basic ward procedures

7/31/2019 Basic Ward Procedures

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Noopur S. Sawarkar

BASIC WARDPROCEDURES


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1. ROUTES OF INJECTIONS

2. IV CANNULATIONS

3. DRAINS

4. OXYGEN THERAPY

5. DRESSINGS

6. CATHETERIZATION

7. AIRWAY

8. BLOOD TRANSFUSION

9. BANDAGES

TOPICS TO BE COVERED


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Routes of injections

Intramuscular

Subcutaneous

Intradermal

Intravenous injections

ROUTES OF INJECTIONS


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INTRAMUSCULAR

INJECTIONS


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1. To find this site you will form an

imaginary box on the upper arm.

2. Find the knobby top of the arm

(Acromion process).

3. The top border of the box is two

finger

widths down from the Acromion

process.

4. The bottom border is an imaginary

linerunning from the crease of the armpit,

from front to back.

Deltoid (Arm)


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Medicines-

Dexamethasone sodium phosphate(8mg)

Tetanus toxoid 0.5 ml

Diclofenac sodium 75mg

Tramadol hydrochloride

Paracetamol 150 mg

Streptomycin

Chlorpheniramine maleate 10 mg

Hydrocortisone sodium succinate 100 mg

Deriphyline (theophylline + etiophylline)


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1. To find the thigh injection site, you will be making an imaginary

box on your upper leg. Find the groin. One hand's width below

the groin becomes the upper border of the box.

2. Find the top of knee. One hand's width above the top of the

knee becomes the lower border of the box.

3. The center of the top to your leg comes the left border of box.

4. center of the side of your leg becomes the right border of box.

5. The best areas to use for injection is in the middle of this

imaginary box.

The sites are marked with X's.

6. Stretch the skin to make it tight.

7. Insert needle at a right angle to the skin (90 degree) straight in.

8. You may give up to 2 ml. (cc) of fluid into the site

LEG (VASTUS LATERALIS) SITE FOR IMINJECTION


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BUTTOCK (GLUTEUS MEDIUS) SITEFOR IM INJECTION

1. Find the trochanter . It is the knobby top portion of

the long bone in your upper leg (femur). It is the size

of a golf ball.

2. Find the posterior iliac crest. Many people have

"dimples "over this bone. The nurse will help you find

the bone landmarks.

3. Draw an imaginary line between the two bones.

4. After locating the center of the imaginary line, find a

point one inch toward your head. This is where (X)

you will put the needle in.

5. Stretch the skin tight.

6. Hold the syringe like a pencil or dart. Insert the

needle at right angle to your skin (90 degree).

7. Give up to 3 ml. (cc) of fluid in this site.


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SUBCUTANEOUS

INJECTIONS


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Subcutaneous injections can be given inthe arms, legs, or abdomen

Locating injection sites


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{ These injections are given because

there is little blood flow to fatty tissue,and the injected medication isgenerally absorbed more slowly,sometimes over 24 hours.

Some medications that can beinjected subcutaneously are growthhormone, insulin, epinephrine, andother substances.

MEDICINES

- Insulin

- Heparin

- Inj. Adrenaline(0.2-0.5 ml) in AcuteBronchial Asthma

SUBCUTANEOUSINJECTIONS


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INJECTION ON THESIDE OF THE FOREARM

INJECTION ON THE


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INJECTION ON THESIDE OF THE FOREARM


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INJECTION IN FRONTOF THE THIGH


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INJECTION ON THEABDOMEN


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{0.1 ML solution is injected and the injectionis very painfulAvoid visible vein.

Stretch the skin , keep the needle parallel toit keeping the bevel of the needle up . Pushthe needle and inject .

Repeated intradermal injections lead todesensitization

Siteforearm(anteriorly)

Deltoid

Below scapula

INTRADERMAL

INJECTIONS


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INTRAVENOUS

CANNULATION


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CANNULA


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Peripheral venous cannulation

One of the most common invasive procedurescarried in the hospital

ACCESS:INTRAVENOUS CANNULATION


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Intravenous fluids

Intravenous drugs

Blood or blood products

Intravenous radiopaque contrast or sedation

Prophylactic use in unstable patients or those undergoing

procedures

INDICATIONS


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Absolute

Inflammation or infection of the underlying skin at proposed

cannula site

Arteriovenous fistula in arm

Lymphoedema on side of proposed upper limb cannulation

Relative

Bleeding tendency

Veins of the forearm(elbow or wrist) in those with renal

failure who may require AV fistula formation in the future

CONTRAINDICATIONS


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Veins consist of three layers:

Tunica adventitia

Tunica media

Tunica intima

ANATOMY OF VEINS


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Colour Size Flow rate Use

Blue 22G 36ml/min2.2l/hr

Elderly patientswith small fragileveins

Pink 20G 61ml/min3.7l/hr

Iv maintenancefluids,drugs

Green 18G 90ml/min5.4l/hr

Blood products

17G 140ml/min6.2l/hr

Rapid infusion offluids or drugs

Grey 16G 200ml/min12l/hr

Rapid infusion ofblood products

Brown/orange 14G 300ml/min18l/hr

Unstable patients,emergencysituations

CANNULA SIZES AND USES


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SITE OF CANNULATION

Factors on which site of cannulation dependsPatient comfort

Size of cannula required

Size , mobility and fragility of the patients veins

Distal cephalic veinknown as housemans veinVeins in the antecubital fossa

Large

Easy to cannulate

Disadvantages-

Obstruction of flow through the cannula tends to occur if the elbow is flexed

Back of the hand or lower armis selected

Advantages-

Unlikely to kink

Easily inspected and accessed


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Position the patient with arm resting on a pillow

Apply a tourniquet to the upper arm (palpate the radial pulse)

Clench and unclench the fist

Palpate and feel for full and bouncy pulse

The site of vein bifurcation is ideal

Clean the area with an 2%chlorhexidine gluconate in 70% Isopropyl alcohol

Hold the skin taut Hold the cannula at 10 degree to 30 degree angle to the skin and in the direction of

vein ,gently advance the cannula through the skin and into the vein

Once flashback is seen , lower the cannula

Watch for second flashback after withdrawal of needle

Slowly advance the cannula by holding the wings only

Remove the tourniquet

Occlude the vein proximal to the tip of the cannula

Secure the cannula safely

Flush the cannula via the injection port with .5 ml 0.9%saline

Document the procedure

PROCEDURE


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Early complications Possibly hit the valve

Catastrophic changes when artery is cannulated accidentally

Arterial cannulation more likely in overweigh patients

Needle stick injuries

Late complications Phlebitis of veins

Systemic sepsis Cannula site infection

Thromboembolism

Extravasation is a common problem

POTENTIAL COMPLICATIONS


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All cannulas should be removed after 72

hours , regardless or whether or not

beyond this.

Cannula no longer in use should be

removed as soon as possible to preventcomplications


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Three sites:

Internal jugular vein

Subclavian vein

Femoral vein

ACCESS :CENTRAL VENOUS


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Intravenous(IV) fluids

Delivered directly into the bloodstream via a vein

IncludesSolutions

Medications

Blood

Rapid effect

IV FLUIDS


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Replacement

Electrolytes

Fluids

Maintenance

Fluid balanceElectrolyte balance

FUNCTIONS

KVO fluids

Keep Vein Open

Maintain an IV line

TherapeuticDelivers medication

to patient


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In abbreviations for IVsolutions:

-Letters identify components

-Numbers identify concentration

Eg.NS(Letters) 0.9%(Numbers)


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Choice of solution is based on patientrequirements

Isotonic-Do not affect fluid balance of cells and tissues

D5W, NS, LR

IV Solutions IV CONCENTRATIONS


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Hypotonic

-Move fluid into surrounding cells and tissues

-Restore proper fluid level in cells and tissues

-Used to correct dehydration

0.45% NS,0.3% NS


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-Draw fluid from cells and tissues into blood stream

-Used to correct severe fluid shifts (burns)

3% Saline

HYPERTONIC


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Patients with normal electrolyte levels are likely toreceive isotonicsolutions.

Patients with high electrolyte levels will receivehypotonicsolutions.

Patients with low electrolyte levels will receivehypertonicsolutions

Before combining any medications, electrolytes, ornutrients with an IV solution, be sure thecomponents are compatible.


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INCOMPATIBLE MEDICATIONS AND SOLUTIONS

Ampicillin D5W

Cefotaxime sodium Sodium bicarbonate

Diazepam Potassium chloride

Dopamine HCl Sodium bicarbonate

Penicillin Heparin

Penicillin Vitamin B complex

Sodium bicarbonate Lactated Ringers

Tetracycline Calcium chloride

COMPATIBILTY SOLUTIONS


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Drip

chamber

Injectionports

Rollerclamp


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TUBING

Macrodrip

Larger drops in drip chamber

Infusion rates of 80 mL/h or more

Microdrip

Smaller drops in drip chamber

Infusion rates less than 80 mL/h and KVO

Pediatric and critical care IVs

EQUIPMENT


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Macrodrip

Larger drops

Drop factors: 10 gtt/mL,

15 gtt/mL, or 20 gtt/mL

Microdrip tubing

Smaller drops

Drop factor: 60 gtt/mL


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Drains

Prophylactic drain-to prevent

accumulation of fluid or blood

Therapeutic drain-to promote escape

of fluids already accumulated


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COTTON GAUZE

Acts as a drain by capillary action in the fabricwhich absorbs fluid

Once it becomes saturated it plugs rather thanas a drain

Hence should be changed twice daily or every24 hours

Uses

To pack the cavity

RED RUBBER


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{ Drainage takes place aroundthe grooves of the drain soblockage is less likely

Used when there is minimalamount of discharge

Secured with sutures and isleft in place for three to fivedays

RED RUBBERCORRUGATED DRAIN

PREOP VIEW


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{Patient with squamous cellcarcinoma of left buccalmucosa ulcerating into theskin of cheek. Markings for

resection and reconstructionhave been made.

PREOP VIEW


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{

Early postoperative view.There is a No. 8 sized infant

feeding tube to drain the deadspace between the paddlesand a suction drain for theneck.

Note that the donor area isprimarily closed.

The patient has nasogastrictube feeding for 5 days after

surgery.

Bipaddled submental artery flap

Ramkumar ,

International Journal of Oral

and Maxillofacial SurgeryVolume 41, Issue 4, April2012, Pages458460

FOLEYS CATHETER AS
http://www.sciencedirect.com/science/journal/09015027http://www.sciencedirect.com/science/journal/09015027http://www.sciencedirect.com/science/journal/09015027/41/4http://www.sciencedirect.com/science/journal/09015027/41/4http://www.sciencedirect.com/science/journal/09015027http://www.sciencedirect.com/science/journal/09015027http://www.sciencedirect.com/science/journal/09015027


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{

Foleys catheter inserted tothe base of the tongue

The immediate lifesaving management

of maxillofacial, life-threateninghaemorrhages due to IED and/or shrapnelinjuries: When hazard is in hesitation, not inthe action

Sabri T. Shuker,

Consultant MaxillofacialSurgery (Formerly Headof Department of Oral and MaxillofacialSurgery),

Baghdad Medical City, Baghdad, Iraq

FOLEYS CATHETER ASA DRAIN
http://www.sciencedirect.com/science/article/pii/S1010518211002150mailto:[email protected]://www.sciencedirect.com/science/article/pii/S1010518211002150


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{

Patient after partial

mandibulectomy withalloplastic (titanium) implantextruding a year aftersurgery. Note granulation

tissue and purulentdrainage.

Jackson-Pratt drain


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{- In drainingbranchial cleft cyst

Jackson-Pratt drain


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{- Extension of dentalabscesses to distantareas of the head

and neck

The Acute Orbit: Etiology, Diagnosis, andTherapyJournal of Oral and MaxillofacialSurgeryVolume 64, Issue 1 , Pages 87-93, January2006

REMOVAL OF DRAIN
http://www.joms.org/issues?issue_key=S0278-2391(05)X0269-5http://www.joms.org/issues?issue_key=S0278-2391(05)X0269-5


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The prophylactically placed drain remove the drain as soon

as drainage has subsided (48 hours)

Therapeutic drain removed gradually to close the drainagetract prevent pocket formation

Corrugated rubber drain should be removed after 3 days orafter cessation of discharge

REMOVAL OF DRAIN


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Pathway of a through-and-through drain of thesubmandibular space.

Note that the drain passesdeep to the medial surface

of the mandible, below theattachment of themylohyoid muscle.

Adapted from Flynn TR.31


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AIRWAY


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A fundamental responsibility of anaesthesia providers is tomaintain a patent airway.

The airway passage has a rigid posterior wall and a collapsibleanterior wall consisting of the tongue and epiglottis.

Under anaesthesia the tongue & epiglottis falls back into theposterior pharynx occluding the airway.

The purpose of airway is to lift the tongue & epiglottis awayfrom the posterior pharyngeal wall & maintain a patent airway.

INTRODUCTION


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Artificial airway-any device that aims to maintain oral or nasal airpassages. It may be

Simple supraglottic devicesuch as oropharyngeal or

nasopharyngeal airways. These may not be sufficient to maintainthe patency of airway on their own & may require pts jaw to besupported as well.

Augmented supraglottic devicesuch as LMA & airwaymanagement device

Infraglottic devicessuch as Endotracheal tubes,tracheostomytubes, jet ventilation catheters

TERMINOLOGY :


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These manoeuvres are designed todisplace the tongue anteriorly ,bringing it forward out of thepharynx and clearing the airway.

AIRWAY MANOEUVRES


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An obstructed or blocked airway

To assist in ventilation of an unconsciouspatient

Prepare for or to assist in advanced airwaymaneuvers

INDICATIONS


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Patients who have actualcervical spine injury should nothave a head tilt /chin lift as this

may exacerbate their injuries :a jaw thrust should be appliedas an alternative

CONTRAINDICATIONS


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Sniffing the morning air position

PROCEDURE


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-Place the fingers of both the sides under thecorresponding side of the mandible , at theangle of the jaw

- Lift the mandible forwards , opening the airway(avoid moving the patients head)

JAW THRUST


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- Use of airway adjuncts can assist

in obtaining or maintaining anunobstructed,open airway.

AIRWAY ADJUNCTS


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- An oropharyngeal (OP) airway is designed tohold the tongue away from the posteriorpharynx ; this allows the passage of boththrough the device itself and around it

Oropharyngeal airway


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Maintaining an airway opened by a head tilt/chin lift or jaw thrust

As an alternative method of opening anobstructed airway when airway maneuvershave failed

As a bite block to protect an endotrachealtube

INDICATIONS

CONTRAINDICATIONS


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-Patients must be unconscious to tolerate anOP airway

-Inserting An Airway in a semiconsciouspatient may stimulate the gag reflexcausing them to vomit , leading to furtherairway compromise and potential

aspiration

CONTRAINDICATIONS


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-A correctly sized airway will extend fromthe corner of the patients mouth(incisors)

to the angle of the mandible

-Improper sizing can cause bleeding of the

airway and obstruction of the glottis .

Size


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The American National Standard specifies that the sizeof oral airways be designated by a no. i.e the length in

cms.size colour length(cm)

000 Violet 3.5

00 Blue 4.5

0 Black 5.5

1 White 6.5

2 Green 7.5

3 Orange 8.5

4 Red 9.5

5 Yellow 10.5


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- It extends from lips to pharynx, fitting between tongue & posteriorpharyngeal wall. Made up of elastomeric or plastic materials.Parts are

Flange: it is at buccal end to prevent it from moving deeper into

mouth & may also serve to fix airway in place.

Bite Portion: it is straight & fits between teeth & gums..

Curved portion(body): extends backwards to correspond theshape of tongue & contour of the hard palate.

Tip portion :at the base of the tongue allowing air passage throughand around the airway .

DESCRIPTION

Guedel Airway


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{

-Most frequently used airway & has large flange &reinforced bite portion with tubular channel for airexchange & suctioning.

Cuffed Oro-Pharyngeal Airway


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It is Guedel`s Airway with an inflatable cuff designed to seal theoropharynx. It has an integral bite block & a 15mm connector forattachment of the breathing circuit.

The cuff is inflated with air to displace the base of tongue & form alow pressure seal with the pharynx & provide an open airway.

y g y

at - yracuse n oscop cAi


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Patil-Syracuse Endoscopic

Airway It was designed to aid

fiber-optic intubation. It ismade of aluminium.

It has lateral channels & acentral groove on thelingual surface to allowpassage of fiberscope. A slit

in distal end allowsfiberscope to bemanipulated in antero-posterior direction butlimits lateral movements.

Airway


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-It is tubular along its entire length. It is open on 1 side so that itcan be split & removed from around a tracheal tube. It can beused as an oral airway or as an aid to fiberoptic or blind oro-tracheal intubation

Berman Intubating Airway


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Designed for blind tracheal intubation & can also be used forfiberoptic intubation or as an oral airway.

It is available in 2 sizes #9 & #10 which will admit upto 8 & 8.5mm tracheal tube respectively.

The proximal half is cylindrical while distal half is open on

lingual surface.

Williams Airway Intubator


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PROCEDURES


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Pharyngeal & laryngeal reflexes should be depressed beforean airway is inserted to avoid coughing & laryngospasm.

Selecting the correct size is important. Correct size is

estimated by holding the airway next to pts mouth & the tipshould be at the angle of mandible.

The best criteria for proper size & position is

unobstructed gas exchange


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NASOPHARYNGEAL AIRWAY (nasalt t/ l i


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It is designed to hold the tongue from posterior pharynx

The NP airway consists of the flange , the shaft and thebevel

trumpet/ nasal airway)

INDICATIONS


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Maintaining an airway opened by a head tilt /chin lift or

jaw thrust procedure

As an alternative method of opening an obstructed

airway when airway maneuvers have failed

Better tolerated than OP airways in semi-conscious

patients

Excellent for use in patients unable to open theirmouths

As a means to facilitate the bronchial suction

INDICATIONS

C


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Known base of skull fracture

Commonly causes nose bleeds so should beavoided in those patients known to have

bleeding tendencies (e.g. on warfarin)

Contraindications

SIZES


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Patient Size of NP(diameter)

Average-height female 6

Average height -male 7

Large male 8

SIZES

NP airways were trditionally sized choosing a diameter which closestmatched that of the patients little finger

The diameter of nasal airway should be the same as needed to insert thetracheal tube (0.5-1.0mm smaller than oral tracheal tube).

PROCEDURE


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Apply a water based lubricant

Insert the NP airway into the right nostril first

The bevel should be on the medial side of the nasopharyngealairway

The NP airway should be inserted at 90 degree of the patientsforehead and should pass with minimal resistance towards thepatients occiput

Rolling the nasopharyngeal tube with your fingers from side to sideas you exert downward pressure may make insertion easier

If resistance then try the other nostril

Reassess the patients airway for patency

PROCEDURE


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Airway obstruction

Epistaxis

Ulceration & Necrosis

Dental Damage

CNS trauma

Laryngospasm & Coughing.

Aspiration or Swallowing of part or all of the airway.

Latex Allergy

Gastric distension.

Complications


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A simple airway maneuvers or a use of an adjunct to open the airway

will allow them to breathe spontaneously .if this is the case high flow

oxygen (15L/minute)should be administered via a mask with non-

rebreathe reservoir

If they are not breathing sufficiently it is necessary to ventilate the

patient .the most convenient method to achieve this is with a bag-

valvemask with reservoir.

It is the device which allows administration of gases to the patient

from breathing system without introducing any apparatus to the

patients mouth.

Bag-valve -mask


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{

A face mask can be made up of black rubber,clear plastics, elastomeric material orcombination of these.

Parts of the face mask

Body: constitutes the main part of the maskTransparent body allows observation ofmoisture, vomitus , secretions etc .

Seal :Comes in contact with the face.Two types are

availablePad or cushion inflated with airFlap flexible extension of the body

Connector ( orifice/ collar ) :Opposite to the sealThickened fitting of 22 mm IDRing with hooks helps in strapping the mask


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1. Anatomical mask :

-Can be moulded to conform to the anatomy of face .

-Has slightly malleable rubber body, a sharp notch for the noseand a curved chin section.


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2. Rendell-baker-soucek(RBS) mask

Designed for paediatric patients < than 10 yrs

It has triangular body and low dead space

Used in tracheostomy and acromegaly patients


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Size Age group Dead space

0 preterm 3 cu.mm

1 infant 4 cu.mm

2 1 to 3 years 8 cu.mm

3 4 to 10 years 12 cu.mm


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Scented mask :

Scent incorporated into the mask bymanufacturer or anaesthesia provider

Added for better acceptability and pleasant

experience during induction

Disadvantage- ethyl alcohol in some flavorsmay affect accuracy of gas monitors

One Hand Method -


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One Hand Method -

the thumb & index finger of left hand are placed

on mask body on opposite sides of connectorpush downward to prevent leak.

The remaining 3 fingers are placed on themandible such that middle finger is applied tothe mentum, ring finger on body of mandible &

little finger at angle of mandible to give jawthrust anteriorly


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Two Handed Method

As it requires both hands, a 2nd person isnecessary for assisted or controlled ventilation.

Here thumbs are placed on either side of bodyof masks, index fingers are placed under theangles of jaw, mandible is lifted & head isextended.

If a leak is present, downward pressure onmask can be increased by anesthesiologists

chin on the mask elbow


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{

Two Handed Jaw Thrust

1 person stands athead end of pt &performs jaw thrust withhis left hand at angle ofleft mandible while hisright hand compressesthe reservoir bag.

The 2nd person standsat pts shoulder facing1st person. This personsRt hand covers the Lthand of the 1st person &

the Lt hand achieves Rtsided Jaw thrust &mask seal.

Claw Hand Technique


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It is useful for children undergoing short duration

procedures.

The Anesthesiologists stands at the side of bed

facing the child. The face mask is applied to face by

using the Rt hand with the palmar surface facing

upwards. The ring & middle finger are placed under

the angle of jaw & the index finger & thumb encircle

the body of mask.


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Squeeze the chamber at the rate of 10-12breathes a minute .

Ensure adequate ventilation by bilateral chestmovement and fogging of the face mask on

expiration

Ad t


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It is useful for children undergoing short duration procedures.

The Anesthesiologists stands at the side of bed facing the child.

The face mask is applied to face by using the Rt hand with thepalmar surface facing upwards. The ring & middle finger areplaced under the angle of jaw & the index finger & thumb encirclethe body of mask.

Advantages


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Complications


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Skin problems- dermatitis, pressure necrosis. Nerve injury.

Eye injury conjunctival chemosis, eyelid edema & cornealinjuries.

Gastric Inflation

Latex allergy

Lack of co-relation between arterial & end tidal CO2.

Environmental Pollution with anesthetic gases

Jaw Pain & User fatigue.

Complications

L l k i


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-The laryngeal mask airway has an important role inadvanced airway management . It is recommended for use inpatients requiring advanced life support and is relatively

easily inserted by a non-specialists.

Laryngeal mask airway

INDICATIONS


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A first line airway management device with limited airwaymanagement device

In unconscious patient who requires assisted ventilation in

the absence of the ability to provide a definitive airway

As an alternative to oropharyngeal and nasopharyngealairways (more suitable for prolonged ventilation)

Emergency airway management at a cardiorespiratoryarrest .

As an alternative to ET tube .

INDICATIONS

CONTRAINDICATIONS


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When a definitive airway is required

High risk anesthetics

Patient with fluctuating consciousness level (intact gag reflexis a contraindication due to risk of introducing vomiting ).

Unconscious patients unable to open mouth (e.g. trismus)

Patients requiring high airway pressure to ventilate (e.g.heavily pregnant , obese , asthmatic

CONTRAINDICATIONS


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Laryngeal mask airway

Airway connector

Valve

Airway tube

Cuff

LMA size Type Weight Inflation volume

1 under 5 kg 4 mlSizes


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1.5 5 to 10 kg 7 ml2 10 to 20 kg 10 ml2.5 20 to 30 kg 14 ml

3 Small adult 30-50 kg 20 ml

4 Normal adult 50-70 kg 30 ml

5 Large adult 70 kg + 40 ml


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Generally, the size 4 LMA will be suitable for most adult female

patients, and the size 5 LMA for adult males up to 100 kg. The

new size 6 is intended for adult patients over 100 kg.

Size 3 is a pediatric size

The larger the size used, the lower the intracuff pressure needed

to obtain an adequate seal.

It is better to use a large size with small inflation volumes than a

small size excessively inflated.

Always have a larger and smaller size LMA immediately available.

Preparation of the Laryngeal Mask


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Ensure laryngeal mask airway has been previouslysterilized.

Check cuff and valve.

Lubricate the LMA with jelly or other sterile surgicallubricant.

Evacuate all air from cuff, preferably using the LMA deflator

Airway for clinical use.


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{

Use the optional cuff deflation deviceto remove all air from the LMA cuffprior to insertion


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{

Step #2:

-Press mask tip upwards against the

hard palate to flatten it out andadvance the mask into the pharynxusing the index finger. (CAUTION: Besure to carefully "fit" the deflated LMAtip into the convexity of the hard

palate as this is the KEY tosuccessful insertion.)

-Press mask tip upwards against thehard palate to flatten it out and

advance the mask into the pharynxusing the index finger.


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{ With neck flexed and head

extended, press the laryngealmask airway into the posteriorpharyngeal wall using theindex finger.


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{-Complete the insertion by

exerting cephalad pressure bythe nondominant hand prior toremoving the index finger.

I fl l l k i


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{

- Inflate laryngeal mask airwayand secure in place with tape

-Connect the LMA to means of

ventilation

-Auscultate for lung sounds andthe absence of epigastric

sounds.

-Insert an oral airway as a biteblock.

-Secure the LMA with tape or

ribbon .

PHLEBOTOMY


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Phlebotomy from Greek words, phlebo, relatesto vein as, tomy, relates to cutting.

Opening a vein to collect blood

Cultures should be drawn before administration ofantibiotics, if possible

PHLEBOTOMY

MATERIALS


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Chlorhexidine swabs (1-2 packages) Alcohol swabs Blood culture bottles (2 bottles per set) 2 syringes (adult: 20 cc, paediatric: 5 cc) 2 needles (adult: 22 gauge or preferably larger butterfly or

standard needle; pediatric: 25 or 23 gauge butterfly orstandard needle) Gloves (sterile &nonsterile) Tourniquet Sterile gauze pad

Adhesive strip or tape Self-sticking patient labels Plastic zip lock specimen bags

MATERIALS

INDICATIONS


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Profile testing e.g. urea , electrolytes , liverfunction testing

Monitoring of hormones , therapeutic

drugs

Toxicology

Venesection

Sampling according to researchprotocols(ensure that you have consent)

INDICATIONS

CONTRAINDICATIONS


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Infection at the site of access e.g. cellulitis

Bleeding tendenciese.g. on warfarin

Thrombophlebitis

Taking sampling from drip arm(stop the

infusion and wait for atleast 2 minutes

before sampling).

CONTRAINDICATIONS

Points of access


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Median Cubital Veins

Cephalic Veins

The Basilic Vein

Dorsal Hand Veins

Foot Veins

Blood collection bottles


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Bottle lid colour Tube contents Tests

Purple EDTA Full blood count , ESR,Malaria, crossmatch andgroup

Gold Clotting accelerator and

separation gel

Biochemistry testing

Light blue Trisodium citrate Coagulation testing

Red Clotting accelerator Serology , vitamin B12 ,folate

Grey Sodium fluoride Glucose

Green Lithium heparin Ammonia

Royal blue Sodium heparin Trace elements

Red top


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Additive None

Mode of action Blood clots, and the serum is separated bycentrifugation

Uses Chemistries, Immunology and Serology,Blood Bank (Crossmatch)

Gold top


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p

Additive None

Mode of actions Serum separator tube (SST) contains a gel at the bottom toseparate blood from serum on centrifugation

Uses Chemistries, Immunology and Serology

Light green top


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Additives Plasma Separating Tube (PST) with Lithiumheparin

Mode of action Anticoagulates with lithium heparin; Plasma isseparated with PST gel at the bottom of the tube

Uses Chemistries

PURPLE TOP


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ADDITIVE EDTA

FORMS CALCIUM SALTS TO FORM CALCIUM

Hematology (CBC) and Blood Bank (Crossmatch);requires full draw - invert 8 times to prevent clottingand platelet clumping

LIGHT BLUE TOP


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SODIUM CITRATE

FORMS CALCIUM SALTS TO REMOVE CALCIUM

Coagulation tests (protime and prothrombin time),FULL draw required

Green top


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Sodium heparin or lithium heparin

Inactivates thrombin and thromboplastin

For lithium level, use sodium heparinFor ammonia level, use sodium or lithium heparin

Grey top


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Sodium fluoride and potassium oxalate

Antiglycolytic agents preserves glucose upto 5 days

Glucoses, requires full draw (may cause hemolysisif short draw)

PINK TOP


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Potassium EDTA

FORMS CALCIUM SALTS

MOLECULAR /VIRAL LOAD TESTING

METHODS FOR BLOODCOLLECTION


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Vacutainer system

Needle and syringe

COLLECTION


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AdvantagesIt is safest

DisadvantagesWhile loading the different blood collection tubes whilstkeeping the needle still within the vein requires somepractice .

Method


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{

A minimum of 10 ml of blood is takenthrough venipuncture and injected

into two or more "blood bottles"with specific media for aerobic andanaerobic organisms.

The blood is collected using cleantechnique.

This requires that both the tops ofthe culture bottles and thevenipuncture site of the patient arecleaned prior to collection withalcohol swabs containing 2%Chlorhexidine and 70% isopropylalcohol.


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{ The area of skin is cleaned with

a disinfectant, or an alcoholswabas the persistentpresence of skin commensals inblood cultures could indicateendocarditis but they are mostoften found as contaminants

The vein is anchored and the


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The vein is anchored and theneedle is inserted

The vacutainer tube is depressed into

th dl t b i d i bl d


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the needle to begin drawing blood

Additional vacutainer tubes can be utilized. Determine whatt t d d d h t t b ill b BEFORE


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tests are ordered and what tubes will be necessary BEFOREyou begin to draw blood.


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When the final tube is being drawn, release the tourniquet.Then remove the tube, and remove the needle

After the needle is removed from the vein apply firm


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After the needle is removed from the vein, apply firmpressure over the site to achieve haemostasis.

Apply a bandage to the area


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Apply a bandage to the area

Preparation of Cap beforeI j i Bl d


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{ Prep the rubber cap of the

blood culture bottles with analcohol pad in a circularmotion. Allow the alcohol todry.

Injecting Blood

Mix


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{-Gently rotate the bottlesto mix the blood & thebroth (do not shakevigorously)

Needle and syringe


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Traditional method for phlebotomy

It is simply a needle (21G-green) attached to asyringe .

Needle and syringe

OPEN METHOD


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16=Transparent

18 =Yellow19=Brown20=Violet

21=Green 22=Black23=Sky blue24=Red25=Dark Blue

26=Oran e

Macrosample collection


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Superficial veins of thefoot


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foot

Wear gloves and apron

Procedure


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Wear gloves and apron

Attempt venepuncture in the non-dominant arm

Place the tourniquet above the antecubital fossa Ideally, tourniquet should not be kept on for more than one minute

Leave at least for 20 sec. for to veins to fill and meanwhile do repetitive fistactions

bouncy vein is more easier and successful rather than thready vein

Wipe the skin carefully with a antiseptic wipe working in circles from centreoutwards

Using the needle with vacutainer system or syringe , insert the bevel upwards ,passing through the skin and into the vein

Attach the collecting bottles

Loosen the tourniquet

Withdraw the needle and place a cotton ball over the access site . Secure withthe tape

If blood collected in bottles then transfer it to bottles

Label the bottles

Complications


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Infection at the puncture site

Clean the skin with an antiseptic wipe

Hematoma

Gentle pressure for 1-2 minutes after the procedureand release the torniquet before removing theneedle. Advise the patient to keep their armstraight

PainA local anesthetic cream applied to the skin

BLOOD CULTURE


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{-A blood culture is alaboratory test in which blood

is injected into bottles withculture media to determinewhether microorganismshave invaded the patients

bloodstream.

BLOODCULTURE

Need for blood culture


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No microbiological test is more essential to the

clinician than the blood culture. The finding of

pathogenic microorganisms in a patientsbloodstream is of great importance in terms of

diagnosis, prognosis, and therapy.

- L. Barth Reller, Clin. Infect. Diseases, 1996

Blood transfusion


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INTRODUCTION

Blood transfusion is defined as the process of receiving bloodproducts into ones circulation intravenously .

This is usually done as a life saving maneuver to replaceblood cells or blood products lost through severe bleeding,during surgery when severe blood loss occurs or to increasethe blood count in an anaemic patient.

Bloodtransfusionsinvolvestheuseofwholeblood,redbloodcells,whitebloodcells,plasma,clottingfactorsandplatelets.


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WHOLE BLOODTRANSFUSION


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TRANSFUSION

Stored between +2 and +6 degrees centigrade in a blood and

f i t


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refrigerator.

Transfusion should be started within 30 minutes of removal from therefrigerator and completed within 4 hours of commencement becausechanges in the composition may occur due to red cell metabolism.

Indications

Red cell replacement in acute blood loss with hypovolemia

Exchange transfusion

Contraindications

Chronic anaemia

Incipient cardiac failure

PACKED RED BLOOD CELLS


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One unit of packed red cells is approx.330ml and has ahematocrit of 50-70%


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hematocrit of 50-70%.

They are stored in a sag-m(saline-adenine-glucose-mannitol)solution to increase their shelf life to 5 weeks at 2-6 degrees centigrade

Indicated in replacement of red cells in anaemic patientsand also used with crystalloid and colloid solutions in acuteblood loss conditions

Safe blood transfusion procedures


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The blood pack should always be inspected for signs of deterioration onarrival and before transfusion if not used immediately.

Discolouration of the blood pack and any signs of leakage indicatecontamination and could cause a severe fatal reaction if transfused.

Warmed blood is most commonly required in large volume rapidtransfusions & exchange transfusion in infants.

p


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Intravenous cannulations for blood transfusion can be done from

Cephalic vein

Basilic vein

Forearm veins

Great Saphenous veins

URINARYCATHETERIZATION


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Catheterization of the urinary bladder is the insertion of a

hollow tube through the urethra into the bladder forremoving urine. It is an aseptic procedure for which sterile

equipment is required.

PURPOSE


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a. Relieve urinary retention.

b. Obtain a sterile urine specimen from a female patient.

c. Measure residual urine.

d. Empty the bladder before, during, or after surgery.

e. Allows accurate measurement of urine output.

PURPOSE

SIZES


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Number 14 Fr.(french) and 16 Fr. areused for female adults.

Number 20 Fr. and 22 Fr. are usuallyused for male adults.

I E

TYPES


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Intermittent Catheter

-An intermittent catheter

is used to drain thebladder for shortperiods (5-10 minutes).It may be inserted by

the patient.


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Retention/Indwelling Catheter

- This type of catheter is placed into

the bladder and secured there for a

period of time.

POSITION


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Position the female patient in a dorsal recumbentposition with the knees flexed and the feet about twofeet apart. Cover the upper body and each leg. Place

the catheter set between the female patient's legs.

Position a male patient in a supine position. Drape thepatient so that only the area around the penis is

exposed. Place the catheter set next to the legs of themale patient.

POSITION

Grasp the patient's penis between your thumb and


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forefinger of your nondominant hand.

Retract the foreskin of an uncircumcised male.

The gloved hand that has touched the patient is now

contaminated.

PROCEDURE-
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-Hold the penis at a 90-degree

angle. Advance the catheter intothe patient's urinary meatus. Youmay encounter resistance at theprostatic sphincter.

(1) Pause and allow the sphincter

to relax.(2) Lower the penis and continue to

advance the catheter.

NOTE:Never force the catheter to

advance. Discontinue the procedure ifthe catheter will not advance or thepatient has unusual discomfort. Getassistance from the charge nurse orphysician.

3.When the catheter has passed through the prostaticsphincter into the bladder, urine will start to flow. Gently
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p , yinsert until 1 to 2 inches beyond where urine is noted

4. Inflate balloon, using correct amount of sterile liquid(usually 10 cc but check actual balloon size)

5. Gently pull catheter until inflation balloon is snug againstbladder neck

6. Connect catheter to drainage system


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7.Anchor the catheter tubing to the lateral abdomen withtape, without tension on tubing

8.Place drainage bag below level of bladder

9.Evaluate catheter function and amount, color, odor, andquality of urine

CATHETERIZATION IN FEMALES


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PROCEDURE-

1. Place the thumb and forefinger of your nondominant hand betweenthe labia minora, spread and separate upward. The gloved handthat has touched the patient is now contaminated.

2. Using the forceps, pick up a cotton ball saturated with antiseptic

solution. Use one cotton ball for each stroke. Swab from above themeatus downward toward the rectum.

3. Keeping the labia separated, cleanse each side of the meatus in thesame downward manner Do not go back over any previouslycleansed area.

4. Deposit each cotton ball into the disposal bag. After the last cottonball is used, deposit the forceps into the bag as well.

5.Continue to hold the labium apartafter cleansing. Insert the lubricatedcatheter into the female patient's


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catheter into the female patient surinary meatus.

6. Angle the catheter upward as it isadvanced. If the catheter will notadvance, instruct the patient toinhale and exhale slowly. This may

relax the sphincter muscle. Do notforce the catheter.

7. When urine starts to flow, insert thecatheter approximately one inchfurther. Place the cup under thestream of flowing urine to obtain asterile specimen if required.

8. Inflate balloon, using correctt f t il li id


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amount of sterile liquid

(usually 10 cc but checkactual balloon size)

9.Gently pull catheter until

inflation balloon is snugagainst bladder neck

10.Connect catheter to

drainage system.

RYLES TUBE FEEDING


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Steps -

Place the patient in semi to highfowlers position or a lateral ifpatient cannot be propped up inorder to prevent gastricdiscomfort or regurgitation of

feed.

Aspirate stomach contents gentlywith 50ml syringe and with testwith blue litmus paper to conform

the position of the tube and notethe residual amount. If the tube isin the stomach the blue litmuspaper change red.


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Observe the nature of aspirate for color, volume and

presence of blood to exclude the malabsorption ofprevious feed and review feeding regime ifnecessary.

Attach funnel / Syringe to the tube and hold it to the

side, at the level of the patients forehead ,If the

syringe is held too high, it increases the pressure atwhich the fluid enters the stomach.

Fill the funnel/ syringe with the prescribed feed, allowing itto flow in by gravity.


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Observe the patient during feed to detect any adversereaction to the feeding.

Record the type and amount of feed and water given.

Nasogastric tubes are changed weekly or when necessary

Conclude feed with water to keep the lumen of tubefeeding.


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WOUND MANAGEMENT


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- The accepted interval from injury to wound closure is up to

6 hours for wounds to the extremities and up to 24 hours for

face and scalp wounds is the golden period for repair

wound preparation (debridement,cleansing, etc.)

dress with saline soaked fine mesh gauze

follow up in 72-96 hours for debridement

repeat cleansing and closure if no evidence of infection

WOUND ASSESSMENT


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Examine for:

amount of tissue destruction

degree of contamination damage to underlying structures

WOUND PREPARATION


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-ANESTHESIA


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Topical Solution or paste

EMLA

Local Direct infiltration 1% lidocaine with or without epinephrine

Bupivacaine or sensoricaine for longer acting anesthesia

Regional Block Local infiltration proximally in order to avoid tissue

disruption

Smaller amount of anesthesia required

Wound Preparation -Hemostasis


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Direct PressureUsually best choice

Ligatures

Use a tourniquet

Chemicals

Epinephrine

Gelfoam

Oxycel

Actifoam

Cautery

Hemostasis

FOREIGN BODY REMOVAL


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Suspect with point tenderness

Visual inspection (to the apex)

Imaging

-Glass, metal, gravel fragments >1mm should be

visible on plain radiographs

-Organic substances and plastics are usually

radiolucent

Always discuss and document possibility of retainedforeign body

HAIR REMOVAL


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ShavingIncreases risk of infection X 10 !

Clip Hair with Scissors

Matt Hair with Ointment

Never shave eyebrows( may not regrow )

CLEANING


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High pressure irrigation (Normal Saline)

100-300 ml with continued irrigation

At least 8 psi force to the wound the irrigation fluid

dislodges foreign bodies, contaminants, and bacteria.

A simple device setup

30-60 ml syringe

SAVLON


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1:1000 SOLUTION

Cleaning and disinfecting of postoperative wounds

1:30 (aqueous solution )

Cleaning and disinfecting of physically dirty wound wherean extra detergent is required

1:30 in 70% alcohol solution

Skin disinfection (preoperative and other invasiveprocedures)

SPIRIT


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Contains 70% isopropyl alcohol

Disinfection of skin before intramuscular and intravenous

injections

Removal of iodine in preparation of skin for operation Cleaning the stitched wound

Cleaning the skin of the surrounding ulcer and open wounds

Used along with the other disinfectants , such as iodinespirit

and cetavlonspirit , for painting the parts before operation .

HYDROGEN PEROXIDE


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2-3% volume hydrogen peroxide

It is not an antiseptic but a cleaning agent

It destroys anaerobic organisms

Whenever there is capillary oozing used as a hemostatic

solution (e.g. incision and drainage) It produces frothing and brings out debris from the depth of the

wound

Povidone-iodine

Betadine


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5% and 10% topical solutions Surgical scrub (7.5%)

Mouthwash

Ointment

Combination of POVIDONE -IODINE(PVP-I)

An effective and useful germicide

High dilutions are active in destroying organisms within 15 secoonds

Antibiotic and antiseptic action Immediate action-nonselective

Used for irrigation of wound(subcutaneous)

Removes devitalized tissue

DEBRIDEMENT


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Removes devitalized tissue

Creates sharp wound edge

Excision with elliptical shape

Respect skin lines

OXYGEN THERAPY


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O2 DELIVERY SYSTEMS:

1.Low flow or variable performance systems.

2.High flow fixed performance systems

NASAL PRONGS


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- The prongs protrude 1cm into nares.

- Well tolerated.

- Less interference in day to dayactivities.

- Useless in mouth breathers.- No reservoir system.

- FiO2 unpredictable.

Simple O2 masks:

Covers the nose & mouth
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- Covers the nose & mouth.

- 4-6 lit/min.

- 0.4 -0.6 FiO2

- Feeling of suffocation.

- Interference with daily activities.

- FiO2 unpredictable.

- Displacement at nights.

Mask with reservoir bags:
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-Polymask with 2 chambers.

-High FiOP2 with 5-6 lits of O2.

O2 CYLINDER


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HAZARDS OF O2
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1.Drying of mucous membrane.

2.Depression of ventilation in COPD.

3.Reversal of compensatory hypoxic

vasoconstriction.

4.Atelectasis due to absorption collapse.

5.O2 toxicity.

THERAPY

O2 TOXICITY


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Pulmonary oxygen toxicity (Lorrain-Smitheffect):

-100%O2 given for 12 hours or more.

-80% O2 for more than 24hrs.-60%O2 more than 36hrs.

Symptoms: substernal pain, irresistible cough,

dyspnoea.


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BANDAGES

1. Bartons bandage

E e bandage


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2. Eye bandage

3. Ear bandage

4. Head bandage

5. Triangular bandage

6. Cravat bandage


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BARREL/BARTONSBANDAGE

1.The middle of the bandage is placedunder the jaw, well back just in frontof the angle; then a simple knot isti d th t f th k ll


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tied over the vertex of the skull .

2.Using both hands, open the knot sothat the front loop comes in front of

the forehead and the back portionunder the occiput

3.The two ends are then taken andupward tension is exerted, and by


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upward tension is exerted, and by

a slight adjustment the tworunning hitches are made tooccupy a position slightly aboveand in front of the ear.

4.The two ends are then tied in areef knot on the top of the head.

Use


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-bandage is used to support the fractured mandible and head injury

THE BARREL BANDAGE FOR FRACTURES

OF THE JAW

BY W. KELSEY FRY, M.C., M1.R.C.S., L.D.S.

iDec. 2, 1939 BARREL BANDAGE FORFRACTURE OF JAW British MedicalJournal page no 1086

Ear bandage


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{-To keep the dressing in

position after mastoidsurgery

Eye bandage


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-To support eye dressings

HEAD BANDAGES


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{1.Wrap the first tailhorizontally around the

head, ensure the tailcovers the dressing


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{2. Hold the first tailin place and wrapthe second tail the

opposite direction,covering thedressing


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{3.Tie a nonslip knot

and secure the tails

at the side of thehead, making surethey DO NOT coverthe eyes or ears

4.Apply a dressing to


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{4.Apply a dressing to

a wound on the topof the head

5. Wrap one tail down underthe chin , up in front of the


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{ear, over the dressing, andin front of the other ear.

6 Wrap the


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{6. Wrap the

remaining tailunder the chin inthe oppositedirection and up

the side of the faceto meet the first tail

7. Cross the tails , bringingone around the forehead


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{one around the forehead(above the eyebrows) andthe other around the back ofthe head (at the base of theskull) to a point just above

and in front of the oppositeear, and tie them using anonslip knot

1 Turn the base (longest side) of

TRIANGULAR BANDAGE


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{1. Turn the base (longest side) of

the bandage up and center itsbase on center of the forehead,letting the point (apex) fall on theback of the neck (Figure A).

2. Take the ends behind the head

and cross the ends over theapex.

3. Take them over the foreheadand tie them (Figure B).

4. Tuck the apex behind thecrossed part of the bandageand/or secure it with a safetypin, if available

CRAVAT BANDAGE


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{1. Place the middle of thebandage over the dressing

(Figure A).

2. Cross the two ends of thebandage in opposite directionscompletely around the head(Figure B).

3. Tie the ends over the dressing

ABC of practical procedures- Tim Nutbeam and Ron Daniels

REFERENCES


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Moore KL , Dalley AF(1999) Clinically Oriented Anatomy , 4th Edition .Lippincott Williams , Philadelphia

American College Of Surgeons (2008) Advanced Trauma Life Support:Student Manual , 8th Edition

Jerry A. Dorsh and Susan E. Dorsh Understanding AnaesthesiaEquipment, 5th Edition,


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THANK YOU

basic ward procedures

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