Manual of common office procedures
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SUNDARAM MEDICAL FOUNDATION
Manual of common office procedures
FORUM 2002
© Sundaram Medical Foundation
Chennai: 600 040
2002
SUNDARAM MEDICAL FOUNDATION
Manual of common office procedures
FORUM 2002
© Sundaram Medical Foundation
Chennai: 600 040
2002
Table of Contents
List of contributors
3
Introduction
4
Nasogastric Tube Insertion
5
Peripheral Venous Cannulation
10
Pap Smear
16
Peritoneal Tap
22
Thoracocentesis
27
Rectal examination and Proctoscopy
32
Blood Pressure measurement
37
Bladder Catheterization
42
Diabetic foot exam
50
Local anesthesia
53
Workshop handouts
57
Common Splints used in Orthopaedics
58
Suturing Techniques
61
Excision of a Lesion
62
Wound Care
64
List of contributors
Inspiration, content verification
Dr.Arjun Rajagopalan , Chief of Medical Staff
Perspiration, support and encouragement
Dr S.Ramakrishnan, Organizing Secretary, Forum 2002
Nasogastric Tube Insertion
Dr Sonu Priyadarshini MBBS, Resident, Department of Surgery
Dr. Alfred Solomon FRCS, Consultant, Department of Surgery
Peripheral Venous Cannulation
Dr.M. Senthil, Consultant, Department of Anesthesia
Dr.Eunice Selvaraj, Consultant, Department of Anesthesia
Pap Smear
Dr.V.K.Shantha, Consultant, Department of Obstetrics & Gynecology
Peritoneal Tap & Thoracocentesis
Dr.V.Sheshadri, Consultant, Department of Internal Medicine
Rectal Examination and Proctoscopy
Dr.Ananda Kumar, Resident, Department of Surgery
Dr.R.Parivalavan, Consultant, Department of Surgery
Blood Pressure Measurement
>
Dr.M. Swamikannnu, Consultant, Department of Internal Medicine
Bladder Catheterization
Dr.Ganesh Kamath, Consultant, Department of Urology
Local Anesthesia
Dr.Shivaram Bharathwaj, Consultant, Department of Plastic Surgery
Diabetic Foot Exam
Dr. Lakshmi Devi, Senior Registrar, Department of Surgery
Dr. V.B.Narayana Murthy, Department of Plastic Surgery
EditorialTeam
Dr.R.Parivalavan, Consultant, Department of Surgery
Dr.Shivaram Bharathwaj, Consultant Department of Plastic Surgery
Dr. Alfred Solomon FRCS, Consultant, Department of Surgery
Introduction
“Clinical competence exists when apractitioner has sufficient knowledge and manual skill, such that a
procedure can beperformed to obtain intended outcomes and without harm to thepatient” (Primary care, Vol
24. no: 2;June 1997)
J
I
|
echnique of clinical procedures constitute an important part of daily work of any practicing clinician. All of
us have learnt these during our training period. Most often than not these procedures are self-learnt
without supervision. Are the knowledge and skills we currently possess adequate? Are we using the right
technique? Are there newer and simpler ways of doing these procedures?
Adequate knowledge of and skills for performing these procedures is the means to quality assurance. In this era of
Consumer Protection Act, it is important to have the knowledge and skills that would enable us to perform these
procedures safely and without undue harm to patients.
To perform common bedside procedures, preliminary knowledge of the clinical situation, relevant anatomy and
equipment is necessary before acquiring the skills to a particular procedure. These elements of knowledge can be
summarized into three areas or domains:
Clinical knowledge and judgment - this will provide answers to Who will need the procedure? On whom
should I not do it? When can I perform the procedure? How do I interpret the results? How do I manage my
patient after the procedure is done?
Knowledge of equipment, instrument and supplies - this will provide answers to:- What are the
instruments needed ? How do I put it all together ? Where do I buy rthem ? How do I maintain them ?
Knowledge of the procedure- this will provide answers to :- How do I prepare my patient ? How do I
actually do it and master the procedure ? Are there any special techniques that I should learn?
This manual has been designed to help you find answers to the above
questions. Each chapter has been divided into five sections as shown
on the left. The clinical background will deal with a small introduction
Clinical background
and
the indications and contraindications for the procedure. The
Relevant anatomy
relevant anatomy will consist of pictures to reorient us to the details of
8 —T
Equipment needed
the anatomy that are relevant in performing the procedure. A list of the
equipment needed will be enumerated next. Finally the steps of the
Steps of the procedure
procedure will be presented with a small note on practical tips and
tricks. At the end of each chapter the link icon (in the CD) will take to
you to the relevant video or PowerPoint presentation
ICON KEY_______
T
4
Nasogastric Tube Insertion
Adynamic ileus or intestinal obstruction can lead to accumulation of gases and liquid in
the GI tract. Unless they are removed significant risk of aspiration is present
Nasogastric tubes are placed in the stomach either to remove luminal contents or for
purposes of enteral nutrition.
I NDICATIONS/CONTRAIN DICATIONS
For Ga:
■
intestinal decompression
Adynamic ileus
Gastric outlet obstruction
Intestinal obstruction
To provide enteral nutrition
■
In severe burns and polytrauma
To remove toxic substances
■
Gastrointestinal bleeding
■
Corrosive / poison ingestion
There are no absolute contraindications for the placement of nasogastric tubes.
The relative contraindications are:
Severe maxillofacial trauma
Base of skull fractures
■
Corrosive ingestion
Placement of nasogastric tubes in patients with severe maxillofacial trauma is fraught with the the danger of
the tube inadvertently entering the cranial fossa. Nasogastric tubes in patients who have consumed
corrosives can cause visceral perforation. However in both these instances, nasogastric tubes can be places
with due caution by expert personnel.
RELEVANT ANATOMY
The nasogastric tube passes through the nose. It
It is important to remember that the openings of
the nasal sisnuses and the Eustachian tube can
become infected. Passage of the tube can be
difficult in cases of severe deflected nasal septum
V>.
The pharynx is an area of complex anatomy. It is worth noting the intimate
relationship of the laryngeal inlet and the cricopharyngeal sphincter.
EQUIPMENT
1.
14 -18Fr NG tube
2.
Lubricant jelly
3.
K-Y jelly is sufficient, but lidocaine jelly may be used
4.
Topical nasal vasoconstrictors such as phenylephrine or cocaine (optional)
5. Topical anesthetic such as 10% lignocaine spray (optional)
6.
Emesis basin
7.
Catheter tip syringe
8.
Suction apparatus (i.e., wall suction or portable apparatus)
9.
Tip suction tube
10. Gloves and eye protection
11. A small cup with water, with a straw for the patient to sip through
12. Tincture benzoin and tape to secure the tube after placement
STEPS OF THE PROCEDURE
1.PREPARE THE
■
PATIENT.
Explain the procedure
Explain the risks and the alternatives
■
Answer any questions
7
2.
PATIENT
POSITION
The bed should ibe inclined
■
3 .
Position the patient upright or decubitus, with the neck flexed.
ESTIMATE THE TUBE
LENGTH.
Measure the distance from the patient's ear to the umbilicus. This is a good estimate of the needed length.
BEND
AND
LUBRICATE THE
TUBE
The tip of the nasogastric tube should be bent to conform to the direction of
passage and lubricated liberally with K-Y or lignocaine jelly
4,
5.
CHOOSE A
NOSTRIL,
SELECT THE
MOST
■
Spray topical anesthetic to the back of the throat.
■
Apply lubrication jelly liberally to the tip of the tube and along the
length of the tube.
■
Have the suction apparatus turned on.
INSERT THE
PATENT ONE.
liL
$ s
TUBE.
■
With the patient's neck flexed (Make sure there is no cervical spine injury), insert the tube into the
nostril
■
Aim straight back toward the occiput.
■
Apply firm constant pressure to the tube.
■
Have the patient hold the cup of water; have the patient take small
and swallow as you apply pressure.
■
Continue to advance the tube to the desired length.
■
Anticipate some gagging during placement. Spraying additional topical anesthetic to the back of the
throat may decrease this.
8
sips
6.
CHECK
POSITION OF TUBE
■
Hold it firmly in place, close to the nostril, which often requires
steadying your hand against the patients nose.
■
Attach the catheter tip syringe to the tube and inject 30 to 60 ml of air
the tube. Listen over the epigastrium with a stethoscope for the
rumbling of air in the stomach.
■
Aspirate back on the syringe to confirm the efflux of gastric fluid; pH should be <5.
into
Confirmation of tube position
Radiographic confirmation of toe placement is often necessary. NG tubes have radio-opaque marker
tape incorporated into their design so that they are visible on routine kidneys, ureter and bladder (KUB)
x-ray.
7.
SECURE
TIPS
TUBE
■
Secure the tube to the nose with benzoin and tape. Avoid taping the
tube in such a way that pressure is applied to the nostril. This is a
common cause of necrosis of the nares.
■
Be sure to tape the tube down to a second site, such as the patients
forehead or shoulder, so that inadvertent traction on the tube does not
dislodge it.
&
TRICKS
If the tube does not pass easily, do the following:
■
■
If the tube coils in the mouth or esophagus, chill the tube in some ice to stiffen it.
If the tube does not pass at all, try the other nostril.
■
If, during advancement, the patient begins to cough, withdraw immediately. This
indicates misplacement into the trachea.
9
Chapter
!enous Cannulation
CLINICAL BACKGROUND
Venous access is a simple bedside process that is carried out on a daily
basis. Proper selection of the vein, using the right sized cannula, proper
fixation and cannula care are important.
SELECTION CRITERIA
■
■
■
■
■
■
■
Use the upper arm preferably, dorsum of the hand
Use as distal a location as possible
Select a straight vein; tortuos or bent veins are prone to counter puncture
Use the largest vein available
Use a soft and resilient vein
Always use the non-dominant limb as it frees his dominant hand
Resuscitation
INDICATIONS/CONTRAINDICATIONS
■
■
■
■
Volume replacement
Fluid replacement
Blood transfusion - acute and chronic blood loss
Intravenous administration of drugs
There are no absolute contraindications fro the placement of IV cannulation.
RELEVANT ANATOMY
Sites for Cannulation
There are several different potential sites for peripheral venous cannulation. The diagrams
below give an outline of the venous anatomy that must be considered.
Veins of the Forearm
Veins of the Hand
1. Cephalic vein
2. Median Cubital vein
3. Accessory Cephalic vein
4. Basilic vein
5. Cephalic vein
6. Median antebrachial vein
1. Digital Dorsal veins
2. Dorsal Metacarpal veins
3. Dorsal venous network
4. Cephalic vein
5. Basilic vein
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■
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4
EQUIPMENT
Instrument tray
Cannula
It might sound obvious! Choose the right sized one
Tourniquet
A quick release one is best. Ensure that it is big enough to go round the
limb
Alcohol swab
and Gauze
Extra gauze needed to prevent blood leaking on the patient /trolley/floor
Gloves
Make sure that the gloves fit you well, especially at the fingertips
Blood Bottles, Sharps Bin, Tape and Saline Flush
Cannula Size
The size of the cannula you are intending to use is an important factor in the usefulness of the cannula.
Generally speaking, the smallest possible cannula is inserted into the largest possible vein. However, in an
emergency situation, the following rule should be followed. - ’Short and Thick does the Trick'
The primary aims of cannulation in an emergency, depending on the patient's
condition, is to provide venous access for drug and fluid administration, and for taking blood
for laboratory analysis. Venous cannulae are gauged according to their size, and color-coded
accordingly. A green cannula (size 18) is the absolute minimum size of cannula that should be
used in an emergency situation. Anything smaller, and you are compromising the amount of
fluid that can be pushed through in a given time, and increasing the risk of any withdrawn
blood haemolysing.
If a bigger cannula can be used, it should be considered. The fluid flow difference between a
green (18G) and gray (16G) cannula is about 100 mls/min. Care should be taken however not
to use too large a cannula - if there is no collateral blood flow
* ~
around the cannula the drugs or fluids will not be distributed
through the bloodstream properly.
J
Information on cannula sizes
colors and maximum flow rates.
Color
Size
Grey
16G
Green
18G
Pink
20G
Blue
22G
Int. Diameter/Length
1.4mm/45mm
1.0mm/45mm
0.8mm/32mm
0.6mm/25mm
’ i
Max Flow
180mls/min
80mls/min
54mls/min
31mls/min
Which Cannula?
Most cannulae are now similar - such as the Angiocath® and Intracath®. Choice of size
depends on need and age of patient.
• Adults
• 12-14G - Volume resuscitation and replacement of acute blood loss
• 16-18G - Fluid replacement
• 18-20G - Elective blood transfusion, IV drug administration.
Infants and Children
• 20-22G - serve most purposes depending on size of child
Newborns and neonates
• 24G - for blood, fluids and IV drugs
12
STEPS OF THE PROCEDURE
1 .
PREPARE
PATIENT
Explain the procedure in detail and the reason for doing it. Inform the patient that it
will be painful.
2.
ASSEMBLE
EQUIPMENT
Make sure that you have a tray of all the equipment needed. It is very embarrassing to be running for things
in the middle of the procedure
3.
APPLY THE TOURNIQUET
Apply the tourniquet approximately 20 ems above your intended cannulation point. The
torniquet should be tight enough to impede venous return but
not restrict arterial flow. Advise your patient to lower their arm
and clench/release their fist (to maximise venous distension).
-XcM'Flicking or slapping veins does not affect how distended they will
become, and can cause pain and haematoma formation particularly in the elderly with fragile veins or
thrombocytopenia.
4.
CHOOSE THE
VEIN
Palpate the vein with your fingertips. You should be assessing its rigidity, turgidity, mobility and likelihood of
success. If you are not confident, look at the other arm as well - there may well be a king size vein waiting
for you!
5.
SWAB THE
SKIN
Swab the skin surrounding the intended cannulation point with an alcohol based
swab, for example chlorhexidine 70% in alcohol, and allow it to dry (to ensure
maximum effectiveness of the antimicrobial properties of the swab).
Do we need to anesthetize before venupunture?
■ Except in an emergency, always apply topical EMLA (Eutectic Mixture of Local
Anaesthetic) cream in infants and children. EMLA is not approved for infants < 3 months of
age).
13
■ Apply an EMLA patch or some EMLA cream (cover with Opsite film) over the selected
vein or veins about 1 hr before placement of an IV.. EMLA may make veins less visible if left
too long. EMI.A analgesia lasts up to 90 minutes.
■ Adult patients will appreciate consideration of analgesia when IV cannulas are placed
electively.
■
6.
■
■
APPLYING SKIN TRACTION
Apply a small amount of traction to the skin below the cannulation point (not above
- you will risk a needlestick injury). This helps to stabilise the vein, and decrease its
lateral movement
7.
HOLDING CANNULA
Hold the cannula in your dominant hand, with your index and middle
fingers on the flanges either side of the cannula, and your thumb on the
cap at the end. This is the steadiest position to hold a cannula, and gives
you the greatest control over its movement.
8.
ENTERING THE
VEIN
With a short, confident motion, push the point of the cannula through the skin at a 30
to 40 degree angle. Advance the cannula slowly towards the vein, until you see a
flashback in the cannula chamber. NOW - STOP! Do not advance the cannula too
much further or you may go straight out of the other side of the vein. Maybe another
millimetre to clear the plastic tube from the entry point is all that is needed
9.
ADVANCING
CANNULA
Holding the needle exactly where it is, advance the cannula itself over the needle. It should advance
reasonably smoothly - a lot of resistance may indicate a failed cannulation. The
cannula should be advanced as far as it will go. Apply some pressure proximally to
the cannula to (try to) occlude the vein, and withdraw the needle disposing of it
appropriately (remember to retain the white stopper on the end of the needle!)
14
a
10. FIXING THE CANNULA TO SKIN
Use your empty syringe to draw as much blood as you need. Cap the cannula with the white stopper, and
secure it to the skin. Document your actions in the nursing or medical notes. Documentation should include
site, size, bloods drawn and time. Flush the cannula, noting any signs of extravasation (pain, local swelling,
difficulty in flushing).
15
Pap Smear
The PAP test is the cytological evaluation of cells from cervix and vagina for detecting pre-cancerous lesions
of the cervix. In 1940 Papanicolaou Traut proposed this method of detecting cervical cancer in its precancerous stage. Hence this screening procedure is known as Papanicolau Smear or Pap test. It is the most
cost effective and simple screening test with the least discomfort to the patient and with good sensitivity and
specificity.
CLINICAL BACKGROUND
Cancer cervix is the commonest cancer in women in developing countries.
According to the International Agency for Research of Cancer (IARC) Scientific
Publication 1997, World wide 450, 000 women die from cancer cervix per year. WHO has declared
invasive cancer of uterine cervix as a preventable cancer as it can be diagnosed in the
asymptomatic pre-cancerous stage and can be controlled.
Does the incidence of cervical cancer justify screening?
World wide estimated new cases of cancer cervix is 500,000 per year of which one fifth of cases
occur in India. In India, the commonest cancer among women is cancer cervix and Chennai is the
most affected among the cities.
Does the screening of cervical cancer decrease the morbidity or mortality?
A single negative Pap test decreases the risk by 45%. Look at the table below:
Screening
frequency
Once in 10 yrs
Reduction in
cancer cervix
64%
Once in 5 yrs
84%
Once in 3 yrs
91%
16
INDICATIONS
■
According to ACOG recommendation, all women who have been sexually active should be screened.
■
Screening begins with the onset of sexual activity or at 18 years of age.
■
In developing countries like India, IARC working group recommends three yearly screening in the 25
- 64 yrs age group and this gives a 91% reduction in invasive cancer.
Optimal screening interval
■ After three consecutive annual normal pap smear test, it is repeated
o
Once in 3 years in low risk women and
o
Once a year in high risk women
CONTRAINDICATIONS
■
Presence of bleeding PV
Presence of active infection
17
RELEVANT ANATOMY
The arrow points to the position of the junction between ectocervix and endocervix. It
gradually migrates inwards as the age progresses.
Multiparous reproductive age
Neonatal
Multioarous reproduction age
Postmenopausal
18
EQUIPMENT
o
Ayre's spatula / Cervical cytobrush or cotton swab ona stick
o
Cusco speculum
o
Water to lubricate - no other lubricants
o
Two glass slides-clean and dried
o
A bottle of liquid fixative or cytofixative
o
A focus light or torch light
o
Completed cytopathology form with the following details are required:
o
Patient and physician details
o
Age
o
Symptoms - Post Coital Bleeding
o
Clinical diagnosis / Routine screening
o
Prior treatment - hormone / infection
o
Previous Pap / Biopsy date and
o
Report
o
Obstetric history - present pregnancy
o
Contraception
o
LMP
o
Site of collection
o
Method of collection
19
STEPS OF THE PROCEDURE
1.PREPARE
THE
PATIENT.
Explain the whole procedure and its importance. Inform the patient that the procedure is inconvenient but
painless
2.
ASSEMBLE
EQUIPMENT
Arrange the tray so that everything is at hand's reach. The lighting should be adequate. Have a person to
hold the patients legs and to help you in preparing and fixing the slides
3.
P ATIE NT POSITION
The Pap test is done as an outpatient procedure in the dorsal position under natural
light or focus light. There is no need for any sedation.
I.
VISUALISING THE CERVIX.
4
■ First, inspect the vulva. After separation of the labia minora, the Cusco
speculum is moistened with water and gently inserted and the blades opened .
■ The cervix is visualized fully all and the squamo-columnar junction is seen all
around.This may be indrawn in postmenopausal women
5. COLLECTING THE PAP SMEAR
SPATULA
■ Choose the contoured end of the spatula which best conforms to the cervix
and the transformation zone.
■
Rotate the spatula 360 degrees about the circumference of the cervix while
maintaining firm contact with the epithelial surface.
■ Spread the material collected on the spatula evenly over the slide with a single
smooth stroke motion.
6. COLLECTING THE PAP SMEAR
CERVIX BRUSH
Introduce the brush into the endocervix
Rotate the brush several times
■ Spread the material collected on the spatula evenly over the slide with a
single smooth stroke motion
■ Cytobrush is specially suited to obtain adequate endocervical smear, in
postmenopausal women where the squamo-columnar junction recedes into the
canal
■
Not currently recommended for pregnancy.
Except in pregnancy, the use of a cotton tip applicator is not recommended.
It usually provides less cellular samples, possibly because of the trapping of material in the
cotton fibers.
PREPARING THE SLIDE
The spatula or brush is quickly swabbed on the slide to evenly spread the cellular material in a single layer on
the slide. Thin out large dumps of material as much as possible, while avoiding excessive manipulation that
can damage cells.
■ Transfer material from both sampling instruments to the slide within a few
seconds and fix immediately in order to avoid air - drying artifact.
■ Immediately fix the specimen by either immersing the slide in 95% ethanol
or coating the slide with a surface fixative.
■ The slides have to be placed in back to back position so that the smears on the surface of the slides
will not stick together.
21
Peritoneal Tap
Synonyms Abdominal Paracentesis; Ascitic Fluid Tap
Paracentesis is a safe procedure when ascites is easily demonstrable on physical examination.
When small amounts of ascites are present, a fluid wave may be difficult to demonstrate even
when <1.5 L ascites is present. CT scan or abdominal ultrasound guided needle aspiration is
particularly useful in these cases.
CLINICAL BACKGROUND
Ascitic fluid is routinely analyzed for cell count, chemistries including LDH,
albumin and protein, Gram's stain, bacterial culture, and cytology. Additional
tests include special cultures for tuberculosis or fungi, ascitic fluid pH, amylase, lipase,
glucose, triglycerides, lactate, CEA, and hyaluronic acid.
NORMAL FINDINGS
Ascitic fluid is traditionally categorized as either "exudative" or "transudative" based on
laboratory analysis. Transudative ascites is caused by either increased portal venous pressure
or decreased portal venous colloid osmotic pressure. Examples of transudates include hepatic
cirrhosis, congestive heart failure, constrictive pericarditis, Budd-Chiari syndrome, inferior
vena caval obstruction, and nephrotic syndrome. Exudative ascites is generally non-cirrhotic
in its pathophysiology and may be due to peritoneal membrane permeability defects.
Examples of exudates include malignancy, spontaneous bacterial peritonitis (SBP), or other
infections
(such
as
tuberculosis),
vasculitis,
pancreatitis,
and
myxedema.
INDICATIONS/CONTRAINDICATIONS
Diagnostic indications include:
■
■
Patients with of ascites of recent onset
Ascites of unknown etiology
■
Patients with clinically suspected ascitic fluid infections
22
Therapeutic paracentesis is indicated in:
■ Ascitic fluid causing respiratory compromise, abdominal pain, or worsening of existing
inguinal or umbilical hernias.
Paracentesis should not be performed to diagnose the presence ofascitic fluid. This should
be known prior to the procedure (by physical examination or radiological imaging).
Contraindications
■ Inability of the physician to demonstrate ascitic fluid on physical examination.
■ Lack of patient cooperation.
The following factors are NOT contraindications for paracentesis:
Morbid obesity, low-grade coagulopathy, multiple abdominal surgical scars and
bacteremia
RELEVANT ANATOMY
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EQUIPMENT
1. Sterile gloves
2. Drapes (optional)
3. Local anesthesia ( 26-gauge subcutaneous needle, 5 ml syringe and 2% lignocaine)
4. Sterile 50 mL or 60 ml syringe and
5. Sterile 1 litre vacuum bottle with connecting tubing
In clinical practice, various needles and angiocatheters are used. A 22-gauge, 1.5" metal needle with a
plastic catheter is recommended. If a thick panniculus is encountered, a 3" to 5" 22-gauge needle may be
substituted.
STEPS OF THE PROCEDURE
1 .PREPARE THE PATIENT.
■
Technique and risks of the procedure are explained
2. ASSEMBLE EQUIPMENT
■
Paracentesis is at times performed on patients with significant hepatic encephalopathy.
■ Additional personnel may be required for conferring with family members and for proper
patient positioning during the procedure.
■
Premedications (eg, sedatives or narcotics) are not routinely required.
■
Laboratory requisitions are completed in advance to avoid delay in fluid processing later.
■ Prothrombin and partial thromboplastin times prior to paracentesis are ordered at
physician's discretion.
24
3. PATIENT POSITION
■ Patient is placed in a semirecumbent position. Patient should be
made to empty his /her bladder prior to procedure.
■
Physician confirms presence of ascites by physical examination or
by ultrasound examination
4. PREFERRED SITE
■
■
Preferred site of entry is inferior & lateral to the umbilicus.
■ If a midline scar is present from prior surgery or if percussion is
not reliable, an area near the flank is selected.
5. ASPI RATE FLUID
■
The site is prepared with iodine solution
■
Skin and deeper tissues are infiltrated with xylocaine
■ The skin is retracted caudally (in order to form "z"
track)and the 22-gauge needle (attached to syringe) is
inserted into the anesthetized area and advanced while
aspirating.
6. COLLECT SPECIMEN
■ When ascitic fluid returns freely, the needle is held in position and not advanced further
(avoiding bowel trauma).
■
Multiple aliquots (50 ml) may be obtained in this manner.
■
Send the specimen for the required tests
7. CONNECT TO DRAIN TUBE
■ For larger volumes, the syringe is removed and connecting
tubing is directly attached to the 22-gauge needle to allow
drainage into drainage bottles.
■ A blood collection bag is an useful alternative as it maintains a
closed sterile environment and provides weak suction effect
25
1
8. REMOVE
NEEDLE AND SEAL SITE
■ Once the desired amount is collected, the needle is withdrawn quickly and the caudal skin
retraction is released, allowing the skin to return to its normal position.
■ This causes the entrance and exit needle sites to form a "Z-tract" which minimizes ascitic
fluid leakage
■
Use a sterile gauze dressing; this can be removed after 24 hours
AFTERCARE
■
No special limitations exist for the patient postprocedure.
■ If large amounts of ascites are removed (several liters),
frequent blood pressure measurements are needed to
monitor possible hypotension.
■ Patients may ambulate postprocedure if vital signs remain
stable.
■ Occasionally, ascites fluid may leak persistently from the
puncture site; in this instance, the patient should remain
supine with the site angled directly upwards, until the leak stops
■
COM PLICATIONS
Paracentesis is a safe procedure, carrying <1% risk of major complications and <1% risk of
minor complications.
The most feared complication is needle perforation of an abdominal viscus or solid organ such
as liver or spleen. Others include: intraperitoneal hemorrhage abdominal wall hematoma,
contamination of ascites by nonsterile technique. Hypotension can be seen when large
amounts of ascites (more than 1500 mL) are removed
26
Thoracocentesis
Synonyms Pleural fluid aspiration; Pleural tap
INDICATIONS
INDICATIONS/ CONTRAINDICATIONS
Diagnostic
Determine the etiology of a pleural effusion
Diagnosis and staging of a suspected or known malignancy
Therapeutic
To relieve respiratory insufficiency
To introduce sclerosing or antineoplastic agents
CONTRAINDICATIONS
Absolute contraindications
Lack of patient cooperation
Respiratory insufficieny or instability
Cardiac instability including unstable angina
Relative contraindications
Mechanical Ventilation
Bullous Lung Disease
Local Chest Wall infection
RELEVANT ANATOMY
V sy^rticiai tascie
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M
wUrct^m vein
iM
f a artery
i
/ nerve
J«
I III
M
needle
IB
'IS
I
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w
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external totercmal-^
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external InurcuaUl
internal intercostal
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parietal pleara |
vi sr em f tJl#«Mra
28
viscera I jjjore
M
■
BwS
fci
teI
M
Idr.Q!
EQUIPMENT
1.
2.
3.
4.
5.
6.
Betadine solution
Dressing tray with drapes
Sterile gloves
2% Xylocaine with 26g needle
Three-way stopcock
Venous cannula 20G (Pliable catheters generally are preferable to the traditional
simple thoracocentesis needle because they decrease the risk of pneumothorax)
7. 60 cc syringe
8. IV set
9. Collecting bottle
STEPS OF THE PROCEDURE
1.PREPARE THE PATIENT.
The procedure and risks are explained to the patient.
Thoracocentesis may be performed safely without premedication and a narcotic or sedative is
undesirable.
2. ASSEMBLE EQUIPMENT
Initially, the physician must verify the presence and location of the pleural fluid, often by
physical examination.
However, a lateral decubitus chest x-ray, ultrasonography, and/or CT may be required if the
disease is loculated
3. PATIENT POSITION
Thoracocentesis is best performed with the patient sitting comfortably, leaning slightly
forward, and resting the arms on a support.
Performing it with the patient lying down is possible but more difficult, usually requiring
ultrasound or CT guidance.
Only high-risk or unstable patients require monitoring (eg, pulse oximeter, ECG).
29
4
PREFERRED SITE
The needle must be inserted in an intercostal space overlying the fluid,
(above the rib below to avoid injury to intercostal vessels and nerves)
For non-loculated effusions, the space is usually one interspace below
the fluid level, in the mid-axillary line
5. PREPARE SKIN & INFILTRATE
LOCAL ANESTHETIC
After cleansing the skin with iodine and applying sterile draping, the
gloved physician uses 1% or 2% lignocaine local to make a skin
wheal, then infiltrates the subcutaneous tissue, and advances the
needle gradually just above the upper border of the rib
When the anesthetizing needle enters the parietal pleura and pleural
fluid is aspirated, the depth of the needle should be noted.
6. MAKE CONNECTIONS TO AVOID AIR LEAK
A large-bore (16- to 19-gauge) catheter device (VENFLON) is attached to a
three-way stopcock, which is then connected to a 50-ml leur-lock type
syringe
The 3-way tap is crucial to prevent pneumothorax and you should make
yourself familiar with its action and turn the tap off whenever the syringe is
withdrawn.
I
7. ASPIRATE FLUID
■ Advance the venous cannula 0.5 cm beyond the noted depth of
the anesthetizing needle perpendicular to the chest wall through the
skin and subcutaneous tissue, along the upper border of the lower
rib into the effusion.
■ The syringe and three-way stopcock must be manipulated with
care: Air should not be allowed to enter the pleural space. Fluid
should never be forcibly aspirated from the pleural space, so as to avoid damaging the lung
with the needle or catheter
■ Multiple small (15- to 30-mL) samples are obtained in tubes containing 0.1 mL of aqueous
heparin; the tubes are processed for appropriate tests.
■
For patients with large effusions, generally no more than 1500 mL should be removed at
one sitting to avoid precipitating hemodynamic instability or pulmonary edema associated
30
with lung reexpansion.
■ As the lung expands against the chest wall, the patient may feel some pleuritic pain. The
procedure must be stopped if severe pain, breathlessness, bradycardia, faintness, or other
significant symptoms occur, even if a substantial amount of fluid remains in the chest.
COLLECTION OF PLEURAL FLUID
8.
COLLECTION FOR ROUTINE LABS
■ Routine appropriate lab bottles for cell count and differential counts;chemistries
including total proteins, albumin, sugar, LDH; aerobic and anaerobic culture media bottles
for bacteriology.
■ For cytology, send sterile vacuum bottles with 5000 units of heparin added.
COLLECTION FOR MICROBIOLOGY
■ Samples should be sent for appropriate bacterial stains and cultures in appropriate
transport media. Special stains may be required to demonstrate certain specific organisms
as the case maybe.
AFTERCARE
■
■
Pressure is applied to the puncture site to prevent bleeding
Chest x-rays (erect posterior-anterior and lateral at inspiration and expiration) should
be obtained after thoracocentesis to document fluid removal, to view the lung parenchyma
previously obscured by the fluid, and to look for possible complications from the procedure
COMPLICATIONS
1.
2.
3.
4.
5.
6.
7.
Pneumothorax
Hemorrhage into the pleural space or chest wall
Vasovagal or simple syncope
Air embolism (rare but catastrophic)
Infection
Puncture of the spleen or liver due to low or unusually deep needle insertion
Reexpansion pulmonary edema, associated with rapid removal of > 1 L of
pleural fluid.
31
Rectal examination and Proctoscopy
These are office procedures done as part of the evaluation of acute and chronic lower gastrointestinal
symptoms in patients
CLINICAL BACKGROUND
Digital Rectal Examination (DRE) and proctoscopy are two simple bedside tests that are
paramount importance in the evaluation of lower abdominal pain and in a patient who
presents with symptoms of lower gastrointestinal symptoms. It is mandatory in a patient who complains of
bleeding per rectum.
DRE forms an integral part of pelvic examination in women.
■ It is worth noting that nearly 2/3rds of carcinoma rectum can be felt with a gloved finger and DRE is a
cheap and effective screening test for this carcinoma.
The following conditions can be diagnosed on inspection alone:
■ Anal fissure, anal hematoma and warts, hemorrhoids, pilonidal sinus, skin tags, lower edge of a
carcinoma, external opening of an anal fistula, perianal and pilonidal abscesses.
Palpation and proctoscopy provide clues to the following conditions:
■
Abscesses [ ischiorectal type or perianal variety]
Internal hemorrhoids
■ Ulcerative colitis, sessile & pedunculated adenoma, villous papillomas, raised indurated edge of
carcinoma
Secondary deposit of growth in the pelvic peritoneum - Blumer's shelf
Deformities of the coccyx, presacral tumors, lipomas or teratomas
32
RELEVANT ANATOMY
Cross-section of male pelvic anatomy
j^V"
Lw.. '.*«!■>to: rd tele
b'acMer
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ftjacy:diary {<dt
4:--
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tntf:fnai spttfncur
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Cross-section of female pelvic anatomy
’ MU
\
T V' i
\
\
<\
i-j’f !?<<<>•:.<$ sV-
4
rV y<:: ft ;> : P®>.« ft <:• •
i> hi::
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: t<51 <> 1
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'
ftfi': -i : UV-dy
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33
EQUIPMENT
Gloves
Proctoscope
Proper lighting
Examination table
■
Jelly for lubrication
Gauze packs
STEPS OF THE PROCEDURE
1. PREPARE
THE
PATIENT.
■
Allay any anxiety, and make the patient to relax his musculature
■
The examiner should be sympathetic yet confident with utmost gentleness
■
Avoid instruments that are badly designed
■
Warn in advance - patient often feels that his bowels are going to act
2.
ASSEMBLE EQUIPMENT
Light source at the foot end in the midline
Instrument trolley behind the light
■
Arm of the lamp sufficiently long
Left hand to retract the right buttock upwards
Right hand within reach of the trolley
3.
PATIENT
POSITION
The left lateral or Sim's position
Hips are flexed to an angle slightly greater than 90°.
Patient's left hip rests on a small firm sandbag
Trunk should lie obliquely across the couch
Knees and ankles parallel and close to the couch
Right shoulder and buttock - slightly prone inclination
Face directed partly into the pillow
Inclination of the body to be maintained throughout the
examination
4.
INSPECTION.
1
Most neglected part of the rectal examination
Light source should be fairly close to the anus
Left hand gently lifts uppermost buttock
■ Fingertips of the two hands placed on the skin over gauze swabs close
to the anal verge either side & gently but firmly separated
i
Look for sphincter spasm
In post anal region and perineum, look for other lesions
■
PALPATION
5.
■
Lubricated right index finger is next stroked across the anus once or twice. It is then gently inserted
into the anal canal, intersphincteric groove and anorectal ring.
-
The following information should be carefully looked for during
palpation:
-
The tone of the sphincter and presence of foreign bodies if any are
noted
Cervix uteri or prostate in relation to the anorectal ring
■
Palpation of extra rectal structures in anterior, lateral and posterior rectal wall, rectovesical or
rectouterine pouch
35
Examination of examining finger on withdrawal
■
6.
Vaginal examination should precede rectal examination
PROCTOSCOPY
■ The proctoscope, after lubrication, is held in the right hand with the obturator and gently pushed into
the anal canal exerting gentle pressure in the direction of the umbilicus. Once it enters the anal canal, it is
eased into the hollow of the sacrum and the obturator is removed. The following are noted as the
proctoscope is gradually withdrawn.
Mucous membrane is normally pale pink with submucous vessels
Ask the patient to bear down
Examine state of the anal valves
Reinsert & examine for more information
■
Don't replace the obturator with the tube still in the lower part of the ana! canal
36
Blood Pressure measurement
Blood pressure measurement forms an integral part of the physical examination of a patient. If
appropriately carried out, this provides vital information concerning the health of the individual.
CLINICAL BACKGROUND
Blood pressure (BP) is characterized by large spontaneous variations, therefore the diagnosis of hypertension
should be based on multiple BP measurements taken on several separate occasions.
■
At the initial visit, an average of three readings, taken at intervals of 2-3 minutes should be recorded.
■ For confirmation of diagnosis of hypertension, record at least 3 sets of readings on 3 different
occasions, one to three weeks apart.
■ If atrial fibrillation is present, additional readings may be required to estimate the average SBP and
DBP.
■ Occasionally, thigh BP (popliteal) has to be measured with appropriately large cuff, especially in
younger persons with hypertension. Normally thigh SBP is higher and DBP a little lower than the arm BP
because of the reflected pulse wave. This is important for suspected coarctation and non-specific
aortoarteritis.
RELEVANT ANATOMY
It is believed that Korotkoff sounds are produced within an artery when the internal pressure of
the blood flow overcomes the pressure of an outside occluding force for a part of the arterial
pressure cycle. This jetting force overcomes the occluding force and causes intermittent turbulent
37
blood flow within the vessel, which creates vibrations heard by the stethoscope. When the cuff
pressure is higher than systolic pressure, the artery remains collapsed so that blood is unable to
flow and no sounds are heard. In contrast, when cuff pressure decreases below diastolic pressure,
the artery no longer closes, laminar (non-turbulent) flow is restored, and no sounds are heard.
130
Korotkoff
Sounds
120
|
|
110
14 mmHg
CUFF
100
PRESSURE
90 ■
mmHg
20 mmHg
^5 mmHg
I^TsmmHq
80
70
60
, Silence I
•
Snapping
Scmfs
I
r
RELATIVE I
INTENSITY
OF
SOUNDS I
2
Mutws
■I
■ ■ Silence
jsji
!■
li
EQUIPMENT
1. Properly calibrated sphygmomanometer
2. Stethoscope
3. Examination couch with chair
4. Appropriate lighting
38
5
STEPS OF THE PROCEDURE
1 .PREPARE THE PATIENT.
- Patients should be asked to refrain from smoking or drinking tea/coffee for at least 30 minutes before
measuring the BP.
■ Allow the patient to sit for at least five minutes in a quiet room before beginning blood pressure
measurement.
2. ASSEMBLE EQUIPMENT
Check the sphygmomanometer for leaks. Make sure the glass tubing is clean and the vent
patent
Choose the right cuff for the patient
3. PATIENT POSITION
■
Seat the subject in a quiet, calm environment with his or her bared arm resting on a
standard table or other support so the midpoint of the upper arm is at the level of the heart
Measure the blood pressure in both arms at the first visit and use the higher of the two
readings. In older persons aged 60 years and above, in diabetic subjects and patients on
antihypertensive therapy, the BP should be measured in both supine / sitting and in standing
positions to detect postural hypotension.
4 CHOOSE THE RIGHT CUFF.
■ Estimate by inspection or measure with a tape the circumference of the bare upper arm at
: and olecranon
------------------,
the midpoint between the---------acromion
process
(between the shoulder and elbow) and select an appropriately
'io
sized cuff.
1 The bladder inside the cuff should encircle 80% of the arm
in adults and 100% of the arm in children less than 13 years old. If in doubt, use a larger cuff.
If the available cuff is too small, this should be noted
5. APPLY THE CUFF
■ Palpate the brachial artery and place the cuff so that the midline of
the bladder is over the arterial pulsation
■
Wrap and secure the cuff snugly around the subject's bare upper
39
arm. Avoid rolling up the sleeve in such a manner that it forms a tight tourniquet around the
upper arm.
■
Loose application of the cuff results in overestimation of the pressure.
■ The lower edge of the cuff should be 1 inch (2 cm) above the antecubital fossa (bend of the
elbow), where the head of the stethoscope is to be placed
6. AVOID PARALLAX ERRORS
Place the manometer so the center of the mercury column or aneroid dial is at eye level and easily
visible to the observer and the tubing from the cuff is unobstructed
7. ESTIMATE SYSTOLIC PRESSURE BY PALPATORY METHOD
Inflate the cuff rapidly to 70 mm Hg, and increase by increments of 10 mm Hg while palpating the
radial pulse.
Note the level of pressure at which the pulse disappears and
subsequently reappears during deflation.
This procedure, the palpatory method, provides a necessary
preliminary approximation of the systolic blood pressure to ensure an
adequate level of inflation when the actual, auscultatory measurement is made. 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 blood pressure.
PLACE THE STETHESCOPE
Place the earpieces of the stethoscope into the ear canals, angled forward to fit snugly.
Switch the stethoscope head to the low-frequency position (bell). The setting can be
confirmed by listening as the stethoscope head is tapped gently.
Place the head of the stethoscope over the brachial artery pulsation just above and medial to the
antecubital fossa but below the lower edge of the cuff, and hold it firmly in place, making sure that
the head makes contact with the skin around its entire circumference.
Wedging the head of the stethoscope under the edge of the cuff may free up one hand but results
in considerable extraneous noise
RECORD SYSTOLIC PRESSURE
Inflate the bladder rapidly and steadily to a pressure 20 to 30 mm Hg above the level previously
determined by palpation, then partially unscrew (open) the valve and deflate the bladder at 2
mm/s while listening for the appearance of the Korotkoff sounds
40
LISTEN TO KOROTKOFF ’S SOUNDS
As the pressure in the bladder falls, note the level of the pressure on the manometer at the
first appearance of repetitive sounds (Phase I) and at the muffling of these sounds (Phase IV)
and when they disappear (Phase V).
During the period the Korotkoff sounds are audible, the rate of deflation should be no more
than 2 mm per pulse beat, thereby compensating for both rapid and slow heart rates.
After the last Korotkoff sound is heard, the cuff should be deflated slowly for at least another
10 mm Hg, to ensure that no further sounds are audible. The point of disappearance of
Korotkoff's sounds is the diastolic pressure.
The cuff is rapidly and completely deflated, and the subject should be allowed to rest for at
least 30 seconds.
RECORD SYSTOLIC AND DIASTOLIC PRESSURES
The systolic (Phase I) and diastolic (Phase V) pressures should be immediately recorded, rounded
off (upwards) to the nearest 2 mm Hg.
In children, and when sounds are heard nearly to a level of 0 mm Hg, the Phase IV pressure
should also be recorded.
All values should be recorded together with the name of the subject, and the date and time of the
measurement, the arm on which the measurement was made, the subject's position, and the cuff
size (when a nonstandard size is used).
REPEAT MEASUREMENT
Record the BP again after 30 to 60 seconds
41
Bladder Catheterization
INTRODUCTION
Bladder catheterization is one among several bedside skills a doctor is
supposed to possess at the end of medical school, however it appears that
not many are formally trained in this apparently simple procedure. Insertion
of a hollow tube into the bladder using aseptic technique is termed bladder catheterization.
INDICATIONS/ CONTRAINDICATIONS
INDICATIONS
■ Therapeutic- relieve retention, incontinence
■ Diagnostic-to obtain a urine sample for analysis and estimation of residual urine
■ Monitoring-urine output in post-operative patients or terminally ill / sick patients.
It is important to be sure that the patient deserves a catheter; one should not insert
catheters as a solution for dysuria.
CONTRAINDICATIONS
There are truly no contra-indications to inserting a catheter, however as a principle it is
prudent to avoid inserting a catheter in a patient presenting with suspected injury to the
urethra with blood at the meatus. This is advised to prevent conversion of a partial injury into
a complete one by injudicious and aggressive use of the catheter in pelvic trauma.
42
RELEVANT ANATOMY
In the male urethra there are three specific points where one may encounter resistance :
External urethral meatus
■
Membranous or sphincter zone
Bladder neck.
■
Contrary to popular belief prostates, however large,rarely obstruct the passage of a catheter
bladder
puboprostatic
1
prostate
uraqent u1 a I
\
owning of •?
I
doct
scrotum
p*
EQUIPMENT
Catheterization tray (autoclaved) consisting of a central hole towel, kidney tray and
swab sticks
Foley catheter of the appropriate size
O
2% Xylocaine jelly in a sterile pack
O
o. Sterile gloves
o Urobag
10ml. syringe filled sterile water. Urinary catheter
o
Povidone-iodine
solution
o
o
The Catheter:
It is vital to understand this piece of equipment in order to select the right tool for the given
situation. In the following passage the different parts and types of catheters in common use will be
discussed.
Morphology of the catheter
Tip: The tip of the catheter needs to be rounded and reinforced for ease of insertion. The
different types of tips are straight, whistle and coude (bent). The coude tip is useful in negotiating
high bladder necks.
Eyes: The drainage hole located at the tip. This should be sub-terminal in location, smooth,
elliptical and beveled for good drainage and easy insertion.
Seif-retaining mechanism: Catheters intended to be placed as indwelling require a self
retaining mechanism. This can be a mushroom (Depezzer), flower wings (Malecot) and the balloon
(Foley). The commonest and most reliable is the Foley balloon. The ideal balloon should have a
capacity of 5-30ml., be symmetrical and flush with the shaft.
Shaft (Body): This part of the catheter extends from the tip to the drainage connector port, it
should be flexible, strong and smooth. The drainage and inflation channels run through the shaft,
hence thicker the shaft smaller is the size of the drainage channel.
Drainage port: This portion of the catheter connects to the collecting device usually the urobag
and should be wide, to accommodate a variety of urobag tips. Some catheters are 3-way with an
additional port for instilling medications or irrigating the bladder.
Inflation port: These are plastic or rubber valves to inflate the balloon, ideally designed for
single-handed use with luer lock.
44
Material: Catheters are made of red rubber, polyurethane, latex with silicon coating and pure
100% silicone. Red rubber catheters are rarely used today. Polyurethane catheters are inexpensive
and rigid, are ideal for one time in-out catheterization use only. Silicone coated latex are the
commonest in use for most situations and can be kept indwelling for up to 2 weeks. When longer
indwelling time (up to 3 months) is required the ideal catheter is the 100% silicone one. These are
least irritating, do not encourage encrustations but are expensive.
The Urobaq: It is vital to maintain a closed system drainage for any indwelling catheter. The
collecting bag should be transparent, have a minimum capacity of 2 - 3 liters, and possess a no
return valve and easy emptying port. The connecting tubing should also be transparent and rigid.
This tube should be comfortably long (2-3 feet) to allow the patient mobility in bed.
STEPS OF THE PROCEDURE
1.PREPARE THE PATIENT.
Inform the patient about the procedure and make him understand the need to relax. This
can be easily achieved by asking the patient to breathe easy with the mouth open. This allays
anxiety and also relaxes the external sphincter
2. ASSEMBLE EQUIPMENT
The first step in any procedure is to ensure that all the necessary items are ready - assemble the
instrument tray on a trolley and make sure everything is within your hand's reach.
3. PATIENT POSITION
Male patients are catheterized in the supine position.
In female patients knees and hips are flexed and supported by an assistant.
4. IDENTIFY EXTERNAL MEATUS
Inspect the external meatus after retracting the prepuce in the male or by retracting the labia
majora and minora in the female
5. PREPARE SKIN & INSTILL LOCAL ANESTHETIC
Prepare the area with povidone iodine and drape with the central hole towel.
45
Instill local anesthetic jelly through the nozzle fixed to the jelly tube and held flush with
the external meatus. You may instill 10 ml. of the jelly into the meatus after gripping the
penis behind the corona and keeping it stretched throughout the procedure.
It is necessary to allow 3-4 mins and to milk the jelly down the urethra for proper
anesthesia.
6. INSERT CATHETER
Insert the catheter housed in its sterile inner pack, do not touch the catheter directly with the
hands.
It is important to maintain the penis in the left hand perpendicular to the body and advance
the catheter slowly till the drainage and inflation port junction lies at the external meatus of
the penis.
7. ENSURE URINE DRAINAGE
Allow a minute or two for the urine to exit, sometimes suprapubic pressure may help or it
may require flushing with 5-10ml. of saline to dislodge jelly blocking the eye.
8 .
INF LATE BALLOON
Only after ensuring urine drains from the bladder should the balloon be inflated and then
connected to the drainage bag.
9. REPOSITION RETRACTED PREPUCE
Always ensure that the prepuce is replaced at the end of the procedure to avoid a
paraphimosis
10. CONNECT UROBAG
The tubing is secured to the front of the thigh with adhesive plaster. The urobag is
suspended at a level below the bladder.
TROUBLE SHOOTING
1. Insertion problems
a)
Meatus - In some bedridden patients it may not be possible to locate the meatus because
of gross oedema. In such situations hold the shaft of the penis vertical and maintain
circumferential pressure to reduce the swelling. If this fails, instill some jelly through the preputial
opening and direct the catheter tip towards the G'o'clock position into the meatus. The final
solution if all else fails would be to do a dorsal slit or a circumcision.
46
b)
Urethra - In the absence of a stricture one is unlikely to encounter any problems till the
area of the external sphincter is reached. At this point one needs to instruct the patient to breathe
relaxed with the mouth open and maintain steady but gentle pressure till the sphincter relaxes.
Bladder neck - In patients with high bladder necks one may have to use the catheter with
the bent or coude tip
C)
2. Bleeding
During insertion some blood staining of the urine or at the side of the catheter may be ignored.
However bright red steady bleeding from the urethra indicates some degree of urethral trauma, in
such cases it may be prudent to abandon the insertion and give pressure over the shaft or the
bulb of the urethra for 10 -15 mins. Do not attempt re-insertion immediately, one may insert a
suprapubic cystostomy or if there is no urgent need to decompress wait for a couple of hours
before attempting urethral insertion.
Bloody urine draining from the bladder usually indicates a source of bleeding from the bladder or
the upper tracts and is unlikely to be related to the procedure. One should obtain a sample of
urine for culture or cytology and give appropriate treatment.
3. Non- drainage of urine
Never inflate the balloon till one is sure the catheter is in the bladder. Sometimes no urine may
drain after reaching the bladder, on many a occasion the jelly will obstruct the eye and flushing the
catheter with 5-10ml. of saline or simple suprapubic pressure for a couple of minutes may help. It
is safer to strap the catheter to the penis without inflating the balloon and obtain confirmation with
an ultrasound.
DO’S AND DON’TS
DO:
1.
Insert a catheter only when it is absolutely necessary.
2.
Always use aseptic technique.
3.
Use the smallest size possible. In an adult without hematuria 14 to 16F is ideal.
4.
Maintain a closed system of drainage always, never disconnect collecting device for
sampling or to facilitate patient ambulation/convenience. Sampling of urine should be done
through the drainage port with a sterile needle and syringe using aseptic precautions.
5.
Keep the drainage bag always below the bladder level.
47
6.
Encourage liberal fluid intake in catheterised patients.
7.
Remember to replace the prepuce after inserting the catheter.
8.
Use a 100% silicone catheter if indwelling time is expected to be longer than 2 weeks.
Don't:
1.
Force catheters during the process of insertion.
2.
Select catheters because they are cheap. Patient will end up paying more for the
complications.
3.
Apply clamps on catheters, these will destroy the inflation channel and prevent removal.
4.
Reuse catheters either by autoclaving or any other method.
5.
Use more than 10 ml. to inflate the balloon; a large balloon will irritate the bladder causing
painful spasms.
6.
Keep catheters in for longer than required.
7.
Use antibiotics.
PROBLEM
IN AFTERCARE
1. Changing of catheters
Problems may be encountered when the balloon refuses to get deflated.
Solutions:
■
Try injecting a few ml. of water to clear the inflation channel, or
■
Cut the inflation port because the valve may be faulty.
■
If this does not help insert a ureteric catheter stillette into the inflation channel
and burst the balloon from within.
Finally if everything fails it may require rupture with trans-abdominal ultrasound
guidance.
2. Leakage of urine
Pericatheter leaks usually occur because of urinary infection and secondary bladder
spasms.
48
Solutions:
■
culture the urine, change the catheter
■
use appropriate antibiotics and anti-cholinergics.
■
In females it may help to change to a larger
catheter keeps slipping out.
sized catheter especially if the
3. Blocking
Catheters can get blocked because of encrustations when maintained for longer than 2
weeks
Solutions:
Change the catheter to a silicone if one is expecting a long indwelling time.
Urine may also suddenly stop flowing because of asymmetric balloon inflation or too
large a balloon pressing the eye of the catheter, in such cases partial deflation will help.
4. Recurrent urinary infections
Urinary infections in catheterized patients can be a challenging clinical problem. The
safest course would be to obtain an aspirated sample from the drainage port, change the
catheter and use antibiotics appropriately. If the infection recurs send the patient to the
specialist or switchover to clean intermittent catheterization.
5. Pain
Pain referred to the urethra or bladder area can be due to too large a catheter, too large
a balloon, urinary infection or bladder spasms. These causes can be sequentially
eliminated and treated. Oxybutynin and liberal fluid intake will offer supportive relief in
these situations.
49
INTRODUCTION
Diabetes affects each and every organ of the body. Early evaluation and
continuous monitoring is necessary in the care of the kidney, heart, eye and
the foot.
Unlike the other organs foot examination is not given importance. The feet get commonly
affected in diabetes and more that 50 % amputations of the leg are due to diabetes mellitus
rendering people wheelchair-bound or immobile, an event every diabetic patient dreads.
Diabetic foot is a spectrum of diseases that starts with the development of neuropathy and
vasculopathy. With the onset of either or both (vasculopathy , neuropathy) the foot becomes
extremely vulnerable to ulceration which is the forerunner of infection which may culminate in
minor or major amputation or even death in severe cases.
. As a general practitioner it is important to spend just 2 minutes of our time to evaluate and
educate the diabetic patient on the care of the foot
RELEVANT ANATOMY
AREAS OF THE FOOT
The foot is divided into well-recognized areas as shown in the figure. Each area of the foot
should be screened for the presence or absence of sensation. This will record the sensory
status of the foot
50
_____________________
EQUIPMENT
Semmes-Weinstein Filaments
■ Nylon, graduated monofilaments
■ 10 gms of pressure is exerted when it deforms
■ 10 gms, when perceived represents protective sensation
Deformation of the filament as shown here Sensation is tested
using this monofilament. (Various drug companies freely distribute
Monofilaments)
STEPS OF THE PROCEDURE
1.PREPARE THE PATIENT.
Inform the patient about the procedure and its importance in preventing future complications
2. INSPECTION
Both the feet are examined together. One foot acts as a comparison to
the other.
A preferred sequence is devised and always followed. This could begin
with the heel and then proceed to the tips of the toes.
Look for cracks, swelling, dryness, callosities and ulcers in the feet.
3.PALPATION
Palpate with the back of the hand to detect any localized increase in
temperature. Compare it with the other areas of the foot and also the
other foot
4. FEEL THE PERIPHERAL PULSES
Palpate both the dorsalis pedis and the posterior tibial
artery pulsations in both feet
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5.TEST SENSATION WITH
NYLON MONOFILAMENTS
Explain to the patient how the monofilaments will be used to detect
the sensation in different areas of the foot.
Demonstrate it with the help of his hand to show how it would feel.
Ask patient to close his eyes and use the monofilament to test
sensation in all the areas of the foot and record the findings
RECORD FINDINGS
Enter your findings in the chart with the date of examination
52
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Local anesthesia
INTRODUCTION
Many minor procedures like excision of small lesions and suturing simple wounds can be
safely and effectively accomplished with local anaesthesia. This section will deal with the
use of local anaesthesia for digital blocks and subcutaneous infiltration.
INDICATIONS/ CONTRAINDICATIONS
INDICATIONS
■ Suturing minor lacerations
■ Excision of small lesions
■ Biopsies of lesions
■ Drainage of paronychia, pulp abscess etc.
CONTRAINDICATIONS
Absolute Contraindication
Hypersensitivity to local anaesthetic agents
Relative Contraindications
Very young patients
Uncooperative patients
Cellulitis around the operative site
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RELEVANT ANATOMY
The figure below shows the cross-section of a digit Note the palmar digital nerves lying palmar to the
digital arteryand the dorsal digital nerves laterally on the dorsum.
3
The distribution in the ulnar and median innervated digits slightly varies.
EQUIPMENT
a. Cleansing solution [povidone iodine or chlorhexidine ]
b. Sterile gauze
c. 5 cc syringe with 18G or 21G needle [for withdrawing solution]
d. 24 gauge 1.5 " needle
e. Local anaesthetic
f. Resuscitation tray
Local anaesthetic agents used commonly
i. Lignocaine 1 % and 2 % [plain]
H. Lignocaine 2 % with 1 in 200,000 adrenaline
iii. Bupivacaine 0.25 % and 0.5 % [plain
54
STEPS OF THE PROCEDURE
1.PREPARE THE PATIENT.
Inform the patient about the procedure and make him understand that the procedure is
meant to numb the area to be operated. Warn him that the process of anesthetizing can
cause pain.
2. ASSEMBLE EQUIPMENT
The first step in any procedure is to ensure all the necessary items are ready - assemble the
instrument tray on a trolley and make sure everything is within your hand's reach.
3. INFILTRATION
■
■
■
Raise a small skin wheal. Advance the needle towards one side in the subdermal
plane, injecting as you do so [there is no need to aspirate].
Withdraw to starting point and repeat on the other side of the lesion [or wound].
Inject through the anaesthetised areas to complete the circle
5. DIGITAL BLOCK (DORSAL APPROACH)
There are several techniques of giving a digital block; this one is a relatively less painful
method.
Use only plain lignocaine or bupivacaine.
I;
B
<w
F •■'•.a
■
Insert the needle to the side of the extensor tendon just proximal to the web.
Raise a skin wheal and inject 1 ml of solution superficial to the extensor hood to
block the dorsal nen/e.
■
Advance the needle towards the palm until the tip is palpable beneath the
palmar skin at the base of the finger, just distal to the web.
Inject 1 ml. here to block the palmar digital nerve.
■
Before removing the needle, redirect it to the opposite side of the finger across
the extensor tendon and raise a small wheal here.
55
■
Withdraw the needle and now repeat the same procedure on the opposite side.
■
Do not try to inject circumferentially
6. TIPS AND TRICKS
■
Use the smallest gauge needle possible
■
When suturing wounds infiltrate through the edges of the wound and prior to
washing the wound.
■
In digital blocks, test sensation prior to giving the block.
■
Wait for at least 5 minutes after the block before operating
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SUNDARAM MEDICAL FOUNDATION
Workshop handouts
FORUM 2002
© Sundaram Medical Foundation
Chennai: 600 040
2002
57
Common Splints used in
Orthopaedics
1.CERVICAL COLLAR
Soft and Hard: External Splintage to neck. Made by plastic
sheet and felt, readymade sizes are available. Used to
relieve pressure upon cervical spine vertebra, disc and
joints.
Uses:
Soft Collar - neck spasm, muscular strain, ligamentous
injuries
Hard Collar- Temporarily to immobilize cervical spine trauma and in
some as definitive treatment
2.CLAVICLE BRACE:
External splintage to splint clavicle fracture. Different types are
available. But the commonest is figure of '8' type.
Used to treat clavicle fractures, applied for 3-4 weeks, can be
adjusted any time
3 . ARM SLING:
Simplest splintage for upper limb, shaped like a triangle,
made out of cotton cloth.
&
Fl
Used to immobilize shoulder injuries
To rest/immobilize in arm &. forearm injuries after splinting
with pop slab/cast
58
I
4. FOREARM SPLINT:
It is a molded, malleable splint made up of plastic & metal strip,
which can be applied around forearm & wrist.
Used to splint injuries of wrist & fore-arm, initially as a temporary
measure and after plaster cast removal (after 3 weeks)
as functional brace.
LUMBOSACRAL BELT:
It is a supportive spinal orthosis for L.S spine made of cotton with straps
reinforced with metal strips. Posteriorly covers pelvis up to
Dorsolumbar junction thus giving stable support to back.
They are used to relieve pain, to support weakened muscles &
unstable joints in functional position & to prevent deformity of
L.S spine
6. ANTERIOR HYPER EXTENSION BRACE (TLSO)
It works on a principle of 3-point fixation to provide mechanical
support of spinal column between the middle of lumbar & middle of
thoracic region.
Consists of rectangular metal/plastic frame with sides which will fit in
front of the thorax & abdomen & plastic strops passes posteriorly which
are tied to keep/maintain the brace in position
Used to support / immobilize D.L injuries / fractures D.L spine,
Osteoporosis & in T.B spine - D.L region.
LONG KNEE BRACE:
it is splint used to immobilize knee by covering
thigh &. leg in extension made by cotton &. metal bars with straps to
fix in
front of thigh & leg.
Used mainly to treat ligament injuries of knee joint
Used temporarily to immobilize bony injuries of knee &
post. Op knee surgery
■I
THOMAS SPLINT:
Consists of a padded oval metal ring to which inner (short)
& outer (long) side bars are attached at the end of distal bars are
joined in the form 'w'. It comes in various ring sizes & bar lengths
Olden days, it was mainly used to treat femoral fractures by fixed traction in a
Thomas splint. It can 'maintain' but not'obtain' the reduction in femoral
fractureNow, it is only used to temporarily immobilize lower limb fractures
59
...
PRINCIPLE:
The plaster material (pop roll) is wrapped around the patient's limb and held there
while it hardens. The Cast/ slab which results accurately follows all the contour of the
encased part of the body, and will support that part firmly and evenly if left in place.
USES
■
To support fractured bones and to rest the damaged soft tissues.
■
To stabilize and rest joints where there is ligamentous injury
■
Post operatively to immobilize joints and limbs until hailing (e.g. repair of
nerves/tendons)
■
To correct the deformity (by wedging)
■
To make negative mould, as a first step in Orthotics/ prosthetics
60
Suturing
INSTRUMENTS NEEDED
2 skin hooks
J Fine non-toothed forceps
s Needle holder
J Suture cutting scissors
Select appropriate suture material [the finest suture compatible with holding the skin
edges together]
1) SIMPLE INTERRUPTED
Si
••
Insert needle through skin at right angles including enough subcutaneous tissue to aid
in everting the skin edges.
Exit through skin of the opposite edge at the same angle including a comparable volume
of subcutaneous tissue.
2) SIMPLE CONTINUOUS
Insert needle as in [1].
Continue suturing without tying, over and over at fixed intervals and tie at the end.
61
3) VERTICAL MATTRESS
Used mainly to aid in everting skin edges in areas with a tendency to invert.
Insert needle as in [1], at least 1cm away from the edge and exit thro' the opposite
edge at the same width and depth.
Using a backhand grip reinsert needle through the skin close to the edges in the reverse
fashion.
of a
Simple Excision
&
itts
Instruments
Marking ink
No. 15 blade scalpel
2 skin hooks
Fine non-toothed forceps
Needle holder
Suture cutting scissors
62
Prepare area.
Outline ellipse with suitable marking material.
Place slight tension on the surrounding skin.
Cut thro' skin at right angles to the surface with a No. 15 blade knife.
Complete skin incision, use skin hooks to hold skin edges and excise lesion.
Undermine [if necessary] the skin edges with a single sweep of the blade, while
holding it with skin hooks.
Suture wound.
Debridement
This is the most essential step in the management of the contaminated or dirty wound.
Thoroughly wash the wound with copious amounts of normal saline under pressure
using either a large syringe , rubber bulb or a pulsatile lavage system.
Remove large particles of dirt with a toothed forceps.
Sharply excise [using a No. 10 blade or sharp scissors] all slough, devitalised tissues and
grossly contaminated tissues.
Wash again.
63
Wound care is an important aspect of wound healing and it is important to know the
scientific basis in the use of various products available, which are used in wound care.
This is commonly referred to as wound dressings. Dressings are required to protect the
delicate epithelial cells from drying and to provide a healthy moist environment to
promote its migration and hence healing, (Fig 1 shows the anatomy of a typical ulcer
with the delicate epithelial layer).
■
■ J'
I
$
Figi.
Wound care essentially aims to provide the following -
i. Antisepsis
ii. Wound Debridement
iii. Agents to promote healing
Dressings involve a three-layered approach. It is a
clever selection of appropriate materials
depending on the needs of each wound e.g. a
clean wound, which has minimal exudation will
require a non-adhesive layer like paraffin gauze, a
sterile gauze and adhesive plaster to retain the
dressings.
Antisepsis:
(Use of skin disinfectants). All traumatic wounds are contaminated and the normal
bacterial flora in the surface of the skin and its appendages are potential pathogens.
Various preparations of skin disinfectants are available. Alcohol, various preparations of
Iodine and cetrimide are available and can be used to disinfect the skin. Pain is present
if there is injury to the delicate epithelial cells. Avoid use of these preparations on the
wound.
Wound debridement agents:
The purpose of debridement is to reduce the bacterial load in the wound. As mentioned
earlier skin disinfectants should not be used on the wound. Surgical debridement and
irrigation of the wound remain the mainstay in the debridement of the wounds. However
certain chemical substances are used to debride contaminated wounds.
Chemical- Hydrogen Peroxide, Eusol, Tr. Benzoin, and 1 and 2% Acetic Acid
64
Enzymes - Collagenase, Streptokinase. These are excellent in removing debris but
expensive and not generally used in our country.
Hydrocollids - Carboxy methylcellulose.(refer below)
Agents promoting wound healing:
Hydrocolloid available as Inderm and Duoderm and Calcium alginate available as
Ka/tostatalso have the properties of keeping the wound moist and the absorptive
capacities help maintain a moist and warm environment thus promoting healing. Use of
these agents also avoids frequent change of dressings, thus avoiding unnecessary injury
to the delicate epithelial layer. Care has to be exercised not to cover heavily infected
wounds with these agents as it can sometimes worsen the wound. Used in correct
conditions it is cost effective, promotes healing, decreases pain and cuts the time taken
for each dressing.
Care of the Exudation:
Acute and infected wounds will produce large amounts of exudate. Wound care involves
use of adequate absorptive layers to absorb the exudate and thus prevent abnormal
soakage of the wound. If this layer becomes soaked it should be changed to prevent
abnormal proliferation of bacteria. Change of dressings is dependent on how long the
dressings remain dry. Thus sometimes it may be necessary to change the dressings
twice or sometimes three times a day. Sterile cotton wool is an excellent absorptive
layer. This is the commonly used gamgee pad. Hydrocolloids and calcium alginate have
absorptive properties and can absorb 10 to 20 times their weight.
Devices to retain the dressings:
Once the wound is debrided and the absorptive layer applied, it is necessary to retain
them. Various devices are available- these are referred to as adjuncts to dressings. They
can broadly be classified into the following groupsRetainers
Tapes, Bandages, Crepe
Splints
POP, Metal, Prefabricated garments.
Stocking
Elastic, Pressure garments
Anatomy of a typical dressing
------
Retainer Layer
Absorbent Layer
c
::
65
Non adherent dressings
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