WARD PROCEDUREBY : dr nikil jain

Preoperative and postoperative care Emergency drugs Drains Dressings catheter

PREOPERATIVE & POST OPERATIVE CARE

Preoperative & post operative care•History•Examination•Investigations•Preoperative preparation•Preoperative orders•Postoperative orders

HistoryThe patient is enquired about;•Illness•diabetes•asthma and tuberculosis•hypertension and myocardial infraction•intake of insulin, steriods, antiepileptics

ExaminationGeneral examination includes•Nutritional status and built•Hydration•Anemia•Jaundice•Oral hygiene•Cvs•Pulmonary function

Routine investigation•Hb•Total leucocyte count, differential leucocyte count•ESR•urine•Blood urea•Blood sugar [fasting and postprandial]•X ray chest•ECG•SGPT•HbsAg•HIV I & II•CT & BT

Preoperative preparationDietAppropriative diet should be considered;Soft diet : edentulous patientFat free diet: biliary tract diseaseLiquid diet : oral tumor and obstructing

esophageal lesionSalt free diet: hypertensive patientVit B ,C : indicated for debilitated patientVit K : jaundiced patient and newborn

Medications

• IV fluids indicated•The use of Antibiotics , cardiac drugs, diuretics and

patient’s current medication must be carefully considered•No medication should be given for the relief of pain

until a diagnosis has been established

Preoperative orders

Emergency admission for the urgent operation

• Diet: NBM[ nothing by mouth]• Medications: no medication should be given for the relief of

the pain until a diagnosis has been established and decision made whether or not to operate , because pain may be the only clue for the diagnosis which must not be masked by narcotics.

• Fluid therapy : IV fluids should be started

• Blood test: blood test for grouping and cross matching in addition to routine investigaiton • Antibiotics :started preoperatively in septic patients• Shaving and preparartion of the part to be operated• Indwelling catheterization if necessary

Post operative care

the patient should be observed diligently and given intensive care until the overall condition stabilizes.

Postoperative orders

•Name of the operation performed and type of anesthesia•Vital signs: temperature , blood pressure, pulse and

respiration should be taken six hourly•Intake, output of fluids and bodyweight to decide the

volume of fluid replacement•Care of tube and drains•Diet:NBM for at least 4 hours after GA•Medication: IV fluid,analgesics, antibiotics, other

medications•Vomitting: It is due to anesthetic agents

Certain common post operative problems

Recovery from anesthesia: Care should be taken for

suction of vomited material. The patient should lie in lateral or supine position with head low and

face turned on one side to prevent aspiration of

vomitus in respiratory tract and falling back of the

tongue.

Shock • Foot end elevation with blocks• IV fluids\ blood transfusion• Oxygen inhalation• Keeping the patient warm by blankets• Vasopressor drugs

Pain:As the patient recovers from the effect of GA , the pain which is relieved by Inj :Diclofenac sodiumInj:Diazepam

Retention of urine: in early postoperative period should be treated with•Change of posture•Hot water bag•Sending the patient to toilet if not contraindicated •Inj carbachol `1ml IM

Care of wound : this is done by cleaning Applying an antisepticApplying dressing

Emergency drugs

injection

Adrenaline Noradrenaline Dopamine Propranolol Atropine sulphate Hydrocortisone Aminophyline Morphine Diazepam Avil

Insulin Lasix bupivacaine

Inj. Adrenaline Dose ,0.2-0.5 ml subcutaneously or intramuscularly, 0.25 ml diluted in saline, slow intravenously, 0.5ml intracardiac.Indications•Along with local anesthetic•Acute attack of bronchial asthma•Cardiac arrest due to drowning, electrocution, during Stokes•Homeostasis •Allergic reactions, e.g. anaphylactic shock, angioneurotic edema of larynx.

Adverse Reactions Palpitation, tremors, pallor, headache. lf injected rapidly and intravenously, adrenaline may

cause sudden marked increase in blood pressure, precipitating subarachnoid hemorrhage and hemiplegia.

Ventricular arrhythmias. Acute pulmonary edema in patients with cardiac

decompensation. Anginal pain. ·

Inj. Noradrenaline

DoseTwo ml of noradrenaline is added to 1000 ml of 5%

dextrose solution (acidic) resulting in a concentration of 4 ug/ml. After judging the response with a test dose of 2-3 ml, solution is administered at the rate of 0.5 ml/minute, according to the blood pressure response.

lf noradrenaline is to be used and infused in normal saline, vitamin C (500-1000 mg)should be added to ma.ke the solution acidic

Indications Treatment of hypotension of circulatory failure. Hypotension following removal of chromaffin cell

tumors.Side Effects Same as for adrenaline. necrosis

Inj. Dopamine

Dose A 5-ml ampoule, containing a total of 200mg solution, is added to

500 ml of normal saline or 5% dextroseIndications Hypotension with inadequate cardiac output, to increase

peripheral circulation. Open heart surgery. Renal failure (renal vasodilator dose is l-2.5 ug/kg/minute) in

acute renal failure due to hypotension. Cardiac failure

Inj. Propranolol

Indications Pheochromocytoma Cardiac arrhythmias Acute myocardial infarction Side Effects Congestive heart failure Bronchospasm Hypoglycemia unresponsiveness Nausea and vomiting Uterine hypomotility and prolonged labour Thrombocytopenia and leucopenia

Inj. Atropine Sulphate

Indications 0.65-mg/ml :preanesthetic medicationBradyarrhythmias.Parkinsonism 6 -mg/ml In the treatment of organophosphorus poisoning

Inj. Neostigmineindications Myasthenia gravis. Acute congestive glaucoma. Treatment of curare poisoning. To reverse the neuromuscular blockade by D-tubocurarine and Pavulon

(muscle relaxant used for relaxation in anesthesia). Treatment of neuromuscular paralysis due to snake-bite Side Effects Salivation, sweating, and lacrimation Nausea, vomiting; abdominal pain, and diarrhea Tremors and fasciculations Hypertension

Inj. Hydrocortisone Indications Life-threatening emergencies, e.g. anaphylactic shock,

status asthmaticus, hypoglycemia, thyrotoxic crisis, Addison’s crisis, hypercalcemia, etc.

Intra-articularly in osteoarthritis, painful fascial nodules, etc.

Topically injected in the treatment of keloids. As retention enema

Side Effects Gastritis, gastric hemorrhage, peptic ulcer, perforation,

and pancreatitis. Hypertension. Osteoporosis. lt suppresses immunity and inflammation and may

mask serious infections. Tuber-culosis often spreads and there may be super—infection with fungi.

Delays wound healing.

Inj. Aminophylline

Indications Bronchial asthma. Cardiac asthmaSide Effects Nausea, vomiting. Epileptiform fits, preceded by twitching of mouth or

severe hyperventilation. Collapse and death

Inj. Morphine

Dose 5-20 mg subcutaneously or intramuscularlyIndications As an analgesic, e.g. in colic (given along with

atropine) and myocardial infarction. . As a preanesthetic medication, In acute left ventricular failure

Side Effects Hypotension. Respiratory depression Drug dependence Urinary retention Tolerance bradycardia

Inj. Diazepam

Dose 10 mg intravenously or intramuscularly.Indications ` As muscle relaxant in tetanus. As preanesthetic rnedication. In the treatment of convulsions: Psychomotor epilepsy

and status epilepticus. As tranquillizers.

Inj. Avil (pheniramine maleate)ActionIt inhibits the action of histamine release on gastrointestinal tract, uterus and

blood vessels, but no effect on bronchospasm, hypotension, and gastric secretion

Indications Allergic reaction Pruritus HypnoticSide Effects l. Sedation, lassitude, and fatigue 2. Dryness of mouth, blurring of vision 3. Nausea, vomiting, and epigastric distress 4. Blood dyscrasias

Inj. Insulin

Plain insulin is available in a concentration of 40 units/ml and 100 units/ml in l0—ml bulb

Indications Diabetic ketoacidotic coma. Glucose insulin drip in hyperkalemia IDDM,NIDDMSide Effect Hypoglycemia.

Inj. Lasix (Frusemide)

20 mg intravenously or intramuscularly. indications In the treatment of pulmonary edema (given intravenously). . To induce forced diuresis in the treatment of barbiturate

poisoning. In the treatment of mannitol-resistant acute oliguria. Advanced renal failure. In prostatectomy, while closing the urinary bladder, and

postoperatively, after 4 hours to induce diuresis and thus to prevent clot retention.

Side- Effects When used unintelligently Lasix can precipitate serious

water and electrolyte disturbances due to excessive loss of sodium (Na), potassium (K), chloride (Cl) and water, leading to weakness, fatigue, dizziness, and cramps

Rapid diuresis in elderly patients may precipitate into retention of urine.

It can cause hepatic coma in the presence of liver disease.

Cardiac arrest Hearing loss

Bupivacaine Hydrochloride (Sensorcaine)

Sensorcaine is used for regional or local anesthesia or analgesia for surgery, for oral surgery procedures, for diagnostic and therapeutic procedures, and for obstetrical procedures. It is four times more potent than lignocaine. It has longer duration of action.

Availability Hyperbaric solution Isobaric solution if Hypobaric solution

Adverse Reactions Systemic: · Underventilation Hypotension Secondary cardiac arrestcentral nervous system reactions: Excitation and/or depression Restlessness, anxiety, dizziness, tinnitus, blurred

vision or tremors may occur, possibly, proceeding to convulsions

Drains

Drain is an appliance or piece of material that acts as a channel for the escape of fluid

Prophylactic To prevent accumulation of fluid (bile, lymph, exudate, etc.)

or blood. to encourage the obliteration of dead space, otherwise the

accumulated fluid acts as a separating agent and will not allow the raw

surfaces to collapse. Therapeutic: To promote escape of fluids already accumulated

Principle The simplest and most effective method of drainage is to

bring the cavity to be drained to the surface, But as this is not always possible. alternatively an artificial drain is passed down to the cavity to be drained.

Advantages Drainage of the collected fluids removes the nidus for the infection. It helps in monitoring the future development of the complications

like hemorrhage or leakage from the suture line. It removes the separating fluid from the cavity, so that raw

surfaces can collapse and come into contact with each other which will enhance the rapid healing.

Disadvantages It forms a portal of entry for the bacteria. It delays the healing. lt can break down suture lines. It initiates the tissue reaction It gets blocked within 6 hrs

Drain PlacementThe drain used should be: soft, so as not to erode the surrounding tissues preferably radio-opaque or having radioopaque line along the tube of a material that will not disintegrate and leave foreign bodies in

the wound it should be non-irritant. Proper daily dressing of the drainage site should be done to

prevent infection It should not damage the nerve or blood vessel. The inner end should not be placed near the suture lines. The drain should be secured properly

Types of Drains

Cotton GauzeGauze acts as a drain by capillary action in the fabric which absorbs the fluid

UsesTo prevent its closure and allow healing from floorAdvIts acts as a temporary drainageDisadv Gets soaked rapidly. Gets sealed within 6 hours by fibrin network. When soaked it acts as a moist channel for the penetration of bacteria. ` When a soaked gauze is removed, it is often followed by a gush of accumulate fluid

from the cavity.

Wicks

The wick is formed from gauge or threads of ligatures or suture material twisted together or bound loosely

Disadvantages: , It becomes soaked by the fluid. It can adhere to the surface It requires frequent change

Glove Rubber Drain

A strip of glove rubber, which is made up of latex, is used to drain the superficial dead space

uses To drain dead space after removal of large subcutaneous

lipoma sebaceous cyst, and after thyroidectomy. Drainage of abdominal wall wound if hematoma or infection

is anticipated. Disadv It drains only deeper tissue since its surface sticks to the raw

area.

Red Rubber Corrugated Drain (Sheet Drain)

It is made up of red rubber which is available in the form of unsterile sheets, from which the strips of required length and breadth are cut and sterilized by autoclaving

Adv; Drainage of the fluid occurs along the grooves of the drain, so chances of

blockage are less. Red rubber is an irritant This drain is used only when there is minimal amount of dischargeDisadv; it is used for a prolonged period and removed at a time, the track of the

drain will start healing from superficial and deep aspects while the middle part remains infected

Uses As per glove rubber drain To drain subcutaneous tissue after removal of multiple

enlarged nodes in neck Drainage of large abscess cavity

Tube Drain

When the fluid enters the tube, it can be guided into a collecting apparatus Advantage: tube drain forms the closed drainage system so that raw surface cannot be

contaminated due to entry of bacteria.Disadvantages: It drains only in the direction of the gravity. If the tube is too thin, the force of capillarity tends to retard the free flow

through it. lt cannot drain viscous fluid. It drains the fluid only when the tube is larger; so the fluid can be replaced

by the air

Types of tube drain Catheters Portex drainage tube Yeates drain Penrose drain Cigartte drain Shirley drain T tube Sump suction Plastic tube drain

DressingsDressingBasic Dressing Materials Gauze, Gamgee Bandages Elastic bandages Elastic adhesives Specialized Dressing Materials Vaseline gauze Framycetin-medicated gauzeSialistic Gauze Advantages: Porous Autoclavable Does not get wet Transparent

Treatment of Wounds While treating any wound, one must broadly consider

whether it is an open wound or closed wound. The decision to repair any injured structure in an open wound depends entirely on whether it is tidy or untidy.

Types of WoundsOpen wounds1. lncised wound: Clean cut by sharp instruments (knife, glass, razor blade). No bruising or crushing. It tends to gap, and bleeds freely. Damage to all structures is linear with minimum loss of

tissue.

Puncture wound (stab) Wound is deeper than its breadth, and is caused by

sharp, pointed narrow objects such as pins. knives, and splinters of wood.

Entrance of wound is surprisingly small and may be missed.

Perforating or penetrating wounds: These are punctured wounds, caused by missiles

which may pass through the tissue.

Lacerated wound: Caused by tearing, crushing, and forcible disruption of

tissues. Loss of skin continuity. It has jagged, rough edges. Extensive tissue devitalization by loss of blood supply. Bleeding is often at first slight.

Abrasion and degloving: Caused by scrapping away of the superficial layers of skin. When more pressure is applied in rubbing, a flap of skin and

subcutaneous tissue may roll off, exposing the deeper tissue.

Closed wounds Contusion Caused by pressure of blunt object. Extravasation of the blood in the tissue augmented by

edema. Skin maybe intact. If skin is involved in contusion, the visible bruise is an

ecchymosis.Hematoma Caused by blunt object. Larger blood vessels are ruptured.

Instructions for the Wound Dressing

Take utmost care to prevent cross-infection. The instruments to be used for the dressing should be sterilized. Wash hands thoroughly before and after the procedure. Use instruments for one dressing only. After dusting or sweeping the room, do not dress for l5 minutes. lt is advisable to have a bag for each dressing. Avoid coughing, sneezing, and talking when the wound is opened. Clean the wound from the centre to its periphery. lf dressing is sticking to the wound, pour Savlon or normal saline to make it wet for

its easy removal. The wound and the drain area should be dressed separately. The amount of discharge should be examined for its color, odor, and consistency. Give an analgesic prior to the painful dressing Isolate the wound by spreading sterile towels.

Treatmentl. The aseptic treatment of a wound: The aim of surgery is

to make all wounds as tidy as possible by removing dead or damaged tissue and by re-aligning living tissues nearly together.If slough present , removed by hydrogen peroxide or Eusol.

2. Cleansing the surrounding skin Pad of sterile dry gauze is held on the wound. Surrounding skin, if hairy, is shaved.

Remove skin fats, grease, and oil debris with 1% cetrimide(Cetavlon). Alternative is bactericidal solution (0.05% Savlon). lf the wound is soiled, the wash can be augmented by ether. Then follow wash with saline or sterile water or spirit.

3. Anesthesia (general or local): Full anesthesia of wound is necessary. One per cent lignocaine is satisfactory for local anesthesia. Needle should not be inserted too far. 4. Cleansing of the wound properly: Sterile towels are applied. ' Operating surgeon should be gloved and gowned. Same order of bland fluid cleansing is used as for surrounding skin. Loose foreign bodies —are removed by sterile forceps. Wash the wound with saline. Exploration, identification. ’ Repair and closure of the wound.

5. Leaving the wound open: Most wounds can be closed primarily and drain should be avoided. Exceptions, however, are _

With extensive muscle loss. Viability of tissues is in doubt. Grossly infected wound. Those caused by velocity projectiles.

After Care Dressings: Most dressings are left undisturbed. Dressing is removed earlier, if there is; (i) hematoma

formation, (ii) soaking with exudate, (iii) local pain, tenderness, and (iv) unexplained pyrexia.

Plaster slab or plaster: The wounds of the limbs, especially the joints, require

immobilization to give rest to the wound. This can be achieved by plaster slab or plaster; it provides scope for dressing.

Removal of sutures Wound can be cleaned with ether. Usually, sutures are removed between the 7th and 10th day.

Care of infected Wounds Infection can be controlled by local mechanical

washing and appropriate antibiotics. Dead tissues (slough) that are easily visible can be

excised without much pain. Time-honored and cheap lavage is hydrogen peroxide

and Eusol. Eusol is prepared by mixing boric acid and bleaching

powder in l liter of water. Eusol has to be fresh and should be prepared every

day.

URINARY CATHETER

INTRODUCTIONA Foley catheter is a thin, sterile tube inserted into your bladder to drain urine Because it can be left in place in the bladder for a period of time.

It is held in place with a balloon at the end, which is filled with sterile water to hold it in place.

The urine drains into a bag and can then be taken from an outlet device to be drained

PARTS OF THE FOLEYS CATHETER

INDICATIONS By inserting a Foley catheter, you are gaining

access to the bladder and its contents.

Thus enabling you to drain bladder contents, decompress the bladder, obtain a specimen, and introduce a passage into the tract.

This will allow you to treat urinary retention, and bladder outlet obstruction.

.

Urinary output is also a sensitive indicator of volume status and renal perfusion (and thus tissue perfusion also).

In the emergency department, catheters can be used to aid in the diagnosis of bleeding.

In some cases, as in urethral stricture or prostatic hypertrophy, insertion will be difficult and early consultation with urology is essential

CONTRAINDICATIONS Foley catheters are contraindicated in

the presence of urethral trauma.

Urethral injuries may occur in patients with multisystem injuries and pelvic fractures, as well as straddle impacts.

If this is suspected, one must perform a genital and rectal exam first.

If one finds blood at the meatus of the urethra, a scrotal hematoma, a pelvic fracture, or a high riding prostate then a high suspicious of urethral tear is present.

One must then perform retrograde urethrography (injecting 20 cc of contrast into the urethra).

Equipment Sterile gloves - consider Universal

Precautions Sterile drapesCleansing solution e.g. SavlonCotton swabs ForcepsSterile water (usually 10 cc)Foley catheter (usually 16-18 French)Syringe (usually 10 cc)Lubricant (water based jelly or xylocaine jelly)Collection bag and tubing

PROCEDURE The urethra and the surrounding areas are

cleaned with a cotton-ball dipped in antiseptic solution.

Beginning at the urethra, the cleansing is performed in a circular motion, moving outward to the surrounding areas.

A Foley catheter, lubricated with water-soluble jelly, is inserted into the bladder through the urethra.

.

Once the catheter is passed, the balloon is in the bladder. It is then slowly inflated with about 10cc of water using a syringe. Inflating the balloon should not be painful

At this time, urine, if present in the bladder, should flow back through the catheter and into the sterile drainage bag.

Removal of the catheter and bag

The catheter balloon is deflated by inserting a syringe into the catheter valve and pulling back on the syringe.

The pressure in the balloon will cause the water to flow into the syringe.

Once the balloon is empty, the Foley catheter can be pulled out.

After the Procedure

A slight irritation in the urethral area may be felt.

Switch to looser fitting cotton clothing. Do not use chemical irritants in the

genital area and keep the area clean.

reference Mansukh b patel & yogesh p upadhyay