Pediatric&Minor Surgery Okt2008

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BLOCK 14

SKILLS LABORATORY MANUAL

PAEDIATRIC EXAMINATION

ANDMINOR SURGERY

Faculty of Medicine

Universitas Gadjah Mada

Yogyakarta

2008


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Paediatric Examination & Minor Surgery

Skills Lab manual Block 14 : Pediatric Examination & Minor Surgery

Author: Skills Laboratory

Faculty of Medicine Universitas Gadjah Mada

Contributors:

Pediatric Examination:Prof. dr. Soenarto, Sp.A(K)

dr. Amalia Setyati, Sp.A

dr. E. Suryadi, SU, PA, MHPE

dr. Santosa Budiharjo, M.Kes, PA

dr. Milana Widyasari

dr. Arum Tri Wahyuningsih

Minor Surgery

dr. Soenoko, SpB-KBTV


dr. Rizki Amalia Gumilang

Pre-print:

dr. Milana Widyasari, dr. Nine Luthansa, Siti Aisyah

Cover Design:

Siti Aisyah

Publisher:

Faculty of Medicine Universitas Gadjah Mada Yogyakarta

All right reserved - This book is protected by copyright

ISBN No. 979-26-1013-8


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CONTRIBUTORS:

Prof. dr. Soenarto, Sp.A(K)

Department of Paediatric, Faculty of Medicine,


z

dr. Amalia Setyati, Sp.A

Department of Paediatric, Faculty of Medicine,Universitas Gadjah Mada

z

dr. Soenoko, SpB-KBTV

Department of Surgery, Faculty of Medicine,


z


Department of Anatomy, Embryology and Anthropology

Faculty of Medicine, Universitas Gadjah Mada

z

dr. Santosa Budiharjo, M.Kes, PA

Department of Anatomy, Embryology and Anthropology

Faculty of Medicine, Universitas Gadjah Madaz

dr. Milana Widyasari

Skills Laboratory, Faculty of Medicine,


z

dr. Arum Tri Wahyuningsih



z

dr. Rizki Amalia Gumilang




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PREFACE

It is very important for medical students to practice clinicalskills, which are necesary for their future career as a medical doctor.Medical schools are nowadays convinced that students should masterthe skills before they make their contact with real patients.Therefore, an early skills training is needed.

In the block 14, two topics of skills training are PaediatricExamination & Minor Surgery. In this block, the paediatricexamination only focused on heteroanamnesis.

The purpose of this book is to help students of the School ofMedicine of Gadjah Mada University to prepare themselves for theirclinical skills training. Particular emphasis is given to the way aprocedure should be performed, including a step-by-step guide onwhat students should do to be able to perform the procedurecorrectly, though some related anatomic and physiology issues arealso discussed briefly. A checklist is attached to help students toassess their own performance, while also used as an assessmentinstrument during the skills evaluation (Skills Test).

We hope this book proves to be useful to students as well as

skills instructors who are involve in skills training.We greatly appreciate the contribution of colleagues from various

departments for their willingness to participate in construction ofthis book. We also express our sincere thanks to experts for theiruseful comments and supports.

Skills Laboratory Team


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CONTENTS

Contributors.................................................................. 3

Preface ....................................................................... 4

Contents ...................................................................... 5

Pediatric examination ...................................................... 7

I. Introduction............................................................. 7

II. The Unique of Paediatric Examination.............................. 9

III. The Order of Examination Implementation ........................ 11

A. Anamnesis .......................................................... 11

B. Physical Examination in Children ............................... 18

C. Physical Examination Data ....................................... 21

General Examination.............................................. 22

Specific Examination ............................................. 28

Specific Examination in Neonates.............................. 31

Appendix 1 ................................................................... 34

Appendix 2 ................................................................... 37

Medical Record............................................................... 38

Simple Skin Suturing ........................................................ 42

General Objective ........................................................... 42

Specific Objective........................................................... 42

Introduction .................................................................. 42

Required Instruments ....................................................... 43

Pincer..................................................................... 43

Needle Holder ........................................................... 44


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Needle and Thread ..................................................... 45

Scissors................................................................... 47

Scalpel .................................................................... 49

Procedure for Wound Suturing ............................................ 50

Disinfecting Operation Area .......................................... 50

Technique for Suturing Wound ....................................... 50

Making a Suturing Knot ................................................ 55

Removing the Suturing ................................................ 56

Reference ..................................................................... 58

Checklist ...................................................................... 59


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PEDIATRIC EXAMINATION

I. INTRODUCTION

Making physical diagnose without laboratory examination, basicallyrequires great care. The verbal and sense capabilities of doctor areneeded to identify the manifestation of diseases by finding the signs

and symptoms. The data that gain from history taking/anamnesisand physical examination use to make diagnose, therapy and prognosis

by a systematically and critical analysis.

There are two steps of activities in making physical diagnose,that is data collecting and data analysis.

A. Data collecting

(1) Subjective Data

All information or data from patient whose seeking doctor arenamed subjective data. Mastering in verbal capabilities orcommunication skills and make a good rapport in the interpersonal

relationship require to success in collecting subjective data. The

subjective data are found and started from both autoanamnesis/anamnesis and heteroanamnesis/alloanamnesis.

(2) Objective Data

All information or data obtained by physical examination andlaboratory examination are called objective data. The techniques ofphysical examination are inspection, palpation, percussion andauscultation.

Inspection is a critical observation. To ensure accurate and usefulinformation, doctors must approach inspection in a careful, unhurriedmanner, pay close attention to details, and try to draw logical

conclusions from findings.


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Palpation is test by touching. To enhance palpation techniques,the hands can be used in different ways. The doctors can takeadvantage of tactile sensitivity to each region of the hand. The tipsand pads of the fingers can be distinguished texture and shape best.The back or dorsal surface can be best feel for warmth. The ulnarsurface, or ball of the hand (at the base of the fingers on thepalmar) can be best feel thrills and fremitus. The thumb and indexcan be assessed hair texture best, grasp tissues and fell for lymphnode enlargement.

Percussion is a test using method of knocking on the surface ofthe body using the finger to produce sounds. There is characteristicsound produce by percussion on typical location.Auscultation is hearing sounds from the inside of the body. Sometimes,body sounds such as the voice, loud wheezing or stomach growl canbe heard fairly easily, but you will need a stethoscope to hear softerones.

At each steps of the motor activities, both in anamnesis andphysical examinations, the doctor s mental aspect are always neededto get involved, ex. critical and analytical thinking. How does thecritical and analytical thinking perform? If a doctor were in one step

to find information, this information should be thought carefully andbecome basic information to emerge hypothesis. The hypothesis isneeded to find for information and proved by it.

Each case has specific characteristic of the symptoms and signsthat are different from another cases. Such as the symptoms andsigns of fever are different from diarrhoea, confusing, headache,paralyse, etc. Therefore, while collecting the data, the doctor doesnot only ask many questions like filling a questionnaire, but doingthe activity like a detective. A detective solves a case by searchingmany relevant evidence. For example, a rape case is directed thedetective to collect data from dirty bed and bedcover, finger prints,loose hair, dried sperm, blood, broken shirt or underwear; in other


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case, such as an engage in a gang fight, the information that hasbeen collected are different from the rape case, so each case needsdata that have meanings to solve the problem.

In paediatrics, especially in neonatal examinations, the congenitaldefect should be observed critically. Such as neural tube defect,hernia, external anogenital defect, schizis, cardiac malformation,chromosomal malformation, etc.

B. Data Analysis

Analysis of data which done by a doctor is not only done aftercompleting the data, but also as soon as the information gained.Before the specific examination is done, the doctor must be able tomake analysis and resume of the examination from data that hasalready exist. By that, the doctor can diagnose the disease.

Only from the anamnesis and physical examinations, doctor might

be able to define the clinical diagnosis correctly, such as malnutrition,congenital defect, hemiplegia, paraparesis, pharyngitis, abces, etc.Moreover, for certain diagnosis there might be only data fromanamnesis that is needed, such as stress (caused by fear of facingexamination, broken heart, etc) that is revealed only by anamnesis.

The activities of collecting data and analysis involve:a. Motor activities, such as anamnesis and examinationsb. Mental activities, such as readiness and capabilities to make

perception of the facts found, then critically make conclusion(temporary) and policies to step forward

c. Intellectuality capabilities about related theoretically conceptsthat has to be mastered firstly and capability to analyse.

II. THE UNIQUE OF PEDIATRICS EXAMINATION

The conceptual and medical techniques perpertives, to makephysical examination in paediatrics, basically, is similar as in adult.


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There are unique or specific techniques of paediatric examination,such are:1. The pattern and manifestation of disease is different from adult,

therefore, appropriate history taking and physical examinationsare needed.

2. Sometimes in paediatrics, history taking based on hetero-anamnesis, the child s feeling is not always same with the parentscomplaint. Mothers have more subjective or over describing thesigns and symptoms caused by their worry, and hope that the

doctor might gave effective drugs.3. Paediatrics examinations need more attention, mastering in skills,

and patience.4. Children patient often uncooperative (crying, struggle to get

loose), so many examinations can not be done, such as executethe reflex; inspection of the conjunctivas mucosa and auscultatethe heart sounds.

5. The order of implementation of the examination is modified;such as the head examination is the last, usually head examinationmake the children afraid. Auscultation of the heart sounds isdone in the beginning.

6. The method to execute percussion is more gently and weakly,because the wall of body cavities are thin.7. The axillar regio is an important site in auscultating the thorax,

both right and left side, which are the lateral side of thoracicwall.

8. The equipment of examination is fitted with body or part ofbody size, such as the head of stethoscope (especially for baby),size of manset (appropriate with length of upper arm), weightbeam, stadiometer, infantometer, tape, etc.

9. There are different reference in normal range compared to theadult normal range, both laboratory and others; such as bloodpressure, Hb, Hmt, body part ratio.


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10. Many signs or patognomonis sign are different between childrenand adult, such as the criteria of neonatal sepsis is specific, thatare differ with criteria in adult; in tetanus neonatorum,contraction of masseter muscle is like fish mouth, not as risussardonicus.

III. THE ORDER OF EXAMINATIONS IMPLEMENTATION

A. ANAMNESIS

The medical student should be practiced to take anamnesis, notjust ask many questions to the patient or parents with the list ofquestion (questionnaire) but how to ask patient and make questionsso its answers become in order or in sequence on the right trackwhich is appropriate the illness history of patient.The main objectives of anamnesis are:a. Reconstruct the history of disease that is suffered by patient. If

the data have obtained clearly and meaningfully, it could be usedto analyse toward diagnosis. The knowledge of natural history of

diseases concept is as important as prior knowledge.b. Reveal the risk factors that relevant for diagnosis, prevention,

and prognosis.c. Knowing the efforts of treatments that already had given by

self, doctor, alternative medicine, and how does the effects ofits treatments. If the past therapy given by doctor or paramedic,furthermore the information are 1) analysed and interpretatedto know the diagnosis that already been made and also kind ofeducational therapy.2) whether the last therapy is a specificdrugs regimen for the disease, such as regimen for tuberculosis,diabetes mellitus, rheumatic fever, asthma, etc. 3) Are therespecific advise that already given, such as should regular control,

allergic manifestation, seizure, etc.


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The content of data in paediatrics anamnesis are:1. Identity: The patients identity: data and place of birth;

nickname, particularly for those between 2 and 10 years of age.The parent s identity: first name of parents (and last name ofeach, if different), their occupations, and where they may bereached during work hours, and also the identity of someonewho give information in anamnesis.

2. The history of the present illness, consists of:z The chief complaint and present illness history.

- Chief complaints. These are the one or more symptomsor other concerns for which the patient is seeking for

care or advice. Make sure whether these are concerns ofthe patient, the parent(s) or both. In some instances athird party, such as schoolteacher, may have expressedconcerns about the child.

- Present illness history amplifies the chief complaints andgives a full, clear chronological, account of how each ofthe symptoms developed and what events were relatedto them. These are included describing of illness, describingthe signs and symptoms, the treatments, and the same

past illness. Should include how each member of the familyresponds to the patients symptoms, their concerns aboutthem, and whether the patient achieves any secondarygains from the illness.

z The family illness and the pedigree of patient.Such congenital and genetic disorder have social-culturalbackground or familial. Marriage with close relative(consanguine) between the parents, diseases present in thefamily (allergy, cardiovascular diseases, DM, cancer, epilepsy,etc.) should be asked, in order to find the relation withpresent illness.


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z Anamnesis of the body systemSearching for the anamnesis of body system has to be relevant

with the chief complaint and suggestion of the final diagnosis,

including the differential diagnosis.

Basically, the systems of the human body are divided into

seven systems. These are systems of the body and symptoms

that usually accomplished by the patient according to the

system.

1. Cerebrospinal system: headache, nervous, vertigo,tremor, etc.

2. Cardiovascular system: palpitation, weakness, cyanosis,

etc

3. Respiratory system: cough, sneezing, dyspneu, snoring,

sputum, etc

4. Gastrointestinal system: nausea, vomits, constipation,

diarrhoea, gripes (colic), puffy, etc.

5. Urogenital system: red urine, pain, pus, etc.

6. Integumentum system: white pimply, red pimply, ulcer,

swelling, etc.

7. Musculosceletal system: paralyse, pareses, deformity,swelling, fracture, etc.

3. Personal history

z The history of intrauterine (antenatal) care, labor and

postnatal care.

Birth history is particularly important during the first 2 years

of life and for neurological and developmental problems.

Hospital records should be reviewed if preliminary information

from the parent(s) indicates significant difficulties before,

during or after delivery.


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- Prenatal (antenatal care):

How many times does the mother visit the doctor during

pregnancy? Minimally, the mother should visit the doctor4 times during pregnancy; once at the first trimester

(before week 14), once at the second trimester (beforeweek 28), and twice at the third trimester (between

week 28-36 and before week 36). Ask about the vaccinethat she got during pregnancy, especially tetanus toxoid,

and how many times the vaccine was administered. Askabout Fe supplement during pregnancy.

Maternal health before and during pregnancy, includingnutrition and specific illness related to or complicated by

pregnancy; dose and duration of all drugs taken duringpregnancy; weight gain; vaginal bleeding; duration of

pregnancy; parental attitudes concerning the pregnancyand parenthood in general and this child in particular.

- Natal care:

The history of natal care is including date and place ofbirth, who was taking care of the delivery, whether it

was obstetrician or midwife, delivery process(spontaneous, cunam extraction, vacuum extraction,

caesarean section), multiple gestation, condition rightafter delivery, and morbidity at the first day after birth.

The gestational age is also important to be asked, whetherit is preterm, aterm, or posterm. Respiratory effort

(Apgar score) after birth is also important to be asked,whether the baby cry spontaneously or not. Birth weight

and length are important too. Morbidity related to thedelivery and at neonates is should be asked, including

asphyxia, delivery trauma, intrapartum infection, icterus,etc. that might be related to the problems appear present.


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- Postnatal care:Regular visit to check the mothers and neonates conditionand where it was done (hospital, community healthcentre).

z The history of feeding and conclusion of history in nutritionstatus.Feeding history is particularly important during the first 2years of life and in dealing with problems of under- andovernutrition. In the feeding history we can ask about the

foods that has been consumed by the child before ill (shortterm) or since infancy (long term). Then measure about thequality and the quantity, whether it is enough or less accordingto the nutrition value.- Infancy:

o Breastfeeding: frequency and duration of feed, use ofcomplementary or supplementary artificial feeding,difficulties encountered, timing and method ofweaning.

o Artificial feeding: type, concentration, amount, andfrequency of feeds, difficulties (regurgitation, colic,

diarrhoea) encountered, timing and method ofweaning.o Solid foods: types and amounts of baby foods given,

when introduced, infants response, introduction ofjunior and table foods, self feeding, parental and infantresponse to feeding process.

- Childhood:o Ask about the supplement food, the age when it was

given first, the type, the amount, and the schedule.Parental attitudes toward eating in general and towardthis childs under- or overeating, parental response tofeeding problems (if present). A diet diary kept over


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7- to 14- day period may be required for an accurateassessment of food intake in childhood feedingproblems.

z Growth and Developmental HistoryParticularly important during infancy and childhood and indealing with problems of delayed physical growth,psychomotor and intellectual retardation, and behaviouraldisturbances.- Physical growth: actual (or approximate) weight and

height at birth and at 1,2,5, and 10 years; history of anyslow or rapid gains or losses; tooth eruption and losspattern.

- Developmental Milestone (see app. 1): for children lessthan 5 years old we have to ask about some developmentalmilestone in gross motor, fine motor, personal-social, andadaptive-language. For the school age, the developmentalcould be assessed grossly by evaluating their study result,i.e. if the child is too old in its class or fail to pass theclass for several times, it could lead us to cognitivedevelopmental disorder. We need to ask about the

menarche and telarche (girls), also the age when pubichairs appear. Disorder in this developmental is oftenrelated to endocrinology disorder. In assessing thedevelopmental history, we should ask whether there werebehavioural and emotional disorder. These conditions areusually has background of purely emotional (anorexianervosa in teenagers) or organic (hyperactivity in childrensuffered from attention deficit disorders).

z The history of immunizationIt is important to ask about the immunization status, thebasic immunization or booster, especially BCG, DPT, Polio,Measles and Hepatitis-B, and also another immunization, such


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as MMR, hepatitis-A, and Hib. Those immunizations have to

be asked in order to know the paediatric protection and also

could help to diagnose. (See app. 2)

Specific dates of administration of each vaccine should be

recorded so that an ongoing booster programs can be

maintained throughout childhood and adolescence. Any

untoward reactions to specific vaccines should also be

recorded.

z The history any kind of past illness.The past history explores prior illness, injuries, and medical

interventions while the current health focuses on the present

state of health and on environmental conditions, personal

habits, and health-related measures that may impinge on it.

z Social-economic and environment state.

The important things about the environmental conditions

are the house conditions, how many people leaving in the

house and with whom the child lives with, location

(downtown, suburb, or village), surroundings, the sanitation,

etc. Is there anybody ill in the house?

There are lots of conditions that cause morbidity andmortality related to social economic and environment, such

as malnutrition and tuberculosis.

After finishing the anamnesis and making analysis, we can take

summary (resume anamnesis) as a base data to make hypothesis.

The data or hypothesis from anamnesis is needed to choose or define

priority steps of the examination or give more attention in physical

examination.

In emergency case, while the first aid/therapy is done, the

anamnesis can be taken.


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B. PHYSICAL EXAMINATION IN CHILDRENA. General examination:

1) General condition: apparent state of health, nutritionalstatus, level of consciousness, posture, activity, and otheraspects that can be seen at a moment.

2) Skin and mucosa examination3) Lymph node examination4) Musculosceletal system examination5) Vital sign examination

B. Specific examination:1) Head examination (in children, it is usually done later)2) Thorax examination: thorax in general, heart, lung3) Abdomen examination4) Anogenital examination5) Extremities examination6) Neurological and reflexes examination

Physical examination in children needs more preparation thanthose in adults, because sometimes children are not cooperative tobe examined. In order to keep the children being cooperative during

examination, and because the parents usually watch the examinationprocess, we (as a doctor) have to perform a good examination skillin an effective way. Therefore, it is very important to master thetheoretical concepts and practice the skills.

1. INSPECTION

Inspection means watch carefully with naked eyes or withinstrument (loupe). Usually, this is the first step of examination.Inspection can be done to all over the body, or just a/severalpart(s) of body.


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2. PALPATIONPalpation means a way of examination using sense of touch(propioceptive). The most sensitive part to touch is usually thevolair surface of fingers, with or without palm; and the mostsensitive parts to sense the temperature are the dorsal parts offinger II-IV.

a) With palpation we can:- feel the senseof body temperature (with dorsum fingers),

skin surface (with volair fingers surface), skin lesions- feel vibration (with palm or volair fingers): ictus cordis,

vocal fremitus- find intra abdominal mass (hard, springy, or soft), the

edge and surface of liver, splenomegaly, tumor, full bladder- find sub cutis mass and its size estimation: lipoma, position

of testis (in scrotum or in canalis inguinalis) with volairside of finger II, III, and IV, abscess (fluctuation)

- tenderness (with volair side of finger II-III/IV), defensemuscular (volair side of finger II-IV)

b) The technique of palpation in children is similar with those inadults. At normal and cooperative children, abdomenpalpation can be done easily because the abdomens wall isthin, and so do the sub cutis tissue.

3. PERCUSSIONPercussion is a test using a method of knocking on the bodysurface using the finger, to detect mass under the body wall.The sounds that can be produced by percussion are:* Flatness : indicates solid mass under the body wall (bone,

muscle; usually it is not done)* Dullness : indicates massive mass under the body wall

(liver, solid tumor, cyst, fluid)


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* Resonance : indicates aerogen mass under the body wall(normal lung tissue)

*Hyper-resonance : over resonance sound*Tympani : indi cates air under the body wall

(abdomen)

The technique of percussion in children is similar with those inadult, but usually we knock gentler. Percussion can be done by

knocking the left middle finger between phalanx II and III, with theright middle finger. To look for the borders of heart, we have to

identify the sound changes from resonance to relative dullness. It issometimes difficult to find a small amount of fluid (ascites or effusion)

by percussion.

4. AUSCULTATION

The aim of auscultation is to listen the sounds of organs activity

(in the body), like heart, lung, and gastrointestinal tract.Auscultation in children needs specific stethoscope with suitable

membrane or bell size. For children, we can use bell with diameter1 inch or membrane with diameter 1,2-1,5 inches. For neonates,

especially for low baby birth weight, we need smaller diameterof bell or membrane. We have to choose the suitable earpiece,

so it can completely cover the external acoustic meatal. It issaid that stethoscope is specific for each examiner, so if they

use different stethoscope, it will decrease the sensitivity indetecting the sounds.

Auscultation technique in children is similar with those in adult.Give special attention to these points:

z Chest auscultation- Perform the heart auscultation first, and then lung

auscultation, especially for uncooperative children


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- Dont forget to listen vascular murmur, if there is anindication

- Listen carefully to the sound of normal heart first, andthen listen to the murmur. If you find murmur, listencarefully to get a detail description. Do the same waywith lung auscultation.

z Abdomen auscultation- Do auscultation first before percussion

C. PHYSICAL EXAMINATION DATAThe important keys of physical examination in children compare

with those in adult are:- there is possibility to find congenital anomaly, especially in

neonates- there is possibility to find abnormality caused by growth disorder

that is influenced by risk factors.The abnormalities:z several of those can be found at general examination:

- many clinical syndrome: like Down syndrome, Hurler syndrome,hypothyroidism

- many growth disorders: like labioschizis, cretinism, progeria,achondroplasiaz several of those can be found at specific examination:

- anatomical abnormality/external morphology: gnatho/palatoschizis, hernia, anus imperforates, retentio testis, fingersabnormality, spina bifida, etc.

- internal organ abnormality: congenital heart disease, herniadiaphragmatica, intra abdominal cyst, etc.

Several of those disorders can be found easily from history taking(both of internal and external organs), like labioschizis, gastroschizis,hernia, stenosis pylori, total biliary obstruction.


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Besides, a carefully-history taking about the history of diseasecan lead us to the diagnosis. Therefore, a carefully-history takingsimplify us to pay attention to specific examination.

GENERAL EXAMINATIONGeneral examination lead to find data about patient condition

generally, about anatomical-morphological and functional. Commonly,general examination begins by enclosing entirely inspection withoutmanipulation. This examination is important to:

a. Ascertain the anatomy of the body generally and the morphologyof the body.

b. Obtain trace of psychological related to patient suffering.c. Obtain trace, even conclusion, about motorist status.

Hearing with ear and smelling with nose without instrument(breathing sound/coughing sound and abnormal smell) have to bepracticed, because they can give important information.Things that need to be attended:a. General condition: in this step of examining, identified briefly

about signs that appear immediately; those signs will be described

specifically later in the related organ, if there are indications.1. Ability to recognize general appearance of a patient aboutthings that immediately recognized needs to be practiced;sometimes this appearance often gives diagnostic guidanceor condition, which needs immediate treatment.a) Appearance of severe illness/suffering: this evaluation

primarily to ascertain immediate management: such aslying down immediately, analgesic, tranquillizer,anticonvulsant, etc. If necessary ascertain Karnofsky score

b) Breathing abnormality: dispneu, apneu, takhipneu,brakhipneu, hiperpneu/hyperventilation, Cheyne-Stokes,Biot, stridor, wheezing.


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c) In general appearance we can estimate the abnormality ofthe sounds (without stethoscope): crying sounds (cramping,cri du chat, very weak cry), grunting, speech disorder(aphoni, aphasia, dumb, hoarseness in laryngitis, nasal soundin palatum molle paralyze), cough (pertussiform)

d) Compulsory position (orthopneu in asthma, heart failure,appendicitis)

e) Abnormality of moving (paralysis, hemiparesys, tremor,balismus, chorea, atetoid, hahnen Tredgang, wide base gait,

convulsion, etc.)

b. Skin and mucosa examinationThe examinations are:1. Inspection:

a) Pigmentation (white, yellow, chocolate, black).b) Color alteration (pale, reddish, vitiligo, rash, bleeding):

children with high prevalence of anemia, there are lots ofpediatric diseases with rash, petechia (and other bleedingmanifestation) are not too common in children, icteric,venectasia, caput medusae, telangiectasia.

c) Cyanosis (extremity, general)d) Edema (local, general/anasarca), skin lesion (squama,lichenification, scar, skin tumor).

e) Mucosa: pale, hyperemia, koplik spot, Bitot spots in sclera.2. Palpation:

By palpation we can examine:a) Skin condition: temperature, skin humidity, skin surface,

skin turgor sub dermal condition, edema, (springy,scleredema or pitting edema), skin elasticity, tumor (hard scar; springy lymphoma; fluctuate cyst, abces).

b) Skin sensation (Hypesthesia, normal, hyperesthesia) in

children is difficult to measure.


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Skin examination technique in pediatric is similar to the adult. If

there is bleeding tendency, it might be needed tourniquet test

(Rumple-Leede test). If there is skin lesions, such as red spotting on

the skin, make sure whether it is petechia, telangiectasias, rash in

Henoch-Schonlein syndrome, or other kind of rashes.

c. Lymph node(s)

The primary examination is palpation: enlargement (local,

general), single, multiple, size, inflammation. Examining

supraclavicular lymph nodes in children is important, because ofthe high prevalence of pulmonal TB in children. Regional

lymphadenopathy suggests us to find another disorder (tumor,

inflammation) in the drainage regio that is connected with the

lymph nodes.

d. Examination of muscle, bones, and joint.

1. Muscle

zzzzz Muscle development describes the nutritional status of the

children or atrophy in flaccid paralyze.

zzzzz Muscle tonus and strength are important to measure severe

diseases.zzzzz Contracture

2. Bone: the developmental and anatomical, fracture, tumor,

tenderness.

3. Joint: anatomical joints, position, free movement/limited

movement, intraartikular swelling (fluctuation)/periarticular,

inflammation signs, ankylosis.

e. Vital Sign Examination1. Pulse measurement, things that should be described: frequency,

regularity, blood vessels filling and tension, pulse type equality,

simetricity, femoral pulse compared to radial pulse:


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a. If the frequency isnt normal:

zzzzz Immediately think of paroxysmal tachycardia, flutter,and fibrillation.

zzzzz Bradycardia think about heart block (SA or NA block)b. If there is irregularity, measure specifically:

zzzzz Regular irregularity (bigemini pulse, trigemini pulse).

zzzzz Irregular irregularity (deficient pulse at premature beat,escape, sinus arrest, heart block)

c. If there is abnormality in blood vessels filling:

zzzzz High filling: pulsus magnus, pulsus celer

zzzzz Very low filling: pulsus parvus (et tardus), pulsus filiformis.

zzzzz Inequality between pulses, remember parasistole, pulsusalternans, pulsus paradoksus think to find otherevidence.

d. If there is asymmetrical:

zzzzz Right pulse isnt equal to the left pulse blood vesselobstruction

zzzzz Femoral artery pulse weaker than the radial artery pulse specific in koarktasio aorta.

e. Other types of pulse: pulsus dikorot, anadikrot.

Arrhythmia isnt uncommon in children:

zzzzz Supraventricular tachycardia in severe sepsis, severegeneral condition.

zzzzz Pulsus filiformis (thready pulse) in shock, severe hypo-

volemia.

zzzzz Heart block as complication of diphtheria.

zzzzz Pulsus deficient.2. Respiration: we should describe:

a. Frequency: tachipneu, bradipneu, apneu.b. Types: Biot respiration, Cheyne-Stokes, Kuszmaul/hyper-

ventilation (in children with metabolic acidosis.


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3. Blood pressure:Normal blood pressure varies according to age (look at thelist of time interpretation of blood pressure). The techniqueis the same as the adult. Things that should be noticed:zzzzz The child should be calm.zzzzz Manset size should be proper, which covers two third of

the upper arm.zzzzz Use the membrane site in order that the korotkoff has

low tone.

zzzzz If there is arrhythmia or inequality of pulse measurethe blood pressure more conscientious.

zzzzz If the lower extremities are pale, cold measure thefemoral blood pressure (koarktasio aorta ?).

f. Measurement of body weight, height, and relevantparameters.Measurement of anthropometrics parameters in children arevery important in order to give information about thechildrens growth, even the childrens development.

1. Body weight: measurement of body weight in baby, even

more in baby with low birth weight need to use accuratecounterweight, whereas for children or bigger baby, thebar counterweight is enough. The bodyweight parameteris used to ascertain nutritional status of the children.Alteration of bodyweight may occur rapidly so that givesimage of Protein and Energy Malnutrition (PEM) that isntoccur in chronic time, the abnormality of height isntoccur yet:zzzzz 90%-110% body weight of 50 per centile NCHS : normalzzzzz 80%-90% body weight of 50 per centile NCHS : PEM Izzzzz 60%-70% body weight of 50 per centile NCHS : PEM II


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zzzzz < 60% body weight of 50 per centile NCHS :

- without edema : marasmic

- with edema : marasmic kwashiorkor

2. Height: measuring the childrens height needs to ascertain

their nutritional status. PEM that occur in a long time

causing the height lower than normal.

zzzzz For children who have been able to stand up, the height

is measured by the scale stocked to the wall or pillar;the ankles cling to the scale.

zzzzz For babies or children who have not been able to stand

up, the height measured by scale that is stocked to

the bar (woods, light metals); one of the bar with

border on that side and a shifter that can be moved

up and down to reach the vertex. The feet must be

900 to the lower leg; the knee joints and thighs are

extension, the foot-sole stick on the border at the

tip. The shifter moved a long the bar up to the vertex.

3. Circumferences:

zzzzz Head circumference: head circumference measurementmust be done if there is appearance oh abnormality

(micro cephalic, macro cephalic, hydrocephalus) and

or morphological abnormality (the abnormal shape of

the head should be related to the diseases such as

dolicocephalic, brachicephalic).

Measuring technique: the soft scale tape twisted around

the head passing the forehead and promontorium.

zzzzz Middle arm circumference: middle arm circumference

is one of the anthropometrics parameters to ascertain

childrens nutritional status.


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Technique: with the usual tape or specific tape,

measure the middle of the upper arm; this parameterhas value if there is no edema.

zzzzz Abdominal circumference is a practical way to measureascites progression, even though its not accurate.Technique: the tape is twisted through the umbilical,so that the techniques equal at each measurement.

SPECIFIC EXAMINATION

Specific examination including part of the body (head, neck,chest, abdomen, anogenital, extremity) also related organ and thefunction. For the children, scary examinations should be done in thelast of the meeting, in example head examination using medicalequipment (light, otoscop, tongue spatula, etc).1. Neck Examination

Several child examinations that needs special attention:- Lymph nodal examination: enlargement of the supraclavicular

lymph, multiple, no inflammation sign suspect primary TBof lung, especially in under nutrition.

- If there is any enlargement in the neck, make sure that is

parotid glands (usually enlargement under the ear) orenlargement of the lymph glands (location can be any where)- Jugular vein pressure examination for the baby is difficult.

2. Chest Examinationa. Chest wall examination

Morphology of the thorax can describe the condition aboutchest wall and intrathoracal organ. Watch carefully about:emphysematous, retraction, dada corong (often in obstructiveair way), pigeon breast, cimetricity, vausseur cardiaque,costa, cimetricity of movements, retraction (supraclavicular,suprasternal, infrasternal, subcostal, intercostals). Palpation


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on between costal is important if there area any bulging.Chest wall on children are commonly very thick, just needssmooth percussions.

b. Heart examinationHeart examination should be done before the lung.Auscultation needs carefully for detect the congenitalabnormality.

c. Lung examinationIf there is an abnormality on chest wall inspection, lung

examination should be done more carefully because itspossible that the etiology was from the respiration system.While do inspection on chest cimetricity, the position of thedoctor should be in sagital area of patient leg. Comparingchest wall right and left on children more easy because thesize of the lungs still little, so it makes the examinationeasier for detect abnormality of the lung. If there is anydifferences between right and left lung in inspection,palpation, and auscultation it show abnormality in one ofthe lung.

In auscultation, listen carefully sound of the breath (vesicular/

bronchial, louder/ softer), after that find additional sound.Auscultation under armpit is often easier for detecting theabnormality of the lung. Stiffness in the lung (infiltrate,compressive atelectase) produce bronchial sound (expiratorysounds are louder and inspiratory sounds are decrease),egophony, fremitus sounds increase in the superficial areaof lung which is stiffing (sounds produced from the vocalcord sound higher in pitch and on palpation feel increasefremitus). By percussion produced dullness and by palpationproduced increase fremitus sound. By inspection there is

might be a unilateral lag (or delay) of the respiratory

movement on the stiffing lung.


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3. Abdominal ExaminationAbdominal examination begins with inspection followed by

auscultation and so on. Inspecting the abdomen should beperformed as the thorax examination. In neonate, dont forget

to check the umbilical cord. If it has already released, make surethat there are no granuloma or hernia.

The abdominal wall is the best area to examine skin turgor andelasticity. Abdominal palpation in children is usually not difficult

if the child is cooperative. The abdominal wall that looks enlargemight shown meteorismus, liquid (cysts, acites, hydronephrosis),

full vesica urinaria, or hard tumors (organo-megaly,neuroblastoma, nephroblastoma, feces accumulation in congenital

megacolon.In the shifting dullness examination, after the border between

the tympani with the dullness has found, incline the patient (thefinger that becomes the percussion base should not move fromthe borderline), after that, percuse to the opposite direction.

The ascites examination by the undulation test is not sensitive ifthe ascites liquid is just a little. Do not forget to examine the

inguinal hernia.

4. Anogenital ExaminationThere are some congenital and acquisital disorder at the

anogenital, which are:a. Congenital: external genital disorder: scrotal hernia,

hypospadia, epispadia, undecended testis, hermaphodyte,ambiguous genitalia, imperforate hymen, imperforate anus.

b. Acquisital: hydrocele, diaper rash, infection, phymosis,paraphymosis.

Those anomalies should be paid more attention in baby.


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5. Extremity ExaminationIn short trace about extremities sizes could illustrate the childrensgrowth. Upper extremity circumference is used to be one ofgrowth parameter. Pseudohypertrophy of lower leg muscle inDMD (Duchene Muscular Dystrophy). Some morphological disorderare present in congenital anomalies (pes equinovarus/equinovalgus, phocomelia, syndactily and other finger disorder,simian line,etc).Active movement or walking style are sometimes meaningfully

in diagnostic. Delay in movement ability may illustrate delay inmotoric development or neurological disorder. There are somespecific attitude and movement in some diseases; specific gettingup position from sitting or laying down position in DMD,monoparalitic gait in post polio, wide base gait in increasedintracranial pressure, atetoid gait in cerebral palsy, Sydenhamchorea in rheumatic fever.

6. Neurological and Reflex ExaminationThese examinations are more difficult to be access in children,even more in uncooperative one. Reflex examinations are often

difficult to do. In neonatal there are specific reflexes that presentor exactly not present in this group.

SPECIFIC EXAMINATION IN NEONATESPhysical examination in neonates needs a special attention because

there are many differences with those in children. The most numberof items in physical examination is inspection, and then otherexaminations with a little manipulation. Practically, auscultation isonly done to examine the heart, although it doesnt mean thatauscultation is not important for neonates. Neonates examinationneeds patient, gentleness, and flexibility. In a calm baby, we shouldauscultate the heart and abdomen after inspection, and then palpate


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the abdomen gently. After palpation, we can perform otherexaminations. The important symptoms that are should be paid moreattention are:- General appearance, sound of crying- Pale, icteric, cyanotic- Level of consciousness, convulsion, twitching.- Dyspnea, apnea, irregular breathing- Blood circulation- Birth weight

- Many congenital anomalies, such as:zzzzz Body constitution: Down syndrome, hypothyroidzzzzz Neural tube defect : labio (gnato-palato-)schizis, spina bifida,

meningo(mielo)celezzzzz Specific organs anomalies: heart, external genital,

imperforate anus.

Especially for newborn, as soon as it births, the Apgar scoreshould be performed to assess resuscitation needs (first minute) andto check the result of resuscitation (fifth minute). The componentsof Apgar are:- Appearance- Pulse- Grimace- Responds to catheter in the nasal.- Skin color

To measure gestational age while the baby born, perform the Dubowitzscore which components are: physical and neurological characteristics.The total score of both physical and neurological characteristics candefinite the gestational age according to the standard graphic (lookat the picture below).


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There are primitive reflects in neonates, the most important is:- Moro reflex: asymmetric response central nervous system

disorder- Grasp reflex- Tonic neck reflex: abnormality central nervous system disorder

Primitive reflexes are reflexes that appear and disappear followingthe developmental period.

Implementation Procedure:1. Take the history taking of the children patient from the

mother effectively and efficiently.2. Write the data on the medical record and make the hypothesis

of the history taking that has been obtained.

Reference:

Bates, B.1987. A Guide to Physical Examination and History Taking.4th edition. J.B. Lippincott Company, Philadelphia.Matondang, CS, Wahidiyat, I, Sastroasmoro, S.2003. Diagnosis Fisis

pada Anak. Sagung Seto, Jakarta.Saifuddin, BA, Wiknjosastro, GF, Affandi, B, Waspodo, J. 2003. BukuPanduan Praktis Pelayanan Kesehatan dan Neonatal. YayasanBina Pustaka Sarwono Prawirohardjo, Jakarta.


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APPENDIX 1

Physical and Mental Development in children 0-5 years old (Gross andFine motor, emotional, social, attitude, and language)

0-3 months Try to lift the head Following object with its eyes Regard face and smile responsively

Respond to sounds /bell Recognize the mother by seeing, smelling, hearing, contact Vocalize

3-6 months Head up 900 and chest up supported by their own forearms Try to reach things/toys Put things in her/his mouth Laughing or screaming if being asked to play with Try to find lost things

6-9 months Able to face downward and upward by her/him self Able to sit without help Able to creep Turn things from one hand to another one Hold small thing with the thumb and pointing finger Speaks meaningless word Afraid to stranger people Participate in clapping hands or hide and seek


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9-12 months Able to stand up without a help Walking with guiding by the hand Imitate speech, try to say one or two words Understand simple command or forbidden Always eager to explore and put tings into mouth Participate in playing games

12-18 months

Walking and explore inside the house and surrounding Able to pile up 2 or 3 cubes Saying 5-10 words Showing jealousy and competition

18-24 months Walking up and down the stairs Able to pile up 6 cubes Pointing to its own eyes and nose Able to compose a sentence with 2 words Try to eat by her/him self Try to control urination and defecation Pay attention to what the elderly do Play games with other children

2-3 years Jumping, climbing Make a bridge with 2 cubes Able to compose simple sentences Able to draw a circle


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3-4 years Walking alone visiting the neighbour Learn to wear / put off clothes Draw a picture of person with head and trunk Recognize 2 or 3 colors Speaking well, mention her/his own name, sex and age Asking how a baby given birth Recognize upper side, down side, front side and back side Able to do simple tasks

4-5 years Jumping, dancing Draw picture of person with head, arms and trunk Draw square and triangle Able to count fingers, mention day in a week Complaining if prohibited what she/he likes to do Recognize 4 colors Estimate shapes and size of things, distinguish big and small Pay attention/imitating adult activities

(Source: Yaumil-Mimi scale, Paediatric Psychology Department ofIndonesian University and Social Paediatric Department of IDAI)


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APPENDIX 2IMMUNISAZION SCHEDULE

Age

Months Years

Immunisation Type

0 1 2 3 4 6 9 15 18 2 6 12

PPI*

Hepatitis B I II III IV

BCG XDPT I II III IV V VI

Polio I II III IV V VI

Mumps X

Others

Act-Hib I II III IVHib

Pedvax Hib I II III

MMR

XTyphoid:

-polysaccharide

-Oral X

Varicela X

Hepatitis A XXX

Taken from Sari Pediatri, June 2000 (with simplify)

*PPI = Program Pengembangan Imunisasi Depkes RI (Immunization DevelopmentProgramme of Health Department)


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MEDICAL RECORD OF PAEDIATRICS(ANAMNESIS)

I. IDENTITYa). The child :

Name :Place/date of birth :Sex :Address :

b). The parents:Name of father : Name of the mother :

Age : Age :Address : Address :Job : Job :Education : Education :Age when got married : Age when got married :

II. HISTORY TAKINGA. History of disease

Chief complaint:

Present Illness:

Family illness:

Pedigree:


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B. Personal History:

1. History of perinatal care

Pregnancy (Antenatal care):

Labor (Natal care):

Postnatal care:

Resume :

2. Eating Habit

Resume :

3. Growth and Development

Gross Motor Fine Motor Personal-Social Language

Resume:


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4. Immunization

BCG

DPT

Polio

Measles

Hep. B

Other Immunization

Resume:

5. History of past disease

6. Social, economic and environment state:

Social-economic state

Environment state

Resume :


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7. Anamnesis of body system:

Cerebrospinal system

Cardiovascular system

Respiratiry system

Gastrointestinal system

Urogenital system

Integumentum system

Musculoskeletal system

HYPOTHESIS :


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SIMPLE SKIN SUTURING

GENERAL OBJECTIVE:

1. Students understand indications for wound suturing2. Students are able to perform wound suturing on a mannequin

SPECIFIC OBJECTIVE:

1. Students are able to provide information on wound suturingprocedure

2. Students are able to put patient into the right position for operation3. Students are able to perform disinfection on a patient4. Students are able to prepare instruments for suturing a wound5. Students are able to perform aseptic procedure6. Students are able to use surgical instruments for suturing a wound7. Students are able to select the appropriate needle and thread8. Students are able to perform wound suturing9. Students are able to make the correct knot with or without the use

of an instrument10. Students are able to apply a bandage

11. Students are able to provide information and educate patient onpost operation care

INTRODUCTION

Wound or vulnus is a damaged or a discontinued tissue. There maybe corpus alienum (i.e. dirt, fragment of broken glass, wood splinter,etc) and mikroorganisme (aerob or anaerob) on the wound which havepotential to cause suppurative infection even more tetanus. A woundless than 8 hours (still in itsgolden period) can be saturated by way of

asepsis. A wound that is still in its golden periodwill heal primarily,

leaving only a slight formation of tissue scrape and good cosmetics.


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A wound that is more than 8 hours will usually have been con-

taminated and therefore an open treatment is applied (not sutured).

These kinds of wound will heal in a secondary manner, leaving a

somewhat thick tissue scrape. In addition, cosmetics (and/or func-

tion) tend to decline. Should an infection occur, then delayed pri-

mary suturing is performed.

Wounds can be classified into two main categories; acute and

chronic. Usually, an acute wound can be treated immediately and

may experience good anatomical restoration and its functional in-tegrity can be restored to its original condition. On the other hand,

chronic wound that has passed itsgolden periodwill usually heal but

its anatomical structure and function will not be restored to its

former condition.

Required Instruments

Instruments that are used to stitch a wound:

1.Pincer

There are 2 types of pincer;

non-serrated anatomic pincer used

to hold the tissue, and serrated

surgical pincer, to grip the skin.

Atraumatic pincers are used when

handling blood vessels and fragile

tissue. Generally, pincers are held

with the left hand similar to holding

a pen.

Figure 1. Example of pincers


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2. Needle Holder

It is held with the right hand, oneblade on the phalanx I digiti I and theother blade on the phalanx II digiti IV.The second and third finger is used tostabilize the holder. The needle is heldon its 1/3 to its backend, approximately1 mm from the tip of the holder, andthen it is fastened (figure 3).

Figure 2. Needle Holder

Figure 3. Method for fastening the needle using the needle holder


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3. Needle and threadThere are several types of needles and threads. Amongst them

are thread and needle that are on their own. Every time they needto be used, the thread must be manually inserted through the needle.These types of thread and needle are considered less practical. Thethread tends to break in the middle of performing the suturing, andthe sterility of these types of thread cannot be ensured because thethread comes in a long roll which is kept inside a cassette and takenaccording to needs. Furthermore, this type of thread needle maycause extra trauma to the tissue. However, the price is relativelycheap. A more ideal type of thread needle is the atraumatic type,but the price can be somewhat more expensive.

Suturing needle can be categorized based on its size and length.According to its circle, there are 2/8, 3/8, 4/8, 5/8 needles, andbased on its longitudinal section, there are triangular needles forsuturing the skin and spherical needle to suture internal tissue.


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Figure 4. Various types of curved needles and various types of longitudinal

needle section

De Jong, 1997. Surgical Science Teaching Book.

A. (1) ellipse eye, (2) square eye, (3) otoumatic eye, B. circle,

3/8 circle, circle, C. (1) needle base, (2) place to secure needle holder,

(3) needle body or stem, (4) needle point, D. (1) spherical needle,

(2) sharp needle, (3) spherical-sharp


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Figure 5. Various types of needle shape

Brown, John Stuart. 1995. Minor Surgical Atlas and Teaching Book

Suturing thread can be categorized based on its material. There

are biological material and synthetic material. Whilst threads

can be categorized based on its capacity to absorb; absorbent

and nonabsorbent thread. For absorbent threads, there are those

that can be absorbed by the tissue in 1 week, 2 weeks or longer,

which can be as long as 3 months. Based on their size, there are

threads no. 2, 1, 0, 2/0, 3/0, 4/0 until the smallest size. Based

on the number of strands, there are 1 strand (monofilamen)

and multifilament that are braded. For simple interrupted skin

suturing, that will be removed in about 7 to 14 days, it isrecommended to use nonabsorbent thread with the size of 3/0

or 2/0. Whilst the facial areas that requires earlier removal of

approximately day 4, it is recommended to use monofilament

thread of the smallest size in order to give a better cosmetic

result.

4. Scissors

The scissors are held with the right hand, similar to holding the

needle holder (figure 7). There are thread scissors and tissue

scissors. Tissue scissors should not be used for cutting the thread


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because it may cause the scissors to become blunt and break

easily. Tissue scissors are usually finer, very sharp, and curved to

ensure visualization of the tissue that is being cut.

Figure 6. Types of Surgical Scissors

Figure 7. Method of holding the surgical scissors


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Figure 8. Scalpel and blade.

Figure 9. Method for holding the scalpel for short linear incision

5. Scalpel

The scalpel comprises the handle and blade which can either be

in one piece (older version) or can be separated, wherein at the

beginning of each operation, the blade must be fastened. The

blade is very sharp, thus it is recommended to not directly hold

it with the bare hand, but should use an instrument in order to

prevent iatrogenic wound. To move the blade, use your thumb

and not your hand.

It is usually held by the right hand similar when holding thekitchen knife for long linear incision. For short linear or ellipsoidal

incision, the scalpel is held like a pen (figure 9).


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PROCEDURE FOR WOUND SUTURING

To perform wound suturing that will ensure a good result, there

are several steps that must be carefully followed; inspecting the

wound carefully, putting the patient into a comfortable position,

and for operators, it should be performed as ergonomical as pos-

sible. Accordingly, all preparations should be prepared well before

the actual operation begins.

Disinfecting the operation area

Disinfecting the operation area is performed by using disinfect-

ing fluid such as povidone iodine.

The method for disinfecting the operation area is by starting

from around the wound, circling the periphery area using a disin-

fecting pincer that is long enough to prevent the operators sterile

hands the possibility of being contaminated from the operation area

that is still dirty. Do not forget to inform the patient in advance that

the disinfecting fluid may cause pain when it comes into contact

with the wound.

Disinfection is especially needed to cleanse the wound from con-tamination such as:

Technique for Suturing Wound

After applying the disinfectant and before performing the op-

eration, the patient may be given local anesthetics either by way of

infiltration, nerve blocking. After that, the surgical area is cleansed

from contamination such as:

- Corpus alienium found on the surface of the wound that can be

easily removed / cleansed


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- Several corpus alienum that has entered the tissue can be detected

by an X-ray and there are others that cannot.

- Chemical materials, toxins, snake poison etc

- Microorganism

The presence of microorganism can be decreased by cleansing

the wound with NaCl phyisiology and debridement. Microbe aerob

can be anticipated by doing health promotive (improving the

bodys endurance: eating nutritious food and having enough rest)

and using antibiotics prophylaksis- Anaerob Microbe especially Clostridium tetani can be anticipated

by cleansing the wound with Hidrogen Peroksida (H2O

2) 10%,

antitetanus serum and tetanus vaksination.

The dominant hand is in a prone position. The needle, with the

thread, is held with a needle holder at 1/3 to the back. It is pierced

in a straight upright manner into the surface of the skin approxi-

mately x mm from the periphery of the wound ( x = thickness of the

sutured skin), pushed it according to the curve of the needle to the

direction of the other side of the wound. The direction should be

straight forward in axis to the wound, penetrating the skin as far asx mm from the periphery of the wound (dominant hand acts as

suspension). The tip of the protruding needle is taken by the pincer

that is held by the non-dominant hand (similar to holding a pen),

and then the needle is pulled out using the needle holder in the

dominant hand after firstly releasing the needle from the other

hand. After this, make three times knots. The periphery of the

wound should be apposition, somewhat tightened, but should not be

too tight as it can effect the ischemic tissue and prolong healing

process (healing starts from the suturing area), and can instigate

the buildup of more tissue scrape therefore disrupting cosmetics


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and function. However, if it is too loose, it may cause a dead space

that may also disrupt the healing process and may even cause infec-

tion. Both ends of the thread are cut using a scissors approximately

x mm from the knot. The knot is placed at the end of the suturing

to simplify when taking out the thread later on. This process is

repeated until all the wound is sutured with distance between each

suturing 2 times the thickness of the skin (x). Inspect, and if re-

quired, restore the apposition edge of the wound and examine the

suturing one more time, and then close the wound using gauze.

Figure 10. Simple interrupted suture

de Jong 1997. Buku Ajar Ilmu Bedah


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Figure 11. Longitudinal wound and method for piercing the needle and

performing suturing

When the needle penetrates the skin in a straight upright manner, the outer layers of

the epidermis will convex outwards (eversion); this is the basis for a proper healing

process (ectropion)

When the needle does not penetrate the skin in a straight upright manner, the epidermis

surface will fold inwards and prolong the healing process (entropion)


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Below are various types of skin suturing:

Figure 12. Various types of skin suturing

De Jong, 1997, Buku Ajar Ilmu Bedah

A. Continuous suturing

B. Vertical Continuous suturing

C. Vertical matras suturing (Donati)

D. Horizontal matras suturing

E. Intracutaneous/subcuticuler suturing


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Making a suturing knot

This section will deal with practicing making a suturing knot by

using an instrument. Type of knot that will be trained is the square

knot or reef knot.

Making a knot using an instrument

Figure 13. Making a knot using instrument

De Jong, 1997, Buku Ajar Ilmu Bedah


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After the skin suturing is completed, evaluate the suture and

then the wound is firmly covered by gauze, the patient should be

given information and education on caring for the wound, which

includes diet, wound treatment such as the wound should not come

into contact with water and should be kept clean, next schedule for

the patient to come back and meet with the doctor who will monitor

the wound. Usually the suture will be removed after 7 to 14 days

unless for face area where the suture will be removed in 4-5 days

due to good vascularisation in this area. If the removal of suture isprolonged the scar will make bad cosmetic result. Should there be

prescribed medicine, do not forget to provide explanation about

dosage, method for using external medicine and side effects that

may occur

Removing the suture according the schedule of removal.

a. Prior to performing the suturing, the wound and its periphery

area should be cleansed with aseptic.

b. Tie the suturing knot with forceps, and pull the knot until it is

fairly raised up. Cut the thread just below the knot as near to

the skin as possible, with the prone position of 45 .

c. Pull the thread to the opposite direction from the knot so that

the thread does not enter the tissue.

d. Apply dressing to the wound


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Figure 14. Method for removing suturing

De Jong,1997, Buku Ajar Ilmu Bedah

After students finish reading this manual, it is expected that

they will follow on by practicing the acquired skills based on the casebelow:

You are a doctor who is on duty at the emergency ward. Apatient comes in with an open wound on his/her lower rightarm about 5 cm long. The wound was caused by a shatteredglass and the accident occurred 4 hours ago.

Perform a wound suturing procedure on the patient by applyingthe simple interrupted suturing method.


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REFERENCES

Sjamsuhidajat,R., De Jong, W. (editor) 1997, Buku Ajar Ilmu Bedah Edisi

Revisi, Jakarta: Penerbit Buku Kedokteran EGC

Schwartz, SeymourI, 1994, Principles of Surgery 2 Vol.10th ed. New York:

Mc-Graw Hill Publishing Company.

Brown, John Stuart. 1995, Buku Ajar dan Atlas Bedah Minor. Jakarta:

Penerbit Buku Kedokteran EGC


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CHECK LIST FORHETEROANAMNESIS IN PAEDIATRIC

No Criteria0

1 Able to make interpersonal relationshipwith the parents and the patient

2 Asking the patients and parents identitycompletely

3 Asking the chief complaint

4 Able to explore present illness complainsystematically

5 Able to explore past illness history

6 Able to explore family illness history

7 Able to make pedigree of the family

8 Able to explore antenatal care history

9 Able to explore natal care history

10 Able to explore postnatal care history

11 Asking eating habits12 Asking about the patients growth and

development since neonates to present

(gross motor, fine motor, personal-social,language)

13 Able to ask about the immunization history

14 Able to explore the social-economics andenvironmental state

15 Able to make anamnesis of the bodysystem

16 Able to cross check unclear information

17 Able to write medical record completelyTotal score


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Jogjakarta, ..............................

Instructor Observer

(.............................) (.........................)

Total ScoreFinal Score = x 100%

34

Explanation:Score 0: not performed at allScore 1: performed unsatisfactoryScore 2: performed satisfactory


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CHECKLIST SIMPLE SKIN SUTURING

ScoNo. Aspects.

0 1

1. Greeting and performing emotional relationship,self introduction

2. Performing brief physical examination needed

according to the case

3. Explaining the procedure and taking theinformed consent

4. Preparing instruments for aseptic procedure

correctly, wearing a clean short sleeves cottonsuit, caps, googles, mask and boot.

5. Preparing minor surgery instruments in aseptic

manner

6. Performing hand washing/scrubbing andwearing the gloves correctly

7. Sterilizing the surgery field with an antimicrobial

agent in central to peripheral direction

8. Placing sterile fenestrated linen over the surgical

field.

9. Performing local anesthesia

10. Cleaning the wound by using NaCl 0,9 % (todilute microorganisms and foreign bodies)

11. Sterilizing the wound from anaerobic bacteria by

using Perhydrol 10% solution followed by NaCl0,9 %.

12. Placing a curved taper cut needle no. 4/8 in

needle holder, between two-third (3

2) distal and

one-third (3

1) proximal, and locking the position

13. Placing the thread no. 3/0 properly on the

curved taper cut needle

14. Lifting up the margin of the wound by usingsmooth serrated pincer, and with wrist in prone

position, the elbow in 90o angle and shoulder

abducted, sticking the needle into the skin,straight vertically toward wound axis.

15. Performing a penetration (x cm) from the wound


62/63

62 Block 14


ScoreNo. Aspects.

0 1 2

16. Sticking the needle with supine wrist movement

and shoulder abduction movement, pushing the

needle according to the curved shape of the

needle

17. Piercing the needle exceeding the wound in

straight vertical direction toward wound axis.

18. Pinching the needle with needle holder after it

appears on the skin surface and pulling it out. The

distance between wound margin and where the

needle pierce the skin should match with skinthickness (x cm) and in straight vertical direction

toward wound axis.

Pulling the thread and leaving 3-4cm from the skin

19. Holding the long thread with the left hand and

holding the needle with the right hand

20. Placing the needle holder in parallel position with

the wound axis.

22. Winding the long thread over the needle holder

23. Taking the tip of short thread by needle holder, and

pulling the short thread toward you. Meanwhile, the

long thread is pulled in opposite direction.

24. Placing the long thread over the needle holder,

winding it over the needle holder.

25. Taking the tip of short thread by needle holder, and

pull the short thread away from yourself.

Meanwhile, the long thread is pulled toward

yourself.

26. Cutting a knot by placing the scissor to the suture,

ready to cut, then placing the scissors above the

knot, turning out the scissors away from the knots

in order to be able to see the length of the thread

and cut finally. The length of the remaining thread

is about the thickness of skin (x cm).

27. Result of the suture should not be too tight or too

loose and the edge of margin should meet

properly.


63/63

63Bl k 14


ScoreNo. Aspects.

0 1 2

28. Knot should be placed on the side of the

wound margin.

29. Checking proximity of wound margin and

performing dressing on the wound.

30. Giving educations that are needed to the

patient.

Explanation:Score 0 = Not performed at all

Score 1 = Performed imperfectly

Score 2 = Performed perfectly

Total score% coverage skills = ----------------- x 100% = %

60

Yogyakarta,

Instructor Student

Name Name

Documents

Pediatric&Minor Surgery Okt2008