
Minimal
Minimal/None
Minimal
Low complexity
Limited
Limited
Low
Moderate complexity
Multiple
Moderate
Moderate
High complexity
Extensive
Extensive
High
528 Chapter 38 — Outpatient Coding
Table 38.5 Documentation Requirements for New Patient Office Visits, New
Patient Codes
CODE LEVELS, 1 -5
HISTORY
EXAMINATION
MEDICAL DECISION
MAKING
TYPICAL FACE-TO-FACE TIME (min)
99201
Problem Focused
Problem Focused
Straightforward
10
99202
Expanded problem
focused
Expanded problem
focused
Straightforward
20
99203
Detailed
Detailed
Low
30
99203
Comprehensive
Comprehensive
Moderate
45
99205
Comprehensive
Comprehensive
60
■ Moderate complexity
High complexity
Elements of medical decision making:
■ Number of diagnoses or management options
■ Amount and/or complexity of data to be reviewed
Risk of significant complications, morbidity and/or mortality
Example A (see earlier) reflects a CPT coding level four (see Table 38-2). This
patient encounter would be coded a level five if the ROS included 10 systems
reviewed and the notation that all other systems were negative when coding
an established patient visit. (See later for the definition of new patients.)
Counseling
Documentation of a patient encounter that is primarily related to counseling
or coordination of care requires a face-to-face encounter with the patient in
the outpatient setting where the time spent is the primary factor qualifying
the documentation of the E/M services. See Table 38-5 for details of docu-
menting an E/M code based on counseling and face-to-face time as part of the
new patient encounter. The documentation requirements for established
patients are similar.
New Patient Visits
The new patient visit is coded differently than an existing patient visit. In
most medical encounters this is because of the amount of time required to
obtain a complete history from the patient. Therefore, all the E/M levels
are adjusted and have different documentation requirements than for the
previously seen patient. It should be noted here that a new patient is defined
by the location of service and not by the provider of service. In other words,
the patient must be establishing care and a medical record for the initial
encounter in the medical practice. Table 38-5 describes the E/M codes and
Chapter 38 — Outpatient Coding 529
the elements of history and physical examination required for each level.
The terminology and definitions remain the same as for established patient
visits. The definition of a new patient, which is coded at a higher level, is a
patient who has not received any professional services from the health
professional or another health professional of the same specialty who
belongs to the same group practice within the last 3 years.
SUMMARY
Many clinicians view coding as just part of billing; however, as noted earlier,
it should be regarded as part of the documentation process and good patient
care. Usually, once medical professionals understand the process and begin
documenting what has occurred in the examination room, all the positive
aspects of good documentation are realized in patient care and reimbursement.
References
American Medical Association: CPT 2005: Current Procedural
Terminology, Standard Edition. AMA, 2005.
Beacon Healthcare Solutions. ICD.9.CM — Diagnostic and Surgical
Procedures Codes. Copyright 2000-2003. Available at:
www.beaconllc.com/hcref/cclookup/icddescription.htm
Centers for Medicare & Medicaid Services: Documentation Guidelines
for Evaluation and Management Services. CMS, 1997.
London Bills of Mortality 1660-1700. (http://uuhsc.utah.edu/dfpm/epi/
section2_London_Bills_of_Mortality.pdf)
Bibliography
Hill E: Understanding when to use the new patient E/M codes. Fam
Pract Manag 10:33-36, 2003.
Oregon Health & Science University, Department of Family Medicine
(www.ohsu.edu/som/fammed/) progress notes and coding templates.
Rose JS, Fisch BJ, Hogan WR, et al: Common medical terminology
comes of age, Part Two: Current code and terminology sets —
strengths and weaknesses. J Healthc Inf Manag 15:319-330, 2001.
Chapter OQ
Documentation
David P. Asprey
Goals and Objectives
Goal: To provide clinicians with the knowledge and skills
necessary to accurately and successfully document clinical
procedures.
Objectives: The student will be able to ...
• Describe the purpose of documenting clinical procedures.
• Discuss the importance of documenting clinical procedures in
the medical record.
• List the components of a standard clinical procedure note.
531
532 Chapter 39 — Documentation
BACKGROUND AND HISTORY
The medical record is a repository of information that is compiled by many
individuals regarding a single patient. The information includes history and
physical examination findings, data, interpretation of data, and descriptions
of medical acts that were performed. The record serves many different
audiences, which may include the clinician, other health professionals
involved in the patient's care, the patient, supervisors, clinical investigators,
and administrators.
Many of the clinical procedures discussed in this text warrant or require
the clinician involved in performing the procedure to prepare and record a
clinical note for the medical record that documents and describes the
performance of the procedure and the associated findings. Performing a
procedure without documenting it in the clinical note can result in loss of
critical information affecting patient care or the ability of the health care
system to receive reimbursement for the care provided. Documentation of
procedures that have been performed in the medical record can serve
several purposes. These purposes include the following:
■ Memory aid: The medical record originally served as a vehicle for
recording information that may otherwise be forgotten about the patient's
medical condition. However, the patient's complete medical database is a
combination of the clinician's written information and thought
processes. Documentation of the clinical procedure and its findings can
serve to assist the clinician in recalling important findings, techniques
used, or complications encountered while performing a procedure.
■ Communication device: The medical record also functions to
communicate information about a procedure performed and its findings
to other clinicians and health professionals. Because medicine is a
team function, many others will access the information recorded in a
patient's medical record as they provide care to the patient. Because
many others will use the same medical record, following an established
standard for the manner in which this information is recorded is very
important.
Quality assurance instrument: Individuals and organizations involved in
providing patient care need to monitor the quality of the care provided.
A key component of this process involves medical record review by
peers. The medical record is assessed for thoroughness, accuracy, and
documentation of essential elements of a procedure. Record review can
serve as a source of feedback that helps to ensure that the clinician is
following established standards of care.
■ Risk reduction aid: One of the best defenses against malpractice
litigation is a detailed, concise, and accurate medical record that
demonstrates the rational and systematic approach the clinician used in
performing a procedure. The medical record serves as a legal document
and may be used in court as evidence.
Chapter 39 — Documentation 533
Reimbursement aid: Most third-party payers require chart review in
assessing reimbursement or reimbursement levels. In performing clinical
procedures, it is essential to document all aspects of the history,
physical examination, indications, and findings to support the charges
for which reimbursement is being requested. The medical record is used
to verify that the procedure performed was indicated and performed
appropriately. In view of this, it becomes critical to carefully document
all the associated activities involved with performing the procedure. The
perspective that the third-party payer may use is: If it is not recorded, it
was not done. Chapter 38, Outpatient Coding, provides a review of the
importance of documentation related to the billing and coding process.
Evaluation tool: Documentation of clinical procedures may be used in
evaluation. Virtually all medical systems have a mechanism of quality
control that includes evaluation of all clinicians' charts by peer review or
quality control boards. Write-ups by students and others in training are
evaluated, and performance is monitored by their supervising faculty
and staff. Developing strong documentation skills is an important
competence for clinicians in training to obtain.
Research tool: The medical record also serves as a data source for
clinical research in some cases. Retrospective chart reviews are
commonly used in clinical epidemiology studies. Data must be carefully
and accurately recorded for it to be useful in research studies.
OTHER POINTS FOR CONSIDERATION
IN RECORDING CLINICAL
PROCEDURES
Record all the pertinent data: Both positive and negative findings from
an examination or procedure findings may contribute directly to
assessment and differential diagnosis. Any diagnosis made or problem
identified should be clearly spelled out in the record. When other
aspects of the history or physical examination suggest that an abnormality
might exist or that it should be ruled out, be sure to include this
information, even if the abnormality is absent or the finding is a pertinent
negative. Another clinician should be able to read your account and be
able to determine the rationale for your conclusion.
Data not recorded are data lost: Regardless of how vividly you may
recall the detailed information associated with your patient and the
procedure performed, it is highly improbable that you will be able to
remember it clearly in a few weeks or a few months. Unless you record
the presence and absence of findings and the specific steps completed in
performing the procedure, you are at risk of being unable to answer
questions regarding the activities associated with that procedure in the
future. The fact that something is not present in the medical record does
534 Chapter 39 — Documentation
not mean that it was not done or not observed (absence of evidence is
not evidence of absence), but it does allow for this to be an equally
plausible explanation.
Be objective: The clinician recording the data in the medical record needs
to take great care to ensure that only objective information is recorded.
Statements that can be interpreted as judgmental or condescending have
no place in the medical record. Although it is important to remain
objective, doing so should not be misconstrued to mean that clinical
impressions should not be recorded; rather, there should be a rational
basis for your conclusions or impressions.
Consider the use of diagrams: Diagrams can sometimes provide a better
description than words alone. Diagrams used to identify topographic
locations of lesions or techniques used in performing a procedure or to
illustrate clinical findings can be powerful tools. Clinicians who learn to
use diagrams can help improve the accuracy of their record and improve
their efficiency. Clinical procedures often have findings that warrant the
use of a diagram to document findings or techniques used in the
procedure.
Avoid the use of nonstandard abbreviations: Although abbreviations
may prove useful in some limited instances to provide a measure of
efficiency in making entries into the medical record, they have significant
potential for error and confusion on the part of those who read and
interpret them. This same principle is true of acronyms and symbols;
exercise caution in electing to use any of these tools in a medical record.
When in doubt, spell it out.
Make sure the record is legible: If your record is not legible to others, it
will not serve its purpose well as a communication tool, nor will it serve
you well as a legal document. Follow the conventional rules used in
making entries into the medical record.
CLINICAL PROCEDURE NOTES
Entries made into the medical record specifically regarding clinical procedures
performed constitute a unique format. Although they may be incorporated
into a subjective, objective assessment and plan (SOAP) note format in some
instances, the more significant procedures often warrant a separate entry
specific to the procedure performed. Each time that an entry is made into the
medical record regarding a clinical procedure, a conventional format should
be used to help ensure that the essential and important aspects of the
procedure are included and to aid others who access the record in finding
the important information. One such format is listed in the following section.
A sample note is presented in Figure 39-1.
Chapter 39 — Documentation 535
Demographic data:
Name: Mary Smith, ID# 123-45-6789, Age: 48 years, Date: 08/09/01 , Time: 1 :45 pm,
Location: Procedure room W139, outpatient clinic.
Procedure performed:
Incision and drainage of abscess in perirectal area
Primary indications for performing the procedure:
Treatment of localized skin infection and relief from associated pain
Contraindications:
None, patient reports no known allergies
Consent:
Informed consent was obtained and form signed and filed in medical record before
performing the procedure.
Personnel:
Procedure was performed by Jane Doe, PA, with assistance from Sara Shoe, RN.
Anesthesia:
A regional field block was performed using 8 ml_ of 1% lidocaine without
epinephrine.
Description of the procedure performed:
The patient was positioned in a dorsal recumbent position and the skin of the
perianal area was cleansed using povidone-iodine (Betadine). A regional field
block was performed with 1% lidocaine. The patient was then draped, and an
elliptic incision was performed parallel to the skin tension lines in the skin over-
lying the abscess. The abscess was explored with a sterile cotton-tipped applicator,
and cultures were obtained and sent to the laboratory. A sterile, blunt hemostat was
then used to disrupt loculations in the skin comprising the abscess with blunt
dissection technique. The area was massaged to facilitate the expression of purulent
material from the depths of the abscess. The wound was irrigated with 300 ml_ of
normal saline solution. The wound was then packed with iodoform gauze. The wound
was covered lightly with an absorbent bandage.
Findings:
The abscess margins were approximately 1 .5 cm deep x 2.0 cm wide. Moderate
amounts of purulent material were expressed from the abscess with no unusual odor
noted. Multiple loculations were present within the abscess, and they were disrupted
with blunt dissection. The depths of the abscess were explored with no evidence of
rectal fissure formation, and the abscess appeared to be limited to the subcutaneous
fat layer of the skin. No foreign bodies or matter were noted in the abscess.
Description of any important physical examination findings, after the procedure:
No evidence of rectal fissure formation was noted on reexamination of the abscess
after drainage.
Complications, including blood loss, side effects, and adverse reactions:
No complications were encountered. Estimated blood loss was 5 ml_.
Instructions and follow-up plans:
The patient was instructed about the proper technique to pack the abscess with
iodoform gauze and bandage the wound. Patient was advised to repack the wound
twice daily. Patient was educated regarding signs of advancing infection and
instructed to contact our office or return to the clinic if they occur. A prescription for
Tylenol No.3 — to be taken 1 to 2 tablets PO every 6 hours during the next 48 hours
"total of 16 tablets" — for pain relief was given. The patient was advised not to drive or
operate equipment while taking this medication. Patient was advised to schedule
a return appointment in 10 days.
Time procedure completed and condition of patient:
The procedure was completed in 20 minutes, and the patient was released to travel
home with her spouse in good condition.
Figure 39- 1 . Sample procedure note.
536 Chapter 39 — Documentation
CLINICAL PROCEDURE NOTE FORMAT
If the clinician performing the procedure determines that a separate note is
warranted, the format proposed in this section may be used to record the
essential information.
1. Demographic data (patient name and identification number, age, date,
time, and location)
2. Name or description of procedure performed
3. Primary indication or indications for performing the procedure
4. Contraindications, including potential allergies to medications that may
be used in performing the procedure
5. Consent (if obtained) — indicate that informed consent was obtained
and that forms were signed and filed in medical record before performing
the procedure
6. Personnel — indicate the clinician who performed the procedure and
any attendants who assisted with the procedure
7. Description of any important physical examination findings before
performing the procedure. This should include vital signs prior to
initiating the procedure.
8. Anesthesia (specific agent, quantity used, and route administered), if
applicable
9. Description of the procedure performed (include description of
equipment used and any variations to the technique); diagrams may be
useful in documenting the location of lesions, and so on
10. Description of the relevant findings associated with the procedure,
including abnormal structures, pending laboratory tests, or specimen
samples sent for examination; diagrams may be useful in recording
pertinent findings
11. Description of any important physical examination findings after the
procedure (e.g., vascular supply intact distally, neurologic examination
findings, functionality of joint or adjacent structures). Documentation of
vital signs post procedure is important.
12. Complications, including blood loss, side effects, and adverse reactions
13. Instructions and follow-up plans
14. Time that procedure was completed and the condition of patient at that
time
CONCLUSION
Documentation of the clinical procedure in the medical record is an essential
component of any complete procedure. Exercising care to be certain that the
entry into the medical record follows a conventional format and is thorough
helps avoid potential problems associated with incomplete entries.
Bibliography
Chapter 39 — Documentation 537
Bates B: A Guide to Physical Examination and History Taking, 6th ed.
Philadelphia, JB Lippincott, 1995.
Coulehan JL, Block MR: The Medical Interview: Mastering Skills for
Clinical Practice, 5th ed. Philadelphia, FA Davis, 2006.
Suggs K, Meehan A, Rahr RR: Patient record. In Ballweg R, Stolberg S,
Sullivan EM (eds): Physician Assistant: A Guide to Clinical Practice,
3rd ed. Philadelphia, WB Saunders, 2003, pp 157-180.
Chapter A f\
Giving Sad and Bad News
F. J. Gianola
Goals and Objectives
Goal: To give sad or bad news consistently and with minimal
anxiety or stress.
Objectives: The student will be able to ...
• Define sad and bad news.
• Describe the goals for giving sad and bad news.
• Describe the principles of SPIKES, the six-step approach for
giving sad and bad news.
• List the six steps in the SPIKES protocol.
539
540 Chapter 40 — Giving Sad and Bad News
An expert in breaking bad news is not someone who gets it right every
time — she or he is merely someone who gets it wrong less often, and who
is less flustered when things do not go smoothly
Robert Buckman, 1992
BACKGROUND AND HISTORY
For the past 3,000 years, physicians have had an exquisite ability to describe
disease processes. Their ability to observe, diagnose, prognosticate, and
treat disease — in a manner appropriate for the time — is well documented
(Simon, 1999). But truth-telling to the patient was not the norm. In 1951 Kline
and Sobin described methods to avoid giving information (Kline, 1951). A
1961 paper in JAMA (Oken, 1961) reported that 90% of physicians would not
choose to let their patients know of a diagnosis of cancer. This was done in
good faith and in the spirit of beneficence, based on the belief that the truth
would shatter patients' hope and hasten their deaths.
By 1971 there was a sea change in attitudes. By that time, 97% of physicians
would tell their patients of a cancer diagnosis (Novack, 1979). However,
sharing bad news with a patient is difficult and causes significant stress, as
discussed in an extensive review (Fallowfield, 2004). A major cause of this
stress is the lack of proper training and evaluation for providers. Lack of
training and subsequent inappropriate communications can result in long-
term devastating effects to both patients and providers. For the most part,
patients want to know the truth even if it is sad, bad, or difficult (Benbassat,
1998). The principle of autonomy (Beauchamp, 2001) requires this level of
information in order for patients to make informed decisions about their
care. A decision not to know is also a choice that is discussed later in this
chapter. A mutually responsive patient-clinician relationship is crucial for
productive, secure, and successful therapeutic encounters, and giving sad
news is often part of the interaction.
INDICATIONS
Many of the clinical procedures within this text provide practitioners with
diagnostic data. For example, the patient-clinician relationship (involving
either the primary care provider or the specialist consultant) can create an
expectation that test results will be shared. In any procedure, preparations
must be made; instruments must be obtained and set up. In many cases, a
step by step method for a procedure has been planned with the knowledge
that normal anatomic variation may change some of the steps. The procedures
are done in a case-based manner, and both the provider and the patient
should be aware of the contraindications and potential complications. This
is also true of breaking difficult news to patients. The most powerful instrument
for this procedure is your words. Words soothe, words cause wars, and words
can bring peace. In the medical profession, words can change the course of
Chapter 40 — Giving Sad and Bad News 541
peoples' lives. When giving sad or bad news, providers must think before
they speak.
What is "bad" news? In Buckman's paper "Breaking bad news: Why is it still
so difficult?" it means "any news that drastically and negatively alters the
patient's view of his or her future" (Buckman, 1984). Despite the passage of
time, breaking bad news is still difficult. Sad, bad news is not necessarily
news of fatal illness. The information can be any chronic disease that changes
a patient's life, such as diabetes, hypertension, macular degeneration, pro-
gressive hearing loss of unknown origin, or multiple sclerosis. Sometimes we
diagnose these so often that it becomes commonplace. However, for the
patient the diagnosis is new and can be both life-changing and life-threatening.
The choice of words and how we present them may well change the patient-
clinician relationship forever in either a positive or negative manner. The
name given an illness can alter the patient's personal, family, and societal life
(Wood, 1991). In the majority of instances when the clinician states and
confirms a life-changing diagnosis, the patient does not hear anything else
during the encounter.
PREPARING TO SHARE BAD NEWS
In preparing to give sad or bad news, one should think about the content of
the message. Confidence is built on a foundation of competence. Cultural
sensitivity and awareness and language should be part of your initial con-
siderations. Remember that sharing the information is a dialogue with the
patient, not a monologue by the provider. Silence is not an enemy; it can
provide needed time for the patient to comprehend the information. An
empathetic, caring, comforting, and pleasant manner is crucial in giving this
news (Larson, 2005). Yet the situation is often so tense that being empathetic
and caring can be very difficult. Many times the news creates an emotionally
explosive reaction and the bearer of the news gets the blame. To remain calm
and reassuring requires preparation and experience. Experience comes only
with time and multiple encounters with such situations.
As stated earlier, with any other procedure, having your instruments set
out properly is the first step. Just as procedures are not exactly the same
every time, bringing sad or bad news requires individualized consideration.
Different approaches are required. Just as experience builds a provider's
confidence and ability in history-taking or performing physical examinations,
the provider's approach to sharing bad news may change with time, and
frequency will help build confidence. Following are some guidelines for this
process. Interviewing skills should incorporate the Buckman recommendations
(Buckman, 1992).
■ Nonverbal communication: make eye contact, lean forward, give
encouraging looks, and nod (when appropriate).
■ Questions should be simple and brief, open-ended progressing to
focused, and closed questions should be used only if necessary to obtain
specific information.
542 Chapter 40 — Giving Sad and Bad News
■ Summarize information periodically and ask clarifying questions to
obtain a fuller understanding of the history
Engage in active listening, including restatement and summarization,
which indicates you have heard the patient.
■ Listen with empathy, reflect back to the patient empathetically what the
patient has said. Respond to the mood and feelings of the patient.
A PROCEDURE FOR SHARING
BAD NEWS
Robert Buckman was one of the first to develop guidelines for sharing bad
news. The guidelines are meant to "be practical and useful in daily clinical
situations based on some consistent and coherent principles, intelligible,
teachable, and, most important, learnable" (Buckman, 1992).
SPIKES
The SPIKES approach (Baile, 2000) to sharing bad news consists of the
following elements:
Setting up: Setting up the interview
■ Perception: assessing the patient's Perception
Invitation: obtaining the patient's Invitation
Knowledge: giving Knowledge and information to the patient
Emotions: addressing the patient's Emotions with empathetic responses
Strategy: Strategy and summary
Setting Up
In setting up the interview there are five areas to be aware of in planning a
strategy. Some may seem obvious but should not be overlooked. Arrange for
privacy in an office or private room; if this is not obtainable, create some
privacy in the patient's room. Have a member of the patient's family or a
close friend of the patient be present. The patient should not be alone for this
information. Sit down so it conveys to the patient you are not in a rush to
leave. Sitting puts you at eye level with the patient and creates a more
supportive impression. Eye contact can establish a connection with the
patient; however, being culturally aware in this situation is fundamental.
Showing common courtesy and respect and not appearing rushed go a long
way toward a successful discussion. Address the patient by his or her
surname unless you know him or her well and have used the first name in the
past. Depending on the comfort level of the patient, touching the patient on
Chapter 40 — Giving Sad and Bad News 543
the arm or shoulder may help make this connection. Set your pager or cell
phone on silent mode and schedule sufficient time for sharing this infor-
mation. If there are any issues with time let the patient know so it is not a
surprise if you must leave. Arrange for no interruptions.
Perception
Assess the patient's perception. How does the patient perceive the medical
situation? How much does the patient know about the illness? The choice of
words in the opening question is important. They should be your words so
that you feel comfortable with them. The content in such questions can be
as follows:
■ Do you know why you had this procedure?
■ What have you been told about your condition?
■ Have you been very worried about this ...?
When these symptoms first started, what did you think it was?
■ How worried have you been about yourself?
■ Have you been worried about this being serious?
■ What do you think is going on with ...?
Asking open-ended questions not only helps gauge how much the patient
knows but also may reveal the patient's expectation of treatment, concerns,
or denial of the present illness. The answers may help the provider find a
starting point. They also allow the provider to correct misconceptions or
misinformation. Listen for the emotional content of the patient's responses
to learn both what he or she wants to talk about and does not want to talk
about. Body language can provide a considerable amount of information if
the patient moves away, wrings the hands, or is tearful. Seemingly happy,
nonchalant, or blase body language and attitude can also give you an
indication of the patient's emotional state.
Invitation
Obtain the patient's invitation for sharing the data acquired from the
procedure. Providers must obtain permission from the patient before divulging
the sad or bad news. Most patients want to know the diagnosis, prognosis,
and any available treatment. Some do not. Health care decisions may be
made or shared with family or community leadership (Mitchell, 1998). If the
patient does not want to know specifics, offer support and an appointment
to talk again in the future. With the patient's permission, talking to a family
member or close friend can be arranged. Again, the style and exact words to
use should be your own. Following are some examples of the content:
Would you like me to tell you the specifics of your condition, or is there
someone else you would like me to have a word with?
544 Chapter 40 — Giving Sad and Bad News
■ How much do you want to know if your condition is serious?
m If this condition turns out to be serious, would you like to know specifically
what the situation is?
Some folks would like to hear the treatment plan first without knowing the
full details of what is wrong. Is that what you would be more comfortable
with?
■ Would you like me to summarize your condition or do you want to know
precisely what we are dealing with?
Knowledge
Provide knowledge and information to the patient. There are two parts to
this section. First, provide understandable information to the patient. Second,
offer a therapeutic conversation in which you listen, hear, and respond to the
patient's reaction to the information. Before starting this section of the
paradigm, it is imperative to know the purpose or goals of the interview. The
goals should incorporate four key components: diagnosis, plan of treatment,
prognosis, and support. Although the content of each component is case-
based and specific for each patient, you are obliged to have a goal for the
interview. Your goal and the patient's may differ, but they may be brought
closer together by the end of the interview. The patient has the right to
accept or reject the information, as well as the treatment or diagnosis. The
patient has a right to respond in any (lawful) way he or she may choose.
Medical providers must be prepared to accept these responses.
By this point in the dialogue, the patient has given consent to the provider
about the amount of information he or she is willing to hear. The process of
imparting knowledge to the patient is a true dialogue. This process must be
assessed frequently by observing the patient's responses to the information.
Sharing the information should be gentle, consistent, and at the patient's
pace. Information should be given in small digestible portions. The clinician
can assess whether the information is being comprehended by asking
questions such as these:
■ Can I clarify anything?
Does this information make sense to you?
■ This can be confusing, but do you follow me so far?
If there is a gap between the patient's expectations and the data being
presented, the following statement may be included:
■ This condition is much more serious than . . .
The patient requires the information in order to make an informed choice.
When providing the information, start at the level of the patient's
understanding and terminology. For example, instead of saying "demyelination,"
say "damage to the insulation covering of the nerve"; instead of saying
"metastasize," use the word "spread." Clarify to make sure your understanding
and the patient's understanding of the words are the same. To do this, ask
Chapter 40 — Giving Sad and Bad News 545
the patient to repeat the general meaning of what has been said. Repeat the
essential portions. People hearing sad or bad news have limitations in
processing information when facing serious illness. An empathetic response
may be as follows:
/ know it is hard to hear and remember all the specifics at once . . .
The use of simple handwritten illustrations or flow charts can be helpful,
and including your name and office number can bring a very personal
feeling to the situation. This handwritten aid may help the patient remember
more of the encounter. Pamphlets and educational materials should also be
used.
Listen for the patient's concerns while proceeding through the sharing of
information. Ask about worries and fears, because many times they stem
from rumors or inaccurate information. The patient may have concerns
about the effects of the treatment or quality-of-life issues. By listening and
acknowledging the patient's concerns, you can address them then or at a
future appointment. Sometimes patients ask questions while the clinician is
talking. These are often important questions and should be addressed care-
fully. Finish the sentence, then ask the patient to repeat the question. Many
times these questions are the heart of the discussion and can be very pro-
ductive. Not infrequently, as the interview is drawing to an end, the patient
wants to restart a portion of it again. This is not necessarily obstinate
behavior, but rather is an indication that the patient is afraid and anxious. Sit
down for a moment to reassure the patient, acknowledge the concern, and
set up another time to talk further about the issue. A short moment may save
significant anguish for the patient and illustrates your concern. Demonstrating
concern by listening allows the clinician to accommodate the patient's
perspective. These actions can help bring together the provider's and patient's
goals and objectives to create a stronger patient-provider relationship.
Emotions
Addressing the patient's emotions with an appropriate empathetic response
can determine the outcome of breaking sad or bad news. Emotional reactions
by the patient are often the cause of considerable trepidation for the provider.
Experience is the one thing that addresses the anxiety of the unknown. Each
encounter decreases the number of unexpected reactions to sad and bad
news. The reactions are as varied as the patients; however, there are some
general categories and behaviors to be expected.
Patient reactions can include disbelief, shock, denial, displacement, fear
and anxiety, anger and blame, anger against specific entities, guilt, depression,
overdependency, crying and tears, "why me," threats, humor, seduction,
bargaining, awkward questions, and the search for meaning. Not all of these
reactions can be addressed here, but those that are seen most frequently are
identified. Additionally, there are specific issues related to breaking sad or
bad news to children, whether the bad news is about themselves or others.
Although these issues are not discussed in depth in this chapter, it is
important to be aware of the different needs that younger patients have.
546 Chapter 40 — Giving Sad and Bad News
Disbelief
Disbelief is a frequent response, especially if the news is not expected. This
reaction is not meant to create tension with the provider; it highlights the
difficulty of taking in the news. The issue is not about factual disagreements,
and the provider needs to focus on acknowledging the patient's difficulty in
acceptance. Consider the following responses:
■ News about this serious illness must come as a shock, especially when you
are feeling so good.
How does this make you feel?
Shock
The common meaning of shock is alarm, distress, or terror. This reaction is
not difficult to identify. The provider's response is much more difficult. How
can you console and support this reaction? This reaction shows a failure to
function and an inability to make decisions. It is most commonly expressed
in silence, with an inability to speak or respond to your questions. Occasion-
ally there can be more dramatic expressions of wailing and deep anguish by
pacing around the room or falling to the floor inconsolably Allowing the
patient to express very deep feelings is okay. Questions that may help are as
follows:
■ Are you okay?
What are you thinking now?
For both disbelief and shock, try:
This news must be overwhelming for you.
Denial
When experiencing denial, the patient has a sincere conviction that the news
is incorrect or a mistake. The patient may ask you to recheck results because
he or she is sure there was a mix-up in the laboratory. In a more subtle form,
the patient may start talking about long-term plans (e.g., planning to build a
house, a year-long sailing excursion) when the news is such that the prob-
ability for these plans to be fulfilled is unrealistic. The provider's reaction to
the patient's denial may be defensive, reacting to the perception that the
provider is viewed as incompetent. Denial is a protective response to protect
the self from harm and to view the future self intact. Denial is a normal
response to overwhelming information that threatens the future existence of
the person. Questions to ask the patient should include the following type of
information:
■ What is it that makes you believe information is inaccurate?
Accepting this news must not be easy.
Denial in the initial period of hearing sad and bad news is normal. Denial
that continues for an extended period of time will increase the patient's
distress, needs to be addressed cautiously, and requires comprehensive
negotiation.
Chapter 40 — Giving Sad and Bad News 547
Fear and Anxiety
Fear and anxiety are often used interchangeably; however, they are different
entities. A specific object or event or the thought of a specific object or event
often prompts fear. Fear is acute, with a quick response to the prompt and a
quick fade when the prompt is removed. Anxiety is chronic. It may come on
rapidly and often takes longer to resolve after the prompt has been removed.
Identify the cause or source of the fear or anxiety by listening adequately to
the patient's feelings. Trying to reassure the patient without discovering the
source will be ineffective and will not decrease the intensity of anxiety or
fear. Acknowledge the patient's feelings. Identifying and acknowledging the
patient's feelings may reduce the fear or anxiety in some cases. Provide as
much detailed information as seems appropriate to the case. See what
happens when the information is provided. If providing it reduces the fear or
anxiety, you have succeeded in this area. You may continue to give infor-
mation as the patient requests it. If the information does not appear to help,
stop giving it, because the patient will not accept the information. If the
patient's fears and anxiety are severe or prolonged, get help and consider
referral to a mental health professional. Following are some empathetic
questions for patients with anxiety or fear:
With all this news, what worries you the most?
Have you been thinking about what might happen to you? That must be
quite stressful for you.
■ Could you tell me your main worries? Endless worry about (recurrence)
must be dreadful.
Finally, with anxious or fearful patients, the greater their anguish, the greater
your urge to over-reassure them. Over-reassurance creates a greater distance
from the reality of the situation, which is counterproductive for both the
provider and patient.
Anger and Blame
Anger and blame are the emotions that are most often directed at the health
care provider. Understanding the anger a patient may feel is useful and can
prepare you for using specific techniques to address it rather than being
overwhelmed by it. Knowledge and recognition of the types of anger will
make it easier for you keep hold of the situation and sustain a sense of
composure to support the patient during the interview. Being judgmental in
this situation is not helpful. Buckman has identified "rough and ready"
classifications of a patient's anger (Buckman, 1992):
Abstract anger (appropriate or inappropriate)
■ Against the disease — symptoms, disability, freedom, "death sentence"
■ Against loss of control and powerlessness — determination of lifestyle,
movements; dependency on others
■ Against loss and potential — loss of hopes and aspirations: career,
relationships, family, life fulfillment
548 Chapter 40 — Giving Sad and Bad News
■ Against laws of nature/randomness — random biologic events,
unfairness (why me?)
Anger against specific entities (appropriate or inappropriate)
Against self — causal anger (if patients feel they are causing their own
disease), body for failing, opportunities missed, own attitude
Against friends and family — own health, "residual anger from old
family rifts or feuds," receiving advice, charity, sympathy; causal anger
may be appropriate (e.g., believes friends caused disease through
passive smoke) or inappropriate (abandonment or distancing)
■ Against medical and other health professionals — "blaming the
messenger" for the news, loss of control (now is with medical team),
medical team members who are healthy, communication gaps (not
listening, uncaring), management decisions (should have diagnosed
earlier and treated differently)
■ Against "outside forces" — workplace, occupation, environment, home,
socioeconomic or political forces
■ Against God — "abandonment (he has forsaken me) . . . perceived
vindictiveness (divine retribution) . . . poor return on faith and
religious observances over many years" (Buckman, 1992)
Appropriate questions may be as follows:
■ You are angry. What other feeling do you have?
■ You sound very angry that this was not picked up earlier
Open-ended questions and acknowledging anger seem simple but can cause an
explosive outburst. Remember that you are in control of the situation and
usually will not be the target of anger. An empathetic question removes the
provider as the target and does not escalate the patient's anger. Often the
conversation can move on to the present situation.
An interesting note: "Human beings seem to be programmed to decrease
their anger when it meets a submissive response. Body language that moves
away from counteraggression helps to diffuse a patient's anger. When a
patient is angry it is worth trying to keep your head lower than the patient's.
A useful technique is to have the patient seated upright on the examination
couch, while you sit on a chair or stool. It is interesting to note how difficult
it is to maintain anger when the target of it is sitting below you." (Buckman,
1992).
Guilt
Guilt appears to have three components. It is a self-focused or directed
emotion. There is self-blame, and there is an aspect of sorrow or regret.
Rarely are any of these components helpful to the patient. In most cases guilt
about an illness is maladaptive. An empathetic content comment may be:
Thinking this (condition) is your fault must be very painful.
Chapter 40 — Giving Sad and Bad News 549
Depression. Situational depression is not an uncommon reaction to sad and
bad news. The diagnostic criteria are well-known: depressed mood, irritability,
weight change, difficulty sleeping or difficulty getting up from sleep, fatigue,
feelings of worthlessness, recurrent thoughts of death or suicide, decreased
ability to think, concentrate, or make decisions. If the symptoms are present
and a diagnosis is made, be prepared to treat. The patient will usually feel
significant relief after the provider has identified the depression for the patient,
reviewed the symptoms, and explained that it is treatable and resolvable.
Crying and tears. Crying and tears are not an emotion but a symptom of
anger, fright, rage, sadness, frustration, despair, and others. Tears come easily
to some and rarely for others. It is odd that in this Western culture, although
tears signal that one is upset, we are uncomfortable comforting strangers
who are crying. Some fairly straightforward actions can help the provider
cope and comfort. Move closer to the patient. Often people who are crying
feel alone. Offer a tissue or handkerchief. Make sure there are tissues in place
when you are giving sad or bad news. Offering a tissue gives the patient
evident permission to cry, gives the patient something to dry the tears and
clean a runny noise (it is very difficult to continue a conversation without
this accommodation), gives the provider something to do, and brings the
provider and patient closer together. Try touching the patient on the shoulder,
elbow, or arm to try to identify the emotion causing the tears and offer an
empathetic response. If the cause is not obvious, simply ask:
Can you tell me what is causing you to cry?
Awkward question. Two questions that many providers find thorny are How
long have I got? and Am I terminal?. How long have I got? is probably the most
common question asked when hearing bad news. It is also difficult to provide
a single answer to cover all the possibilities. However, there are three
principles to keep in mind. Assess what the patient thinks the situation is at
the moment. Ask the patient what he or she has been thinking about this
question. Clarify what the patient is truly asking. Assume nothing. You can
inquire:
■ Are you asking me how long you have to live?
Give the patient some type of answer that is close to the clinical data.
Remember the power of words and that the answer will be remembered for
a long time, even if it is inaccurate. Give hard data, if possible, because the
outcome is patient-specific. Statements could include the following:
■ It could be several months or a small number of years, but probably not
many
This condition is very serious, maybe several weeks or a few months.
Uncertainty is difficult and unpleasant. People are unique organisms who
know they are going to die sometime, yet the exact time and date are always
uncertain. It is very difficult to make a genuine heartfelt empathetic
statement. Simply offer a comforting acknowledgement, such as:
It must be very difficult not knowing what will happen next or when it will
happen.
550 Chapter 40 — Giving Sad and Bad News
When the patient asks Am I terminal?, be sure to clarify what terminal
means to the patient. Providing an answer to the question you assume is
being asked can be very embarrassing and may be less than endearing. The
content of your response could include the following:
■ Your question is very important and I will attempt to answer it. But could
you tell me what you are thinking when you ask about being terminal?
Sad and bad news presented to children. Breaking sad or bad news to
children about themselves or others requires a unique skill set and a high-
quality delivery. There is much literature on this subject, including books
and new guidelines developed by the American Academy of Pediatrics. It is
generally thought that early knowledge of a life-threatening diagnosis and not
suppressing or concealing it is associated with healthy psychological adjust-
ment for the child (Slavin, 1982). Providing this information is normally done
with the help of a skilled specialist counselor, but there could be times when
it may need to be done without a counselor. Buckman has identified five
principles for delivering sad and bad news to children (Buckman, 1992):
The closest adult family member should always be present and an
agreed-upon approach to the interview should be followed. The family
member may request participation. Family members often have helpful
insights that can help avoid unexpected surprises. Only in the most
ominous, urgent situation should you attempt to discuss these issues
without a close relative present.
Review frequently with the child his or her understanding of the
information you are providing. A child's perception of what you are
saying can be very different from what the child is hearing. Provide the
information in a language that reflects the questions that the child is
asking.
■ It is common for the same question to be asked repeatedly, to go over
the same information. It is the normal manner in which children process
information they have been told so they can be sure they have understood
correctly what has been said.
Many children believe that if they think something, then it will happen. If
they are angry with someone who later becomes seriously ill, children
may believe their anger toward the person caused the illness. This is
called "magical thinking." If a child is asked repeatedly by a parent to
perform a task such as putting toys away and the child does not
remember to perform the task, the child may feel guilty and responsible
if the parent then becomes ill. (If only I had picked up my toys papa would
not be so sick). This type of thinking is not obvious; however, one way to
assuage the child's potential guilt is to say directly:
■ Sometimes people get ill for no apparent reason.
■ It's not your papa's fault he is ill, it's not our fault, and it definitely is not
your fault. Sometimes these things just happen.
Chapter 40 — Giving Sad and Bad News 551
If you are inexperienced or uncertain, find assistance as soon as
possible. Find an expert or a more experienced team member. You may
be asked to be in further interviews with the child if a bond has been
created or you know the family well.
Strategy
Contemplate a strategy for the case. By this point in the interview, depending
on the sad or bad news, the patient may feel isolated and uncertain. The
patient will be looking to you to help make sense out of the uncertainty.
Knowing the patient's perspective on the illness and how much he or she
knows about the situation and combining the patient's goals and your
modified goals, expresses an alliance with the patient in creating a plan for
the near future. The medical treatment plan forms the initial element of the
patient's support strategy.
Help the patient identify his or her best coping skills and what type of
support system can be created. Engaging the patient in some responsible
action can be empowering. The concept of support does not mean doing
everything possible for the patient. That is impractical and impossible.
Active, effective listening is the initial step in support. Listen in a non-
judgmental manner to what the patient says. Help the patient identify the
observed emotions and behavior and support the patient, especially if you
may not agree personally with the other point of view. Summarize the
discussion to include the patient's condition and the plan for the future. In
the plan it is helpful to provide the patient with the sequence of coming
events, including tests, treatment or palliative care, and the next appoint-
ment time frame. Writing these down for the patient provides a reminder of
the events to come and the personal interaction that is needed in giving sad
and bad news. Finally, ask the patient in your style and words:
■ Is there anything we missed or other questions you would like to ask?
CONCLUSION AND FURTHER
THOUGHTS
This process may appear arduous, complex and time-consuming. It is not. As
with any procedure, experience improves and bolsters confidence. It does
not necessarily make it easier.
Clinical empathy as an element of emotional labor can provide the clinician
more professional satisfaction (Larson, 2005). When giving sad and bad news,
remember that we have two things in common with all human beings on
earth. We are born and we die. We are the only species that is aware of life's
limitation. Between birth and death is commentary. As medical providers we
have the honor of witnessing the commentary and listening to our patients'
stories. Providing sad and bad news is part of our commentary.
552 Chapter 40 — Giving Sad and Bad News
References
Baile WF, Buckman R, Lenzi R, et al: SPIKES — A six-step protocol for
delivering bad news: Application to the patient with cancer.
Oncologist 5:302-311, 2000.
Beauchamp T, Childress JF: Principles and Practices of Biomedical
Ethics, 5th ed. New York, Oxford University Press, 2001.
Benbassat J, Pilpel D, Tidhar M: Patients' preferences for participation
in clinical decision making: A review of published surveys. Behav
Med 24:81-88, 1991.
Buckman R: Breaking bad news: Why is it still so difficult? Br Med J
(Clin Res Ed) 288:1597-1599, 1992.
Buckman R: How to Break Bad News: A Guide for Health Professionals.
Baltimore, Md, The Johns Hopkins University Press, 1992.
Fallowfield L, Jenkins V: Communicating sad, bad, and difficult news in
medicine. Lancet 363:312-319, 2004.
Kline NS, Sobin J: The psychological management of cancer patients.
JAMA 146:1547-1551, 1951.
Larson EB, Yao X: Clinical empathy as emotional labor in the patient-
physician relationship. JAMA 293:1100-1106, 2005.
Mitchell JL: Cross-cultural issues in the disclosure of cancer. Cancer
Pract 6:153-160, 1988.
Novack DH, Plumer R, Smith PL, et al: Changes in physicians' attitudes
toward telling the cancer patient. JAMA 241:897-900, 1979.
Oken D: What to tell cancer patients: A study of medical attitudes.
JAMA 175:1120-1128, 1961.
Simon SR: Moses Maimonides: Medieval physician and scholar. Arch Int
Med 159:1841-1845, 1999.
Slavin LA, O'Malley JE, Koocher GP, Foster DJ: Communication of the
cancer diagnosis to pediatric patients; impact on long-term
adjustment. Am J Psychiatry 139:179-183, 1982.
Wood ML: Naming the illness: The power of words. Fam Med 23:534-538,
1991.
Bibliography
Beauchamp T, Childress JF: Principles and Practices of Biomedical
Ethics, 5th ed. New York, Oxford University Press, 2001.
Buckman R: How to Break Bad News: A Guide for Health Professionals.
Baltimore, Md, The Johns Hopkins University Press, 1992.
Fallowfield L, Jenkins V: Communicating sad, bad, and difficult news in
medicine. Lancet 363:312-319, 2004.
University of Washington School of Medicine: Ethics in medicine:
Breaking bad news. Accessed 12/01/05:
http://eduserv.hscer.washington.edu.offcampus.lib.washington.edu/bi
oethics/topics/badnws.html
Ind
ex
Note: Page numbers followed by f and t refer to figures and tables, respectively.
A
Anesthesia — cont'd
Arterial puncture — cont'd
Abscess
local — cont'd
patient preparation for, 88-89
etiology of, 372-373
drugs for, 296, 29 7t, 304-306
procedure for, 89-91, 90f, 91 f
incision and drainage of, 369-379
factors affecting quality of, 296, 298-300
special considerations in, 91
analgesia after, 378
indications for, 300
Arterial spasm, during or after arterial
anatomy and physiology for, 371
for intravenous catheter insertion, 75
puncture, 86
background and history of, 370
materials utilized for, 304-306
Aspiration
clinical evaluation for, 371
patient preparation for, 303-304
from ampule, 103-104, 103f
complications of, 370-371
in patient preparation for intubation,
joint and bursal, 259-273. See also Bursal
contraindications to, 370
150-151
aspiration; Joint aspiration.
follow-up care and instructions in,
plus buffering agent, 299
from vial, 104, 104f
378-379
plus epinephrine, 298
ATS standard, in pulmonary function
indications for, 370
procedure for, 299, 306-310
testing, 176
materials utilized for, 373-374
for removal of ingrown toenail, 414
Auscultatory gap, 41
patient preparation for, 373
in patient preparation for intubation,
Autonomy, protection of, in informed
procedure for, 374-377, 375f, 376f
150-151, 152-153
consent, 2-3
special considerations in, 377
topical
at injection site, 96
contraindications to, 300
therapy for, 371-372
drugs for, 296, 29 7t, 304-305
Acne surgery, 363-365, 365f
materials utilized for, 304-305
B
Acrochordon, snip excision of, 345, 348, 350
procedure for, 306-307
Bacteremia, 64
Adhesives, in wound closure
Anger, after hearing sad and bad news,
Bad news. See Sad and bad news.
follow-up care and instructions for, 340
547-548
Baker's cyst, 262
materials utilized for, 336
Ankle, blood pressure measurement in, 43
Barriers, protective, 18-19
procedure for, 336-337
Anorectal junction, 437
Bartholin's glands, 232f, 233
"Affirmative duty" to disclose information,
Anorectal ring, 42 7f, 428
Basal cell carcinoma, curettage and
3
Anoscope, 429, 429f
desiccation for, 350
Age, patient education and, 511-512
Anoscopy, 425-431
Basilic vein, for venipuncture, 50, 5 If, 54
Air embolism, from intravenous therapy, 73
anatomy and physiology for, 427-428, 42 7f
Battery, in failure to obtain informed
Airborne precautions, 15t-16t
background and history of, 426
consent, 3
Airway, examination of, before sedation,
complications of, 427
Benzocaine, 151, 297t, 302
498-499, 499f
contraindications to, 426
Benzodiazepines
Alginate dressings, 385, 388, 388f
follow-up care and instructions in, 431
in procedural sedation, 501, 502t
Allen test, 85, 85f
indications for, 426
reversing agent for, 502, 503t
Allergic reactions, to local anesthetics,
materials utilized for, 429, 429f
Bethesda system, in Pap smear analysis,
302-303
patient preparation for, 428
230, 231t
Aluminum chloride, for post-biopsy
procedure for, 430-431, 430f
Bicycle ergometer, for exercise stress
bleeding, 346
Anterior chamber of eye, 459-460, 459f
testing, 135-136
Ambulatory blood pressure measurement,
Antibiotics
Bimanual examination, in pelvic
42
after abscess incision and drainage, 377
examination, 245
American Academy of Physician Assistants,
for high-risk wound, 338
Biopsy, 344-360
protection of patient autonomy
at intravenous catheter insertion site, 81
background and history of, 344, 344f
guidelines of, 2
topical, after corneal abrasion or ocular
endometrial, 471-480. See also
American Society of Anesthesiologists,
foreign body removal, 467
Endometrial biopsy.
physical status classification of, 496t
Antimicrobial soap, 26
excisional, 356-360. See also Excisional
Amide anesthetics, 296, 297t, 298
Antisepsis, surgical hand, 26
biopsy.
Ampule, aspiration from, 103-104, 103f
Anxiety, after hearing sad and bad news, 547
punch, 351-355. See also Punch biopsy.
Anal canal, 437
Anxiolysis, 494. See also Sedation.
shave, 345-351. See also Shave biopsy.
Anal verge, 427, 42 7f
Apprehensive patient, blood pressure
Biosynthetic dressings, 389, 389f
Analgesia. See also Sedation.
measurement in, 42
"Blackheads," acne surgery for, 363-365, 365f
after abscess incision and drainage, 378
Apron, in universal precautions, 19
Bladder, catheterization of, 203-216. See
after corneal abrasion or ocular foreign
Aqueous fluid, 460
also Urinary bladder catheterization.
body removal, 467
Arm
Blame, after hearing sad and bad news,
definition of, 494
large, blood pressure measurement in,
547-548
Anaphylactic reaction, to parenteral
42-43
Bleeding. See Hematoma; Hemorrhage.
medications, 95
venous anatomy of, 66f
Block
Anesthesia
Arm ergometer, for exercise stress testing,
digital, 309, 309f
in endometrial biopsy, 477
136
field, 308, 308f
general, definition of, 495
Arterial puncture, 83-92
Blood and body fluids, universal
local, 295-310
Allen test prior to, 85, 85f
precautions for, 13-14, 14t-17t
for abscess incision and drainage, 374
anatomy and physiology for, 87-88, 87f, 88f
Blood cells, types of, 50
anatomy and physiology for, 296,
background and history of, 84
Blood culture(s), 63-69
298-300
complications of, 86-87
anatomy and physiology for, 65-66, 66f
for arterial puncture, 90
contraindications to, 85-86
background and history of, 64
background and history of, 296
follow-up care and instructions in, 92
complications of, 65
complications of, 301-303
indications for, 84-85
contraindications to, 65
contraindications to, 300-301
materials utilized for, 89
follow-up care and instructions in, 69
553
554 Index
Blood culture(s) — cont'd
indications for, 64
materials utilized for, 67
patient preparation for, 67
procedure for obtaining, 67-68, 68f
special considerations in, 68
Blood gas, arterial. See Arterial puncture.
Blood pressure
classification of, 45t
measurement of, 33-45
ambulatory, 42
anatomy and physiology in, 36-38, 37f,
38f
in apprehensive patient, 42
background and history of, 34-36
complications of, 36
contraindications to, 36
cuff size and, 35-36, 40, 42-43, 42t
in elderly persons, 43
follow-up care and instructions in,
44-45, 45t
indications for, 36
in infants and children, 43
materials utilized for, 39-40, 39f
in obese or large arm, 42-43, 42t
patient preparation for, 38-39
procedure for, 40-41, 41 f
orthostatic, 43-44
Bloodletting, 48
Body fluids, universal precautions for, 13-14,
14t-17t
Body substance isolation, 13
Boil, 370, 371
Boot, cast, 292
Borg scales, in exercise stress testing, 139,
139f, 140-141
Bowen's disease, curettage and desiccation
for, 350
Brachial artery
anatomy of, 36, 37f
for arterial puncture, 87, 87f
Breast
abscess of, 372
anatomy and physiology of, 220-222,
221f
cancer of, 218-219, 221,222
clinical examination of, 217-227
anatomy and physiology for, 220-222,
221f
background and history of, 218-219
complications of, 220
contraindications to, 219
follow-up care and instructions in,
226-227
indications for, 219
materials utilized for, 223
patient preparation for, 222
procedure for, 223-226, 223f-226f
special considerations in, 226
cyst of, 222
fibroadenoma of, 221-222
self-examination of, 227
Brush, scrub, for surgical hand scrub, 26
BTPS correction factor, in pulmonary
function testing, 173
Buffering agent, local anesthesia plus, 299
Bupivacaine, 297t, 302, 306
BURP mnemonic, 161
Bursal aspiration
anatomy and physiology for, 270, 2 7 If
Bursal aspiration — cont'd
background and history of, 260
complications of, 262
contraindications to, 261
follow-up care and instructions in, 273
indications for, 260-261
materials utilized for, 265, 266t
patient preparation for, 270, 272
procedure for, 272-273, 272f
Butterfly catheter, 75, 76f, 79-80, 80f
Butterfly set venipuncture, 59
Caffeine, for postdural puncture headache,
201
Canal of Schlemm, 460
Cancer
breast, 218-219, 221,222
colorectal, screening for, 252, 434-435, 436
endometrial, 472
prostate, screening for, 252
skin, cryosurgery of, 40 It, 407, 407t
Cap, surgical, 30
Capacity to consent, 3-4, 8
Carbon dioxide monitoring, during
sedation, 500
Carbuncle, 371
Cardiac conduction system, 117-118, 118f,
119f
Cardiovascular stress testing. See Exercise
stress testing.
Cast(s). See also Casting and splinting,
aftercare for, 292-293
general procedures for applying, 284-285,
285f
removal of, 293-294, 293f
short-arm, 276f, 285-287, 286f, 287f
short-leg, 2111, 287-288, 288f
types of, 276, 276f, 277f
window-like opening in, 294
Casting and splinting, 275-294
anatomy and physiology for, 282
background and history of, 276-279
complications of, 280-281
contraindications to, 280
follow-up care and instructions in,
292-294, 293f
indications for, 279
materials utilized for, 283-284
patient preparation for, 282-283
procedures for, 284-292
Catheter(s)
butterfly, 75, 76f, 79-80, 80f
central. See also Arterial puncture;
Intravenous catheter insertion,
for obtaining blood cultures, 68
Coude, 205f, 210
embolization of, in intravenous therapy,
73
Foley, 204, 205f, 210
over-the-needle, 75, 76f, 77f-79f, 78-79
Robinson, 204-205, 205f, 210
urinary
size of, 210-211
types of, 205f, 209-210
Catheterization, urinary bladder, 203-216.
See also Urinary bladder
catheterization.
Caustic eye injuries, 457, 457f
CDC Guidelines for Isolation Precautions in
Hospitals, 12-13
Central catheter. See also Arterial puncture;
Intravenous catheter insertion.
for obtaining blood cultures, 68
Cephalic vein, for venipuncture, 50, 5 If, 54
Cerebrospinal fluid
analysis of, lumbar puncture for, 192-193
circulation of, 195
Cerumen and foreign body removal from
ear, 445-451
anatomy and physiology for, 447-448, 447f
background and history of, 446
complications of, 447
contraindications to, 446
follow-up care and instructions in, 451
indications for, 446
materials utilized for, 448-449, 448f, 449f
patient preparation for, 448
procedure for, 449-451, 450f
special considerations in, 451
Cervical cancer, screening for, 230, 23 It
Cervical cells, obtaining. See Papanicolaou
(Pap) smear.
Cervical dilators, 476f, 477
Cervix, anatomy of, 234, 234f, 235f
Cetacaine, in patient preparation for
intubation, 151
Chaperone, for pelvic examination, 238
Chief complaint, 523
Children
blood pressure measurement in, 43
giving sad and bad news to, 550-551
injections in, 110-111
intravenous catheter insertion in, 81
lumbar puncture in, 199, 199f
patient education for, 511
pelvic examination in, 245, 246f
Chlorhexidine gluconate, for surgical hand
scrub, 26
Choroid, 460
Cleansing, wound, 321, 322-323, 322t
Clinical note, format of, 534-536, 535f. See
also Documentation.
Clitoris, anatomy of, 232f, 233
Coagulation disorders, as contraindication
to lumbar puncture, 193
Cocaine
in patient preparation for intubation, 151
topical, 297t
Cocaine-containing anesthetics
contraindications to, 300
examples of, 304-305
Coding, 517-529
background and history of, 518
clinical thinking in diagnosis and
treatment and, 527-529
of counseling, 528, 528t
of examinations, 524-527, 526t
examples of, 521-522, 524t, 525
importance of, 519, 521
of medical decision making, 527-528, 527t
of new patient visits, 528-529, 528t
overview of, 522-529
of patient history, 523-524
procedure for, 519, 520t
purpose of, 519
of single organ system examination, 527
Collagen dressings, 388f, 389
Ind
ex
555
Collodion dressings, flexible, 392
Colon
anatomy of, 437, 437f
examination of. See Sigmoidoscopy.
Colorectal cancer, screening for, 252,
434-435, 436
Comedones, acne surgery for, 363-365, 365f
Compartment pressure, measurement of, 281
Compartment syndrome, after cast
application, 280-281
Competency, informed consent and, 4, 8
Conduction rate, local anesthesia and, 298
Conduction system, cardiac, 117-118, 118f,
119f
Conjunctiva
anatomy of, 460
anesthesia of, 304
Conscious sedation, 494, 495
Consent to treatment, 1-9. See also Informed
consent.
Contact lens wearers, Pseudomonas
infection of cornea in, 457-458
Contact precautions, 16t
Contaminated material, disposal of, 31
Contamination, of blood cultures, 65
Continuous-running-baseball suture,
332-333, 333f
Cornea
anatomy of, 459f, 460
Pseudomonas infection of, 457-458
rust ring in, 465, 466f
Corneal abrasion and ocular foreign body
removal, 453-469
anatomy and physiology for, 459-460, 459f
background and history of, 454
complications of, 458
contraindications to, 455-457
follow-up care and instructions in,
467-469
indications for, 454
materials utilized for, 461
patient preparation for, 460
precautions in, 457-458
procedure for
concluding examination in, 466
eye examination in, 461-462, 462f, 463f
findings in, 463-464, 463f, 464f
foreign body removal in, 465, 465f, 466f
special considerations in, 466
Corneal burr, 465, 465f
Corneal flap, dislodgement of, 457, 458f
Corneal spud, 465, 465f
Corneal ulceration, recurrent, 464
Coronary artery disease
exercise stress testing for, 125-128
incremental testing strategy for, 127f
pretest probability of, 126t
Coude catheter, 205f, 210
Counseling, coding and documentation of,
528, 528t
Counted stroke method for surgical hand
scrub, 27
Cricoid cartilage, anatomy of, 148f, 149
Cricothyroidotomy, 146
Crying and tears, after hearing sad and bad
news, 549
Cryoanesthetic, before local anesthesia,
303-304
Cryogens, effective Celsius temperature of,
403t
Cryosurgery, 399-408
anatomy and physiology for, 403
background and history of, 400
complications of, 402-403
contraindications to, 402
follow-up care and instructions in, 408
freeze times in, 407, 407t
indications for, 400-402, 40 It
materials utilized for, 404, 405f
patient preparation for, 403-404
procedure for, 405-406, 406f, 407t
special considerations in, 407
Cubital fossa, 50
Cultures, blood, 63-69. See also Blood
culture(s).
Curettage, 345, 349, 350
Current procedural terminology (CPT)
system, 518
Cycloplegic drops, after corneal abrasion or
ocular foreign body removal, 466
Cyst
Baker's, 262
of breast, 222
Cytobrush, for collecting Pap smear sample,
243, 243f, 244f
D
De Graaf, Reinier, injection syringe and, 94
Death, sudden, during exercise stress
testing, 130
Debridement, for prevention of wound
infection, 387
Decision making, medical, coding of,
527-528, 527t
Deep vein thrombosis, immobilization-
induced, 282
Deltoid muscle, as injection site, 97, 98f
Dendritic keratitis, 464, 464f
Denial, after hearing sad and bad news,
546
Dentate line, 427-428, 427f
Depression, after hearing sad and bad news,
549
Dermatitis, cast, 281
Dermatologic procedure(s), 343-365
acne surgery as, 363-365, 365f
biopsies as, 344-360. See also Biopsy,
electrosurgery as, 360-363
Dermis, 316, 316f
Diabetes mellitus
categories of, 484t
diagnostic criteria for, 484t
foot examination in, 483-490. See also
Foot examination, diabetic.
Diazepam, in procedural sedation, 501,
502t
Dibucaine, 297t
Dicloxacillin, after abscess incision and
drainage, 377
Digital block, 309, 309f
Digital rectal examination, 430
Diphenhydramine, 306
Disbelief, after hearing sad and bad news,
546
Disclosure standards, in informed consent,
3,4-5
Disease, chronicity of, patient education
and, 513-514
Documentation, 531-538. See also Coding.
background and history of, 532-533
clinical note format in, 534-536, 535f
of counseling, 528, 528t
general considerations in, 533-534
importance of, 519, 521
of new patient visits, 528-529, 528t
purposes of, 519, 532-533
Documentation Guidelines for Evaluation and
Management Services (E/M codes), 518
Dog ear deformity, correction of, 330, 330f
Dorsogluteal muscle, as injection site, 97,
99, 99f
Double lid eversion, 462
Double product, 132
Draping, sterile technique for, 28-29
Dressing, wound, 381-397. See also Wound
dressing(s).
Dressing stabilizer, 392
Droplet precautions, 16t
"Dry tap," 199
E
Ear
anatomy of, 447-448, 447f
cerumen and foreign body removal from,
445-451. See also Cerumen and
foreign body removal from ear.
Echocardiography, stress, 124, 136
Education, patient, 507-514. See also Patient
education.
Einthoven's triangle, 114
Elbow bursa
anatomy of, 270
aspiration of, 262, 272-273, 272f
Elderly persons
blood pressure measurement in, 43
intravenous catheter insertion in, 81
pelvic examination in, 245
Electrocardiogram, 113-122
anatomy and physiology for, 116-118,
116f-119f
background and history of, 114, 114f
complications of, 115
contraindications to, 115
in exercise stress testing, 133f, 138-139.
See also Exercise stress testing.
follow-up care and instructions in, 122
indications for, 114-115
materials utilized for, 120
patient preparation for, 118, 120
procedure for, 120-122, 121f
special considerations in, 122
Electrodesiccation, 360-363
Electrosurgery, 360-363
Embolism, from intravenous therapy, 73
Emergency equipment, for exercise stress
testing, 136-137, 137t
Emergency exception to informed consent,
7-8
Emergency medications and solutions, for
exercise stress testing, 137t
EMLA or ELA-Max cream, 305, 306
Emotions, after hearing sad and bad news,
545-548
Endocervical curettage, 480
Endometrial biopsy, 471-480
anatomy and physiology for, 474, 474f
556 Index
Endometrial biopsy — cont'd
background and history of, 472
complications of, 472-473
contraindications to, 472, 473t
follow-up care and instructions in, 480
indications for, 472, 473t
materials utilized for, 475-477, 476f
patient preparation for, 475
procedure for, 478-480, 479f
supplementary and alternative
procedures for, 480
Endometrial cancer, 472
Endometrial hyperplasia, 474
Endometrial thickness, evaluation of, 480
Endotracheal intubation, 145-163. See also
Intubation.
Endotracheal tubes, 157-158, 157f
Enteral nutrition, nasogastric tube
placement for, 182
Environmental control, in standard
precautions, 15t
Epidermis, 316, 316f
Epidermoid tumors, intraspinal, after
lumbar puncture, 194
Epidural blood patch, for postdural
puncture headache, 201
Epinephrine
contraindications to, 301
local anesthesia plus, 298
side effects of, 302
Epithelializing wound, 386
Epithelization, after corneal abrasion or
ocular foreign body removal, 467-468
Ergometer
arm, 136
bicycle, 135-136
Erythrocyte, 50
Esophagus, anatomy of, 184f, 185
Ester anesthetics, 296, 297t, 300
Ethical issues, in informed consent, 8
Ethnicity, patient education and, 512
Etomidate, in patient preparation for
intubation, 152-153
Eutectic mixture of local anesthetics
(EMLA) or ELA-Max cream, 305, 306
Examinations, coding of, 524-527, 526t
Excisional biopsy, 356-360
complications of, 356-357
follow-up care and instructions in, 360
indications for, 356
materials utilized for, 357-358
patient preparation for, 357
procedure for, 358-359, 358f
special considerations in, 359
Exercise stress testing, 123-142
anatomy and physiology for, 131-132, 133f
background and history of, 124
contraindications to, 128-131
follow-up care and instructions in, 141-142
indications for, 124-128
materials utilized for, 134-137, 137t
patient preparation for, 132-134
personnel for, 138
procedure for, 138-140
special considerations in, 140-141
sudden death during, 130
Extremities, immobilization of, 275-294. See
also Casting and splinting.
Eye
anatomy of, 459-460, 459f
Eye — cont'd
injury to. See also Corneal abrasion and
ocular foreign body removal,
background and history of, 454
caustic/splash, 457, 457f
examination in, 461-462, 462f, 463f
ruptured globe as, 455-456, 455f, 456f
viral infection of, 464, 464f
Eye protection
for prevention of injuries, 466, 468
in universal precautions, 14t, 19
Eyebrow, wound closure around, 335
Eyelid
eversion of, 462, 463f
laceration of, 456-457, 456f
Face shield, in universal precautions,
14t, 19
Facial furuncle, 370
Fainting. See Syncope.
Fallopian tubes, anatomy of, 234, 234f, 236f
Family, patient education and, 510, 512-513
Family history, 524
Fascia, anatomy of, 316-317, 31 6f
Fear, after hearing sad and bad news, 547
Femoral artery, for arterial puncture, 88, 88f
Fentanyl
in patient preparation for intubation, 152
in procedural sedation, 501, 50 It
Fiberglass, for casting and splinting, 278-279,
283
Fiberoptic sigmoidoscope, 438-439, 439f
Fibroadenoma, of breast, 221-222
Field block, 308, 308f
Flexible collodion dressing, 392
Flexible sigmoidoscopy, 433-442. See also
Sigmoidoscopy, flexible.
Flumazenil, 503t
Fluorescein strip, 462, 462f
Foam dressings, 389, 390f
Foley catheter, 204, 205f, 210
Foot examination, diabetic, 483-490
anatomy and physiology for, 486, 487f
background and history of, 484
complications of, 485
contraindications to, 485
follow-up care and instructions in, 490
indications for, 484-485
materials utilized for, 486, 488f
patient preparation for, 486
procedure for
palpation in, 489
tests for sensation in, 489, 489f
visual inspection in, 488-489
special considerations in, 490
Foramen magnum, herniation into, after
lumbar puncture, 194
Forceps, for suturing, 325f, 326
Foreign body removal
from ear, 445-451. See also Cerumen and
foreign body removal from ear.
from eye, 453-469. See also Corneal
abrasion and ocular foreign body
removal.
Fox shield, 455, 455f
Fracture, immobilization after, 279
Freeze times, in cryosurgery, 407, 407t
"Frog leg" position, for pediatric pelvic
examination, 245, 246f
Furuncle, 370, 371
Galen, circulation observed by, 34
Gastric contents, removal or sampling of,
nasogastric tube placement for, 182
Gauze, wrapping or rolling, 392
Gauze dressing, 385, 391-392
General consent, 6
Genitalia
female, examination of. See Pelvic
examination,
male, examination of, 251-258
anatomy and physiology for, 253-254,
253f
background and history of, 252
complications of, 253
contraindications to, 253
follow-up care and instructions in, 258
indications for, 252
materials utilized for, 255
by patient, 258
patient preparation for, 254
procedure for, 255-257, 256f, 257f
special considerations in, 257-258
Geriatric persons. See Elderly persons.
Globe, ruptured, 455-456, 455f, 456f
Gloves, in universal precautions, 14t, 16t,
18-19
Gluteus medius muscle, as injection site, 97,
99, 99f, lOOf
Gluteus minimus muscle, as injection site,
99, lOOf
Glycopyrrolate, in patient preparation for
intubation, 150
Gown
surgical, 30, 30f
in universal precautions, 14t, 17t, 19
Granulating wound, 385-386
Guilt, after hearing sad and bad news,
548-549
in children, 550-551
Gutter splint, 277, 277f
short-arm ulnar, 289
H
Hair, wound closure and, 335
Hales, Stephen, blood pressure
measurement by, 34
Hand, venous anatomy of, 66f
Hand scrub, surgical, 25-27, 27f
Hand washing
for prevention of wound infection, 387
in universal precautions, 14t, 16t
Harvey, William, circulation observed by, 34
Headache, postdural puncture, 194, 201
Healing, wound
poor, 387
stages in, 386
Heart
anatomy of, 116-117, 116f, 1 1 7f
electrical patterns of, 117-118, 118f, 119f
Heart rate, during exercise stress testing,
131
Index 557
Hematoma
from arterial puncture, 86
from lumbar puncture, 194
subungual, draining of, 417-422. See also
Subungual hematoma, draining of.
from venipuncture, 49-50, 65
Hemorrhage
from arterial puncture, 86
from venipuncture, 49-50
Heparin injection, 107
Hernia, inguinal, 254
Herniation, into foramen magnum, after
lumbar puncture, 194
Hippocrates
bloodletting and, 48
circulation observed by, 34
sterile technique and, 24
History of present illness (HPI), 523
Horizontal mattress suture, 332, 332f
Human papillomavirus (HPV) infection,
cervical cancer and, 230
Hunter, Charles, hypodermic injections and,
94-95
Hydrocolloid dressings, 385, 389-390, 390f
Hydrogel dressings, 390-391, 39 If
Hymen, 233, 233f
Hypertension, "white coat," 42
Hysteroscopy, 480
I
Imaging equipment, for exercise stress
testing, 136
Immobilization
after abscess incision and drainage, 378
of extremities, 275-294. See also Casting
and splinting.
Implied consent, 6
Incision and drainage, of abscess, 369-379.
See also Abscess, incision and drainage
of.
Infants
blood pressure measurement in, 43
injections in, 110-111
intravenous catheter insertion in, 81
lumbar puncture in, 200, 200f
premature, topical anesthesia in, 300
Infarction, myocardial, exercise stress
testing after, 128
Infection
after arterial puncture, 87
after endometrial biopsy, 473
at injection site, 96
after lumbar puncture, 194-195
standard precautions for, 1 1-20
Infection control practices
general, 19
after urinary bladder catheterization, 216
Informed consent, 1-9
adequate information and, 4-5
barriers to, 5
components of, 3-6
disclosure standards in, 3, 4-5
exceptions to, 7-9
failure to obtain, litigation involving, 3
historical basis of, 2
for joint aspiration, 265
patient capacity and, 3-4, 8
patient waiver of right to give, 8-9
Informed consent — cont'd
purpose of, 2-3
refusal of treatment and, 7
types of, 6-7
voluntary choice and, 6
Ingrown toenail, 411-416. See also Toenail,
ingrown.
Inguinal hernia, 254
Injections, 93-111
aspiration of medication prior to, 103-104,
103f, 104f
background and history of, 94-95
complications of, 95-96
contraindications to, 95
follow-up care and instructions in, 111
indications for, 95
in infants and children, 110-111
intradermal, 97, 100, 105, 105f
intramuscular, 97-99, 98f-100f, 101, 107-110,
108f-109f
Z-track, 109-110, 109f
of local anesthetics. See Anesthesia, local,
materials utilized for administering,
101-103, 102f
patient preparation for, 101
procedures for administering, 105-110
special considerations in, 110-111
subcutaneous, 97, 97f, 100, 106, 106f
Instrument tie, procedure for performing,
328-329, 328f
Insulin injection, 107
Insulin syringe, 102
International Classification of Diseases,
Clinical Modification (ICD-CM) codes,
518
Intracranial pressure, increased, as
contraindication to lumbar puncture,
193
Intradermal injections, 97, 100, 105, 105f
Intramuscular injections, 97-99, 98f-100f,
101, 107-110, 108f-109f
Z-track, 109-110, 109f
Intraocular pressure, measurement of, 455,
456f
Intraspinal epidermoid tumors, after lumbar
puncture, 194
Intravenous catheter insertion, 71-82
anatomy and physiology for, 73-74, 74f
background and history of, 72
complications of, 72-73
contraindications to, 72
follow-up care and instructions in, 82
indications for, 72
materials utilized for, 75-76, 76f
patient preparation for, 74-75
procedure for, 76-81, 77f-81f
with butterfly needle cannulation, 79-80,
80f
with over-the-needle catheter
cannulation, 77f-79f, 78-79
special considerations in, 81
Intubation, 145-163
anatomy and physiology for, 148-149, 148f
background and history of, 146
complications of, 147-148
contraindications to, 146
difficult, predictive factors for, 149
failed, causes of, 159
follow-up care and instructions in, 163
indications for, 146
Intubation — cont'd
materials utilized for, 155-159, 156f, 157f
nasal, procedure for, 162-163
oral, procedure for, 159-162, 160f
patient preparation for, 150-155
pharmacologic, 150-154
physical, 154-155, 155f
physical protection after, 163
psychological protection after, 163
Irrigation
for cerumen removal from ear, 449, 450,
450f
of wound, 322-323, 387
Isolation, body substance, 13
Isolation precautions, 12, 13-14, 14t-17t. See
also Standard precautions.
Joint aspiration, 259-273
anatomy and pathomechanics for, 263-264,
264f
background and history of, 260
complications of, 261-262
contraindications to, 261
follow-up care and instructions in, 270
indications for, 260
materials utilized for, 265, 266t
pathophysiology and, 262-263, 263f
patient preparation for, 265
procedure for, 267-269, 268f, 269f
K
Keratitis, dendritic, 464, 464f
Ketamine, in patient preparation for
intubation, 152-153
Knee joint
anatomy of, 263-264, 264f
aspiration of, 267-269, 268f, 269f
bursae of, 270, 271f
pathophysiology of, 262-263, 263f
synovial surfaces of, 263, 263f
Knowledge, providing, in giving sad and bad
news, 544-545
Knudson standard, in pulmonary function
testing, 176
Korotkoff sounds, 34-35, 35t, 37-38, 38f
Labia majora, 232, 232f
Labia minora, 232, 232f
Laennec, Rene, invention of stethoscope by,
34
Langer's lines, 317, 318f, 335
Laryngoscopes, for intubation, 156-157,
156f, 157f
Larynx, anatomy of, 148f, 149
Leg, blood pressure measurement in, 42-43
Legal issues, in informed consent, 3
Leukocyte, 50
Levin nasogastric tube, 186
Lidocaine
for arterial puncture, 90
injectable, 297t, 305
for intravenous catheter insertion, 75
558 Index
Lidocaine — cont'd
in patient preparation for intubation, 151
plus epinephrine, 298
plus prilocaine, 297t
topical, 297t
Linen, in standard precautions, 15t
Lipodystrophy, from injections, 96
Lips, vermilion border of, suturing around,
335
Lister, Joseph, sterile technique and, 24
Local anesthesia, 295-310. See also
Anesthesia, local.
Lorazepam, in procedural sedation, 501, 502t
Lower extremity, anatomy of, 48 7f
Lumbar puncture, 191-201
anatomy and physiology for, 195-196, 195f
background and history of, 192
complications of, 194-195
contraindications to, 193-194
follow-up care and instructions in, 201
indications for, 192-193
materials utilized for, 196-197, 197f
patient preparation for, 196
procedure for
in adults, 197-198, 198f
in children, 199, 199f
in infants, 200, 200f
special considerations in, 199
traumatic, 199
Lung disorders
from intravenous therapy, 73
mixed, 171
obstructive, 169, 169t, 170f, 170t
restrictive, 169t, 170-171, 170f, 170t
Lung function tests. See Pulmonary function
testing.
Lungs, anatomy of, 168-169
Lunula, 413
M
Magill forceps, for intubation, 156f, 159
Malpighi, Marcello, circulation observed by,
34
Mask
surgical, 29, 30f
in universal precautions, 14t, 16t, 19
Mastitis, 222
Median cubital vein, for venipuncture, 50,
51f, 54
Medical decision making, coding of, 527-528,
527t
Medical records
coding in, 517-529
documentation in, 531-538
Medication errors, prevention of, 96
Meperidine, in procedural sedation, 501, 50 It
Mepivacaine, 29 7t, 305
Mercury sphygmomanometer, 39, 40
Metabolic equivalent (MET), 131
Methylxanthines, for postdural puncture
headache, 201
Midazolam
in patient preparation for intubation, 152
in procedural sedation, 501, 502t
"Miscuffing," in blood pressure
measurement, 35-36
Moh's micrographic surgical procedures,
356
Monofilament, Semmes-Weinstein, 486, 488f
Monofilament testing, 489, 489f
Monsel's solution, for post-biopsy bleeding,
346
Morgan lens, 457, 457f
Morphine, in procedural sedation, 501, 501t
Morris standard, in pulmonary function
testing, 176
Mucous membranes, anesthesia of, 304
Multisystem examination (MSE), coding of,
524, 526t
Myelin, local anesthesia and, 298
Myocardial infarction, exercise stress
testing after, 128
N
Nail
anatomy of, 413, 413f, 419-420, 419f
anesthesia around, 309-310
hematoma under, draining of, 417-422. See
also Subungual hematoma, draining
of.
ingrown, 411-416. See also Toenail,
ingrown.
Nail bed, anatomy of, 413, 413f, 419f, 420
Nail matrix, ablation of, 415-416
Nail plate, 419f, 420
Naloxone, 503t
Nasal intubation, procedure for, 162-163
Nasogastric tube placement, 181-189
anatomy and physiology for, 184-185, 184f
background and history of, 182
complications of, 183-184
contraindications to, 182
follow-up care and instructions in, 189
indications for, 182, 183t
materials utilized for, 186-187
patient preparation for, 185-186
procedure for, 187-188, 187f, 188f
special considerations in, 189
Nasopharynx, anatomy of, 148f, 149
NAVEL mnemonic, 88
Necrotic wound, 385
Needle
breakage of, complicating lumbar
puncture, 195
for injections, 102-103, 102f
for lumbar puncture, 197, 197f
suture, 323-324, 325f
Needle driver-holder, for suturing, 325-326,
325f, 326f
Needlestick injuries, prevention of, 19, 111
Negligence, in failure to obtain informed
consent, 3
Nerve damage
from arterial puncture, 86
after cast application, 281
from lumbar puncture, 194
Nerve fiber diameter, local anesthesia and,
298
Nerve root pain, during lumbar puncture,
199
Neurogenic bladder, catheterization for, 205
Neuromuscular blocking drugs, in patient
preparation for intubation, 153-154
NHANES III standard, in pulmonary function
testing, 176
Novak curette, 475, 476f
Obese patient, blood pressure measurement
in, 42-43, 42t
Occupational health and blood-borne
pathogens, in standard precautions, 15t
Olecranon bursa
anatomy of, 270
aspiration of, 262, 272-273, 272f
Onychocryptosis, 411-416. See also Toenail,
ingrown.
Operative site, preparing, sterile technique
for, 27-28, 28f
Opioids
in procedural sedation, 501, 501t
reversing agent for effects of, 502, 503t
Oral intubation, procedure for, 159-162, 160f
Oropharynx, anatomy of, 148f, 149
Orthostatic blood pressure, 43-44
Outpatient coding, 517-529. See also Coding.
Ovaries, anatomy of, 234, 234f, 236
Over-the-needle catheter, 75, 76f, 77f-79f,
78-79
Oxygen consumption, during exercise stress
testing, 131-132
Padding, cast, 283
Pain
control of. See Analgesia.
injection, 96
nerve root, during lumbar puncture, 199
Palpation
of breast, 224-226, 225f, 226f
in diabetic foot examination, 489
Papanicolaou (Pap) smear, 229-248
background and history of, 230
collection procedure for, 242-244, 243f,
244f
complications of, 231-232
follow-up care and instructions in, 246
indications for, 230, 23 It
interpretation of, 247, 247t, 248t
materials utilized for, 238-239, 238f, 240f
Parenteral, 94. See also Injections.
Paronychia, 371
PARQ mnemonic, in informed consent, 4
Past, family, and/or social history (PFSH),
524
Pasteur, Louis, sterile technique and, 24
Paternalism, 2
Patient
capacity of, informed consent and, 3-4, 8
new visits by, coding and documentation
of, 528-529, 528t
placement of, in universal precautions,
15t, 16t
right of, to refuse treatment, 7
transport of, in universal precautions,
16t, 17t
Patient care equipment, in universal
precautions, 14t, 17t
Patient education, 507-514
age and, 511-512
background and history of, 508
Cole's suggestions concerning, 509-511
disease chronicity and, 513-514
ethnicity and, 512
factors influencing, 511-514
Ind
ex
559
Patient education — cont'd
family and, 510, 512-513
socioeconomic status and, 513
sources of, 514
Patient history, coding of, 523-524
Patient-provider relationship, history of, 2
Pediatric patients. See Children; Infants.
Pelvic examination, 229-248
anatomy and physiology for
external, 232-233, 232f, 233f
internal, 234-236, 234f-236f
background and history of, 230
bimanual examination in, 245
chaperone for, 238
in children, 245, 246f
complications of, 231-232
contraindications to, 231
in elderly person, 245
follow-up care and instructions in, 246
indications for, 230, 23 It
materials utilized for, 238-239, 238f, 240f
patient preparation for, 236-238
in first pelvic examination, 236-237, 237f
in returning patient, 237-238
procedure for, 240-245, 240f-244f
special considerations in, 245
Penis
anatomy of, 253f, 254
examination of, 255-256
Perception, patient, in hearing sad and bad
news, 543
Periungual anesthesia, 309-310
Phlebotomy, definition of, 48
Physical examination
coding of, 524-527, 526t
elements of, 525, 526t
Physical status, classification of, 496t
Pigment alterations, after
electrodesiccation, 361
Pipelle aspirator, 475, 476f
Plasma, 50
Plaster, for casting and splinting, 278, 283
Plastic broom, for collecting Pap smear
sample, 243-244
Polypectomy, during flexible
sigmoidoscopy, 436, 441
Popliteal bursae, 262
Postdural puncture headache (PDPH), 194,
201
Posterior mold splint, 277-278, 278f
short-leg, 290-291
Povidone-iodine
for surgical hand scrub, 26
wound dressings and, 392
Pravaz, Charles, injection syringe and, 94
Precautions, standard, 1 1-20. See also
Standard precautions.
Premature infants, topical anesthesia in, 300
Present illness, history of, 523
Pressure sores, cast, 281
Prilocaine, 297t, 302
plus lidocaine, 297t
Primary intention, 318
Procaine, 297t
Procedural sedation. See Sedation.
Proctosigmoidoscopy, 434
Propofol, in patient preparation for
intubation, 152, 153
Prostate
cancer of, screening for, 252
Prostate — cont'd
enlarged, urinary bladder catheterization
and, 206, 208
examination of, 256-257, 257f
Protective barriers, 18-19
Pseudomonas infection, of cornea, 457-458
Public health requirements, as exception to
informed consent, 9
Pulmonary disorders. See Lung disorders.
Pulmonary embolism, from intravenous
therapy, 73
Pulmonary function testing, 165-178
abnormal, 170f
pulmonary disorders yielding, 169-171,
169t, 170t
understanding, 177, 177t
anatomy and physiology for, 168-171
background and history of, 166
complications of, 168
contraindications to, 167
economics of, 167-168
follow-up care and instructions in, 177-178
indications for, 166-167
materials utilized for, 172
normal, 170f, 177, 177t
patient preparation for, 171-172, 172t
patient variability in, 176-177
procedure for, 173-176
calibration in, 1 73
comparison of results with standards
in, 176
obtaining a meaningful spirogram in,
174, 175f
patient instructions in, 173-174, 173f
postbronchodilator test in, 176
special considerations in, 176-177
Punch biopsy, 351-355
complications of, 352
contraindications to, 351-352
follow-up care and instructions in, 355
indications for, 351
materials utilized for, 353
patient preparation for, 352
procedure for, 354-355, 354f
Questions, awkward, after hearing sad and
bad news, 549-550
Quincke, Heinrich, lumbar puncture by, 192
R
Radial artery, for arterial puncture, 85, 85f,
87
Radiography, in nasogastric tube
placement, 188
Rate-pressure product, 132
"Reasonable person" standard, 4-5
"Reasonable physician" standard, 4
Recommendations for Isolation Precautions
in Hospitals, 14, 14t-17t
Rectum
anatomy of, 427, 427f, 437, 437f
digital examination of, 430
male, examination procedure for, 256-257,
257f
Refusal of treatment, 7
Respiratory protection, in airborne
precautions, 15t
Retina, 460
Reversing agents, in procedural sedation,
502, 503t
Review of systems (ROS), 524
Right
to give informed consent, waiver of, 8-9
to refuse treatment, 7
Riva-Rocci sphygmomanometer, 34
Robinson catheter, 204-205, 205f, 210
Rocuronium, in patient preparation for
intubation, 154
Rust ring, in cornea, 465, 466f
Sad and bad news, giving, 539-551
awkward questions after, 549-550
background and history of, 540
to children, 550-551
crying and tears after, 549
depression after, 549
emotions after, 545-548
indications for, 540-541
invitation in, 543-544
knowledge in, 544-545
perception in, 543
preparation for, 541-542
procedure for, 542-551
setting up interview in, 542-543
SPIKES approach to, 542-551
strategy in, 551
Saline infusion sonography, 480
Saw, cast, 284, 293-294, 293f
Scalp vein IV line, 81
Schiotz manometer, 456f
Schlemm, canal of, 460
Scintigraphy, exercise stress, 124, 136
Scissors, for suturing, 326f, 327
Sclera, 460
Scratches, corneal, 463, 463f
Scrotal sac
anatomy of, 253f, 254
examination of, 256, 256f
Scrub brush, for surgical hand scrub, 26
Secondary intention, 318-319
Sedation, 493-505
agents for, 500-502, 501t-502t
anatomy and physiology for, 498-499, 499f
background and history of, 494-495
complications of, 497-498
conscious, 494, 495
contraindications to, 495-497, 496t
definitions of, 494-495
discharge criteria and instructions in, 505
indications for, 495
before intubation, 151-152
materials utilized for, 499-500
monitoring during, 500
patient preparation for, 498
procedure for, 503-504
reversing agents in, 502, 503t
Seidel sign, 455-456
Semmes-Weinstein monofilament, 486, 488f
Sensation, tests for, in diabetic foot
examination, 489, 489f
Septicemia, 64
Serum, definition of, 50
560 Index
Shave biopsy, 345-351
anatomy and physiology for, 346, 347f
complications of, 346
contraindications to, 345
follow-up care and instructions in, 350-351
indications for, 345
materials utilized for, 348-349
patient preparation for, 347
procedure for, 349-350, 349f
Shock, after hearing sad and bad news, 546
Sigmoidoscopy
flexible, 433-442
anatomy and physiology for, 437, 437f
background and history of, 434-435
complications of, 436-437
contraindications to, 436
follow-up care and instructions in, 442
indications for, 435-436
materials utilized for, 438-439, 439f
patient preparation for, 438
procedure for, 439-441, 440f
special considerations in, 442
rigid, 433
Silver nitrate, for post-biopsy bleeding, 346
Simple interrupted suture, 329-330
Sims' position, for flexible sigmoidoscopy,
440
Single organ system examination (SOSE),
coding of, 527
Skene's glands, 232f, 233
Skin
anatomy of, 316-317, 31 6f
intact, local infiltration of, 308
procedures for. See Dermatologic
procedure(s).
stapling of, 335-336, 337-338, 340
tension lines of, 317, 318f, 335
Skin lesions
cryosurgery of, 399-408. See also
Cryosurgery,
in health care workers, sterile technique
and, 31
Skin tags, snip excision of, 345, 348, 350
Sling, for upper extremity casts and splints,
292
"Sniffing" position, in patient preparation
for intubation, 154, 155, 155f
Snip excision, 345, 348, 350
Soap, antimicrobial, 26
Social history, 524
Socioeconomic status, patient education
and, 513
Sodium bicarbonate, local anesthesia plus,
299
Soft tissue injuries, immobilization after, 279
Sonography
saline infusion, 480
transvaginal, 480
Spasm, arterial, during or after arterial
puncture, 86
Spatula, for collecting Pap smear sample,
242-243, 243f
Special consent, 6
Specimen container, 348
Speculum, vaginal, 238-239, 238f
Sphygmomanometer
for blood pressure measurement, 39, 39f, 40
invention of, 34
SPIKES approach to giving sad and bad
news, 542-551
Spinal cord, anatomy of, 195-196, 195f
Spinal needle with stylet, 197, 197f
Spinal tap. See Lumbar puncture.
Spirometry. See Pulmonary function testing.
Splash eye injuries, 457, 457f
Splint. See also Casting and splinting.
gutter, 277, 277f
short-arm ulnar, 289
posterior mold, 277-278, 278f
short-leg, 290-291
procedures for applying, 289-292
sugar tong, 278, 278f, 279f
lower arm (forearm, short-arm), 292
lower leg, 291-292
upper arm, 292
types of, 276-278, 277f-279f
ST segment depression, during exercise
stress testing, 132, 133f
Standard precautions, 11-20
application of, to clinical procedures,
19-20
background and history of, 12-13
body substance isolation and, 13
new guidelines for, 14t-15t, 17-18
protective barriers and, 18-19
sterile technique and, 31
universal precautions and, 13-14, 14t-17t,
18-19
Staplers
follow-up care and instructions for,
337-338, 340
removal of, 340
in wound closure, 335-336
Stationary bicycle ergometer, for exercise
stress testing, 135-136
Sterile supplies, 29
Sterile technique, 23-31
background and history of, 24
disposal of materials and, 31
for draping, 28-29
for maintaining sterile field, 29
for preparing operative site, 27-28, 28f
principles of, 24-25
standard precautions and, 31
for surgical hand scrub, 25-27, 27f
for wearing surgical masks, caps, and
gowns, 29-30, 30f
Stethoscope
for blood pressure measurement, 39f
invention of, 34
Stitch. See Suture(s).
Stockinette, in cast application, 283
Stratum germinativum, 316, 316f
Stress testing. See Exercise stress testing.
Stylets, for intubation, 156f, 158
Subcutaneous injections, 97, 97f, 100, 106,
106f
Subcuticular suture, 334, 334f
"Subjective" standard, in informed consent,
5
"Substituted judgment," in informed
consent, 8
Subungual hematoma, draining of, 417-422
anatomy and physiology for, 419-420, 419f
background and history of, 418
complications of, 419
contraindications to, 418-419
follow-up care and instructions in, 422
indications for, 418
materials utilized for, 420-421
Subungual hematoma, draining of — cont'd
patient preparation for, 420
procedure for, 421-422, 42 If
special considerations in, 422
Succinylcholine, in patient preparation for
intubation, 154
Sudden death, during exercise stress
testing, 130
Sugar tong splint, 278, 278f, 279f
lower arm (forearm, short-arm), 292
lower leg, 291-292
upper arm, 292
Superficial veins
for intravenous therapy, 73, 74f
for venipuncture, 50-51, 5 If, 54
Surgical cap, 30
Surgical gown, 30, 30f
Surgical hand scrub, 25-27, 27f
Surgical mask, 29, 30f
Surgical Materials Testing Laboratory
(SMTL), 397
Surrogate decision-maker, in informed
consent, 8
Suture (s)
continuous-running-baseball, 332-333,
333f
follow-up care and instructions for, 337-340
general techniques for, 325-327
horizontal mattress, 332, 332f
instrument tie for, 328-329, 328f
materials utilized for, 323-324, 324t, 325f
placement of, procedure for, 327, 32 7f
removal of, 338-340, 338t, 339f
after punch biopsy, 355
simple interrupted, 329-330
size of, 323, 324t
subcuticular, 334, 334f
vertical mattress, 331, 33 If
Syncope, vasovagal, from venipuncture, 50
Synovial fluid
acquisition of. See Joint aspiration.
testing of, 266t
Synovial surfaces, of knee joint, 263, 263f
Syringe
for injections, 94, 102, 102f
metal ear, 448f
for venipuncture, 58, 58f
Tao brush, 475, 476f
Tension lines, of skin, 317, 318f, 335
Terminal illness, awkward questions
concerning, 549-550
Testicles, 253f, 254
Testicular cancer, screening for, 252
Tetanus prophylaxis, for wound closure,
319-321, 320t
Tetracaine, 151, 297t
Theophylline, for postdural puncture
headache, 201
Therapeutic privilege, as exception to
informed consent, 9
Thiopental, in patient preparation for
intubation, 152, 153
Third intention, 319
Thrombocyte, 50
Thrombophlebitis, from intravenous
therapy, 72-73
Ind
ex
561
Thrombosis
from arterial puncture, 86
deep vein, immobilization-induced, 282
from intravenous therapy, 72-73
Timed method for surgical hand scrub, 27,
27f
Tinea pedis, in diabetic patient, 490
Tis-U-Trap set, 475, 476f
Toenail, ingrown, 411-416
anatomy and physiology for, 413, 413f
background and history of, 412
complications of, 412-413
contraindications to, 412
follow-up care and instructions in, 415-416
indications for, 412
materials utilized for, 414
patient preparation for, 413
procedure for, 414-415, 41 6f
Tonopen, 456f
Topical anesthesia
contraindications to, 300
drugs for, 296, 29 7t, 304-305
materials utilized for, 304-305
procedure for, 306-307
Tourniquet, for venipuncture, 53, 55, 55f
Toxic reaction, to parenteral medications,
95
Trachea, translaryngeal intubation of. See
Intubation.
Tracheal tubes, for intubation, 157-158, 157f
Tracheostomy, 146
Transmission-based precautions, 15t-17t
Transparent film dressings, 391
Transport, patient, in universal precautions,
16t, 17t
Transvaginal sonography, 480
Trauma patient, prevention of wound
infection in, 387-388
Traumatic lumbar puncture, 199
Treadmill, for exercise stress testing, 134-135
Trochanteric bursae, anatomy of, 270, 27 If
Truth-telling, about sad and bad news, 540
Tuberculin syringe, 102
Tuberculosis, in airborne precautions, 16t
Tubes, endotracheal, 157-158, 157f
Tumor, intraspinal epidermoid, after lumbar
puncture, 194
U
Ulcer, foot, in diabetes mellitus, 484-485
Universal precautions, 14, 14t-17t, 18-19. See
also Standard precautions.
Urethra, male, 253f, 254
Urethral dilation, after urinary bladder
catheterization, 206
Urethral meatus, blood at, as
contraindication to urinary bladder
catheterization, 205-206
Urethral stricture disease, urinary bladder
catheterization and, 206
Urinary bladder catheterization, 203-216
anatomy and physiology for, 207-208, 207f
background and history of, 204
catheter size requirements for, 210-211
catheter types for, 205f, 209-210
complications of, 206-207
contraindications to, 205-206
follow-up care and instructions in, 215-216
Urinary bladder catheterization — cont'd
indications for, 204-205, 205f
indwelling, 215-216
materials utilized for, 208-211
patient preparation for, 208
procedure for
in female, 213-215, 214f
in male, 211-213, 212f
short-term or in-and-out, 215
Urinary tract, anatomy of, 207-208, 207f
Uterus
abnormal bleeding from, evaluation of,
472. See also Endometrial biopsy,
anatomy of, 234, 234f, 474, 474f
perforation of, in endometrial biopsy,
472-473
Vacutainers, venipuncture procedure using,
53-57, 55f, 57f
Vagina, anatomy of, 234, 234f
Vaginal speculum, 238-239, 238f
Vancomycin, resistance to, in contact
precautions, 17t
Vascularity, local anesthesia and, 298
Vasovagal reaction, local anesthesia and, 301
Vasovagal syncope, from venipuncture, 50
Vastus lateralis muscle, as injection site, 99,
lOOf
Venipuncture, 47-60
anatomy and physiology for, 50-51, 51f
background and history of, 48
butterfly set, 59
complications of, 49-50
contraindications to, 48-49
definition of, 51
follow-up care and instructions in, 60
indications for, 48
materials utilized for, 52-53
patient preparation for, 52
procedure for, using vacutainers, 53-57,
55f, 57f
special considerations in, 59-60
standard precautions for, 51
syringe, 58, 58f
Ventrogluteal muscle, as injection site, 99,
lOOf
Verbal consent, 6
Vermilion border of lips, suturing around, 335
Vertical mattress suture, 331, 33 If
Vial, aspiration from, 104, 104f
Viral infection, of eye, 464, 464f
Voluntary choice, informed consent and, 6
Vulva, anatomy of, 232, 232f
W
Warfarin, blood culture in patient taking, 65
"White coat" hypertension, 42
"Whiteheads," acne surgery for, 363-365, 365f
Window, cast, 294
Wood, Alexander, morphine injections and,
94
Wound
chronic, 396-397
classification of, 317
clean, 317
Wound — cont'd
clean-contaminated, 317
closed, 385
contaminated, 317
direct infiltration of, 307-308, 308f
epithelializing, 386
granulating, 385-386
healing of
poor, 387
stages in, 386
high-risk, antibiotics for, 338
infection of, 317, 385
prevention of, 387-388
necrotic, 385
open, 385
tetanus-prone, characteristics of, 320
types of, 385-386
Wound closure, 313-340
adhesives in
follow-up care and instructions for, 340
materials utilized for, 336
procedure for, 336-337
anatomy and physiology for, 316-319,
316f, 318f
background and history of, 314
classification of, 318-319
cleansing agents for, 321, 322t
complications of, 315
contraindications to, 314-315
dog ear deformity correction in, 330,
330f
follow-up care and instructions in,
337-340
indications for, 314
irrigation and cleansing procedure in,
322-323
materials utilized for, 321, 322t
patient preparation for, 319-321
skin staplers in, 335-336
special considerations in, 335
suturing in. See also Suture(s).
materials utilized for, 323-324, 324t, 325f
procedures for, 325-334
tetanus prophylaxis for, 319-321, 320t
timing of, 317
Wound dressing(s), 381-397
anatomy and physiology for, 385-388
background and history of, 382-383
contraindications to, 384
follow-up care and instructions in,
395-396
ideal, 383, 383f
indications for, 383-384
materials utilized for, 388-392
patient preparation for, 388
primary, 388-391, 388f-391f
procedure for performing, 393-395,
393f-395f
resources on, 396-397
secondary, 391-392
Wren, Christopher
injections and, 94
intravenous therapy and, 72
Written consent, 6-7
Z-track intramuscular injections, 109-110,
109f
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